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Clinical Challenge
April 2018

An Uncommon Cutaneous Lesion

Author Affiliations
  • 1Department of Otolaryngology–Head & Neck Surgery, MedStar Georgetown University Hospital, Washington, DC
  • 2Department of Pathology, James A. Haley Veterans’ Hospital, Tampa, Florida
  • 3Department of Otolaryngology–Head & Neck Surgery, University of South Florida, Tampa
JAMA Otolaryngol Head Neck Surg. 2018;144(4):377-378. doi:10.1001/jamaoto.2017.3417

A male smoker in his 60s presented to the dermatology department with a right supraclavicular cutaneous mass that had persisted for 2 years (Figure, A). This mass underwent progressive growth during the first year but subsequently stabilized. Despite causing occasional pruritus, the lesion was otherwise asymptomatic. A shave biopsy specimen revealed islands of large epithelioid cells with increased mitotic index surrounded by a dense lymphocytic infiltrate (Figure, B and C). The tumor cells expressed p16 (Figure, D) and epithelial membrane antigen (EMA), p63, and CK903, and were negative for prostate-specific antigen, CDX2, thyroid transcription factor 1, S-100, chromogranin, synaptophysin, and CD56. In situ hybridization for Epstein-Barr virus (EBV) was negative. Otolaryngology referral was sought to rule out a head or neck primary neoplasm. With the exception of the cutaneous neoplasm, the findings from the otolaryngologic examination were unremarkable. A screening chest computed tomographic (CT) image showed multiple right lung nodules, the largest of which measured 2.4 cm in diameter. A biopsy of this pulmonary nodule showed a well-differentiated adenocarcinoma with lepidic pattern, and further workup revealed an intestinal tumor as the primary source. Positron emission tomography and CT imaging demonstrated a mildly fludeoxyglucose F 18–avid superficial supraclavicular soft-tissue mass but no primary head or neck malignant neoplasm or local nodal metastases. A wide local excision of the cutaneous mass and a right level Vb neck dissection were performed. The final pathology report showed residual neoplasm with negative margins and 5 negative lymph nodes. Clinical observation was recommended.

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