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Dermatopathology Diagnosis by First Impression
Dermatopathology: Diagnosis by Fi...
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Dermatopathology Diagnosis by First Impression
Dermatopathology: Diagnosis by First Impression Christine J. Ko and Ronald J. Barr © 2008 Christine J. Ko and Ronald J. Barr . ISBN: 978-1-405-17734-4
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To Ulla, Anna, Jessica, and Sara, who let me pursue my career while they took care of everything else. (RJB) To Peter, who made it all possible. (CJK)
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Dermatopathology Diagnosis by First Impression Christine J. Ko Assistant Professor Dermatology and Pathology Yale University School of Medicine New Haven Connecticut USA
Ronald J. Barr Dermatopathologist Laguna Pathology Medical Group Laguna Beach California; Professor Emeritus Dermatology and Pathology University of California Irvine USA
A John Wiley & Sons, Ltd., Publication
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This edition first published 2008 © 2008 by Christine J. Ko and Ronald J. Barr Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell. Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloguing-in-Publication Data Ko, Christine J. Dermatopathology : diagnosis by first impression / Christine J. Ko, Ronald J. Barr. p. ; cm. ISBN 978-1-4051-7734-4 (alk. paper) 1. Skin—Diseases—Diagnosis—Atlases. 2. Skin—Pathophysiology—Atlases. I. Barr, Ronald J. II. Title. [DNLM: 1. Skin Diseases—diagnosis—Atlases. 2. Microscopy—Atlases. WR 17 K75d 2008] RL96.K6 2008 616.5′075—dc22 2008003421 ISBN: 978-1-4051-7734-4 A catalogue record for this book is available from the British Library. Set in 9/12pt Frutiger by Graphicraft Limited, Hong Kong Printed in Singapore by Fabulous Printers Pte Ltd 1
2008
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Contents
Preface, vi
Interface reaction, 141
Acknowledgments, vii
Dermal material, 149 Change in fat, 162
Chapter 1 Shape on Low Power, 1 Polypoid, 3
Chapter 3 Cell Type, 175
Square/rectangular, 8
Clear, 177
Regular acanthosis, 15
Melanocytic, 194
Pseudoepitheliomatous hyperplasia above abscesses, 19
Spindle, 203
Proliferation downward from epidermis, 23
Giant, 216
Central pore, 32 Palisading reactions, 36 Space with a lining, 40 Cords and tubules, 52 Papillated dermal tumor, 59 Circular dermal islands, 66
Chapter 4 Color Blue, 225 Blue tumor, 227 Blue infiltrate, 235 Mucin and glands or ducts, 244 Mucin, 248
(Suggestion of) vessels, 70
Chapter 2 Top–Down, 83 Hyperkeratosis, 85 Parakeratosis, 94 Upper epidermal changes, 97
Chapter 5 Color Pink, 257 Pink material, 259 Pink dermis, 264 Epidermal necrosis, 267
Acantholysis, 107 Eosinophilic spongiosis, 117
Chapter 6 Appendix by Pattern, 273
Subepidermal space/cleft, 124 Perivascular infiltrate, 132 Band-like upper dermal infiltrate, 137
Chapter 7 Index by Histological Category, 277
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Preface
The purpose of this book is to focus on a selection of commonly tested entities, showing low- to high-power views. Major differences among diagnoses that are sometimes confused are emphasized on “Key differences” pages. As a picture is worth a thousand words, text is kept to a minimum. Since this book is not meant to replace major textbooks of dermatopathology, the atlas and the categories of differential diagnoses found in the Appendix are not comprehensive, although some entities not pictured are listed. Ultimately, the book should be used as a
companion to dermatopathology textbooks and as a pictorial reference/study tool, given that this approach is utilized by the experienced dermatopathologist when constructing examination questions. Often, the major distractors are based on gestalt rather than etiology or conventional classifications. It is often the look-a-likes that prove to be the most deceptive, even though they have no obvious relationship to the correct diagnosis. This book will also be helpful to the dermatopathology novice as it introduces a simple and effective way to approach a slide.
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Acknowledgments
Dr. James H. Graham, MD, master of dermatopathology and dermatology, who taught me most of what I know. (RJB) Firstly, I would like to recognize Dr. Ronald Barr, who introduced me to the wonderful world of dermatopathology. Dermatopathology and dermatology are inextricably linked, and I also thank my other teachers at the University of California, Irvine; specifically, Dr. Gary Cole, Dr. Edward Jeffes, Dr. Vandana
Nanda, Dr. Kenneth Linden, Dr. Gerald Weinstein, and Dr. Jeffrey Herten. Credit is also due to Dr. Scott Binder, an incomparable teacher and fellowship director, and to my dermatopathology colleagues at Yale (Dr. Jennifer McNiff, Dr. Earl Glusac, Dr. Rossitza Lazova, Dr. Shawn Cowper, Dr. Antonio Subtil, and Dr. Anjela Galan), who teach me things every day. Last, but not least, my family has been invaluable in supporting me through everything. (CJK)
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1
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Shape on Low Power • Polypoid, 3 • Square/rectangular, 8 • Regular acanthosis, 15 • Pseudoepitheliomatous hyperplasia above abscesses, 19 • Proliferation downward from epidermis, 23 • Central pore, 32 • Palisading reactions, 36 • Space with a lining, 40 • Cords and tubules, 52 • Papillated dermal tumor, 59 • Circular dermal islands, 66 • (Suggestion of) vessels, 70
Dermatopathology: Diagnosis by First Impression Christine J. Ko and Ronald J. Barr © 2008 Christine J. Ko and Ronald J. Barr . ISBN: 978-1-405-17734-4
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Shape on Low Power | Polypoid
3
• Polypoid shape • Acral skin [thick stratum corneum with stratum lucidum (long arrow) ] • Dermal nerve bundles (short arrows)
Accessory digit
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Shape on Low Power | Polypoid
• Polypoid shape • May see a slight invagination of surface epidermis with underlying sebaceous glands • Surface epidermis often slightly acanthotic and hyperpigmented
Accessory nipple
• May see mammary ducts or apocrine glands deep • Dermis with numerous smooth muscle bundles (arrows)
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Shape on Low Power | Polypoid
• • • •
Polypoid shape Thin epidermis Vellus hairs (arrows) Cartilage not always present
5
• Differential diagnosis of numerous vellus hairs • Eyelid/earlobe/sometimes facial skin • Vellus hair nevus
Accessory tragus
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Shape on Low Power | Polypoid
• Polypoid shape • Acral skin • Fibrovascular stroma [thick collagen (arrows) ]
Digital fibrokeratoma
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Shape on Low Power | Polypoid
(a)
(b)
(c)
(d)
Polypoid shape • a Accessory digit: nerve bundles in the dermis • b Accessory nipple: sebaceous glands, mammary ducts or apocrine glands, smooth muscle bundles in the dermis • c Accessory tragus: vellus hairs in the dermis
7
• d Digital fibrokeratoma: collagen in the dermis • Note Other entities may also be polypoid, e.g. intradermal nevus, neurofibroma, fibrous papule
Key differences
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• • • •
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Shape on Low Power | Square/rectangular
Square/rectangular shape Thick, pink smudgy collagen in dermis Plasma cells around vessels Atrophic or absent adnexal structures
Morphea
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Shape on Low Power | Square/rectangular
9
• Square/rectangular shape • Altered, reddened collagen (necrobiosis) layered with inflammation • Giant cells and plasma cells are prominent
Necrobiosis lipoidica
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Shape on Low Power | Square/rectangular
• Square/rectangular shape • Normal-appearing collagen bundles in dermis • No increased mucin
Normal back skin
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Shape on Low Power | Square/rectangular
11
• Square/rectangular shape • Slight widening of space between collagen due to mucin (arrow) • No increase in fibroblasts
Scleredema
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Shape on Low Power | Square/rectangular
• Square/rectangular shape • Slight widening of space between collagen due to mucin (long arrow) • Increased fibroblasts (short arrows)
Scleromyxedema
• Note Lichen myxedematosus is histologically similar but clinically different • Note Nephrogenic systemic fibrosis may show similar findings
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Shape on Low Power | Square/rectangular
(a)
13
(b)
(c)
Square/rectangular shape • a Morphea: thickened bundles of collagen with loss of fenestrations between collagen bundles • b Necrobiosis lipoidica: reddened collagen sandwiched between layers of inflammatory cells (giant cells, plasma cells) (see also p. 39)
• c Normal back: normal-sized collagen bundles, no increased mucin
Key differences
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Shape on Low Power | Square/rectangular
(d)
Square/rectangular shape (cont.) • d Scleredema: mucin between collagen • e Scleromyxedema: mucin and increased fibroblasts
Key differences
(e)
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Shape on Low Power | Regular acanthosis
15
• Regular epidermal acanthosis • Parakeratosis • Full-thickness disorder of keratinocytes with atypical cells (short arrows) and mitoses • Basal layer may appear normal (“eyeliner” sign) (long arrow)
Bowen’s disease
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Shape on Low Power | Regular acanthosis
• Regular epidermal acanthosis • Clear cells well demarcated from the normal epidermis and adnexal keratinocytes
Clear cell acanthoma
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Shape on Low Power | Regular acanthosis
• • • •
Regular epidermal acanthosis Parakeratosis Neutrophils in stratum corneum (asterisk) Hypogranulosis
17
• Thinned suprapapillary plates (long arrow) • Dilated vessels in papillary dermis (short arrows)
Psoriasis
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Shape on Low Power | Regular acanthosis
(a)
(b)
Regular epidermal acanthosis • a Bowen’s disease: disordered keratinocytes and atypical mitoses • b Clear cell acanthoma: pale/clear keratinocytes well demarcated from normal epidermis
Key differences
(c)
• c Psoriasis: confluent parakeratosis above thickened epidermis, neutrophils in stratum corneum, normal keratinocytes, thin suprapapillary plates, dilated vessels
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Shape on Low Power | Pseudoepitheliomatous hyperplasia above abscesses
19
• Pseudoepitheliomatous hyperplasia above abscesses • Yeast forms (arrow) that classically show broad-based budding
Blastomycosis
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Shape on Low Power | Pseudoepitheliomatous hyperplasia above abscesses
• Pseudoepitheliomatous hyperplasia above abscesses • Brown-colored septate rounded “hot cross buns” (Medlar bodies, sclerotic bodies, copper pennies) (arrow)
Chromomycosis
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Shape on Low Power | Pseudoepitheliomatous hyperplasia above abscesses
21
• Pseudoepitheliomatous hyperplasia above abscesses • Large (80– 200 mm) spherules containing endospores (arrows)
Coccidioidomycosis
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Shape on Low Power | Pseudoepitheliomatous hyperplasia above abscesses
(a)
(b)
(c)
Pseudoepitheliomatous hyperplasia above abscesses • a Blastomycosis: 8– 30 mm yeast form (arrow) • b Chromomycosis: 5–12 mm Medlar bodies • c Coccidioidomycosis: 80– 200 mm spherules with endospores
Key differences
• Note Paracoccidioidomycosis (6–60 mm mariner’s wheel; an uncommon infection in the United States), sporotrichosis (organisms usually not evident in biopsies), and tuberculosis verrucosa cutis may also show this pattern
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Shape on Low Power | Proliferation downward from epidermis
23
• Proliferation downward from epidermis • Strands of basaloid cells in a fibrovascular stroma often emanating from strands of squamous epithelium • Some hints of palisading of cells (arrow)
Fibroepithelioma of Pinkus
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Shape on Low Power | Proliferation downward from epidermis
• Proliferation downward from epidermis • Fibrotic stroma adjacent to the hair follicle has reticulated strands of epithelium • This entity has overlap with trichodiscoma (some consider these a spectrum of the same entity)
Fibrofolliculoma
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Shape on Low Power | Proliferation downward from epidermis
25
• Proliferation downward from epidermis • Normal-appearing keratinocytes with some arranged in squamous eddies causing intraepithelial fenestrations
Inverted follicular keratosis
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Shape on Low Power | Proliferation downward from epidermis
• Proliferation downward from epidermis • Sebaceous glands, basaloid proliferations (arrow) connect to the epidermis • Apocrine glands may be seen deep • Absent terminal hairs in mature stage
Nevus sebaceus of Jadassohn
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Shape on Low Power | Proliferation downward from epidermis
27
• Proliferation downward from epidermis • Uniform blue cells with interspersed ducts (arrows) • Fibrotic or hyalinized stroma with dilated vessels
Poroma
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Shape on Low Power | Proliferation downward from epidermis
• Proliferation downward from epidermis • Proliferation composed of pale/clear cells • Peripheral palisading (long arrow) with thickened basement membrane (short arrow)
Trichilemmoma
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Shape on Low Power | Proliferation downward from epidermis
