Quiz 31: What is your diagnosis?

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Diagnosis: Quiz 31

Quiz 31

Answer:  Squamous-cell carcinoma, solar keratotic type

Criteria for diagnosis clinically: This subtly domed nodule, red in loci, covered in large part by scale-crust, and punctuated by small ulcers with a jagged outline is a squamous-cell carcinoma.

Differential diagnosis clinically: This could be a neoplasm of another kind, but in the context of the numerous solar keratoses nearby, the diagnosis most reasonable is squamous-cell carcinoma of the solar keratotic type. Biopsy is essential to coming to a diagnosis with specificity.

Criteria for diagnosis histopathologically: This ulcerated and crusted asymmetrical neoplasm made up of aggregations of abnormal keratocytes, whose nuclei are crowded and arranged in a jumble, some conglomerations of it being marked in the center by a zone of necrosis en masse  and at the periphery of it being characterized in the epidermis (both surface and infundibular) by suprabasal clefts, above which reside acantholytic dyskeratotic cells, is a solar keratotic type of squamous-cell carcinoma.

Differential diagnosis histopathologically: There is none.

Clinicopathologic correlation: The lesion is elevated by virtue of the proliferation of neoplastic cells, it is red because of the many superficially located capillaries and venules dilated widely and filled with erythrocytes, it is ulcerated clinically because of the ulceration observable histopathologically, and the scale-crusts are accounted for by mounds of parakeratosis replete with serum in conjunction with extravasated erythrocytes and neutrophils.

Options for therapy predicated on knowledge of histopathologic findings: A neoplasm such as this one must be excised

1) There are several different kinds of squamous-cell carcinoma, just as there are of basal-cell carcinoma, the types of the latter being designated superficial, nodular, morpheiform, fibroepitheliomatous, and infundibulocystic. The different kinds of squamous-cell carcinoma are the solar keratotic, Bowen's, bowenoid papulotic, keratoacanthomatous, and verrucous. The squamous-cell carcinoma pictured here is solar keratotic histopathologically because at the very periphery of it, in continuity with the bulk of the neoplasm, are signs indubitable of solar keratosis.

2) Solar keratosis is a superficial squamous-cell carcinoma of one type, the others being the arsenical, radiation, Bowen's, and bowenoid papulotic. Of course, the keratoacanthomatous and verrucous types of squamous-cell carcinoma also begin superficially, but the appearance of them architecturally, even at an "early" stage, is very different from that of the just mentioned five types. Not uncommonly, solar keratosis sports suprabasal clefts in surface and infundibular epidermis, as well as in nubbins of neoplastic keratocytes that grace the upper part of dermal eccrine ducts. The cells situated below the cleft are typical of squamous-cell carcinoma, the nuclei being crowded, large, and pleomorphic, and the cells in the clefts themselves are acantholytic and dyskeratotic. Those changes are apparent in several series of photomicrographs of the squamous-cell carcinoma pictured here.

3) Neoplastic cells of squamous-cell carcinoma express aberrant cornification in the form, not only of dyskeratotic cells, but of whorls of parakeratosis ("horn pearls") and parakeratosis of surface epidermis. In addition to faulty cornification, the neoplastic cells of squamous-cell carcinoma may undergo necrosis en masse, as is seen here as zones typified by pyknosis, karyorrhexis, and karyolysis, the last of those signs of necrosis being exemplified best in the cystic space created by death of innumerable cells in a large aggregation present on the right side of the photomicrograph "shot" at scanning magnification.

4) Beneath the ulcers histopathologic is granulation tissue typified by highly vascularized and edematous stroma, it being joined by a mixed infiltrate of inflammatory cells.

5) The patchy infiltrate of lymphocytes mostly present in the upper part of the dermis beneath the solar keratosis at the periphery of the neoplasm is a finding expected, albeit not invariable.

6) Another biopsy specimen taken from the face of this same patient, but by punch technique, shows a solar keratotic type of squamous-cell carcinoma at that incipient stage known as "solar keratosis." Note that that exceedingly superficial neoplasm shows the very same changes as are seen at the periphery of the just presented solar keratotic type of squamous-cell carcinoma, it extending in continuity from the epidermis far into the dermis. 

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