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Basal cell carcinoma simulators: Poroma, trichoepithelioma and fibrous papules of the face
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Adnexal tumors like giant solitary trichoepitheliomas are uncommon to most of us to permit a ready familiarity with them. Information regarding the genesis, clinical profile, behavior, and management options for this tumor is limited. There are 18 cases reported in the world literature till date. This review attempts to provide insight to this rare tumor. Our search included indexed literature from Pubmed, Directory of Open Access Journals, Health Inter Network Access to Research Initiative and Google databases in addition to standard dermatology texts. Giant solitary trichoepithelioma is a rare trichogenic tumor with potential for local recurrence. It has predilection for the older age, but may present at any age including at birth. It has close resemblance to basal cell carcinoma and other skin adnexal tumors - clinically, cytologically, and histologically. CD10, CD 34, PHLDA1 but not p75NTR are useful adjunct markers. Surgical excision is the standard treatment. Recurrence and possible transformation into BCC cautions follow up at regular intervals.
Solitary trichoepithelioma (TE) is a rare, benign tumor of follicular origin that in certain cases is difficult to differentiate from basal cell carcinoma (BCC). We report the case of an 8-year-old girl with a pale pink, soft lesion on the neck. The clinical image of the lesion was equivocal, while some dermoscopic findings-blue-gray globules and arborizing vessels-could not exclude the presence of BCC from the differential diagnosis, although that would have been a very unlikely case considering the age of the patient. The histopathologic examination established the diagnosis of TE. Given the occasion of this challenging case we try to list the key clinical, dermoscopic and histopathological characteristics of TE and BCC in order to elucidate the differential diagnosis of these two entities.
Poroma is a benign adnexal neoplasm of the terminal sweat gland duct. Although poromas have traditionally been thought to originate from the eccrine sweat gland, there have been cases of apocrine etiology as well. Eccrine and apocrine poromas typically present as erythematous or flesh-colored nodules on the palms and soles. As these features overlap with a multitude of differential diagnoses, it is imperative to have a firm understanding of the characteristics that make the diagnosis of poroma. In addition, the malignant counterpart to the poroma, the eccrine porocarcinoma, manifests in a similar nonspecific fashion. Case studies and literature reviews have contributed immensely to our present knowledge of poroma and porocarcinoma. Given the rarity of these neoplasms, however, there remains a relative paucity of information on atypical presentations and rates of malignant transformation. In this article, the epidemiology, clinical presentation, diagnosis, and management of poroma and porocarcinoma will be reviewed. This systematic approach may serve as a guide in navigating the diagnostic dilemma of these rare cutaneous lesions.
Skin diseases on the nose are seen in a variety of medical disciplines. Dermatologists, otorhinolaryngologists, general practitioners and general plastic and dermatologic surgeons are regularly consulted regarding cutaneous lesions on the nose. This article is the second part of a review series dealing with cutaneous lesions on the head and face, which are frequently seen in daily practice by a dermatologic surgeon. In this review, we focus on those skin diseases on the nose where surgery or laser therapy is considered a possible treatment option or that can be surgically evaluated.
Trichoblastoma is a benign cutaneous neoplasm that is clinically and histologically similar to basal cell carcinoma. We report the dermoscopic features seen in 2 cases of facial trichoblastoma. One case presented with very short, delicate, scarcely branching telangiectases against a pearly white background. In the second case, the veins were also short and scarcely branching, but they were arranged in a crown pattern, with white striae and milia-like cysts. Although dermoscopic evidence of fine, scarcely branching telangiectases is not specific to a diagnosis of trichoblastoma, these features may be useful for differentiating this neoplasm from nodular basal cell carcinoma.
Copyright © 2014 Elsevier España, S.L.U. y AEDV. All rights reserved.
Naevus sebaceous is a congenital hamartoma commonly associated with the development of secondary neoplasms. There are sparse data relating to the dermoscopy of tumours arising in naevus sebaceous.
To evaluate the dermoscopic features of a large series of neoplasms arising in naevus sebaceous.
Digital dermoscopic images of 58 histopathologically confirmed cases of secondary neoplasms arising in naevus sebaceous collected from 11 hospitals in Spain, France, Italy and Austria were evaluated for the presence of dermoscopic structures and patterns.