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• Proliferation downward from epidermis • Pale cells in columns with “windows” of dermis in between • Peripheral palisading
Tumor of the follicular infundibulum
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Shape on Low Power | Proliferation downward from epidermis
(a)
(b)
(c)
(d)
Proliferation downward from epidermis • a Fibroepithelioma of Pinkus: strands of basaloid epithelium in fibrovascular stroma • b Fibrofolliculoma: hair follicle with adjacent fibrotic stroma and reticulated epithelium
Key differences
• c Inverted follicular keratosis: squamous eddies • d Nevus sebaceus of Jadassohn: proliferation of epidermis connecting to sebaceous lobules and basaloid proliferations
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Shape on Low Power | Proliferation downward from epidermis
(e)
31
(f)
(g)
Proliferation downward from epidermis (cont.) • e Poroma: uniform blue cells with interspersed ducts • f Trichilemmoma: pale/clear keratinocytes with peripheral palisading and thickened basement membrane • g Tumor of the follicular infundibulum: pale cells in columns with “windows” of dermis in between
Key differences
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Shape on Low Power | Central pore
• Central pore • Invaginated epidermis is acanthotic
Dilated pore of Winer
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Shape on Low Power | Central pore
33
• Central pore • Invaginated epidermis is acanthotic and has areas resembling outer root sheath with peripheral palisading around slightly pale cells (arrows)
Pilar sheath acanthoma
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Shape on Low Power | Central pore
• Central pore • Invaginated epidermis connects to a primary hair follicle • Multiple secondary hair follicles radiating away from the central follicle
Trichofolliculoma
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Shape on Low Power | Central pore
(a)
35
(b)
(c)
Central pore • a Dilated pore of Winer: acanthotic epidermis • b Pilar sheath acanthoma: epidermal acanthosis and areas resembling outer root sheath • c Trichofolliculoma: primary follicle and surrounding secondary follicles
Key differences
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Shape on Low Power | Palisading reactions
• Palisading of histiocytes around amorphous white –gray substance with a feathery edge
Gout
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Shape on Low Power | Palisading reactions
37
• Palisading of histiocytes around altered collagen, basophilic mucin (long arrow) • Lymphocytes around vessels (short arrow)
Granuloma annulare
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Shape on Low Power | Palisading reactions
• Palisading of histiocytes around central pink fibrin • The reaction is often deep
Rheumatoid nodule
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Shape on Low Power | Palisading reactions
(a)
(b)
(c)
(d)
Palisading reactions • a Gout: central white–gray feathery material • b Granuloma annulare: central altered collagen interspersed with blue mucin
39
• c Rheumatoid nodule: central pink fibrin • d Necrobiosis lipoidica: altered collagen surrounded by giant cells, plasma cells (see also pp. 9 and 13)
Key differences
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Shape on Low Power | Space with a lining
• Space with a lining • Lining composed of an inner layer of cells with decapitation secretion (long arrow) and a compressed layer of myoepithelial cells (short arrow)
Apocrine hidrocystoma
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Shape on Low Power | Space with a lining
41
• Space with a lining • “Lining” is not a true epithelial layer but is cartilage • Centrally, there is degeneration of cartilage
Auricular pseudocyst
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Shape on Low Power | Space with a lining
• Space with a lining • Lining composed of squamous or sometimes cuboidal/ columnar epithelium often with squamous metaplasia • Prominent lymphoid follicles in wall
Branchial cleft cyst
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Shape on Low Power | Space with a lining
43
• Space with a lining • Lining composed of cuboidal/columnar epithelium with cilia (arrows)
Cutaneous ciliated cyst
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Shape on Low Power | Space with a lining
• Space with a lining • Spaces embedded in a fibrovascular stroma (endometrial stroma) • Lining composed of crowded blue cells • Hemosiderin deposits common in stroma
Cutaneous endometriosis
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Shape on Low Power | Space with a lining
45
• Space with a lining • Lining composed of squamous epithelium • Walls contain adnexal structures
Dermoid cyst
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Shape on Low Power | Space with a lining
• Space with a lining • Lining composed of squamous epithelium with a granular layer (arrow) • Cyst contents composed of flakes of keratin
Epidermal inclusion cyst
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Shape on Low Power | Space with a lining
47
• Space with a lining • Lining composed of squamous epithelium without a granular layer • Cyst contents composed of dense pink keratin
Pilar cyst
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Shape on Low Power | Space with a lining
• Space with a lining • Lining composed of layered epithelium with a bright pink crenulated keratin (arrow) • Sebaceous glands in wall
Steatocystoma
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Shape on Low Power | Space with a lining
(a)
49
(b)
(c)
Space with a lining • a Apocrine hidrocystoma: decapitation secretion • b Auricular pseudocyst: degeneration surrounded by cartilage • c Branchial cleft cyst: prominent lymphoid follicles in wall
Key differences
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Shape on Low Power | Space with a lining
(d)
(e)
(f)
Space with a lining (cont.) • d Cutaneous ciliated cyst: columnar epithelium with cilia; no structures in wall • e Cutaneous endometriosis: fibrovascular stroma with glands
Key differences
• f Dermoid cyst: sebaceous glands and other adnexal structures in wall
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Shape on Low Power | Space with a lining
(g)
51
(h)
(i)
Space with a lining (cont.) • g Epidermal inclusion cyst: epithelium with granular layer, flakes of keratin in center • h Pilar cyst: epithelium without granular layer, dense keratin in center • i Steatocystoma: crenulated keratin lining the cyst; sebaceous glands in wall
• Note Bronchogenic cysts are uncommon, and are diagnosed by clinical history and the presence of columnar epithelium +/– cilia, +/– cartilage in the wall; venous lakes are common and are composed of flattened endothelial cells with erythrocytes in the space
Key differences
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• • • • •
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Shape on Low Power | Cords and tubules
Cords and tubules in dermis Numerous horn cysts (long arrow) in fibrotic stroma Tubules of two-layered epithelium (short arrow) Calcification often present Confined to dermis
Desmoplastic trichoepithelioma
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Shape on Low Power | Cords and tubules
• Cords and tubules in dermis • Tubules of single-layered (“Indian filing”, long arrow) and multilayered epithelium • Some cells forming gland-like structures (short arrow)
53
• Other metastatic carcinomas may look like this – need clinical history; immunohistochemistry may be helpful
Metastatic breast carcinoma
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Shape on Low Power | Cords and tubules
• Cords and tubules in dermis • Tubules of epithelium connect to islands of epithelium with duct-like spaces (arrow) • Deeply infiltrative (fills dermis) • Perineural involvement
Microcystic adnexal carcinoma
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Shape on Low Power | Cords and tubules
55
• Cords and tubules in dermis • Cords of epithelium composed of basaloid cells with hints of peripheral palisading • New collagen forming around islands (arrow) • Deeply infiltrative
Morpheaform basal cell carcinoma
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Shape on Low Power | Cords and tubules
• Cords and tubules in dermis • Restricted to upper dermis • “Tadpoles” of epithelium with duct-like structures in heads (arrow)
Syringoma
• Darker cells at periphery, clear cells in center • Eosinophilic cuticle lining lumina • No horn cysts
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Shape on Low Power | Cords and tubules
(a)
57
(b)
(c)
Cords and tubules • a Desmoplastic trichoepithelioma: horn cysts, no clear cells, circular areas of epithelium surround keratin • b Metastatic breast carcinoma: single filing of atypical cells, deeply infiltrative
• c Microcystic adnexal carcinoma: like syringoma with tadpole-like structures but deeply infiltrative, perineural involvement
Key differences
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Shape on Low Power | Cords and tubules
(d)
Cords and tubules (cont.) • d Morpheaform basal cell carcinoma: infiltrative cords of basaloid cells with hints of peripheral palisading; may have some duct-like structures (but fewer than c) • e Syringoma: superficial tadpoles with clear cells
Key differences
(e)
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Shape on Low Power | Papillated dermal tumor
59
• Papillated dermal tumor • Disordered layers of epithelium in large papillations with some tubules • Variable cytological atypia and mitotic figures • Acral location
Aggressive digital papillary adenocarcinoma
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Shape on Low Power | Papillated dermal tumor
• Papillated dermal tumor • Finger-like projections have cores of collagen/fibroblasts (arrow) • No connection to epidermis
Hidradenoma papilliferum
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Shape on Low Power | Papillated dermal tumor
61
• Papillated dermal tumor • Islands of epithelium with papillated projections • With or without epidermal connection
Papillary eccrine adenoma
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Shape on Low Power | Papillated dermal tumor
• Papillated dermal tumor • Papillations contain numerous plasma cells (arrow) • Tumor often connected to epidermis
Syringocystadenoma papilliferum
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Shape on Low Power | Papillated dermal tumor
63
• Papillated dermal tumor • Evidence of decapitation secretion • Overlaps with papillary eccrine adenoma
Tubular apocrine adenoma
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Shape on Low Power | Papillated dermal tumor
(a)
(b)
(c)
Papillated dermal tumor • a Aggressive digital papillary adenocarcinoma: large tumor, atypical cells, and mitoses piled up • b Hidradenoma papilliferum: thin papillations with fibrovascular cores
Key differences
• c Papillary eccrine adenoma: islands of epithelium with papillated areas
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Shape on Low Power | Papillated dermal tumor
(d)
65
(e)
Papillated dermal tumor (cont.) • d Syringocystadenoma papilliferum: broad papillations with plasma cells in cores • e Tubular apocrine adenoma: decapitation secretion and papillations within islands
Key differences
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Shape on Low Power | Circular dermal islands
• Circular dermal islands • Islands contain basaloid cells with a cribriform pattern of duct-like spaces filled with amorphous material
Adenoid cystic carcinoma
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Shape on Low Power | Circular dermal islands
67
• Circular dermal islands • Islands contain basaloid cells surrounded by a thick pink basement membrane (arrow) • Islands arranged like a “jigsaw puzzle”
Cylindroma
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Shape on Low Power | Circular dermal islands
• Circular dermal islands • Islands of epithelium with central flaky keratin (horn cysts)
Trichoadenoma
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Page 69
Shape on Low Power | Circular dermal islands
(a)
69
(b)
(c)
Circular dermal islands • a Adenoid cystic carcinoma: cribriform pattern of duct-like structures • b Cylindroma: puzzle-like arrangement, thick/pink basement membrane • c Trichoadenoma: numerous horn cysts
Key differences
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Shape on Low Power | (Suggestion of) vessels
• (Suggestion of) vessels • Circular pink mass in dermis • Scar-like appearance
Angioleiomyoma
• Mass composed of smooth muscle cells (cigar-shaped nuclei, long arrows) with compressed vessels (short arrows) (sometimes dilated)
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Shape on Low Power | (Suggestion of) vessels
71
• (Suggestion of) vessels • Numerous vessels with epithelioid (“hobnail”) endothelial cells (arrow) surrounded by inflammation • Clusters of epithelioid endothelial cells may mimic granulomas • Eosinophils may be prominent
Angiolymphoid hyperplasia with eosinophilia
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Page 72
Shape on Low Power | (Suggestion of) vessels
• (Suggestion of) vessels • Maze-like arrangement of vessels lined by atypical cells • Deeply infiltrative
Angiosarcoma
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Shape on Low Power | (Suggestion of) vessels
73
• (Suggestion of) vessels • Superficial vessels surrounded by plasma cells and red–blue “clouds” of organisms that stain with silver
Bacillary angiomatosis
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Page 74
Shape on Low Power | (Suggestion of) vessels
• (Suggestion of) vessels • Superficial vessels surrounded by plasma cells and red–blue “clouds” of organisms that stain with silver
Bacillary angiomatosis (cont.)
