Giant keratoacanthoma of the nasal pyramid - diagnosis and treatment challenges

Keratoacanthoma (KA) is a benign tumor that originates in the pilosebaceous glands and
closely resembles clinically and histopathologically with squamous cell carcinoma
(SCC), is some cases being impossible to differentiate them resulting in speculation and
controversies, especially because is considered to be a pseudoepitheliomatous
hyperplasia.
A 90 year-old female, from rural area presented to our hospital with a giant tumor located
on the left side of the nasal pyramid penetrating the nasal vestibule as a 3 mm hole with
elevated borders and the surface was covered by a hematic and honey colored crusts. The
onset of the tumor was long by the patient could not tell the exact moment of the
appearance of the tumor.
The patient reported that the tumor bled and grew in size, after a previous local
trauma that took place a month earlier.
To confirm the diagnosis, we performed a incisional biopsy under local anesthesia.
From our point of view the result of the histological exam was inconclusive, showing
microscopic structure of ulcerated, hyperkeratotic papilloma with well represented
chronic inflammatory infiltrate. So, we performed an native and post-contrast MRI
showing a heterogeneous tumor located on the alar and triangles cartilages, with nasal
invasion, mainly on the left side of the nasal septum; white matter in infra and supratentorial spaces, with no focal lesions or other changes that sugest recent vascular lesions
or space-occupying processes; cerebral and cerebellar atrophy due to patients age;
midline symmetrical ventricular system
Taking in consideration the advanced age of the patient and the medical history, the
reparative plastic surgery department and otorhinolaryngology clinique advised against
surgery and reccommended roentgen teraphy. The patient refused the treatment and we
initiated isotretinoin 1mg/kg/day for 60 days. The evolution was spectacular, the tumor
resorbed and the keratotic plug was removed leaving a retractile and atrophic scar and a
lack of substance located on the left nostril.