The most frequent tumours collected were: trichoblastoma (39.6%), basal cell carcinoma (20.7%) and syringocystadenoma papilliferum (15.6%). The most remarkable findings were: (i) the pattern composed of asymmetrical large blue-grey ovoid nests was more common in basal cell carcinomas than in trichoblastoma (58.3% vs. 4.3%; P < 0.001) and the pattern composed of a symmetrical total large blue-grey ovoid nest (a blue-grey homogeneous area which occupies the whole lesion) was more common in trichoblastoma (82.6% vs. 16.6%; P < 0.001); (ii) the most frequent pattern associated with syringocystadenoma papilliferum was a symmetric, erythematous lesion with exophytic papillary structures, ulceration and vessels (55.5%); (iii) the most common pattern associated with apocrine hidrocystomas was a total symmetric homogeneous area and arborizing telangiectasias (60%).
Benign adnexal tumours associated with naevus sebaceous are dermoscopic mimickers of basal cell carcinomas. A pigmented nodule arising in a naevus sebaceous with a total blue large ovoid nest on dermoscopy could be a trichoblastoma, basal cell carcinoma, hidrocystoma or hidradenoma. Dermoscopy can be a useful diagnostic tool which generates a more accurate preoperative diagnosis.
© 2015 European Academy of Dermatology and Venereology.
Background
Fibrous papules of the face are frequent benign lesions seen in the nasal and perinasal region. Their clinical aspect is indistinct and the histological signs are sometimes mild or possibly misleading in the case of atypical forms. We carried out a retrospective study of 283 fibrous papules diagnosed at our histology laboratory. The goal of this study was to characterize this type of frequent but occasionally unrecognized lesion.
Patients and methods
We performed a retrospective study of fibrous papules of the face diagnosed in the dermatopathology laboratory of our dermatology centre between January 2002 and December 2011. The study concerned the clinical information noted in the examination request and the morphological abnormalities seen at optical microscopy. An immunohistological study of factor XIIIa was performed in selected cases.
Results
The fibrous papules of the face came from 129 men and 154 women aged between 18 and 90 years (mean: 46 years). Two hundred and thirty-seven (83.7%) lesions were taken from the nasal region and none were taken from anywhere other than the face. The clinically mentioned diagnoses varied. A diagnosis of fibrous papule of the face was stated in 42% of cases, and the main differential diagnoses were nevus (stated in 34% of cases) and basal cell carcinoma (stated in 14% of cases). The fibrous papules were classic in 85.5% of cases. We observed 6 variants of fibrous papule: hypercellular, inflammatory, pleomorphic, pigmented, clear-cell and granular-cell types. Immunohistochemistry of factor XIIIa was positive in all cases except clear-cell fibrous papules.
Discussion
This study shows that despite their frequency, these lesions often go unrecognized, since the hypothesis of a fibrous papule of the face was mentioned in fewer than 50% of cases at the time of biopsy. Diagnosis is often made by the histopathologist, who may be misled by some rare types. The principal differential diagnoses are nevus and basal cell carcinoma, thus warranting methodical histological analysis of all pieces.
Background:
Eccrine poroma (EP) belongs to the group of benign adnexal tumors, but cases of eccrine porocarcinoma (EPC) arising on long-standing and untreated EP suggest a certain risk of malignant transformation.
Objectives:
To describe the clinical, dermoscopic and histopathologic features associated with different extremes in the spectrum of eccrine poroid neoplasms and to review the according literature.
Methods:
A retrospective analysis of patient characteristics and morphologic features associated with EP, EPC in situ and invasive porocarcinoma patients who attended two skin lesion clinics in Italy and Turkey between 2010 and 2011.
Results:
A total of 4 cases including 1 EP, 1 EPC in situ and 2 cases of invasive EPC in 4 patients were analyzed. Recent changes including bleeding, ulceration and sudden enlargement of a pre-existing lesion were associated with malignant transformation. Dermoscopically, polymorphous vessels consisting of coiled, hairpin and linear vessels were seen at all stages of progression. Histopathological findings of EPC in situ were limited to the epidermal component and were evident only at higher magnification.
Conclusions:
Clinicians and pathologists should carefully evaluate EPs with a recent history of change and erosion in order to avoid overlooking the potential development of EPC.
Reflectance Confocal Microscopy (RCM) can be useful for evaluation of solitary pink papules that are suspicious for skin cancer. RCM has been challenging to apply to curvy facial areas because of the need for attaining full contact between the skin and RCM probe. A smaller diameter handheld RCM probe has been recently introduced to clinical practice.
To describe the utility of RCM handheld probe as a bedside adjunct for clinical diagnosis of solitary facial papules.