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Shape on Low Power | (Suggestion of) vessels
• • • •
75
(Suggestion of) vessels Fibrotic stroma Concentric fibrosis around vessels/adnexae (long arrow) Stellate fibroblasts (short arrow)
Fibrous papule
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Shape on Low Power | (Suggestion of) vessels
• (Suggestion of) vessels • Vessels forming around other vessels (promontory sign) • Vessels may be lined by inconspicuous endothelial cells
Kaposi’s sarcoma
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Shape on Low Power | (Suggestion of) vessels
77
• (Suggestion of) vessels • Lobules of dilated vessels embedded in loose stroma with inflammatory cells
Pyogenic granuloma
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Shape on Low Power | (Suggestion of) vessels
• • • •
(Suggestion of) vessels Hyperkeratosis Variable spongiosis Small-caliber thick-walled capillaries in clusters in the upper dermis (arrows) • Hemosiderin
Stasis dermatitis
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Shape on Low Power | (Suggestion of) vessels
79
• (Suggestion of) vessels • Somewhat wedge-shaped arrangement of vessels • Hemosiderin (arrow) around the peripheral vessels
Targetoid hemangioma
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Shape on Low Power | (Suggestion of) vessels
(a)
(b)
(c)
(Suggestion of) vessels • a Angioleiomyoma: well-circumscribed pink circle composed of cigar-shaped spindle cells and compressed to dilated vessels
Key differences
• b Angiolymphoid hyperplasia with eosinophilia: dilated vessels with prominent hobnail endothelial cells surrounded by inflammation, +/– numerous eosinophils • c Angiosarcoma: maze-like connection of vessels lined by atypical cells
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Shape on Low Power | (Suggestion of) vessels
(d)
81
(e)
(f)
(Suggestion of) vessels (cont.) • d Bacillary angiomatosis: dilated vessels surrounded by inflammation that includes plasma cells and ill-defined “clouds” • e Fibrous papule: fibrotic stroma with stellate fibroblasts and dilated vessels
• f Kaposi’s sarcoma: slit-like or angulated spaces dissecting through collagen; vessels around vessels
Key differences
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Shape on Low Power | (Suggestion of) vessels
(g)
(h)
(i)
(Suggestion of) vessels (cont.) • g Pyogenic granuloma: clusters of dilated vessels surrounded by mixed inflammation • h Stasis dermatitis: small clusters of capillaries in upper dermis with hemosiderin
Key differences
• i Targetoid hemangioma: wedge-shaped area of increased vessels with hemosiderin at periphery
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2
Page 83
Top–Down • Hyperkeratosis, 85 • Parakeratosis, 94 • Upper epidermal changes, 97 • Acantholysis, 107 • Eosinophilic spongiosis, 117 • Subepidermal space/cleft, 124 • Perivascular infiltrate, 132 • Band-like upper dermal infiltrate, 137 • Interface reaction, 141 • Dermal material, 149 • Change in fat, 162
Dermatopathology: Diagnosis by First Impression Christine J. Ko and Ronald J. Barr © 2008 Christine J. Ko and Ronald J. Barr . ISBN: 978-1-405-17734-4
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Top–Down | Hyperkeratosis
85
• Hyperkeratosis • Central erosion/ulceration of epidermis with underlying pink fibrin and flanking vessels • Vascular ectasia with plump endothelial cells • Cartilage may be present beneath fibrin
Chondrodermatitis nodularis helicis
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• • • •
1:26 PM
Page 86
Top–Down | Hyperkeratosis
Hyperkeratosis Follicular plugging Thinned epidermis Vacuolar change at dermoepidermal junction
Discoid lupus erythematosus
• Thickened basement membrane • Pigment incontinence • Periadnexal and perivascular lymphocytic infiltrate
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Page 87
Top–Down | Hyperkeratosis
• • • •
87
Hyperkeratosis Scattered “dyskeratotic” keratinocytes Slightly acanthotic epidermis Variable inflammatory infiltrate
Flegel’s disease
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Top–Down | Hyperkeratosis
• Hyperkeratosis • Hyperkeratosis alternates with parakeratosis • Acanthotic epidermis
Inflammatory linear verrucous epidermal nevus
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Top–Down | Hyperkeratosis
• • • • •
89
Hyperkeratosis Vacuolar change at dermoepidermal junction Pink homogenization of papillary dermis Underlying band-like inflammatory infiltrate See also p. 264
Lichen sclerosus et atrophicus
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Top–Down | Hyperkeratosis
• Hyperkeratosis • Hyperkeratosis alternates with parakeratosis in a checkerboard pattern • Follicular plugging • Irregular acanthosis of epidermis
Pityriasis rubra pilaris
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Top–Down | Hyperkeratosis
91
• Hyperkeratosis • Cornoid lamellae (tiered parakeratosis above altered granular layer) (arrow) • A lichenoid infiltrate may be present
Porokeratosis
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Page 92
Top–Down | Hyperkeratosis
(a)
(b)
(c)
(d)
Hyperkeratosis • a Chondrodermatitis nodularis helicis: epidermal erosion/ ulceration with underlying fibrin and flanking vessels • b Discoid lupus erythematosus: follicular plugging, thickened basement membrane, periadnexal inflammation
Key differences
• c Flegel’s disease: hyperkeratosis over slight acanthosis, minimal inflammation • d Inflammatory linear verrucous epidermal nevus: hyperkeratosis alternating with parakeratosis over acanthosis
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Page 93
Top–Down | Hyperkeratosis
(e)
93
(f)
(g)
Hyperkeratosis (cont.) • e Lichen sclerosus et atrophicus: pink homogenized papillary dermis with underlying inflammation (see also p. 266) • f Pityriasis rubra pilaris: checkerboard parakeratosis and hyperkeratosis, irregular acanthosis • g Porokeratosis: cornoid lamellae
Key differences
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Top–Down | Parakeratosis
• Parakeratosis • Granules retained in the stratum corneum (arrows)
Axillary granular parakeratosis
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Top–Down | Parakeratosis
95
• Parakeratosis may be seen above orthokeratosis (“sandwich sign”) • Slightly refractile organisms (spheres and tubules) in stratum corneum • Obvious organisms on periodic acid–Schiff (arrows)
Dermatophytosis
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Page 96
Top–Down | Parakeratosis
(a)
(b)
Parakeratosis • a Axillary granular parakeratosis: retained granules in stratum corneum • b Dermatophytosis: circles and linear hyphae in stratum corneum
Key differences
• Note Tinea versicolor is in the differential; dermatophytosis and tinea versicolor may be subtle and appear like “normal” skin on low power
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Top–Down | Upper epidermal changes
97
• Upper epidermal change of nests of keratinocytes • Nests are composed of monomorphous, typical keratinocytes
Clonal seborrheic keratosis
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Page 98
Top–Down | Upper epidermal changes
• Upper epidermal change of keratinocytes with blue–gray expanded cytoplasm and haloes around nuclei
Epidermodysplasia verruciformis
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Top–Down | Upper epidermal changes
99
• Upper epidermal change of prominent keratohyaline granules and chicken-wire cell membranes – granular-vacuolar change (arrows)
Epidermolytic hyperkeratosis
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Top–Down | Upper epidermal changes
• Upper epidermal change of koilocytes with very prominent keratohyaline granules • A type of wart that tends to be on the plantar surface
Myrmecium
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Top–Down | Upper epidermal changes
101
• Upper epidermal change of reticular degeneration (edema of the cells with retention of cell membranes) and pink intracytoplasmic globules (arrows) • Usually acral skin
Orf
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Top–Down | Upper epidermal changes
• Upper epidermal change of scattered large cells singly and in nests • May be able to see a compressed basal layer beneath nests (eye-liner) • Large cells have expanded cytoplasm and nuclei at periphery
Paget’s disease
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Top–Down | Upper epidermal changes
103
• Upper epidermal change of koilocytes – cells with haloes around nuclei • Epidermal surface is only slightly papillated
Verruca plana
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Top–Down | Upper epidermal changes
• Upper epidermal change of koilocytes • Epidermal surface papillated • Toeing-in (arborization) of rete ridges
Verruca vulgaris
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Top–Down | Upper epidermal changes
(a)
(b)
(c)
(d)
Upper epidermal change • a Clonal seborrheic keratosis: nests of typical, monomorphous keratinocytes • b Epidermodysplasia verruciformis: expanded blue–gray cytoplasm, some perinuclear haloes
105
• c Epidermolytic hyperkeratosis: strung-out cell membranes, loss of nuclei, granular–vacuolar change • d Myrmecium: very prominent keratohyaline granules
Key differences
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Page 106
Top–Down | Upper epidermal changes
(f)
(e)
(g)
Upper epidermal change (cont.) • e Orf: reticular degeneration (pink cell membranes with loss of nuclei) with scattered inclusions • f Paget’s disease: scattered cells that lack intercellular bridges with prominent grayish cytoplasm • g Verruca: koilocytes
Key differences
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Top–Down | Acantholysis
107
• Benign acantholytic dyskeratosis with corp ronds (long arrow) and grains (short arrow) • Parakeratosis above the acantholytic dyskeratosis
Darier’s disease
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Page 108
Top–Down | Acantholysis
• Benign acantholytic dyskeratosis in small foci • Also foci of spongiosis, acantholysis without dyskeratosis (Hailey–Hailey pattern and pemphigus patterns)
Grover’s disease
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Top–Down | Acantholysis
109
• Benign acantholysis (sometimes with dyskeratosis) in full thickness to two-thirds of the epidermis • Resembles a “dilapidated brick wall”
Hailey–Hailey disease
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Page 110
Top–Down | Acantholysis
• Benign non-dyskeratotic acantholysis with ballooning degeneration • Multinucleated cells with rimming of chromatin • Follicular necrosis/acantholysis is a clue
Herpes virus infection
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Top–Down | Acantholysis
111
• Benign acantholysis in the upper stratum spinosum, making the granular layer appear altered • May see “cling-ons” (acantholytic cells on roof of split)
Pemphigus foliaceus
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Page 112
Top–Down | Acantholysis
• Benign acantholysis above the basal layer • Basal layer intact and appears like “tombstones”
Pemphigus vulgaris
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Top–Down | Acantholysis
113
• Malignant dyskeratotic acantholysis in a large, infiltrative tumor • Prominent atypical cells and mitoses
Squamous cell carcinoma, adenoid type
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Page 114
Top–Down | Acantholysis
• Benign dyskeratotic acantholysis like Darier’s disease with corp ronds (long arrow) and grains (short arrow) but may have more prominent cup-shape and/or follicular involvement • Clinically a solitary lesion
Warty dyskeratoma
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Page 115
Top–Down | Acantholysis
(a)
(b)
(c)
(d)
Acantholysis a Darier’s disease: prominent parakeratosis above corp ronds and grains b Grover’s disease: multiple patterns of acantholysis (Darier’s-like, Hailey–Hailey-like, pemphigus-like) and spongiosis in small foci
115
c Hailey–Hailey disease: majority of epidermis involved by acantholysis d Herpes virus infection: ballooning degeneration, multinucleated cells with chromatin rimming
Key differences
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Page 116
Top–Down | Acantholysis
(e)
(f)
(g)
(h)
Acantholysis (cont.) e Pemphigus foliaceus: granular layer prominent with acantholysis f Pemphigus vulgaris: acantholysis above tombstoned basal layer; follicles may be involved
Key differences
g Squamous cell carcinoma, adenoid type: acantholysis and squamous pearls, atypical keratinocytes and mitoses (malignant dyskeratotic acantholysis) h Warty dyskeratoma: cup-shaped area of acantholytic dyskeratosis, villi at base
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Page 117
Top–Down | Eosinophilic spongiosis
117
• Eosinophilic spongiosis • Vesicles within epidermis may be prominent
Allergic contact dermatitis
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Page 118
Top–Down | Eosinophilic spongiosis
• Eosinophilic spongiosis • Wedge-shaped pattern of inflammation on low-power view • Vesicles within epidermis may be prominent
Arthropod bite reaction
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Top–Down | Eosinophilic spongiosis
119
• Eosinophilic spongiosis • Dyskeratotic keratinocytes (arrows)
Incontinentia pigmenti
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Page 120
Top–Down | Eosinophilic spongiosis
• Eosinophilic abscesses within epidermis • Acantholysis may be absent to subtle • Hyperplastic epidermis
Pemphigus vegetans
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Top–Down | Eosinophilic spongiosis
121
• Eosinophilic spongiosis • Mites, scybala, eggs within stratum corneum
Scabies
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Page 122
Top–Down | Eosinophilic spongiosis
(a)
(b)
(c)
Eosinophilic spongiosis a Allergic contact dermatitis: orderly vesicles and eosinophils in epidermis b Arthropod bite reaction: prominent vesicles and eosinophils in epidermis, may see an erosion
Key differences
c Bullous pemphigoid: subepidermal cleft and eosinophils at base (see also p. 125)
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Top–Down | Eosinophilic spongiosis
(d)
123
(e)
(f)
Eosinophilic spongiosis (cont.) d Incontinentia pigmenti: eosinophilic spongiosis with dyskeratotic cells e Pemphigus vegetans: eosinophilic abscesses within acanthotic epidermis f Scabies: mites/scybala /eggs in stratum corneum
Key differences
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Page 124
Top–Down | Subepidermal space/cleft
• Subepidermal space (can appear intraepidermal) • Thin “grenz zone” (arrow) • Filled with erythrocytes
Angiokeratoma
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Top–Down | Subepidermal space/cleft
125
• Subepidermal space • Eosinophils (arrows) are prominent at the base • May see festooning (papillated bulla base)
Bullous pemphigoid/Herpes gestationis
