Quiz 4: What is your diagnosis?

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Diagnosis: Quiz 4

Quiz 4

Answer:  Squamous-cell carcinoma, solar keratotic

Criteria for diagnosis clinically: An eroded, poorly circumscribed plaque covered by scales is consonant with squamous-cell carcinoma.

Differential diagnosis clinically:  This could be an example of long-standing allergic contact dermatitis that has been excoriated or even of a process infectious, such as one induced by an atypical mycobacterium. Biopsy is requisite for coming to a diagnosis with specificity.

Criteria for diagnosis histopathologically: A small neoplasm with the silhouette of a malignant process that extends throughout much of the dermis and is made up of strikingly abnormal keratocytes, many of them acantholytic and dyskeratotic, in company with numerous clusters of dyskeratotic cells, as well as with parakeratosis, is a squamous-cell carcinoma.

Differential diagnosis histopathologically: There is none.

Clinicopathologic correlation: The plaque is formed by the sheet of neoplastic cells; the scale is a manifestation of parakeratosis; and the slightly reddish cast is a consequence of venules in the vicinity of the neoplasm, in vivo, having been dilated widely and filled with erythrocytes.

Options for therapy predicated on knowledge of histopathologic findings: This squamous-cell carcinoma, ill-defined clinically, must be removed in toto by a surgical method, one consideration being the Mohs micrographic technique, for the purpose of preserving as much of the lower part of the ear as possible.

1) Although clinically the lesion is a plaque, it appears histopathologically as a nodule that cuts a swath through the dermis to about the level of the subcutaneous fat. That seeming disparity between the appearance clinical and the one histopathologic is a consequence of the neoplasm having been sectioned along the short axis of it.

2) Because this squamous-cell carcinoma is typified by acantholytic dyskeratotic cells, the inference may be drawn that at a stage very superficial it took the form morphologic of a solar keratosis. In fact, in a locus there are findings histopathologic of solar keratosis. In short, a solar keratosis is nothing other than a superficial squamous-cell carcinoma of one type, characterized often by suprabasal clefts above which there are acantholytic dyskeratotic cells.

3) The moderately dense patchy infiltrate of lymphocytes in the immediate vicinity of the neoplasm is a finding expected in many a squamous-cell carcinoma.

4) Note that this squamous-cell carcinoma on an ear has obliterated vellus hair follicles, they being noted in normal number at the periphery of it.

5) Much of the dermis has been replaced by elastotic material, it representing the effects of decades of damage to the skin by ultraviolet radiation.



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