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ARTICLE IN PRESS
doi:
10.25259/IJDVL_489_2021

Asymptomatic solitary nodule over the left flank

Consultant Dermatologist, Katihar, Bihar, India
Department of Dermatology, Katihar Medical College, Bihar, India
Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
Corresponding author: Dr Anupam Das, Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India. anupamdasdr@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Das P, Kumar P, Das A. Asymptomatic solitary nodule over the left flank. Indian J Dermatol Venereol Leprol doi: 10.25259/IJDVL_489_2021

A 30-year-old man presented with a solitary mass on the left flank, for the last three and a half years. Initially it was a pea-sized lesion, which gradually increased in size. Cutaneous examination revealed a solitary 2×2 cm solid non tender, non pruritic, rough surfaced hyperpigmented nodule on the left flank [Figure 1]. It was not fixed to the underlying tissue. There was no regional lymphadenopathy and no other mucocutaneous findings. Systemic examination was noncontributory. The nodule was excised and sent for histopathological examination. Biopsy showed a well-circumscribed diffuse dense and nodular proliferation of large cells with abundant pink staining cytoplasm with a small vesicular central nucleus. The cytoplasm was packed with pink staining granules of different sizes (0.5–2 microns). The neoplastic cells were packed closely in nodules and fascicles with compressed collagen in between them [Figures 2 and 3]. Overlying epidermis showed pseudocarcinomatous hyperplasia and the granules stained positive with periodic acid-Schiff [Figure 4]. Immunohistochemistry could not be performed due to logistic reasons.

Figure 1:: Hyperpigmented nodule on the left flank
Figure 2:: Well-circumscribed diffuse dense and nodular proliferation of large cells (H and E, × 100)
Figure 3:: Densely packed cells with abundant pink staining cytoplasm with a small vesicular central nucleus
Figure 4:: Distinctly stained granules (PAS, × 400)

Question

What is your diagnosis?

Answer

Granular cell tumour.

Discussion

A granular cell tumour is an uncommon benign neoplasm, originating from Schwann cells. The commonest site of involvement is the tongue, dermis and subcutaneous tissues. However, atypical sites of involvement have been reported like larynx, bronchus, uvea, oesophagus, stomach etc. There is no age predilection, and cases are more commonly seen in women. The lesions are usually solitary and painless, and in less than 25% of cases, multiple lesions have been noted. Rarely the tumour may be painful.1

Histopathology typically shows sheets of polygonal cells infiltrating into the dermis. The cells are typified by the presence of centrally placed small round to oval vesiculated nuclei with abundant granular eosinophilic cytoplasm. On immunohistochemistry, cells stain with vimentin, neuron-specific enolase, S-100, myelin protein, calretinin, nerve growth factor receptor five, microphthalmia-associated transcription factor, inhibin-alpha and protein gene product 9.5.2 LeBoit et al. and subsequently by others described rare subtypes: polypoid granular cell tumour and primitive non neural granular cell tumour which were S-100 negative.3 The granular appearance of the neoplastic cells is attributed to the presence of large lysosomes, which are positive for periodic acid–Schiff and diastase-resistant. Histological differentials include dermatofibroma, rhabdomyoma, Reed neuroid spindle cell tumour, xanthoma and metastatic breast carcinoma (all of them show granular cytoplasm on histology). Rarely, tumour cells in granular cell tumour may involve the overlying epidermis and distinction from melanoma may be difficult. HMB45 stain may help in differentiating the two conditions, which is usually negative in granular cell tumour.

Malignancy is uncommon (1–2%) and clinically it manifests with a rapid increase in size and locoregional lymph node enlargement. Spindling of neoplasic cells on histology is thought to be a marker of malignant transformation. Other features which suggest malignancy include an increased number of mitotic figures (>2 mitoses per 10 high-power fields), necrosis, pleomorphic nuclei, increased nucleocytoplasmic ratio and vesicular nuclei with prominent nucleoli.4 Presence of two of these criteria makes the tumour “atypical”, and granular cell tumours with three or more of these criteria are classified as malignant.5

The therapy of choice is complete excision with free surgical margins. Patients should be followed up periodically to look for recurrences.6

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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  2. , , , , , . Granular cell tumor: a clinical study of 81 patients. Actas Dermosifiliogr (Engl Ed). 2021;112:441-6.
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  3. , , , , , . Primitive polypoid granular-cell tumor and other cutaneous granular-cell neoplasms of apparent nonneural origin. Am J Surg Pathol. 1991;15:48-58.
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  4. , . Multiple asymptomatic lesions on the lips. Clin Exp Dermatol. 2019;44:316-8.
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  6. , , , . A case of granular cell tumor with an interesting clinical course. Indian J Dermatol Venereol Leprol. 2012;78:193-5.
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