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Page 126
Top–Down | Subepidermal space/cleft
• Subepidermal space • Neutrophils (arrows) are prominent at the base • May see clusters of neutrophils in papillae adjacent to blister
Dermatitis herpetiformis
• Note that this same histologic pattern can be seen with linear immunoglobulin A disease, neutrophil-rich bullous pemphigoid, bullous lupus erythematosus, and epidermolysis bullosa acquisita • May see reverse festooning (papillated inferior surface of bulla roof)
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Top–Down | Subepidermal space/cleft
127
• Subepidermal space with internal papillations • Thin “grenz zone” (long arrow) • Spaces lined by endothelial cells (short arrows) and may contain a few erythrocytes
Lymphangioma
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Page 128
Top–Down | Subepidermal space/cleft
• Subepidermal space (edema) • Superficial and deep vessels surrounded by lymphocytes
Polymorphous light eruption
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Top–Down | Subepidermal space/cleft
• • • • •
Subepidermal space Often a non-inflammatory base Festooning of papillary dermis Thickened vessel walls (long arrow) Caterpillar bodies in epidermis (short arrow)
129
• Note that the differential diagnosis of non-inflammatory subepidermal bullae includes non-inflammatory bullous pemphigoid, epidermolysis bullosa acquisita, diabetic bullae, and epidermolysis bullosa subtypes
Porphyria cutanea tarda
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Page 130
Top–Down | Subepidermal space/cleft
(a)
(b)
(c)
Subepidermal space/cleft a Bullous pemphigoid: eosinophils at base, festooning b Dermatitis herpetiformis: neutrophils at base, reverse festooning c Angiokeratoma: erythrocytes fill the spaces
Key differences
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Page 131
Top–Down | Subepidermal space/cleft
(d)
131
(e)
(f)
Subepidermal space/cleft (cont.) d Lymphangioma: spaces lined by endothelial cells and are empty e Polymorphous light eruption: perivascular lymphocytes f Porphyria cutanea tarda: non-inflammatory base, festooning, caterpillar bodies
Key differences
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1:31 PM
Page 132
Top–Down | Perivascular infiltrate
• Superficial and deep perivascular infiltrate of lymphocytes • Lymphocytes tightly cuffed around vessels • Note that the differential diagnosis includes polymorphous light eruption (classically has dermal edema), Jessner’s lymphocytic infiltrate, and connective tissue disorders
Gyrate erythema
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Top–Down | Perivascular infiltrate
• • • •
133
Perivascular infiltrate of neutrophils and nuclear debris Alteration/necrosis of collagen (arrow) Extravasated erythrocytes Fibrin within vessels
Leukocytoclastic vasculitis
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Page 134
Top–Down | Perivascular infiltrate
• Superficial perivascular infiltrate of lymphocytes (sometimes minimal) • Extravasated erythrocytes (arrows) • Hemosiderophages
Pigmented purpuric dermatosis
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Page 135
Top–Down | Perivascular infiltrate
• • • •
Superficial perivascular infiltrate of lymphocytes Mounds of parakeratosis (long arrows) Mild epidermal spongiosis (short arrow) Extravasated erythrocytes
135
• Note that guttate psoriasis is in the differential diagnosis; guttate psoriasis is favored if there are neutrophils in the mounds of parakeratosis
Pityriasis rosea
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Page 136
Top–Down | Perivascular infiltrate
(a)
(b)
(c)
(d)
Superficial perivascular infiltrate • a Gyrate erythema: tightly cuffed superficial and deep perivascular infiltrate of lymphocytes, epidermis is normal • b Leukocytoclastic vasculitis: dermis looks “messy” on low power with perivascular neutrophils and nuclear debris, pink donuts of degenerated collagen, extravasated erythrocytes
Key differences
• c Pigmented purpuric dermatosis: perivascular (to lichenoid) infiltrate of lymphocytes, extravasated erythrocytes, hemosiderophages • d Pityriasis rosea: mounds of parakeratosis, mild epidermal spongiosis superficial perivascular infiltrate of lymphocytes, and extravasated erythrocytes • Note Lymphocytic angiitis describes a pattern of perivascular lymphocytes and is a non-diagnostic finding as many diseases may have such a pattern
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Page 137
Top–Down | Band-like upper dermal infiltrate
• • • •
137
Band-like upper dermal infiltrate Infiltrate abuts and involves epidermis Cells in infiltrate have kidney-shaped nuclei (arrows) Eosinophils may be present
Langerhans cell histiocytosis
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Page 138
Top–Down | Band-like upper dermal infiltrate
• Band-like upper dermal infiltrate • A small grenz zone is usually present • Cells in infiltrate have round nuclei and granular gray–blue cytoplasm (arrows) • Eosinophils may be present
Mastocytosis
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Page 139
Top–Down | Band-like upper dermal infiltrate
• • • •
139
Band-like upper dermal infiltrate Infiltrate abuts and involves epidermis May see Pautrier’s microabscesses Cells in infiltrate have atypical nuclei (arrows)
Mycosis fungoides
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Page 140
Top–Down | Band-like upper dermal infiltrate
(a)
(b)
(c)
Band-like upper dermal infiltrate • a Langerhans cell histiocytosis: kidney-shaped nuclei • b Mastocytosis: round nuclei and slightly granular cytoplasm • c Mycosis fungoides: cells in infiltrate have atypical nuclei, vacuolar change, fibrosis in dermis, lining up of lymphocytes at dermoepidermal junction
Key differences
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Page 141
Top–Down | Interface reaction
• • • • • •
141
Interface reaction Lichenoid infiltrate Numerous necrotic keratinocytes Incontinence of pigment Deep perivascular infiltrate Infiltrate is mixed with eosinophils
Fixed drug reaction
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Page 142
Top–Down | Interface reaction
• Interface reaction • Vacuolar change at dermoepidermal junction • Necrotic keratinocytes (arrows) in epidermis and follicles surrounded by lymphocytes (satellite cell necrosis)
Graft-versus-host disease
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Top–Down | Interface reaction
143
• Interface reaction • Lichenoid infiltrate that is the “ball” being held by fingers of epidermis (the “claw”) • Infiltrate is composed of lymphocytes and histiocytes and occasional giant cells
Lichen nitidus
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• • • • • •
1:46 PM
Page 144
Top–Down | Interface reaction
Interface reaction Lichenoid infiltrate Hyperkeratosis, irregular acanthosis, hypergranulosis Saw-toothing of basal layer Colloid bodies, Civatte bodies Pigment incontinence
Lichen planus
• Usually no eosinophils • If a mucosal surface, plasma cells may be present • Note that lichenoid drug reactions can look the same but usually show parakeratosis and eosinophils • Note that benign lichenoid keratosis can look the same (need clinical history)
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Top–Down | Interface reaction
145
• Interface reaction • Lichenoid infiltrate and deep perivascular/periadnexal infiltrate • Peri-eccrine lymphocytic infiltrate is a clue • Scattered (high and low) apoptotic keratinocytes
Lichen striatus
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Page 146
Top–Down | Interface reaction
• Interface reaction • Lichenoid and deep perivascular lymphocytic infiltrate (wedge shaped on low power) • Parakeratosis • Erythrocytes in the epidermis and extravasated in the dermis • Necrosis of the epidermis
Pityriasis lichenoides et varioliformis acuta
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Top–Down | Interface reaction
(a)
147
(b)
(c)
Interface reaction • a Fixed drug reaction: lichenoid and deep perivascular mixed infiltrate with eosinophils, linear necrosis of basal cells • b Graft-versus-host disease: vacuolar change with scattered necrotic keratinocytes in epidermis and hair follicles (satellite cell necrosis)
• c Lichen nitidus: ball of lymphocytes and histiocytes in the dermis held by an epidermal claw
Key differences
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Top–Down | Interface reaction
(d)
(e)
(f)
Interface reaction (cont.) • d Lichen planus: lichenoid infiltrate, hyperkeratosis, hypergranulosis, saw-toothed base of acanthotic epidermis • e Lichen striatus: lichenoid and deep infiltrate that involves eccrine glands, scattered necrotic keratinocytes
Key differences
• f Pityriasis lichenoides et varioliformis acuta: parakeratosis, necrotic epidermis, extravasated erythrocytes, lichenoid and deep lymphocytic infiltrate • Note Apoptosis is the type of keratinocyte necrosis seen in interface dermatitis
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Top–Down | Dermal material
149
• Dermal material that is pink and amorphous, diffuse, and perivascular • Plasma cells (arrows) are often present around vessels
Amyloidosis, nodular
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Top–Down | Dermal material
• Dermal material that is blue–purple and chunky • Calcium deposits can be seen in adnexal tumors (trichoepithelioma, pilomatrixoma) • Calcium may be deposited on the altered elastic fibers in pseudoxanthoma elasticum
Calcinosis cutis
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Top–Down | Dermal material
151
• Dermal material that is pink and amorphous and fills the upper half of the dermis • Early lesions have pink material around vessels
Erythropoietic protoporphyria
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Top–Down | Dermal material
• Dermal material that is bluish, curvy, and ribbon-like
Gel foam
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Top–Down | Dermal material
153
• Dermal material that is pink and amorphous, often filling the dermis full-thickness • May be perpendicular to epidermis and around adnexae and vessels
Lipoid proteinosis
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Top–Down | Dermal material
• Dermal material that is banana-shaped and brown–orange (arrows)
Ochronosis
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Top–Down | Dermal material
155
• Dermal material • Bright, dense pink trabeculae with nuclei with haloes around them (osteocytes) • Pilomatricomas can be ossified
Osteoma cutis
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Top–Down | Dermal material
• Dermal material that is lost during processing and is “seen” as irregularly shaped circular spaces (arrows) • Dark pink sclerotic stroma • Swiss-cheese appearance
Paraffinoma
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Top–Down | Dermal material
157
• Dermal material that is blue and squiggly (arrows) • Sometimes the corkscrew fibers are calcified
Pseudoxanthoma elasticum
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Top–Down | Dermal material
• Dermal material that is black (most commonly) and is free in the dermis as well as within macrophages
Tattoo
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Top–Down | Dermal material
(a)
(b)
(c)
(d)
Dermal material • a Amyloidosis, nodular: amorphous pink material with plasma cells • b Calcinosis cutis: blue–purple chunks
159
• c Erythropoietic protoporphyria: amorphous pink material around vessels and in upper dermis • d Gel foam: blue interconnected ribbons
Key differences
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Top–Down | Dermal material
(e)
(f)
(g)
Dermal material (cont.) • e Lipoid proteinosis: amorphous pink material filling the entire dermis; often around adnexae • f Ochronosis: brown– orange banana shapes • g Osteoma cutis: well-defined pink shapes with nuclei
Key differences
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Top–Down | Dermal material
(h)
161
(i)
(j)
Dermal material (cont.) • h Paraffinoma: irregular circular spaces like Swiss cheese • i Pseudoxanthoma elasticum: squiggly blue lines • j Tattoo: black particles within macrophages and free in dermis
Key differences
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Top–Down | Change in fat
• Change in the fat • Normal-appearing adipocytes in lobules with an increased number of small vessels, some containing fibrin (arrows)
Angiolipoma
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Top–Down | Change in fat
163
• Change in the fat • Lobular panniculitis with mixed inflammation (histiocytes, lymphocytes, neutrophils) • Inflammation around vessels (vasculitis) in the septae • “Panniculitis > vasculitis”; compare with polyarteritis nodosa
Erythema induratum
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Top–Down | Change in fat
• Change in the fat • Septal panniculitis with thickened septae between lobules of adipocytes
Erythema nodosum
• Septae contain giant cells (short arrow) • Early lesions may have neutrophils, eosinophils • Miescher’s radial granuloma may be seen (long arrow)
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Top–Down | Change in fat
165
• Change in the fat • Individual adipocytes are lost and replaced by arabesques of pink, ruffled membranes (lipomembranous fat necrosis) (arrows)
Lipodermatosclerosis
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• • • • •
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Top–Down | Change in fat
Change in the fat Lymphoplasmacytic infiltrate (lobular panniculitis) Lymphoid follicles may be present Fibrinoid (hyaline) necrosis of fat Later stages show hyalinization of fat (hyaline sclerosis)
Lupus profundus
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Top–Down | Change in fat
167
• Change in the fat • Necrosis of the fat with “ghost-like” shadows of fat cells remaining • Calcification/neutrophils /eosinophils may be present • Septal vessels are inflamed
Pancreatic fat necrosis
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Top–Down | Change in fat
• Change in the fat • Septal panniculitis • Often at dermal–subcutis junction, a large vessel is involved with inflammation (vasculitis) (arrow)
Polyarteritis nodosa
• “Vasculitis > panniculitis”; compare with erythema induratum
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Top–Down | Change in fat
• Change in the fat • Lobular panniculitis • Inflammation and radial crystalline shapes (arrows) within fat lobules
169
• Note that post-steroid panniculitis can look the same • Note that sclerema neonatorum also has crystalline shapes but lacks inflammation
Subcutaneous fat necrosis of the newborn
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Top–Down | Change in fat
• Change in the fat • Lobular involvement of inflammation • Atypical lymphocytes rim fat cells Figures are courtesy of Antonio Subtil, MD.
