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Skin pathology

Keloid (852)

hyalinized collagen
bundles

Normal epidermis

Thick connective
tissue deposition

Histopathology:
keloidal collagen bundles
absence of vertically orientated blood
vessels
keloidal collagen:
markedly eosinophilic
thickened
haphazardly arranged and
hyalinized
relatively normal epidermis
whorls of thick, hyalinized collagen
bundles and keloidal collagen
(prominent keloidal collagen) with an
infiltrative advancing lateral edge
refers to a type of scar that extends beyond skin adjacent
to the wound. A simple hypertrophic scar as distinct from
a keloid does not extend beyond the wound.
Benign, non-contagious
fibrous tissue and collagen
more common in African-Americans and Asians
In Turner syndrome, formation frequency is higher.
Clinical presentation:
most occur within a year after injury
painful (needle-like), pruritic nodular scar that grow
beyond the area of original injury
earlobe, upper arm, shoulder, upper back , anterior
chest
recurrence ~50% to 80% at site after attempt to
remove by surgical excision
does not regress with time.
Keloids are firm, rubbery lesions or shiny fibrous
nodules, can vary from pink to flesh-colored or red to
dark brown in color.
Nodular scar that extends beyond the area of injury
irregular shaped
characteristic keloidal collagen bundles that are
thickened, brightly eosinophilic

Molluscum contagiosum (855)

Firm, pink umbilicated papules due to


poxvirus (DNA virus)
Most often arise in children, also occur in
sexually active adults
common in AIDS and
immunocompromised individuals
Infection is usually spread by direct
contact
Treatment: cryotherapy
Chemical presentations:
multiple lesions may occur on the
skin and mucous membranes, with a
predilection for the trunk and
anogenital areas
individual lesions are firm, often
pruritic, pink to skin-colored
Basal cell layer of epidermis
umbilicated papules generally ranging
in diameter from 0.2 to 0.4 cm.
Rarely, giant forms occur
measuring up to 2 cm in diameter.
Small bowl-shaped lesions with central
areas of depression (umbilication) filled
with keratin.
Depression contains viral particles called
molluscum bodies.
material from the central umbilication
stained with Giemsa reagent often
shows diagnostic molluscum bodies.
molluscum bodies viral inclusions
within affected keratinocytes.
Large dark purple mass
intracytoplasmic homogenous
ellipsoid inclusion bodies
can be seen forming in the lower
epidermis. Increase in size as
infected cells move toward the
surface.
The molluscum bodies in the upper
layers of the epidermis displace and
compress the nucleus so that it appears as
a thin crescent at the periphery of the
cell.

Seborrheic keratosis (853)


Most common benign tumor in older
people
Occurs in individuals > 50 years of age
benign pigmented epidermal tumor
extremities and shoulders are most
common sites occur commonly on the
face in elderly patients
Treatment
Cryotherapy
Curettage
Shave biopsy/excision
Gross:
Arised lesion
papule or nodule with a stuck-on
appearance
Keratin filled cyst (horn cyst)
soft, brownish in color (it may have a
grayish appearance)
coin-like, macular to raised verrucoid
lesion
most lesions measure only a few
millimeters in diameter, some
occasionally reach a size of several
centimeters
Proliferation of the squamous cells
Sheets of basal-like cells,
hyperkeratosis, and keratin-filled
cysts
A well-demarcated coinlike pigmented
lesion containing dark keratin-filled
surface plugs is composed histologically
of benign basaloid cells associated with
prominent keratin-filled horn cysts,
some of which communicate with the
surface (pseudo-horn cysts)
Squamous horn cysts in seborrheic
keratosis
Pigmented seborrheic keratosis
(cytoplasmic melanin pigmentation)

Keratoacanthoma (854)

Male predominance
Grows within 4 to 6 weeks
Develops usually on sun-exposed skin of more elderly
adults
Regresses spontaneously with scarring usually within 6
months
Excision is recommended
Rapidly growing, benign crateriform tumor
Endophytic papillary proliferations of keratinocytes
Clinical presentation:
exo-endophytic architecture
the lesion is cup-shaped, with a central, keratin-filled
plug (keratin debris in the center) and overhanging
edges
pink to light red
This symmetric crater-like nodule has a prominent
central keratin plug.
The crater-like architecture: the dermis is red, epithelial
elements are gray, and the central keratin plug is yellow

Keratoacanthoma is composed of large,


glassy squamous cell and central islands
of eosinophilic keratin
Histopathology:
Compact ortho- and parakeratosis
keratin filled central crater with
overhanging epidermal lips
proliferation of large keratinocytes
with glassy, eosinophilic staining
cytoplasms
Mild to moderate keratinocytic
nuclear atypia, especially at base
Mild to moderate inflammatory
infiltrate at base, often with
eosinophils
A keratin-filled crater is lined by glassy
proliferating keratinocytes that invade
the dermis
Keratinocytes are large and have
abundant homogeneous eosinophilic
(glassy) cytoplasm.
Keratoacanthoma, the MAIN lesion to
differentiate from squamous cell
carcinoma

Benign pilomatrixoma (858)

Predominantly in children and young


adults, mostly on the head, neck, and
upper extremities
also known as calcifying epithelioma of
Malherbe
a benign tumor with cells resembling
cells of the hair matrix and areas of
intratumor calcification
Lobular appearance and can be hard
when palpated if there is extensive
calcification within
often become red (inflamed, associated
with granulomatous reaction
histologically)
The basal cells are keratinized as does
cortex of hair (without granular layer)
and produce ghost cells.
Calcification, ossification, and
granulomatous reaction common
Circumscribed tumor in dermis or
subcutaneous tissue with basaloid cells at
periphery (may have ordinary squamous
epithelium at periphery)
Microscopically, it is composed of solid
nests of small basaloid cells. The key
feature is the fact that these basaloid cells
undergo abrupt keratinization, leading to
the formation of ghost and shadow
cells (cells without nuclei)
Pilomatrixomas consist of anucleate
squamous cells (ghost cells). Benign
viable squamous cells and multinucleated giant cells.

