Quiz 6: What is your diagnosis?

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Diagnosis: Quiz 6

Quiz 6

Answer:  Pseudocarcinomatous hyperplasia secondary to ulceration consequent to severe venous insufficiency

Criteria for diagnosis clinically:  Numerous ulcers typified by a ragged margin, some of them with a pink or red base and others covered by what seems to be purulence, in company with white zones of what appears to be scar, are a result of severe venous insufficiency.

Differential diagnosis clinically:  Although the attributes clinical are suggestive highly of ulceration secondary to severe vascular compromise alone, also to be considered is the possibility of a malignant neoplastic process, such as squamous-cell carcinoma. Biopsy is essential if the facts of the matter are to be established.

Criteria for diagnosis histopathologically: Large aggregations, variable markedly in size and shape, some of which have assumed peculiar geometric outlines, made up of slightly abnormal keratocytes and enveloped by granulomation tissue joined by a mixed infiltrate of inflammatory cells, neutrophils especially, are findings of pseudocarcinomatous hyperplasia.

Differential diagnosis histopathologically:  This is not a squamous-cell carcinoma because nuclei of proliferative keratocytes are neither crowded nor abnormal overtly and, moreover, no signs of aberrant cornification within aggregations of keratocytes proliferative, among those dyskeratotic cells or "horn pearls" are apparent.

Clinicopathologic correlation: The biopsy specimen was taken from a locus not ulcerated and, therefore, no ulcer is seen histopathologically. The plaques are made up of hyperplasic infundibular epithelium and granulation tissue, and what seems to be scale-crust is composed mostly of parakeratosis accompanied by only a tad of serum.

Options for therapy predicated on knowledge of histopathologic findings: Because this is pseudocarcinomatous hyperplasia and not squamous-cell carcinoma, attention in regard to therapy must be directed at the process underlying it, namely, the vascular insufficiency.

1) Pseudocarcinomatous hyperplasia in skin manifests itself histopathologically as proliferations of infundibular and eccrine ductal epithelium being somewhat linear and oriented perpendicular to the surface of the skin. That distinctive pattern derives from the hyperplastic keratocytes being those of pre-existing normal structures (infundibula and eccrine ducts) whose course is vertical to surface epidermis. In the example of pseudocarcinomatous hyperplasia shown here, the bulk of proliferative keratocytes is bulbous rather than linear, the reason being the orientation of the oblique specimen prior to section of tissue having been cut from it. In short, surface epidermis is not a contributor of import to pseucarcinomatous hyperplasia.

2) In the ultimate analysis, attributes cytopathologic of keratocytes, as well as pattern architectural, are crucial for distinguishing pseudocarcinomatous hyperplasia from squamous-cell carcinoma; nuclei in the former are not crowded, large, or pleomorphic at the periphery of aggregations, and cytoplasm is not cornified in prominently aberrant fashion, such as by dyskeratosis. Never are there "horn pearls" in pseudocarcinomatous hyperplasia and practically never are there abnormal mitotic figures in keratocytes participant.

3) The stroma associated with pseudocarcinomatous hyperplasia often differs dramatically from that of squamous-cell carcinoma. Although fibrosis may be an accompaniment of both (a scar in the former and desmoplasia in the latter), granulation tissue is a finding expected often in pseudocarcinomatous hyperplasia, it being a proliferative response of keratocytes to injuries of various kinds that induce highly vascular edematous stroma and affiliated with a mix of inflammatory cells. Among those are neutrophils, which also may be present in hyperplastic epithelium, which is the case here, those polymorphonuclear leukocytes having also induced acantholytic necrotic cells. In contrast, granulation tissue is not a change met with commonly in squamous-cell carcinoma.

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