Subcutaneous T-cell lymphoma
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Top–Down | Change in fat
171
(a)
(c)
Change in the fat • a Angiolipoma: normal adipocytes, increased numbers of vessels with fibrin • b Erythema induratum: vasculitis and lobular mixed inflammation, “panniculitis > vasculitis”
(b)
• c Erythema nodosum: septal thickening with giant cells (sometimes eosinophils)
Key differences
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Top–Down | Change in fat
(d)
(f)
Change in the fat (cont.) • d Lipodermatosclerosis: pink arabesques of membranes replacing adipocytes • e Lupus profundus: hyaline fat necrosis, lymphocytic lobular infiltrate
Key differences
(e)
• f Pancreatic fat necrosis: ghost-like necrosis of fat, +/– calcification
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Top–Down | Change in fat
(g)
173
(h)
(i)
Change in the fat (cont.) • g Polyarteritis nodosa: vasculitis of a medium-sized vessel, often at dermal–subcutis junction, “vasculitis > panniculitis” • h Subcutaneous fat necrosis of the newborn: crystalline shapes and inflammation within fat lobules
• i Subcutaneous T-cell lymphoma: rimming of adipocytes with atypical lymphocytes Figure (i) is courtesy of Antonio Subtil, MD.
Key differences
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3
Page 175
Cell Type • Clear, 177 • Melanocytic, 194 • Spindle, 203 • Giant, 216
Dermatopathology: Diagnosis by First Impression Christine J. Ko and Ronald J. Barr © 2008 Christine J. Ko and Ronald J. Barr . ISBN: 978-1-405-17734-4
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Cell Type | Clear
177
• Clear “cells” • The organisms (long arrows) are surrounded by capsules, which are seen in sections as clear spaces (short arrows)
Cryptococcosis, gelatinous
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Cell Type | Clear
• “Clear” cells • Epidermis may be acanthotic or display pseudoepitheliomatous hyperplasia
Granular cell tumor
• Cells are polygonal to oval and contain a granular pink material (phagolysosomes) • Large granules are surrounded by haloes
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Cell Type | Clear
179
• “Clear” cells • Cells are adipocytes that are so-called “mulberry” cells, with a net-like vacuolar pattern around the nuclei
Hibernoma
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Cell Type | Clear
• “Clear” cells • Cells are macrophages that contain the organisms
Leishmaniasis
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Cell Type | Clear
• “Clear” cells • Cells are histiocytes (“Virchow cells”) that look subtly foamy and are filled with organisms (seen with special stains) • Vacuoles with clusters of organisms (globi)
181
• On low power, the histiocytes are arranged in linear configurations • Grenz zone present • Nerves may appear thickened
Lepromatous leprosy
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Cell Type | Clear
• “Clear” cells • Cells are adipocytes, with a peripheral, compressed nucleus (arrow)
Lipoma
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Cell Type | Clear
• “Clear” cells • Cells are melanocytes that have clear/foamy cytoplasm • Cells have atypical nuclei (arrows)
183
• Special stains are generally necessary to confirm the diagnosis • Look for foci of conventional melanoma or a junctional component
Melanoma, balloon cell
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Cell Type | Clear
• “Clear” cells • Cells are arranged in lobules with areas of ductal differentiation • Hyalinized collagen often present (arrows)
Nodular hidradenoma
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Cell Type | Clear
185
• “Clear” cells • Often in cords, islands, or pseudoglandular structures • Cells are of renal origin and are surrounded by prominent blood vessels /extravasated erythrocytes
Renal cell carcinoma
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Cell Type | Clear
• “Clear” cells • Cells are sebocytes with spiky/scalloped nuclei bordered by several layers of basaloid cells • Generally on low power there is a downward lobular proliferation from the epidermis
Sebaceous adenoma
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Cell Type | Clear
187
• “Clear” cells • Cells are foamy histiocytes (filled with lipid), arranged in between collagen bundles • Often a thin epidermis (eyelid skin) • Vellus hairs may be present (eyelid skin)
Xanthelasma
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Cell Type | Clear
• “Clear” cells • Cells are histiocytes, arranged in a well-circumscribed mass in the upper dermis • Touton giant cells and eosinophils often seen
Xanthogranuloma (older lesion)
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Cell Type | Clear
189
• “Clear” cells • Cells are foamy histiocytes (filled with lipid), in clusters in the dermis • Free lipid is present in eruptive xanthomas
Xanthoma
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Page 190
Cell Type | Clear
(a)
(b)
(c)
(d)
“Clear cells” • a Cryptococcosis, gelatinous: clear spaces representing the capsule of the organism
Key differences
• b Granular cell tumor: cells with grainy cytoplasm, small and large • c Hibernoma: cells with net-like vacuolated cytoplasm • d Leishmaniasis: macrophages filled with organisms
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Cell Type | Clear
(e)
191
(f)
(g)
“Clear cells” (cont.) • e Lepromatous leprosy: histiocytes filled with organisms; linear arrangement on low power • f Lipoma: clear adipocytes; peripheral nuclei • g Melanoma, balloon cell: atypical nuclei with clear cytoplasm
Key differences
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Cell Type | Clear
(h)
(i)
(j)
“Clear cells” (cont.) • h Nodular hidradenoma: clear cells with interspersed ducts and hyalinized collagen • i Renal cell carcinoma: clear cells with extravasated erythrocytes
Key differences
• j Sebaceous adenoma: clear sebocytes with star-shaped nuclei with a rim of basaloid cells
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Cell Type | Clear
(k)
193
(l)
(m)
“Clear cells” (cont.) • k Xanthelasma: foamy cells interspersed in eyelid skin • l Xanthogranuloma: foamy cells with some Touton cells • m Xanthoma: foamy cells and extracellular lipid
Key differences
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Page 194
Cell Type | Melanocytic
• Melanocytic cells • Cells are small and spindled/dendritic with occasional cells containing melanin pigment • Dermis often hyalinized • Melanophages often present
Blue nevus
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Cell Type | Melanocytic
195
• Melanocytic cells • Epithelioid melanocytes are admixed with or bordered by uniformly distributed melanophages • Pattern on low power is wedge-shaped (often centered around a follicle)
Deep penetrating nevus
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Page 196
Cell Type | Melanocytic
• Melanocytic cells • Cells are confluent at the junction with irregularly sized nests, scattered high and low within the epidermis • Atypical cells and mitoses in epidermal and dermal nests
Melanoma
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Cell Type | Melanocytic
197
• Melanocytic cells • Cells are spindled and arranged in bundles infiltrating through collagen • Cells are atypical • Often overlying in situ melanoma changes in epidermis
Melanoma, desmoplastic
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Cell Type | Melanocytic
• Melanocytic cells • Pigmented spindle cells are arranged in vertical fascicles in the base of the epidermis
Pigmented spindle cell nevus of Reed
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Cell Type | Melanocytic
199
• Melanocytic cells • Cells are in irregularly shaped nests, sometimes confluent, confined to the area above a dermal scar • Predominantly junctional involvement
Recurrent nevus
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Cell Type | Melanocytic
• Melanocytic cells, spindled and epithelioid • Cells are in vertical fascicles within the epidermis (“school of fish”) • Well circumscribed and symmetric • Kamino bodies
Spitz nevus
• Clefting above nests • Cells are atypical but all resemble each other
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Cell Type | Melanocytic
(a)
(b)
(c)
(d)
Melanocytic cells • a Blue nevus: finely pigmented spindle/dendritic cells within the dermis • b Deep penetrating nevus: wedge-shaped epithelioid melanocytes admixed with melanophages
201
• c Melanoma: atypical cells in epidermis and dermis, asymmetric, dermal mitoses • d Melanoma, desmoplastic: atypical spindle cells infiltrating through collagen
Key differences
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Cell Type | Melanocytic
(e)
(f)
(g)
Melanocytic cells (cont.) • e Pigmented spindle cell nevus of Reed: vertically arranged pigmented cells in base of epidermis
Key differences
• f Recurrent nevus: irregular nests of pigmented cells above a scar • g Spitz nevus: vertically arranged epithelioid and spindle cells; symmetric
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Cell Type | Spindle
203
• Spindle cells (which also appear rounded when fascicles are cut cross-wise) (so-called biphasic pattern) • Often bulbous into the deep dermis • Scattered melanin pigment within the cells
Blue nevus, cellular
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Page 204
Cell Type | Spindle
• Spindle cells in a “busy dermis” • Epidermis often acanthotic and pigmented • Cells entrap collagen at the periphery (arrows)
Dermatofibroma
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Cell Type | Spindle
205
• Spindle cells filling dermis • Cells are monomorphous and arranged in a storiform (cartwheel) pattern • Infiltration into the fat in layered or honeycomb pattern
Dermatofibrosarcoma protuberans
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Page 206
Cell Type | Spindle
• Spindle cells • Cells have round pink cytoplasmic inclusions (arrows) • Cells are arranged in long fascicles
Infantile digital fibromatosis
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Cell Type | Spindle
• Spindle cells • Cells are arranged in fascicles which intersect at 90 degree angles • Spindle cells cut longitudinally show “cigar-shaped” nuclei (arrows)
207
• Cells cut in cross-section have perinuclear vacuoles around round nuclei • Note that normal nipple has small bundles of smooth muscle cells (same appearance as an accessory nipple, see p. 4)
Leiomyoma
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Cell Type | Spindle
• Spindle cells • Cells have thin, wavy nuclei (long arrow), looks like “shredded carrot” • Bubble-gum pink stroma
Neurofibroma
• Scattered mast cells (short arrow) • Not encapsulated
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Cell Type | Spindle
• Spindle cells • Myxoid areas of elongated cells with oval nuclei with tapered ends and elongated cytoplasm (“tissue-culture” fibroblasts) • Extravasated erythrocytes
209
• Mitoses may be seen • Radial arrangement of blood vessels at periphery • Deep tumor, often no epidermis present
Nodular fasciitis
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Cell Type | Spindle
• Spindle cells • Cells are arranged in fascicles with characteristic clefting • Not truly encapsulated
Palisaded encapsulated neuroma
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Cell Type | Spindle
211
• Spindle cells • Cells are arranged parallel to epidermis • Vessels oriented perpendicular to epidermal surface
Scar
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• • • •
2:05 PM
Page 212
Cell Type | Spindle
Spindle cells Antoni A areas – cellular Antoni B areas – myxoid Verocay bodies (arrows) – palisaded arrangement of nuclei around a central pink area of collagen
