Quiz 43: What is your diagnosis?

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Diagnosis: Quiz 43

Quiz 43

Answer: Keloid

Criteria for diagnosis histopathologically: A bifid tumor formed of fibrosis that extends throughout the reticular dermis and well into the subcutaneous fat, composed in the center, especially in the upper half, of bundles of collagen thickened remarkably and arrayed haphazardly in company with an increase in number of fibrocytes with plump oval nuclei, many with cytoplasm stellate in outline, all of these changes being joined by numerous venules scattered throughout, is a keloid.

Differential diagnosis histopathologically: There is none.

Criteria for diagnosis clinically: A smooth-surfaced, slightly red tumor in the lobe of an ear is a keloid.

Differential diagnosis clinically: There is none.

Clinicopathologic correlation: The tumor itself came into being consequent to fibroplasia that cuts a swath through the dermis and extends well into the subcutaneous fat, the redness is a reflection of venules in the upper part of the dermis that, in vivo were dilated widely and crammed with erythrocytes, and the surface of the lesion is smooth because the cornified layer is normal.

Options for therapy predicated on knowledge of histopathologic findings: Once in receipt of a diagnosis histopathologic of a keloid, a surgeon must be alert exquisitely to the difficulty of being able to remove the lesion with finality. Because a keloid always is a response to trauma of some kind (there is no such thing as a "spontaneous" keloid), a surgical procedure designed to extirpate it may act paradoxically as a stimulus to even greater growth of it. In order to minimize the likelihood of "recurrence" of a keloid, a variety of methods have been advocated, none of them effective consistently, among those being compression, injection locally of corticosteroid, and X-irradiation following immediately on the surgical procedure.

1) A keloid is a type of fibroplasia, just as is the case for a scar and a dermatofibroma. Each of those types of fibrosis inherent in an inflammatory process is identifiable, clinically and histopathologically, for what it is. The attributes pictured here, by both inspection gross and examination microscopic, are stereotypical of a keloid.

2) The findings histopathologic at an early stage of a keloid are very different from those in a keloid formed fully. Early in the course of development of a keloid are changes pictured here at the base of the lesion; no "keloidal" collagen is present, only a prominent increase in number of fibrocytes in company with fibrillar bundles of collagen. The bulbous outline of some masses of fibrotic tissue seen at the base is a clue to this particular example of fibroplasia being a keloid, despite the absence in those bulks of keloidal collagen.

3) Keloidal collagen is not restricted to keloids alone. That distinctive expression morphologic of fibroplasia can be encountered in other inflammatory conditions, such as near the surface of a dermatofibroma, and in malignant neoplasms, such as in some types of basal-cell carcinoma. In short, keloidal collagen is a nonepithelial pattern histopathologic analogous to cellular granularity, "flame figures," and palisaded granulomas, which themselves are analogues of histopathologic epithelial patterns, such as epidermolytic hyperkeratosis, focal acantholytic dyskeratosis, pale-cell acanthosis, epithelial ("follicular") mucinosis, and cornoid lamellation.

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