This is a retrospective descriptive case series of six patients presented with a diagnostically equivocal solitary facial papule. All lesions reported were evaluated and imaged clinically, dermoscopically and with handheld RCM, followed by biopsy for histopathological analysis.
The series included biopsy-proven basal cell carcinomas (BCCs) (n = 2), squamous cell carcinoma (n = 1), sebaceous hyperplasia (n = 1), desmoplastic trichoepithelioma (n = 1) and compound nevus (n = 1). Handheld RCM was easy to apply to the curved facial surfaces and allowed for reaching a correct bedside diagnosis.
For clinically and dermoscopically equivocal small papules on curved facial surfaces, handheld RCM may be particularly helpful in differentiating benign lesions from skin cancer.
Background:
Desmoplastic trichoepithelioma (DT) is a rare benign adnexal neoplasm considered to have follicular differentiation. It usually presents as an asymptomatic, firm, annular plaque with a raised border. The diagnosis of DT is based on clinical and histological features which can be similar to those of morpheiform basal cell carcinoma. Taking this into consideration, the use of another diagnostic technique would be very useful. Dermoscopy is a noninvasive diagnostic technique allowing a more accurate diagnosis.
Objectives:
To differentiate DT and morpheiform basal cell carcinoma by means of dermoscopy.
Methods:
Here, we describe the dermoscopic features of a case of DT, and make a direct clinicopathological correlation by using the horizontally cut slides provided by Mohs micrographic surgery.
Results:
On dermoscopy, DT shows well-defined borders and an ivory-white color, as well as prominent arborizing telangiectasias in the central area and on the right side. There are no leaf-like structures and no ovoid nests. This observation confirms and completes the first dermoscopic analysis of DT reported in the literature so far.
Fibrous papule (FP), synonymous with angiofibroma, is a common lesion that is often biopsied to exclude carcinoma. Clinically, FPs are small, dome-shaped, solitary, flesh colored papules arising on the nose and face of adults. Histologically, FPs are characterized by a dome-shape, fibrotic collagenized stroma, sparse inflammatory cell infiltrate, and variably increased and dilated vascular spaces. The vast majority of FPs are readily diagnosable based on these clinical and histologic criteria. Rare histopathologic variants have been reported. Recognition of these variants may avoid misdiagnosis of this common benign lesion. We illustrate four rare variants of FP that can cause diagnostic uncertainty including: hypercellular, clear cell, pigmented, and pleomorphic variants. Cellular FP has a dense infiltrate of round fibroblasts that have a nevoid appearance. Clear cell FP has a proliferation of round clear cells, some with slightly foamy cytoplasm, resembling histiocytes or clear epithelial cells. Pleomorphic FP demonstrates bizarre, stellate fibroblasts like those seen in pleomorphic fibroma. Pigmented FP has prominent melanocytic hyperplasia and dermal melanophages that can be confused with a melanocytic lesion. It is important to recognize these unusual variants of FP in order to accurately diagnose this common benign lesion and avoid over treatment or rebiopsy.
Background:
The "eccrine" poroma is a benign neoplasm previously thought to originate from the eccrine sweat gland. Early studies suggested that these were primarily lesions of the hairless acral surfaces.
Objective:
This article reports the clinical and histologic findings of 10 cases of poroma of the head and neck area.
Methods:
The clinical and histologic findings of 10 cases of poroma of the head and neck area are compared with 10 poromas occurring on the extremities.
Results:
Some poromas demonstrated evidence for apocrine origin. Unlike poromas found on the extremities, head and neck poromas were usually asymptomatic and were never correctly diagnosed clinically. Although 9 of 10 poromas on the extremities occurred in male patients, the head and neck poromas showed no gender predilection.
Conclusion:
Clinicians should be aware that poromas can occur in the head and neck area and may be of apocrine origin.
The correct assessment of a solitary red nodule in clinical practice is of crucial importance, amelanotic melanoma being the most important differential diagnosis. Dermoscopy is nowadays a pivotal tool in the management of skin tumors, however it has some limitations in the evaluation of nonpigmented lesions, in which the diagnosis is merely based on the evaluation of the vascular pattern. Recently, reflectance confocal microscopy has been introduced as a new, noninvasive technique for the diagnosis of skin lesions. Confocal microscopy provides skin imaging in vivo at cellular level resolution, close to conventional histology. We present a series of clinical scenarios of red nodules, including melanoma metastasis, pyogenic granuloma, eccrine poroma, Spitz nevus and dermatofibroma. Reflectance confocal microscopy examination added important information to the clinical diagnosis and subsequent management in all cases except for dermatofibroma. We discuss the advantages and limitations of this technique in this particular field of application.