Schwannoma
• Encapsulated • Vascular spaces may be very dilated • Often a deep tumor with no epidermis present
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Cell Type | Spindle
(a)
(b)
(c)
(d)
Spindle cells • a Blue nevus, cellular: bulbous projection into deeper dermis, some cells have melanin pigment • b Dermatofibroma: collagen entrapment at periphery, epidermal acanthosis
213
• c Dermatofibrosarcoma protuberans: monomorphous cells in cartwheel arrangement; infiltration into fat • d Infantile digital fibromatosis: bright pink cytoplasmic inclusions
Key differences
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Cell Type | Spindle
(e)
(f)
(g)
Spindle cells (cont.) • e Leiomyoma: cigar-shaped nuclei in long fascicles • f Neurofibroma: wavy nuclei, mast cells, bubble-gum pink stroma • g Nodular fasciitis: tissue-culture fibroblasts, extravasated erythrocytes, often deep in the fat
Key differences
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Cell Type | Spindle
(h)
215
(i)
(j)
Spindle cells (cont.) • h Palisaded encapsulated neuroma: clefts between collections of spindle cells with nuclear palisading • i Scar: spindle cells arranged parallel to epidermal surface • j Schwannoma: Verocay bodies, myxoid areas, encapsulated
Key differences
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• • • •
2:06 PM
Page 216
Cell Type | Giant
Giant cells with bizarre nuclei Cells are atypical Mitoses Often a grenz zone above the atypical cells and solar elastosis flanking the atypical cells
Atypical fibroxanthoma
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Page 217
Cell Type | Giant
• Giant cells of osteoclastic type (nuclei arranged haphazardly on one side of the cell) • Nuclei of giant cells resemble the nuclei of adjacent histiocytes
217
• Hemosiderophages • Often a deep tumor (no epidermis present)
Giant cell tumor of tendon sheath
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Page 218
Cell Type | Giant
• Touton giant cells (wreath of nuclei with pink center and foamy cytoplasm outside the wreath) arranged at periphery of collection of histiocytes • Eosinophils may be present • Scattered foamy cells may be present
Juvenile xanthogranuloma
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Cell Type | Giant
219
• Oncocytic giant cells (multinucleated cells with ground-glass pink cytoplasm) (arrows)
Reticulohistiocytosis
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Cell Type | Giant
• Foreign-body giant cells (haphazardly arranged nuclei), neutrophils • Keratin spicules can be seen near/engulfed by multinucleated cells
Ruptured cyst/keratin granuloma
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Cell Type | Giant
221
• Langhans giant cells (nuclei arranged in a horseshoe shape) (arrow) • Epidermis usually normal • Giant cells within collections of histiocytes that are usually “naked” (lacking surrounding lymphocytes)
Sarcoidosis
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Page 222
Cell Type | Giant
• Foreign-body giant cells • Cells surrounding suture material (braided in this case)
Suture granuloma
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Page 223
Cell Type | Giant
(a)
(b)
(c)
(d)
223
Giant cells • a Atypical fibroxanthoma: atypical nuclei, mitoses • b Giant cell tumor of tendon sheath: osteoclastic giant cells • c Juvenile xanthogranuloma: Touton giant cells • d Reticulohistiocytosis: oncocytic giant cells
Key differences
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Cell Type | Giant
(e)
(f)
(g)
Giant cells (cont.) • e Ruptured cyst/keratin granuloma: foreign-body giant cells, keratin spicules • f Sarcoidosis: Langhans giant cells, naked granulomas • g Suture granuloma: foreign-body giant cells, suture material
Key differences
• Note Infections and scars are other common entities that frequently have giant cells • Note This list is of the classical type of giant cell for each entity; none of the giant cells are pathognomonic
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Page 225
Color Blue • Blue tumor, 227 • Blue infiltrate, 235 • Mucin and glands or ducts, 244 • Mucin, 248
Dermatopathology: Diagnosis by First Impression Christine J. Ko and Ronald J. Barr © 2008 Christine J. Ko and Ronald J. Barr . ISBN: 978-1-405-17734-4
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Color Blue | Blue tumor
227
• Blue tumor • Tumor composed of cells with monomorphous, centrally located, round nuclei (arrows) • Cells surround vascular spaces
Glomus tumor
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• • • • •
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Page 228
Color Blue | Blue tumor
Blue tumor Trabecular or nodular pattern on low power Tumor composed of cells with pale nuclei on high power Nuclei have a “salt and pepper” look Numerous scattered mitoses and necrotic cells
Merkel cell carcinoma
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Color Blue | Blue tumor
• Blue tumor • “Blue balls” in the dermis • Islands of tumor may be peppered by lymphocytes and hyaline pink droplets
229
• Tumor composed of more peripheral blue cells and more central pale/clear cells that may be arranged in a trabeculated pattern • Occasional ductal components
Spiradenoma
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Page 230
Color Blue | Blue tumor
• Blue tumor • Peripheral palisading • Generally no epidermal connection
Trichoblastoma
• Well circumscribed with clefts between the tumor as a whole and the normal dermis • Papillary mesenchymal bodies may be seen
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Page 231
Color Blue | Blue tumor
• Blue tumor • Often an epidermal connection • Grape-like fronds of cells or reticulated islands of basaloid cells with peripheral palisading
231
• Fibrotic stroma • Clefting between the fibrotic stroma and bordering normal dermis • Papillary mesenchymal bodies may be seen
Trichoepithelioma
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Color Blue | Blue tumor
• Blue tumor • Groups of cells in dermis (“cannon balls”) forming small vascular spaces with erythrocytes • Clefts may be seen around the groups of cells
Tufted hemangioma
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Color Blue | Blue tumor
(a)
233
(b)
(c)
Blue tumors • a Glomus tumor: round monomorphous cells • b Merkel cell carcinoma: pale salt and pepper nuclei • c Spiradenoma: two cell types – pale and blue
Key differences
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Page 234
Color Blue | Blue tumor
(e)
(d)
(f)
Blue tumors (cont.) • d Trichoblastoma: peripheral palisading, papillary mesenchymal bodies • e Trichoepithelioma: grape-like fronds of cells with peripheral palisading, fibrotic stroma
Key differences
• f Tufted hemangioma: “cannon balls” of blue cells forming vascular spaces • Note Some pathologists consider trichoepithelioma to be a variant of trichoblastoma
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Page 235
Color Blue | Blue infiltrate
235
• Blue dense infiltrate • Lymphoplasmacytic infiltrate surrounds and destroys hair follicles • Free hair shafts may be seen in the dermis • Scarring
Acne keloidalis
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Color Blue | Blue infiltrate
• Blue dense infiltrate • Grenz zone • Infiltrate composed of lymphocytes, histiocytes, eosinophils, and neutrophils • Variable presence of vasculitis
Granuloma faciale
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Color Blue | Blue infiltrate
237
• Blue dense infiltrate • Infiltrate is perivascular and infiltrating through collagen • Cells are atypical with slightly granular cytoplasm (arrows)
Leukemia (myelogenous)
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• • • •
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Color Blue | Blue infiltrate
Blue dense infiltrate Infiltrate composed of monomorphous atypical lymphocytes Often a “bottom-heavy” infiltrate Note that clinical history and special stains may be critical in making the diagnosis
Lymphoma
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Color Blue | Blue infiltrate
239
• Blue dense infiltrate • Infiltrate composed of mast cells (arrows) with “fried egg” appearance (round nucleus, granular cytoplasm)
Mastocytoma
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Color Blue | Blue infiltrate
• Blue dense infiltrate • Infiltrate composed of plasma cells (arrows) with eccentric nucleus, perinuclear Hopf (clear space)
Myeloma
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Color Blue | Blue infiltrate
• • • •
241
Blue dense infiltrate Papillary dermal edema Infiltrate composed of neutrophils Generally vasculitis is not prominent
Sweet’s syndrome
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Color Blue | Blue infiltrate
(a)
(b)
(c)
(d)
Blue dense infiltrate • a Acne keloidalis: lymphoplasmacytic infiltrate around/destroying hair follicles with scarring • b Granuloma faciale: mixed infiltrate with eosinophils under a grenz zone, vasculitis
Key differences
• c Leukemia (myelogenous): atypical cells with granular cytoplasm around vessels and infiltrating dermis • d Lymphoma: monomorphous lymphocytes filling dermis
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Color Blue | Blue infiltrate
(e)
243
(f)
(g)
Blue dense infiltrate (cont.) • e Mastocytoma: dense collection of mast cells with “fried egg” appearance • f Myeloma: dense collection of plasma cells • g Sweet’s syndrome: infiltrate of neutrophils • Note Infections may also have a dense infiltrate
Key differences
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Color Blue | Mucin and glands or ducts
• Mucin and glands or ducts • Bluish-pink chondroid areas (long arrows) and duct-like spaces (short arrows) • Well circumscribed
Chondroid syringoma
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Color Blue | Mucin and glands or ducts
245
• Mucin and glands or ducts • Mucin in pools dissecting collagen bundles • In the center of the pools, there are epithelial islands with variable ductal differentiation
Mucinous carcinoma
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• • • •
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Color Blue | Mucin and glands or ducts
Mucin and glands or ducts Mucin often surrounded by giant cells There may be a partial or total epithelial lining May see mucosal epithelium and/or minor salivary glands
Mucocele
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Color Blue | Mucin and glands or ducts
(a)
247
(b)
(c)
Mucin and glands or ducts • a Chondroid syringoma: well-circumscribed blue–pink cartilaginous area containing duct-like spaces
• b Mucinous carcinoma: pools of mucin containing epithelial islands • c Mucocele: pool of mucin with surrounding fibrosis/ inflammation; adjacent salivary glands
Key differences
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Color Blue | Mucin
• Well-circumscribed mucin (blue, lacy appearance) • Acral skin • Not a true cyst (no epithelial lining)
Digital mucous cyst
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Color Blue | Mucin
249
• Well-circumscribed mucin • Non-acral location
Focal cutaneous mucinosis
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Color Blue | Mucin
• Mucin within a distorted hair follicle
Follicular mucinosis
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Color Blue | Mucin
251
• Mucin between collagen bundles • Perivascular lymphocytes
Lupus tumidus
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Color Blue | Mucin
• Variable mucin in nodular collections with spindle cells • Nodules separated by fibrosis • Note that lesions with abundant mucin are probably best referred to as nerve sheath myxomas
Neurothekeoma
