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Carr RA, Wiggins J, Slater DN. Follicular (Infundibular-Tricholemmal) Squamous Cell Carcinoma: A New WHO Entity. Clinicopathological Features in 103 Cases, Including Follow-Up and Implications for Patient Management. Am J Dermatopathol 2024; 46:416-432. [PMID: 38648027 DOI: 10.1097/dad.0000000000002713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
AIMS Cutaneous follicular (infundibular-tricholemmal) squamous cell carcinoma (FSCC) is a new World Health Organization entity. We present the largest series of published cases, summarizing clinical data, diagnostic criteria, differential diagnosis, and implications for patient management. METHODS Cases were identified from 2004 to 2011. Inclusion criteria included discrete attachment(s) of the tumor to the overlying epidermis via follicular infundibula, tricholemmal keratinization, and cellular pleomorphism. Keratoacanthoma and lesions with adjacent bowenoid epidermal dysplasia were excluded. RESULTS One hundred three cases of FSCC identified. 48.5% demonstrated completely circumscript borders ( in situ for practical purposes), 12.6% uncertain for invasion (overwhelmingly pushing borders), and only 38.8% as clearly invasive. Follicular mucin in acantholytic spaces within tumor epithelium was a distinctive finding in 57.2% of cases. Clinical data indicated predominance in elderly (median 78.5 years) men (70.4%), with preferential head and neck location (81.6%). Many were clinically suspected as squamous cell carcinoma (48.5%). However, a significant minority were clinically diagnosed as basal cell carcinoma (40.8%). This may reflect that FSCC commonly presented as a papule or nodule (51.3%). By contrast, keratoacanthoma was less frequently suggested (17.2%) and still fewer lesions were suspected to be actinic keratosis/Bowen's disease (13.6%). Follow-up in 82 cases (median 26.5 months, range 3-144) identified 5 (6.1%) local recurrences. There was no instance of metastasis in the subgroup of lesions with completely circumscript borders. Three of 45 (6.7%) patients, with follow-up, considered to have tumors with invasive pushing, and/or infiltrative borders developed lymph node metastases. CONCLUSIONS FSCC is identified as a common skin cancer, incorporating historical entities, such as infundibular carcinoma and tricholemmal carcinoma, with readily identifiable histologic features. Correct diagnosis has implications for patient management; a significant subgroup of lesions show completely circumscript borders that are considered in situ for practical purposes.
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Affiliation(s)
- Richard A Carr
- Department of Cellular Pathology, Warwick Hospital, Warwick, United Kingdom; and
| | - James Wiggins
- Department of Cellular Pathology, Warwick Hospital, Warwick, United Kingdom; and
| | - David N Slater
- Department of Histopathology, Royal Hallamshire Hospital, Sheffield, United Kingdom
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Carr RA, Mesiano D, Heffron C, Radonic T, Wiggins J, Tso S, Agrawal R, Cheung E, Slater DN, Nichols L, Craig P. Aberrant p16, p53 and Ki-67 immunohistochemistry staining patterns can distinguish solitary keratoacanthoma from cutaneous squamous cell carcinoma. Pathology 2023; 55:772-784. [PMID: 37573161 DOI: 10.1016/j.pathol.2023.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 06/16/2023] [Accepted: 07/09/2023] [Indexed: 08/14/2023]
Abstract
Keratoacanthoma (KA) is widely considered a benign, usually self-resolving, neoplasm distinct from cutaneous squamous cell carcinoma (cSCC), while some consider KA to be indistinguishable from cSCC. Published studies indicate utility for p16, p53, Ki-67 immunostaining and elastic van Gieson (EVG) in the assessment of KA and cSCC. We compared clinical features and staining patterns for p16, p53, Ki-67 and EVG in fully excised KA, cSCC with KA-like features (cSCC-KAL) and other cSCC (cSCC-OTHER). Significant differences between KA, cSCC-KAL and cSCC-OTHER were found for head and neck location (20%, 86%, 84%), and duration <5 months (95%, 63%, 36%). KA shows both a mosaic pattern for p16 (>25-90% of neoplasm area) and peripheral graded pattern for p53 (up to 50% moderate and strong nuclear staining) in 92% compared with 0% of cSCC-KAL and 0% of cSCC-OTHER. In contrast, a highly aberrant pattern (usually null) for one or both p16 and p53, was present in 0% of KA, 83.8% of cSCC-KAL and 90.9% of cSCC-OTHER. Abnormal distribution of Ki-67 beyond the peripheral 1-3 cells was uncommon in KA (4.2%) and common in cSCC-KAL (67.6%) and cSCC-OTHER (88.4%). Moderate to striking entrapment of elastic and collagen fibres was present in the majority of KA (84%), cSCC-KAL (81%) and cSCC-OTHER (65%). KA are clinically distinct neoplasms typically of short duration occurring preferentially outside the head and neck and generally lacking aberrations of p16, p53 and Ki-67, compared with cSCC that have high rates of aberrant or highly aberrant p16, p53 and Ki-67, but EVG lacked specificity.
