DERMATOLOGICA SINICA 34 (2016) 213e214

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Dermatologica Sinica
journal homepage: http://www.derm-sinica.com

CORRESPONDENCE

Primary cutaneous extraskeletal osteosarcoma

Dear Editor, forming soft-tissue tumors considered in the differential diag-

nosis included myositis ossicans and sarcomas with osseous
A 55-year-old female presented with a nodule on her left upper metaplasia such as atypical broxanthoma, undifferentiated pleo-
back that had been slowly growing for 1 month. She had no subjec- morphic sarcoma, synovial sarcoma, epithelioid sarcoma, and lip-
tive symptoms such as pain or tenderness, and no history of trauma osarcoma. The reverse zonation4 in our patient revealed central
or injection. On physical examination, the nodule was movable and lace-like osteoid formation and malignant spindle cells at the pe-
measured 1.6 cm  1.4 cm. There were no overlying skin changes riphery, which distinguished it from myositis ossicans. Osseous
(Figure 1). There was no palpable lymph node. The tumor was metaplasia observed in various sarcomas is usually not the pre-
excised under the clinical diagnosis of neuroma. dominant component and does not exhibit malignant cellular
Histopathological examination revealed a rather well-dened features.
tumor nodule (Figure 2A). The tumor was composed of spindle cells There are single cases associated with previous electrodessica-
with many pleomorphic anaplastic nuclei and multinucleated tu- tion of actinic keratoses,5 old scars,6 and radiotherapy.7 However,
mor giant cells (Figure 2B). Focal osteoid formation (Figure 2C) the relationship among these conditions and the development of
and chondroid differentiation were noted. Neither necrosis nor
calcication was observed. Brisk mitotic gures were identied.
No glandular or epithelial components were observed.
Physical examination and laboratory test results were within
normal limits. A complete radiological evaluation, which included
computed tomography and a bone scan, was performed. No pri-
mary bone lesions were detected. This tumor was a high-grade, pri-
mary cutaneous extraskeletal osteosarcoma (ESOS). It subsequently
underwent a wide excision. The margins were tumor-free. The pa-
tient received adjuvant local radiotherapy and experienced no re-
currences or metastases during a 6-month follow up.
Extraskeletal osteosarcoma, initially described by Wilson1 in
1941, is dened as a malignant mesenchymal neoplasm composed
of tumor cells producing malignant osteoid, bone, and/or chon-
droid differentiation without attachment to skeletal structures.
An ESOS usually occurs in patients aged 50e60 years without a
sex predilection.2
Most previous reported cases of ESOS were in deep soft tis-
sues.3 The skin as the primary site is extremely rare. Osteogenic
changes in the skin usually represent metastasis or osseous meta-
plasia of a primary epithelial neoplasm. The possibility of a met-
astatic lesion to the skin was excluded by the absence of any
primary bone tumor under complete radiological evaluation. No
epithelial component was found in this tumor to suggest a pri- Figure 1 A solitary nodule on the left upper back without changes in the overlying
mary epithelial neoplasm with osseous metaplasia. Other bone- skin.

Conicts of interest: The authors declare that they have no nancial or non-nancial conicts of interest related to the subject matter or materials discussed in this article.

http://dx.doi.org/10.1016/j.dsi.2016.03.002
1027-8117/Copyright 2016, Taiwanese Dermatological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
214 Correspondence / Dermatologica Sinica 34 (2016) 213e214

ESOS remains uncertain. The prognosis of ESOS is overall generally

poor with a 5-year mortality rate of 25e50%.8 Rapid local recur-
rence, followed by disseminated metastasis, is very common.
Among previously reported primary cutaneous ESOS cases, six pa-
tients presented with metastasis or died because of the progression
of osteosarcoma.9 Only a few cases of primary cutaneous ESOS have
been reported; therefore, determining whether cutaneous ESOS
has a more favorable prognosis is difcult.
The traditional treatment of ESOS has been restricted to local in-
terventions such as surgery alone or a combination of surgery and
radiotherapy. To date, no guidelines for adjuvant treatment exist.
Adjuvant radiation and chemotherapy are recommended for
high-grade, large and/or incompletely resected lesions.
In summary, we reported a case of primary cutaneous extra-
skeletal osteosarcoma on the left upper back of a 55-year-old fe-
male. To ensure accurate diagnosis and treatment, dermatologists
should be aware that this entity may occur at supercial sites and
should consider this condition in the differential diagnosis when
bone formation is within the dermis.

Chia-Hsin Lu, Chien-Hsun Chen*

Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan

Tseng-tong Kuo
Department of Pathology, Chang Gung Memorial Hospital, Taipei, Taiwan
*
Corresponding author. Department of Dermatology, Chang Gung Memorial
Hospital, Number 199, Dunhua North Road, Songshan District, Taipei City 105,
Taiwan.
E-mail address: kenkunchen@hotmail.com (C.-H. Chen).

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Figure 2 Histopathological ndings. (A) Scanning view of the nodule [hematoxylin and
eosin (H&E); magnication, 40]. (B) The tumor is composed of spindle cells with scat-
Received: Feb 18, 2016
tered pleomorphic nuclei (H&E; magnication, 400). (C) Malignant osteoid formation Revised: Mar 14, 2016
with intervening pleomorphic malignant cells (H&E; magnication, 100). Accepted: Mar 16, 2016