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Color Blue | Mucin
253
• Mucin filling the dermis (spares papillary dermis)
Pretibial myxedema
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Color Blue | Mucin
(b)
(a)
(c)
Mucin • a Digital mucous cyst: acral location • b Focal cutaneous mucinosis: non-acral location • c Follicular mucinosis: mucin within follicle
Key differences
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Color Blue | Mucin
(d)
255
(e)
(f)
Mucin (cont.) • d Neurothekeoma: lobules of spindle or epithelioid cells in variable myxoid background • e Nodular fasciitis: elongated “tissue culture” cells in myxoid background • f Pretibial myxedema: mucin filling reticular dermis
Key differences
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Color Pink • Pink material, 259 • Pink dermis, 264 • Epidermal necrosis, 267
Dermatopathology: Diagnosis by First Impression Christine J. Ko and Ronald J. Barr © 2008 Christine J. Ko and Ronald J. Barr . ISBN: 978-1-405-17734-4
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Color Pink | Pink material
259
• Amorphous pink material in upper dermis • Plasma cells
Amyloid
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Color Pink | Pink material
• Pink material with shadows of nuclei within, may have a “butterscotch” color • Basaloid cells • Calcification may be present • Giant cells often seen
Pilomatricoma
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Color Pink | Pink material
261
• Pink material that is dense keratin • Stratified squamous epithelium with no granular layer (tricholemmal differentiation)
Proliferating pilar tumor
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Color Pink | Pink material
• Pink material arranged in a fenestrated or clefted fashion • Hyalinized, relatively acellular collagen
Sclerotic fibroma
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Color Pink | Pink material
(a)
(b)
(c)
(d)
Pink material • a Amyloid: amorphous pink material, plasma cells • b Pilomatricoma: shadow cells, basaloid cells
263
• c Proliferating pilar tumor: dense pink keratin, no granular layer between keratin and epithelium • d Sclerotic fibroma: clefts between strands of sclerotic collagen
Key differences
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Color Pink | Pink dermis
• Pink hyalinized dermis beneath vacuolated basal layer • Lichenoid infiltrate below hyalinized dermis • See also p. 89
Lichen sclerosus et atrophicus
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Color Pink | Pink dermis
265
• Pink dermis • Atypical, bizarre fibroblasts within dermis • Dilated vessels with plump endothelial cells
Radiation dermatitis
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Color Pink | Pink dermis
(a)
(b)
Pink dermis • a Lichen sclerosus et atrophicus: pink band of dermis with inflammation below it (see also p. 93) • b Radiation dermatitis: pink dermis with dilated vessels; atypical fibroblasts on higher power
Key differences
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Color Pink | Epidermal necrosis
267
• Epidermal and dermal necrosis • Vessels necrotic with extravasated erythrocytes and visible fungal hyphae that are septate and branching
Aspergillosis
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Color Pink | Epidermal necrosis
• Epidermal necrosis with variable dermal change • Reversal of epidermal staining (more basophilic superficially than deep) • Acute lesions are non-inflammatory
Burn
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Color Pink | Epidermal necrosis
269
• Epidermal necrosis (linear, primarily affecting basal layer) below basket-weave stratum corneum in early lesions
Erythema multiforme
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Color Pink | Epidermal necrosis
• Epidermal necrosis with acantholytic cells and multinucleated cells • Follicular necrosis is a clue
Herpes simplex infection
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Color Pink | Epidermal necrosis
271
• Epidermal necrosis or pallor underlying parakeratosis • Basal layer relatively normal
Nutritional deficiency
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Color Pink | Epidermal necrosis
(c)
(a)
(d)
(b)
Epidermal necrosis • a Aspergillosis: epidermal and dermal necrosis with fungi in areas of destroyed vessels • b Burn: epidermal necrosis, sharp demarcation • c Erythema multiforme: basket-weave stratum corneum, linear basal cell necrosis
Key differences
(e)
• d Herpes simplex infection: acantholysis and multinucleated cells with rimmed chromatin • e Nutritional deficiency: parakeratosis above epidermal necrosis, basal layer often unaffected
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6
Appendix by Pattern
Polypoid Accessory digit, 3, 7 Accessory nipple, 4, 7 Accessory tragus, 5, 7 Acquired digital fibrokeratoma, see Digital fibrokeratoma Digital fibrokeratoma, 6, 7 Fibroepithelial polyp (not pictured) Fibrous papule, 75, 81 Intradermal nevus (not pictured) Neurofibroma, 208, 214 Nevus lipomatosus (not pictured) Umbilical polyp (not pictured)
Square/rectangular Chronic radiodermatitis, 265 Keloid (not pictured) Lichen myxedematosus, 12 Morphea, 8, 13 Necrobiosis lipoidica, 9, 13, 39 Nephrogenic systemic fibrosis (not pictured) Normal back, 10, 13 Scleredema, 11, 14 Scleromyxedema, 12, 14
Regular acanthosis Bowen’s disease, 15, 18 Clear cell acanthoma, 16, 18 Normal elbow (not pictured) Psoriasis, 17, 18 Inflammatory linear verrucous epidermal nevus, 88, 92 Verruciform xanthoma (not pictured)
Pseudoepitheliomatous hyperplasia above abscesses Atypical mycobacterial infection (not pictured) Blastomycosis, 19, 22 Chromomycosis, 20, 22 Coccidioidomycosis, 21, 22 Keratoacanthoma (not pictured) Paracoccidioidomycosis (not pictured) Pyoderma gangrenosum (not pictured) Sporotrichosis (not pictured) Dermatopathology: Diagnosis by First Impression Christine J. Ko and Ronald J. Barr © 2008 Christine J. Ko and Ronald J. Barr . ISBN: 978-1-405-17734-4
Tuberculosis verrucosa cutis (not pictured) Halogenoderma/bromoderma (not pictured)
Proliferation downward from epidermis Fibroepithelioma of Pinkus, 23, 30 Fibrofolliculoma, 24, 30 Inverted follicular keratosis, 25, 30 Nevus sebaceous of Jadassohn, 26, 30 Poroma, 27, 31 Sebaceus adenoma, 186, 192 Seborrheic keratosis, reticulated (not pictured) Syringofibroadenoma (not pictured) Trichilemmoma, 28, 31 Tumor of the follicular infundibulum, 29, 31
Central pore Dilated pore of Winer, 32, 35 Pilar sheath acanthoma, 33, 35 Trichofolliculoma, 34, 35 Sebaceous hyperplasia (not pictured)
Palisading reactions Churg–Strauss (not pictured) Gout, 36, 39 Granuloma annulare, 37, 39 Interstitial granulomatous dermatitis (not pictured) Rheumatoid nodule, 38, 39 Necrobiosis lipoidica, 9, 13, 39 Wegener’s granulomatosis (not pictured)
Space with a lining Angiokeratoma, 124, 130 Apocrine hidrocystoma, 40, 49 Auricular pseudocyst, 41, 49 Branchial cleft cyst, 42, 49 Bronchogenic cyst (not pictured) Cutaneous ciliated cyst, 43, 50 Cutaneous endometriosis, 44, 50 Dermoid cyst, 45, 50 Epidermal inclusion cyst, 46, 51 Lymphangioma, 127, 131 Median raphe cyst (not pictured) Pilar cyst, 47, 51
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Appendix by Pattern
Steatocystoma, 48, 51 Thyroglossal duct cyst (not pictured) Venous lake (not pictured) Glomangioma (not pictured)
Cords and tubules Desmoplastic trichoepithelioma, 52, 57 Metastatic breast carcinoma, 53, 57 Microcystic adnexal carcinoma, 54, 57 Morpheaform basal cell carcinoma, 55, 58 Syringoma, 56, 58
Papillated dermal tumor Aggressive digital papillary adenocarcinoma, 59, 64 Hidradenoma papilliferum, 60, 64 Papillary eccrine adenoma, 61, 64 Syringocystadenoma papilliferum, 62, 65 Tubular apocrine adenoma, 63, 65
Circular dermal islands Adenoid cystic carcinoma, 66, 69 Cylindroma, 67, 69 Spiradenoma, 229, 233 Trichoadenoma, 68, 69 Trichoblastoma, 230, 234
(Suggestion of) vessels Angioleiomyoma, 70, 80 Angiolymphoid hyperplasia with eosinophilia, 71, 80 Angiosarcoma, 72, 80 Bacillary angiomatosis, 73, 74, 81 Chondrodermatitis nodularis helicis, 85, 92 Fibrous papule, 75, 81 Glomus tumor/glomangioma, 227, 233 Kaposi’s sarcoma, 76, 81 Pyogenic granuloma, 77, 82 Stasis dermatitis, 78, 82 Targetoid hemangioma, 79, 82
Hyperkeratosis Chondrodermatitis nodularis helicis, 85, 92 Dermatophytosis, 95, 96 Discoid lupus erythematosus, 86, 92 Epidermolytic hyperkeratosis, 99, 105 Flegel’s disease, 87, 92 Ichthyosis vulgaris (not pictured) Inflammatory linear verrucous epidermal nevus, 88, 92 Lichen planus, 144, 148 Lichen sclerosus et atrophicus, 89, 93, 264, 266 Pityriasis rubra pilaris, 90, 93 Porokeratosis, 91, 93
Parakeratosis Axillary granular parakeratosis, 94, 96 Bowen’s disease, 15, 18
Dermatophytosis, 95, 96 Nutritional deficiency, 271, 272 Papulosquamous diseases (not all are pictured), 17 ,18, 90, 93 Pityriasis lichenoides et varioliformis acuta, 146, 148 Porokeratosis, 91, 93 Spongiotic diseases (not all are pictured), 78, 82, 117, 118, 135, 136 Tinea versicolor (not pictured)
Upper epidermal change Bowen’s disease, 15, 18 Clonal seborrheic keratosis, 97, 105 Epidermodysplasia verruciformis, 98, 105 Epidermolytic hyperkeratosis, 99, 105 Myrmecium, 100, 105 Orf, 101, 106 Paget’s disease, 102, 106 Verruca plana, 103, 106 Verruca vulgaris, 104, 106
Acantholysis Acantholytic acanthoma (not pictured) Actinic keratosis (not pictured) Acantholytic dyskeratotic acanthoma (not pictured) Darier’s disease, 107, 115 Grover’s disease, 108, 115 Hailey–Hailey disease, 109, 115 Herpes virus infection, 110, 115 Pemphigus foliaceus, 111, 116 Pemphigus vulgaris, 112, 116 Pityriasis rubra pilaris, 90, 93 Squamous cell carcinoma, 113, 116 Warty dyskeratoma, 114, 116
Eosinophilic spongiosis Allergic contact dermatitis, 117, 122 Arthropod bite reaction, 118, 122 Bullous pemphigoid, 122, 125, 130 Incontinentia pigmenti, 119, 123 Pemphigoid gestationis, 125 Pemphigus vegetans, 120, 123 Pemphigus vulgaris, 112, 116 Scabies, 121, 123
Subepidermal space cleft Angiokeratoma, 124, 130 Bullous pemphigoid, 122, 125, 130 Dermatitis herpetiformis, 126, 130 Diabetic bullae (not pictured) Epidermolysis bullosa (not pictured) Erythema multiforme, 269, 272 Herpes gestationis, 125 Lichen planus (not pictured)
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Appendix by Pattern Lymphangioma, 127, 131 Phototoxic reactions (not pictured) Polymorphous light eruption, 128, 131 Porphyria cutanea tarda, 129, 131 Pseudoporphyria (not pictured) Suction blister (not pictured) Sweet’s syndrome, 241, 243
Perivascular infiltrate Erythema annulare centrifuguum (not pictured) Guttate psoriasis (not pictured) Gyrate erythema, 132, 136 Leukocytoclastic vasculitis, 133, 136 Lymphocytic angiitis (not pictured) Pigmented purpuric dermatosis, 134, 136 Pityriasis rosea, 135, 136
Band-like upper dermal infiltrate Fixed drug reaction, 141, 147 Langerhans cell histiocytosis, 137, 140 Lichen planus, 144, 148 Mastocytosis, 138, 140 Mycosis fungoides, 139, 140
Interface reaction Benign lichenoid keratosis (not pictured) Discoid lupus erythematosus, 86, 92 Erythema multiforme, 269, 272 Fixed drug reaction, 141, 147 Graft-versus-host disease, 142, 147 Halo nevus (not pictured) Lichen nitidus, 143, 147 Lichen planus, 144, 148 Lichen sclerosus et atrophicus, 89, 93, 264, 266 Lichen striatus, 145, 148 Pigmented purpuric dermatosis, 134, 136 Pityriasis lichenoides et varioliformis acuta, 146, 148 Porokeratosis, 91, 93 Regressed melanoma (not pictured) Secondary syphilis (not pictured) Some neoplasms (not pictured)
Dermal material Amyloidosis, nodular, 149, 159 Calcinosis cutis, 150, 159 Erythropoietic protoporphyria, 151, 159 Gel foam, 152, 159 Gout, 36, 39 Lipoid proteinosis, 153, 160 Ochronosis, 154, 160 Osteoma cutis, 155, 160 Paraffinoma, 156, 161 Pseudoxanthoma elasticum, 157, 161 Tattoo, 158, 161 See also Mucin, 248 and Pink material, 259
