A 12-year-old boy presented with an asymptomatic hyperkeratotic papule measuring 10 × 8 mm located in the center of the right palm (Figure 1) of one year's duration. Dermoscopic examination revealed reddish-brown dots in the center of the hyperkeratotic papule. This lesion had previously been clinically diagnosed as a foreign body granuloma and later as a wart. Monthly treatment with liquid nitrogen along with daily topical keratolytic treatment had been administered by three different physicians during the preceding 12 months, but this did not prevent growth of the lesion. During this period, no associated subjective symptoms or discomfort were experienced by the child. Despite the benign-appearing clinical presentation, due to the lack of response to treatment, a punch biopsy was performed, taking care to reach the deep dermis. Histopathological examination (Figure 2) showed an orthokeratotic epidermis without koilocytes. The deep dermis showed the presence of spindle and epithelioid tumor cells with abundant eosinophilic cytoplasm and pleomorphic, hyperchromatic nuclei. On immunohistochemistry, tumor cells stained positive for cytokeratins (CK) AE1/AE3, with a loss of integrase interactor 1 (INI-1/ SMARCB1) expression, a tumor suppressor protein that is constitutively expressed in most normal cells in the body. The combination of these morphological, histopathological, and immunohistochemical characteristics was conclusive for epithelioid sarcoma (ES). The lesion was treated with a wide surgical excision. Margins were clear, and staging (PET-CT, CT scan, and MRI) did not show any signs of local extension or disseminated spread. At nine-month follow-up, there were no signs of recurrence on local MRI and thoracic CT, which are currently repeated every 3 months. Epithelioid sarcoma, an entity first described by Enzinger in 1970, 1 is a rare soft-tissue sarcoma usually affecting children and young adults. Due to its benign clinical presentation and infrequent occurrence, epithelioid sarcoma can be clinically mistaken for benign lesions such as warts, foreign body granuloma, granuloma annulare, or fibroma. Epithelioid sarcoma can be divided into two subtypes, classic (distal) or proximal, each with distinct clinicopathological features. The classic type of ES typically presents as a subcutaneous or deep dermal mass in distal portions of the extremities (less frequently head, neck, vulva, or penis) of adolescents and young adults. It has a tendency to recur and may metastasize to regional lymph nodes. 2 In