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Affiliation(s)
- Richard A Carr
- Cellular Pathology, South Warwickshire NHS Foundation Trust, Warwick, UK.
| | - Domenico Mesiano
- Cellular Pathology, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Cynthia Heffron
- Department of Pathology, Cork University Hospital, Cork, Ireland
| | - Teodora Radonic
- Department of Pathology, Amsterdam University Medical Center, Netherlands
| | - James Wiggins
- Cellular Pathology, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Simon Tso
- Jephson Dermatology Centre, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Rishi Agrawal
- Histopathology Department, New Cross Hospital, Wolverhampton, UK
| | - Elaine Cheung
- Department of Pathology, Queen Elizabeth Hospital, Hong Kong
| | | | - Linda Nichols
- Department of Statistics, University of Warwick, Coventry, UK
| | - Paul Craig
- Department of Histopathology, Cheltenham General Hospital, Gloucestershire, UK
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Claeson M, Pandeya N, Dusingize JC, Thompson BS, Green AC, Neale RE, Olsen CM, Whiteman DC. Assessment of Incidence Rate and Risk Factors for Keratoacanthoma Among Residents of Queensland, Australia. JAMA Dermatol 2021; 156:1324-1332. [PMID: 33026421 DOI: 10.1001/jamadermatol.2020.4097] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Keratoacanthoma (KA) is a common and generally benign keratinocyte skin tumor. Reports of the incidence rates of KA are scant. In addition, the risk factors for KA are not well understood, although associations with UV radiation exposure and older age have been described. Objective To investigate the incidence rate of KA and the risk factors for developing KA. Design, Setting, and Participants The study included data from 40 438 of 193 344 randomly selected residents of Queensland, Australia, who participated in the QSkin Sun and Health (QSkin) prospective population-based cohort study. All participants completed a baseline survey between 2010 and 2011 and were ages 40 to 69 years at baseline. Histopathologic reports of KA were prospectively collected until June 30, 2014, through data linkage with pathologic records. Cox proportional hazards models were used to identify risk factors associated with KA while controlling for potential confounding variables. Data were analyzed from January 2 to April 8, 2020. Exposures Demographic characteristics, phenotypes, UV radiation exposure, medical history, and lifestyle. Results Among 40 438 participants (mean [SD] age, 56 [8] years; 18 240 men [45.1%]), 596 individuals (mean [SD] age, 62 [6] years; 349 men [58.6%]) developed 776 KA tumors during a median follow-up period of 3.0 years (interquartile range, 2.8-3.3 years). The person-based age-standardized incidence rate for KA in the age-restricted cohort was 409 individuals per 100 000 person-years (based on the 2001 Australian population). Risk factors after adjustment for potential confounders were older age (age ≥60 years vs age <50 years; hazard ratio [HR], 6.38; 95% CI, 4.65-8.75), male sex (HR, 1.56; 95% CI, 1.33-1.84), fair skin (vs olive, dark, or black skin; HR, 3.42; 95% CI, 1.66-7.04), inability to tan (vs ability to tan deeply; HR, 1.69; 95% CI, 1.19-2.40), previous excisions of keratinocyte cancers (ever had an excision vs never had an excision; HR, 6.28; 95% CI, 5.03-7.83), current smoking (vs never smoking, HR, 2.02; 95% CI, 1.59-2.57), and high alcohol use (≥14 alcoholic drinks per week vs no alcoholic drinks per week; HR, 1.42; 95% CI, 1.09-1.86). Conclusions and Relevance This is, to date, the first large prospective population-based study to report the incidence rate and risk factors for KA. The high person-based incidence rate (409 individuals per 100 000 person-years) highlights the substantial burden of KA in Queensland, Australia. Furthermore, the study's findings suggest that older age (≥60 years), male sex, UV radiation-sensitive phenotypes, indications of high sun exposure (eg, previous keratinocyte cancer excisions), smoking, and high alcohol use are independent risk factors for the development of KA.