Change in the fat Angiolipoma, 162, 171 Dermatofibrosarcoma protuberans (often extends into the fat), 205, 213 Erythema induratum, 163, 171 Erythema nodosum, 164, 171 Hibernoma, 179, 190 Lipodermatosclerosis, 165, 172 Lupus profundus, 166, 172 Nodular fasciitis (often deep in the fat), 209, 214, 255 Other adipose tumors (not pictured) Other panniculitides (not pictured) Pancreatic fat necrosis, 167, 172 Polyarteritis nodosa, 168, 173 Post-steroid panniculitis, 169 Sclerema neonatorum (not pictured) Subcutaneous fat necrosis of the newborn, 169, 173 Subcutaneous T-cell lymphoma, 170, 173
“Clear cells” Clear cell acanthoma, 16, 18 Cryptococcosis, gelatinous, 177, 190 Granular cell tumor, 178, 190 Hibernoma, 179, 190 Leishmaniasis, 180, 190 Lepromatous leprosy, 181, 191 Lipoma, 182, 191 Melanoma, balloon cell, 183, 191 Nodular hidradenoma, 184, 192 Other clear cell neoplasms (e.g. clear cell basal cell carcinoma) (not pictured) Renal cell carcinoma, 185, 192 Sebaceous adenoma, 186, 192 Trichilemmoma, 28, 31 Xanthelasma, 187, 193 Xanthogranuloma, 188, 193 Xanthoma, 189, 193
Melanocytic cells Blue nevus, 194, 201 Blue nevus, cellular, 203, 213 Deep penetrating nevus, 195, 201 Melanoma, 196, 201 Melanoma, desmoplastic, 197, 201 Other melanocytic tumors/proliferations (not pictured) Pigmented spindle cell nevus of Reed, 198, 202 Recurrent nevus, 199, 202 Spitz nevus, 200, 202
Spindle cells Atypical fibroxanthoma, 216, 223 Blue nevus, cellular, 203, 213 Dermatofibroma, 204, 213 Dermatofibrosarcoma protuberans, 205, 213 Fibrous papule, 75, 81
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Appendix by Pattern
Infantile digital fibromatosis, 206, 213 Kaposi’s sarcoma, 76, 81 Leiomyoma, 207, 214 Neurofibroma, 208, 214 Neurothekeoma, 252, 255 Nodular fasciitis, 209, 214, 255 Other fibrous tumors (not pictured) Other neural tumors (not pictured) Other smooth muscle tumors (not pictured) Palisaded encapsulated neuroma, 210, 215 Scar, 211, 215 Schwannoma, 212, 215 Squamous cell carcinoma, 113, 116
Mucin Digital mucous cyst, 248, 254 Focal cutaneous mucinosis, 249, 254 Follicular mucinosis, 250, 254 Lichen myxedematosus, 12 Lupus tumidus, 251 Neurothekeoma, 252, 255 Nodular fasciitis, 209, 214, 255 Pretibial myxedema, 253, 255 Reticular erythematous mucinosis (not pictured) Scleredema, 11, 14 Scleromyxedema, 12, 14
Pink material Giant cells Atypical fibroxanthoma, 216, 223 Erythema nodosum, 164, 171 Giant cell tumor of tendon sheath, 217, 223 Infections (not pictured) Juvenile xanthogranuloma, 218, 223 Mucocele, 246, 247 Necrobiosis lipoidica, 9, 13, 39 Pilomatricoma, 260 Reticulohistiocytosis, 219, 223 Ruptured cyst/keratin granuloma, 220, 224 Sarcoidosis, 221, 224 Scar (not pictured) Suture granuloma, 222, 224
Blue tumor Basal cell carcinoma, morpheaform, 55, 58 Glomus tumor, 227, 233 Lymphoma, 238, 242 Merkel cell carcinoma, 228, 233 Sebaceoma (not pictured) Spiradenoma, 229, 233 Trichoblastoma, 230, 234 Trichoepithelioma, 231, 234 Tufted hemangioma, 232, 234
Amyloid, 259, 263 Colloid milium (not pictured) Erythropoietic protoporphyria, 151, 159 Gout, 36, 39 Lichen sclerosus et atrophicus, 89, 93, 264, 266 Lipoid proteinosis, 153, 160 Pilar cyst, 47, 51 Pilomatricoma, 260, 263 Proliferating pilar tumor, 261, 263 Rheumatoid nodule, 38, 39 Sclerotic fibroma, 262, 263
Pink dermis Lichen sclerosus et atrophicus, 89, 93, 264, 266 Morphea, 8, 13 Radiation dermatitis, 265, 266
Epidermal necrosis Aspergillosis, 267, 272 Burn, 268, 272 Erythema multiforme, 269, 272 Herpes simplex infection, 270, 272 Nutritional deficiency, 271, 272 Pressure necrolysis (not pictured)
“Normal” skin on low power Blue dense infiltrate Acne keloidalis, 235, 242 Granuloma faciale, 236, 242 Infections (not pictured) Leukemia (myelogenous), 237, 242 Lymphoma, 238, 242 Mastocytoma, 239, 243 Myeloma, 240, 243 Sweet’s syndrome, 241, 243
Mucin and glands or ducts Chondroid syringoma, 244, 247 Mucinous carcinoma, 245, 247 Mucocele, 246, 247
Anetoderma (not pictured) Connective tissue nevus (not pictured) Dermatophyte/tinea versicolor* (not pictured) Erythema dyschromicum perstans* (not pictured) Ichthyosis vulgaris (not pictured) Scleredema, 11, 14 Vitiligo (not pictured) Macular amyloidosis* (not pictured) Urticaria (not pictured) Telangiectasia macularis eruptiva perstans (TMEP) (not pictured) Argyria (not pictured) *When subtle
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Index by Histological Category
Acantholytic disorders Darier’s disease, 107, 115 Grover’s disease, 108, 115 Hailey–Hailey disease, 109, 115 Herpes virus infection, 110, 115 Pemphigus foliaceus, 111, 116 Pemphigus vegetans, 120, 123 Pemphigus vulgaris, 112, 116 Squamous cell carcinoma, acantholytic, 113, 116 Warty dyskeratoma, 114, 116
Benign tumors Adipose tumors Angiolipoma, 162, 171 Hibernoma, 179, 190 Lipoma, 182, 191
Adnexal tumors Follicular Desmoplastic trichoepithelioma, 52, 57 Fibroepithelioma of Pinkus, 23, 30 Fibrofolliculoma, 24, 30 Pilar sheath acanthoma, 33, 35 Pilomatricoma, 260, 263 Trichilemmoma, 28, 31 Trichoadenoma, 68, 69 Trichoblastoma, 230, 234 Trichoepithelioma, 231, 234 Trichofolliculoma, 34, 35 Tumor of the follicular infundibulum, 29, 31 Glandular (apocrine and eccrine) Apocrine hidrocystoma, 40, 49 Chondroid syringoma, 244, 247 Cylindroma, 67, 69 Hidradenoma papilliferum, 60, 64 Nodular hidradenoma, 184, 192 Papillary eccrine adenoma, 61, 64 Poroma, 27, 31 Spiradenoma, 229, 233 Syringocystadenoma papilliferum, 62, 65 Syringoma, 56, 58 Tubular apocrine adenoma, 63, 65
Dermatopathology: Diagnosis by First Impression Christine J. Ko and Ronald J. Barr © 2008 Christine J. Ko and Ronald J. Barr . ISBN: 978-1-405-17734-4
Sebaceous Nevus sebaceus of Jadassohn, 26, 30 Sebaceous adenoma, 186, 192
Fibrous tumors Dermatofibroma, 204, 213 Dermatofibrosarcoma protuberans, 205, 213 Digital fibrokeratoma, 6, 7 Fibrous papule, 75, 81 Giant cell tumor of tendon sheath, 217, 223 Infantile digital fibromatosis, 206, 213 Nodular fasciitis, 209, 214, 255 Scar, 211, 215 Sclerotic fibroma, 262, 263
Melanocytic tumors Blue nevus, 194, 201 Blue nevus, cellular, 203, 213 Deep penetrating nevus, 195, 201 Pigmented spindle cell nevus of Reed, 198, 202 Recurrent nevus, 199, 202 Spitz nevus, 200, 202
Miscellaneous tumors Bronchogenic cyst, 51 Clear cell acanthoma, 16, 18 Cutaneous ciliated cyst, 43, 50 Dilated pore of Winer, 32, 35 Epidermal inclusion cyst, 46, 51 Granular cell tumor, 178, 190 Inverted follicular keratosis, 25, 30 Mastocytoma, 239, 243 Pilar cyst, 47, 51 Seborrheic keratosis, clonal type, 97, 105 Steatocystoma, 48, 51
Neural tumors Accessory digit, 3, 7 Palisaded encapsulated neuroma, 210, 215 Neurofibroma, 208, 214 Neurothekeoma, 252, 255 Schwannoma, 212, 215
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Index by Histological Category
Smooth muscle tumors Accessory nipple, 4, 7 Angioleiomyoma, 70, 80 Leiomyoma, 207, 214
Vascular tumors
Necrobiosis lipoidica, 9, 13, 39 Rheumatoid nodule, 38, 39 Ruptured cyst/keratin granuloma, 220, 224 Sarcoidosis, 221, 224 Suture granuloma, 222, 224
Angiokeratoma, 124, 130 Angiolymphoid hyperplasia with eosinophilia, 71, 80 Glomus tumor, 227, 233 Lymphangioma, 127, 131 Pyogenic granuloma, 77, 82 Targetoid hemangioma, 79, 82 Tufted hemangioma, 232, 234
Histiocytic
Connective tissue disorders
Aspergillosis, 267, 272 Bacillary angiomatosis, 73, 74, 81 Blastomycosis, 19, 22 Chromomycosis, 20, 22 Coccidioidomycosis, 21, 22 Cryptococcosis, 177, 190 Dermatophytosis, 95, 96 Epidermodysplasia verruciformis, 98, 105 Herpes, 110, 115, 270, 272 Kaposi’s sarcoma, 76, 81 Leishmaniasis, 180, 190 Lepromatous leprosy, 181, 191 Orf, 101, 106 Myrmecium, 100, 105 Verruca plana, 103, 106 Verruca vulgaris, 104, 106
Discoid lupus erythematosus, 86, 92 Lichen sclerosus et atrophicus, 89, 93, 264, 266 Lupus profundus, 166, 172 Lupus tumidus, 251 Morphea, 8, 13 Polyarteritis nodosa, 168, 173 Rheumatoid nodule, 38, 39 Scleredema, 11, 14 Scleromyxedema, 12, 14
Depositions Endogenous material Amyloidosis, 149, 159, 259 Calcinosis cutis, 150, 159 Digital mucous cyst, 248, 254 Erythropoietic protoporphyria, 151, 159 Focal cutaneous mucinosis, 249, 254 Follicular mucinosis, 250, 254 Gout, 36, 39 Lipoid proteinosis, 153, 160 Mucocele, 246, 247 Osteoma cutis, 155, 160 Pretibial myxedema, 253, 255 Pseudoxanthoma elasticum, 157, 161
Foreign material Gel foam, 152, 159 Ochronosis, 154, 160 Paraffinoma, 156, 161 Tattoo, 158, 161
Genodermatoses Epidermolytic hyperkeratosis, 99, 105 Erythropoietic protoporphyria, 151, 159 Incontinentia pigmenti, 119, 123 Lipoid proteinosis, 153, 160
Granulomatous Granuloma annulare, 37, 39
Langerhans cell histiocytosis, 137, 140 Reticulohistiocytosis, 219, 223 Xanthelasma, 187, 193 Xanthogranuloma, 188, 193, 218, 223 Xanthoma, 189, 193
Infections
Inflammatory disorders Blistering disorders Bullous pemphigoid, 122, 125, 130 Dermatitis herpetiformis, 126, 130 Herpes gestationis, 125 Porphyria cutanea tarda, 129, 131
Interface reactions Discoid lupus erythematosus, 86, 92 Erythema multiforme, 269, 272 Fixed drug reaction, 141, 147 Graft-versus-host disease, 142, 147 Lichen nitidus, 143, 147 Lichen planus, 144, 148 Lichen striatus, 145, 148 Pigmented purpuric dermatosis, 134, 136 Pityriasis lichenoides et varioliformis acuta, 146, 148 Porokeratosis, 91, 93
Miscellaneous Acne keloidalis, 235, 242 Axillary granular parakeratosis, 94, 96 Burn, 268, 272 Chondrodermatitis nodularis helicis, 85, 92
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Index by Histological Category Flegel’s disease, 87, 92 Granuloma faciale, 236, 242 Mastocytosis, 138, 140, 239, 243 Nutritional deficiency, 271, 272 Pigmented purpuric dermatosis, 134, 136 Polymorphous light eruption, 128, 131 Porokeratosis, 91, 93 Radiation dermatitis, 265, 266 Scabies, 121, 123 Sweet’s syndrome, 241, 243
Malformations Accessory digit, 3, 7 Accessory nipple, 4, 7 Accessory tragus, 5, 7 Auricular pseudocyst, 41, 49 Branchial cleft cyst, 42, 49 Cutaneous endometriosis, 44, 50 Dermoid cyst, 45, 50
Malignant tumors Carcinomas
Panniculitis and other disorders of adipose tissue Erythema induratum, 163, 171 Erythema nodosum, 164, 171 Lipodermatosclerosis, 165, 172 Lupus profundus, 166, 172 Pancreatic fat necrosis, 167, 172 Polyarteritis nodosa, 168, 173 Subcutaneous fat necrosis of the newborn, 169, 173 Subcutaneous T-cell lymphoma, 170, 173
Adenoid cystic carcinoma, 66, 69 Aggressive digital papillary adenocarcinoma, 59, 64 Basal cell carcinoma, morpheaform, 55, 58 Bowen’s disease, 15, 18 Merkel cell carcinoma, 228, 233 Metastatic breast carcinoma, 53, 57 Microcystic adnexal carcinoma, 54, 57 Mucinous carcinoma, 245, 247 Paget’s disease, 102, 106 Proliferating pilar tumor, 261, 263
Melanocytic tumors Papulosquamous disorders Pityriasis rubra pilaris, 90, 93 Psoriasis, 17, 18 Inflammatory linear verrucous epidermal nevus, 88, 92
Spongiotic disorders Arthropod bite reaction, 118, 122 Eosinophilic spongiosis, 117–123 Pityriasis rosea, 135, 136 Stasis dermatitis, 78, 82
Vasculitis Erythema induratum, 163, 171 Granuloma faciale, 236, 242 Leukocytoclastic vasculitis, 133, 136 Polyarteritis nodosa, 168, 173
Melanoma, 196, 201 Melanoma, balloon cell, 183, 191 Melanoma, desmoplastic, 197, 201
Miscellaneous Atypical fibroxanthoma, 216, 223 Dermatofibrosarcoma protuberans, 205, 213 Langerhans cell histiocytosis, 137, 140 Leukemia (myelogenous), 237, 242 Lymphoma, 238, 242 Mycosis fungoides, 139, 140 Myeloma, 240, 243 Renal cell carcinoma, 185, 192 Subcutaneous T-cell lymphoma, 170, 173
Vascular tumors Angiosarcoma, 72, 80
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