DERMATOPATHOLOGY

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DERMATOPATHOLOGY

• CASE STUDIES

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CASE 1

• History
• This 63 year old male has multiple raised velvety
  coin-like tan to brown lesions over the face and
  upper chest that have a "stuck on" appearance.
  They have appeared over the past 5 years and have
  slowly enlarged.

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Microscopic Appearance Note that the lesion
appears to be mostly above the level of the
surrounding epidermis (and, hence, the "stuck on"
appearance). The lesion is composed of squamous
epithelium with cells that are quite uniform and
bland. The nuclei are not hyperchromatic. The
cytoplasm contains brown melanin pigment. There
are numerous cysts filled with keratin.
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Questions

• What is the diagnosis?
• What is the natural history of this lesion?

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CASE 1 Seborrheic keratosis

• What is the diagnosis?
• Seborrheic keratosis
• What is the natural history of this lesion?
• The lesions are seen in older persons and they
  slowly enlarge over time. The lesions do not
  bleed or itch, but they are cosmetically
  unpleasing. They are not malignant.

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CASE 2

• History
• This slide is typical of what would be seen in a
  19 year old male who has had severe outbreaks of
  acne for years.

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Inflammation
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Questions

• What causes acne?
• What is the course of this disease?

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CASE 2 Congolate acne

• What causes acne?
• This disease of teenagers and young adults
  results from increased sebum production in
  sebaceous glands after puberty. Sebum and
  keratinaceous debris block hair follicles,
  leading to comedone formation. Bacteria in the
  comedones cause inflammation and rupture, with
  additional surrounding inflammation.
• 2. What is the course of this disease?
• It is self-limited. Skin cleansing agents can be
  used to treat in most cases, though antibiotics
  and retinoids may be used in more severe cases. A
  small subset of patients develop the lesion seen
  in this slide. The result of severe acne can be
  scarring. About 10 to 20 of adults may manifest
  acne.

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CASE 3

• History
• This is a lesion from the ear of a 32 year old
  African-American male who had a history of just a
  minor cut a few months ago, but the scar that
  formed is now quite prominent.

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Microscopic appearance The epidermis is normal,
but the dermis has nodules composed of swirls of
dense pink collagenous tissue that is not very
cellular.
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Fibrosis
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Questions

• What is the diagnosis?
• Why does this happen?

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CASE 3 Keloid

• What is the diagnosis?
• This is a keloid. There is an over-exuberant
  healing and repair reaction with production of
  abundant collagenous tissue forming the
  tumor-like mass. Ear piercing in women may
  promote keloid formation. A keloid is an
  overgrowth of dermal scar tissue that forms over
  months following the injury.
• Why does this happen?
• Persons with more darkly pigmented skin are more
  prone to keloid formation, but it can occur in
  all races. Plastic surgery procedures and
  corticosteroids can help, but keloids typically
  recur.

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CASE 4

• History
• Just about everyone has at least one of these.
  They may be flat and pigmented, or they may be
  pale and nodular, but they are never very large
  and they hardly seem to enlarge as you get older.

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Microscopic appearance The dermis contains
sheets of small, uniform blue cells. Some of
these cells are also seen along the
dermal-epidermal junction and are pigmented.
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Intradermal nevus
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Questions

• What is the diagnosis?
• Are these lesions premalignant?

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CASE 4 Nevus

• What is the diagnosis?
• Benign nevus.
• Are these lesions premalignant?
• Probably not. Most melanomas arise as such.
  Persons with dysplastic nevi and persons with
  lots of nevi are at greater risk.

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CASE 5

• History
• A 48 year old rancher (stockman) noted a "mole"
  on his arm that seemed to be getting larger and
  then changed color in the past couple of months.
  He went to his physician who then removed the
  lesion and sent it in to the pathologist for
  diagnosis.

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Microscopic appearance Extending from the
dermal-epidermal junction are infiltrating nests
of large polygonal cells with hyperchromatic and
pleomorphic nuclei that have very large nucleoli
and occasional mitotic figures. Melanin pigment
is present.
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Melanoma cells
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Questions

• What is the diagnosis?
• From examination of the lesion on the slide, how
  could you say something about the prognosis?

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CASE 5 Melanoma

• What is the diagnosis?
• This is a malignant melanoma
• From examination of the lesion on the slide, how
  could you say something about the prognosis?
• The measurement of the depth of the lesion will
  be useful in predicting the prognosis, as follows

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CASE 6

• History
• This 41 year old former lifeguard spent a lot of
  time on the beach. She developed multiple
  scaling, erythematous lesions on the face that
  were 0.5 to 1 cm in size. One of the larger
  lesions that was ulcerated and had an indurated
  border was excised.

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Nests of epithelial cells
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Questions

• What is the diagnosis?
• Why did this lesion develop?

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CASE 6 Squamous cell carcinoma

• What is the diagnosis?
• Squamous cell carcinoma. The surrounding skin
  probably shows actinic keratoses.
• Why did this lesion develop?
• Sun exposure predisposes to development of skin
  malignancies.

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CASE 7

• History
• This 66 year old male is an avid fly-fisherman
  who spends as many weekends and holidays as
  possible during the summer on the Gallatin River
  in Montana. He has noted a slowly enlarging
  nodule on the outer helix of his right ear. His
  physician noted that the nodule was pearly pink,
  1.1 cm in diameter, with a central umbilicated
  ulcerated area.

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Nests
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Questions

• What is the diagnosis?
• What patterns of growth can be seen with this
  lesion?

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CASE 7 Basal cell carcinoma

• What is the diagnosis?
• Basal cell carcinoma.
• What patterns of growth can be seen with this
  lesion?
• These neoplasms grow slowly but persistently.
  Most often they are unifocal, but sometimes they
  can be multifocal.

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CASE 8

• History
• This 25 year old male has multiple firm nodules,
  some of which are up to several cm in size and
  are disfiguring. Also noted on physical
  examination are ten light brown macules with
  smooth borders averaging about 2 to 3 cm in size
  scattered over the trunk and arms.

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Microscopic appearance The lesion consists of an
unencapsulated but well delineated dermal mass of
small wavy spindle cells cells that resemble
nerve. The stroma has abundant collagen.
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Questions

• What is the diagnosis?
• What is the natural history of this process?

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CASE 8 Neurofibromatosis type I

• What is the diagnosis?
• Neurofibromatosis type I.
• What is the natural history of this process?
• Neurofibromatosis type I mainly involves the
  skin with neurofibromas and cafe-au-lait spots
  (von Recklinghausen disease) but there can also
  be neurofibromas involving visceral organs, and
  there is also a greater risk for other benign and
  malignant neoplasms including meningiomas,
  gliomas, and pheochromocytomas.