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Affiliation(s)
- Magdalena Claeson
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Dermatology Research Centre, University of Queensland Diamantina Institute, Brisbane, Queensland, Australia.,Department of Dermatology and Venereology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nirmala Pandeya
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jean-Claude Dusingize
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Bridie S Thompson
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Adele C Green
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Cancer Research UK Manchester Institute and University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Rachel E Neale
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Catherine M Olsen
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - David C Whiteman
- Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Taibjee S, Carr R, Craig P, Radonic T. Comment on ‘The detection rate of human papillomavirus in well‐differentiated squamous cell carcinoma and keratoacanthoma: is there new evidence for a viral pathogenesis of keratoacanthoma?’. Br J Dermatol 2019; 181:1343-1345. [DOI: 10.1111/bjd.18383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S. Taibjee
- Department of Dermatology Dorset Country Hospital Dorset U.K
| | - R. Carr
- Department of Pathology South Warwickshire NHS Foundation Trust Warwick U.K
| | - P. Craig
- Department of Pathology Gloucestershire NHS Foundation Trust Cheltenham U.K
| | - T. Radonic
- Department of Pathology Amsterdam University Medical Centres Amsterdam the Netherlands
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Fernández-Figueras M, Saenz-Sardà X, Vargas P, Thompson C, Carrato C, Puig L, Ferrándiz C, Ariza A. The depth of follicular extension in actinic keratosis correlates with the depth of invasion in squamous cell carcinoma: implication for clinical treatment. J Eur Acad Dermatol Venereol 2018; 32:1657-1661. [DOI: 10.1111/jdv.14901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 01/30/2018] [Indexed: 11/29/2022]
Affiliation(s)
- M.T. Fernández-Figueras
- Department of Pathology; Hospital Universitari General de Catalunya; Universitat Internacional de Catalunya; Sant Cugat del Vallés Spain
| | - X. Saenz-Sardà
- Department of Pathology; Hospital Universitari Germans Trias i Pujol; Universitat Autònoma de Barcelona; Badalona Spain
- Division of Oncology and Pathology; Department of Clinical Sciences Lund; Lund University; Lund Sweden
| | - P. Vargas
- Department of Pathology; Hospital Universitari Germans Trias i Pujol; Universitat Autònoma de Barcelona; Badalona Spain
| | - C.T. Thompson
- Departments of Biomedical Engineering, Pathology, and Dermatology; Oregon Health Sciences University; Portland Oregon
| | - C. Carrato
- Department of Pathology; Hospital Universitari Germans Trias i Pujol; Universitat Autònoma de Barcelona; Badalona Spain
| | - L. Puig
- Department of Dermatology; Hospital Santa Creu i Sant Pau; Universitat Autònoma de Barcelona; Barcelona Spain
| | - C. Ferrándiz
- Department of Dermatology; Hospital Universitari Germans Trias i Pujol; Universitat Autònoma de Barcelona; Badalona, Barcelona Spain
| | - A. Ariza
- Department of Pathology; Hospital Universitari Germans Trias i Pujol; Universitat Autònoma de Barcelona; Badalona Spain
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Sud A, Shipman AR, Odeke M, Varma K, Read-Jones M, Carr RA. Follicular porokeratosis: four new cases. Clin Exp Dermatol 2017; 42:881-886. [PMID: 28748571 DOI: 10.1111/ced.13195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2016] [Indexed: 01/01/2023]
Abstract
Porokeratosis, a disorder of keratinisation, is clinically characterized by the presence of annular plaques with a surrounding keratotic ridge. Clinical variants include linear, disseminated superficial actinic, verrucous/hypertrophic, disseminated eruptive, palmoplantar and porokeratosis of Mibelli (one or two typical plaques with atrophic centre and guttered keratotic rim). All of these subtypes share the histological feature of a cornoid lamella, characterized by a column of 'stacked' parakeratosis with focal absence of the granular layer, and dysmaturation (prematurely keratinised cells in the upper spinous layer). In recent years, a proposed new subtype, follicular porokeratosis (FP_, has been described, in which the cornoid lamella are exclusively located in the follicular ostia. We present four new cases that showed typical histological features of FP.