Ghost cells

Basal cell carcinoma (857)

Normal looking
loose stroma
Palisading nuclei at
edge of nests

Nests of tumor cells

Basal cell carcinoma (857)


Malignant proliferation of basal cells of epidermis
Risk factor include:
chronic sun exposure, especially in people with fair skin, light hair, and blue, green, or gray eyes
albinism
xeroderma pigmentosum
other contributing factors such as burns, exposure to radiation, and arsenical intoxication
Most commonly develop on sun-exposed areas (e.g., nose, lip). Classic location: arises on the
upper lip. (squamous cell carcinoma usually lower lip)
Older persons, exceptionally children and young adults are affected
Classic appearance clinically:
elevated nodule, with the central area of ulceration
pearly papule often containing prominent, dilated subepidermal blood vessels (telangiectasias)
can ulcerate; formerly called rodent ulcers.
Pearly, telangiectatic nodules are composed of nests of basaloid cells within the dermis that are often
separated from the adjacent stroma by thin clefts, which may sometimes help distinguish BCC from
other skin neoplasms.
No hair
Nests of neoplastic cells resembling basal cells of the epidermis. The nests have peripheral palisading
and separation clefts and are embedded in mucoid matrix
the nests of basal cell carcinoma are surrounded by a typical loose stroma
nodules represents the tumor
peripheral palisading cells which are a little bit darker than the rest of these cells.
The central part of each nest contains closely packed keratinocytes
Remember!
Basal cell carcinoma invades stroma but does not metastasize. Basal cell carcinoma is a slow
growing malignant neoplasm, which invades locally but almost never metastasizes.
It may ulcerate and be very invasive, therefore it used to be known as ulcus rodens (rodent ulcer)
Treatment is surgical excision, metastasis is rare.
The periphery of each nest shows an organized layer of polarized, columnar keratinocytes,
(peripheral palisading).
The tumor cells have slightly elongated nuclei with very little cytoplasm

Pigmented compound nevus (135)

synonyms: pigmented nevus, mole


definition: tumor of modified
melanocytes (nevus cells)
occur in young adults. Nests of
melanocytes form droplets extending
deep into the dermis and diminish in size
as they mature (vertical maturation).
Melanocytes goes deeper as they
mature

The symmetry and uniform pigment


distribution suggest a benign process.
Histologically , compound nevi combine
the features of junctional nevi with nests
and cords of nevus cells in the
underlying dermis.
High-power view shows nests of nevus
cells at the dermoepidermal junciton. The
nevus cells are uniform and without
cytologic features of malignancy. Brown
pigment (melanin) is present in the
cytoplasm of some nevus cells.
Intraepidermal nest of melanocytes is
surrounded by keratinocytes. Nests of
melanocytes are seen in the epidermis,
and some of the cells have migrated into
the dermis.

The melanocytic nevi are classified according to their location and cytologic features
junctional nevus intraepidermal nests of nevus cells are found along the dermal junction
compound nevus nests of nevus cells are found intraepidermally along the dermoepidermal
junction and in the underlying dermis
dermal nevus nests of nevus cells only in the dermis

Melanocytic nevi are tan to brown, uniformly pigmented, small (usually <6 mm across), solid
regions of relatively flat (macules) to elevated skin (papules) with well-defined, rounded borders.
They may become more prominent during pregnancy, indicating a degree of hormone sensitivity

Malignant melanoma (859)

Malignant neoplasm of melanocytes


Risk factors:
susceptibility genes (history of
melanoma in first- or second-degree
relative)
prolonged exposure / exposure at an
early age to sunlight in fair skinned
individuals (melanoma is caused by
ultraviolet radiation that damages the
DNA of melanocytes; is related to
UVB light exposure)
albinism
xeroderma pigmentosum (no enzymes
necessary to repair DNA damage that
occur due to UVB light)
Clinical presentation:
potential signs of melanoma:
asymmetry, irregular border, variable
pigmentation (lesion may be dark
brown, black, or multicolored, can
also be hypopigmented), diameter of
more than 6mm, elevation. The
lesions may also become crusted and
bleed.
Warning signs of melanoma:
increasing size of nevus; itching
and/or pain; change in size, shape,
or color of nevus, growth
ABCD criteria for malignancy:
assymetry of shape
borders are irregular
color variation
diameter > 6 mm
Growth pattern of melanoma:
radial: grows horizontally along
epidermia and superficial dermis, not
associated with metastases
Vertical: grows downward into deep
dermis; is associated with metastases
vertical growth melanomas include
nodular melanomas
Morphologic findings include a flat,
brownish, irregularly colored tumor

Histopathology:
nests of melanoma cells invade
various layers of epidermis and
dermis
characteristic:
binucleated tumor cells
eccentric nuclei
melanin in cytoplasm
irregular nests and sing-cell growth
of melanoma cells within the
epidermis and an underlying
inflammatory response within the
dermis
malignant melanoma often produce
pigment. Not all malignant melanomas
produce pigment, and tumor must always
be considered in diagnosis of
malignancies with large pleomorphic
cells and prominent nucleoli.
Nuclei show features of malignancy:
polymorphism, large nucleoli with
irregular contours