Nonpigmented eccrine poromas (EPs) occasionally mimic various skin tumours, but their dermoscopic features have not been clarified.
To evaluate the dermoscopic features of nonpigmented EPs in association with their histopathological features.
Retrospective analysis of the dermoscopic features of 10 histopathologically proven cases of nonpigmented EP at the Department of Dermatology, Shinshu University Hospital (Matsumoto, Japan).
Specific features in vascular structures were observed in five of 10 nonpigmented EPs. Three cases showed a polymorphous vascular pattern: two cases of a combination of hairpin and dotted vessels, and one case of a combination of hairpin, dotted and linear-irregular vessels. In addition, there were two cases of monomorphous vascular pattern: one case of linear-irregular vessels, and one case of hairpin vessels. We did not observe arborizing, crown or comma vessels. Comedo-like openings, milia-like cysts, cerebriform pattern and ulceration were observed in one case each. Furthermore, nine of 10 cases showed the characteristic feature, described as well-circumscribed reddish globule/lacuna-like structures with separation of mesh bands, which were reminiscent of frog eggs aggregation. This characteristic feature on dermoscopy was explained by the histopathological features of horizontal sections at a depth of 300-400 μm from the surface. Island-shaped oedematous stroma with numerous microvessels, which were surrounded by poroid cells in mesh-like forms, were seen.
Vascular structures and 'frog eggs-like appearance' are important features on dermoscopic examination of nonpigmented EP. Further studies are required to evaluate their diagnostic accuracy to differentiate nonpigmented EP from other tumours.
Factor XIIIa, a blood coagulation factor, has been found in a variety of cell types, including dendritic reticulum cells and fibroblast-like mesenchymal cells. We hypothesized that fibrous papule, a lesion of uncertain histogenesis, was composed of dermal stellate cells and in this report demonstrate that this neoplasm consists of cells that contain this factor. Nevus cells do not contain factor XIIIa.
Most eccrine poromas are devoid of melanin pigmentation clinically and melanocytes on microscopic examination. Pigmented variant of eccrine poroma has been reported only sporadically. Dermatoscopy (epiluminescence microscopy) has recently proved to be a useful, noninvasive technique for the diagnosis of cutaneous pigmented lesions. However, detailed information about the pigmented variant of eccrine poroma is not available.
We report two additional cases of pigmented eccrine poroma and describe their dermatoscopic features.
The dermatoscopic features of pigmented poromas except the maple leaf-like structures and spoke-wheel areas were similar to those of pigmented basal cell carcinomas.
Physicians therefore should be aware of the dermatoscopic differentiation between pigmented poromas and basal cell carcinomas.
Eccrine poroma (EP) may clinically mimic a number of benign and malignant skin tumors. Dermoscopy improves the clinical diagnosis of many pigmented and nonpigmented skin tumors, but to date little is known about the impact of dermoscopy in the diagnosis of EP. We report 2 patients with EP and discuss the diagnostic significance of the observed dermoscopic findings.
Trichoepitheliomas (TE) are benign neoplasms of follicular differentiation. Solitary lesions are often confused with basal cell carcinoma (BCC). Reflectance confocal microscopy (RCM) and dermoscopy are imaging tools for in vivo, noninvasive evaluation of skin lesions. To date, there has been no description of their findings in the evaluation of TE.
Our aim is to describe the dermoscopic and RCM findings of histopathologically confirmed TE.
Four TE were evaluated, 2 each of the desmoplastic and nondesmoplastic variants. RCM was performed on 1 of the desmoplastic and both of the nondesmoplastic lesions.
Dermoscopically, all of the lesions showed arborizing telangiectasias. The desmoplastic lesions also had an ivory-white background throughout. RCM showed oval, darker-appearing tumor islands that contained brightly refractile material, consistent with keratin horn cysts at the center, as well as parallel bundles of highly refractile dermal collagen surrounding the tumor islands.
The ivory-white background throughout the lesion seen on dermoscopy may be helpful in distinguishing desmoplastic TE from BCC. The RCM findings in TE of keratin-filled cysts in tumor islands and attachment of the tumor to follicular structures have not been previously observed in BCC, and thus may also be diagnostically helpful. Further study is necessary for validation of these findings.
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