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Affiliation(s)
- A Sud
- Department of Dermatology, Warwick Hospital, Warwick, Warwickshire, UK.,Department of Cellular Pathology, Warwick Hospital, Warwick, Warwickshire, UK
| | - A R Shipman
- Department of Dermatology, Warwick Hospital, Warwick, Warwickshire, UK
| | - M Odeke
- Department of Plastic Surgery, University Hospital Coventry and Warwickshire, Coventry, Warwickshire, UK
| | - K Varma
- Department of Dermatology, Nuffield Health Wolverhampton Hospital, Wolverhampton, West Midlands, UK
| | - M Read-Jones
- Hastings House Medical Centre, Wellesbourne, Warwick, Warwickshire, UK
| | - R A Carr
- Department of Cellular Pathology, Warwick Hospital, Warwick, Warwickshire, UK
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Acantholytic squamous cell carcinoma is usually associated with hair follicles, not acantholytic actinic keratosis, and is not "high risk": Diagnosis, management, and clinical outcomes in a series of 115 cases. J Am Acad Dermatol 2016; 76:327-333. [PMID: 27889291 DOI: 10.1016/j.jaad.2016.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/14/2016] [Accepted: 09/20/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acantholytic squamous cell carcinoma (aSCC) is regarded as a high-risk variant of cutaneous squamous cell carcinoma (SCC). Acantholytic actinic keratosis (aAK) has been regarded as a precursor risk factor for aSCC. However, supporting evidence is limited. OBJECTIVE We sought to document clinical features, histologic features, management, and outcomes in a series of aSCC cases. METHODS Definitions of aSCC, aAK, and aSCC arising in association with aAK were applied to a consecutive series of aSCC cases. Clinical characteristics and outcomes were obtained from electronic medical records. RESULTS Of 115 aSCC cases (103 patients, mean age 71.8 years), actinic keratosis was present in 23% (27/115) but only 7.8% (9/115) exhibited associated aAK. Ten cases (10/115, 9%) fulfilled strict histologic criteria for follicular SCC as previously defined, but 50 of 115 (43%) of our aSCC cases exhibited predominant involvement of follicular epithelium rather than epidermis. Clinical outcome (median follow-up, 36 months) was available in 106 of 115 (92%). One patient experienced regional extension (parotid), and 1 patient experienced a local recurrence (nose). No disease-related metastases or deaths were documented. LIMITATIONS This was a single-institution retrospective study from the United States. CONCLUSIONS The presence of acantholysis in cutaneous SCC does not specifically confer aggressive behavior, a finding that may inform clinical practice guidelines.
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Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol 2016; 74:1220-33. [PMID: 26853179 DOI: 10.1016/j.jaad.2015.11.033] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 11/03/2015] [Accepted: 11/12/2015] [Indexed: 02/03/2023]
Abstract
Keratoacanthoma (KA) is a common but underreported tumor of the skin. Two striking features of KA are its clinical behavior with spontaneous regression after rapid growth and its nosological position on the border between benignity and malignancy. We review current knowledge on the clinical, histopathological, and dermoscopic features of KA to ensure a proper diagnosis and describe its variants, including different types of multiple KAs. We highlight current concepts of KA ethiopathogenesis with special emphasis on the genetic background of multiple familial KA, the role of Wnt signaling pathway, and induction of KA by BRAF inhibitors and procedures of esthetic dermatology. Finally, treatment strategies are presented with surgical excision as a first option, followed by other modalities, including intralesional chemotherapy, topical and systemic agents, lasers, cryotherapy, and photodynamic therapy.
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Affiliation(s)
- Bartlomiej Kwiek
- Dermatology and Immunodermatology, Medical University of Warsaw, Warsaw, Poland.
| | - Robert A Schwartz
- Dermatology and Pathology, Rutgers University New Jersey Medical School, and Rutgers University School of Public Affairs and Administration, Newark, New Jersey
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Misago N, Inoue T, Nagase K, Tsuruta N, Tara-Hashimoto A, Kimura H, Takahara K, Narita T, Narisawa Y. Crater/ulcerated form of infundibular squamous cell carcinoma: A possible distinct entity as a malignant (or high-grade) counterpart to keratoacanthoma. J Dermatol 2015; 42:667-73. [PMID: 25854192 DOI: 10.1111/1346-8138.12871] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 02/20/2015] [Indexed: 11/30/2022]
Abstract
Follicular squamous cell carcinoma (SCC) with infundibular differentiation includes the common and crater forms of infundibular SCC. We previously considered the crater/ulcerated infundibular SCC to be a progressive condition of the common form and histopathologically studied an additional five cases of the crater/ulcerated infundibular SCC, the results of which suggested the following characteristic histopathological features and possible developmental process in this type of SCC: (i) a considerable number of continuous hyperplastic follicular infundibula, which may develop at the beginning of the disease; (ii) hyperplastic infundibula exhibiting an abrupt or gradual transition to the SCC component, which frequently change relative to the neoplastic infundibular canal; and (iii) the presence of multiple sites of branching of the neoplastic infundibular canals and/or complete involvement of large cysts in the neoplastic process over the center of the lesion, resulting in ulceration. Based on these histopathological findings, we considered that crater/ulcerated infundibular SCC involve a considerable number of continuous follicular infundibula from the start, although some cases may develop from the common form. We also emphasize the possible aggressive biological behavior of the crater/ulcerated form. Keratoacanthoma (KA) is a unique, benign or borderline malignant neoplasm exhibiting follicular (infundibular/isthmic) differentiation characterized by the involvement of continuous follicular infundibula in multiples. From this standpoint, we consider that crater/ulcerated infundibular SCC is possibly related to KA in terms of histogenesis and is a malignant (or high-grade) counterpart of KA.
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Affiliation(s)
- Noriyuki Misago
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Takuya Inoue
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Kotaro Nagase
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Noriko Tsuruta
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Akiko Tara-Hashimoto
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiromi Kimura
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Kanako Takahara
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tomomi Narita
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yutaka Narisawa
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
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