A clinical and biological review of keratoacanthoma*
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Abstract:
Keratoacanthoma (KA) is a common skin tumour that remains controversial regarding classification, epidemiology, diagnosis, prognosis and management. Classically, a KA manifests as a rapidly growing, well-differentiated, squamoid lesion with a predilection for sun-exposed sites in elderly people and a tendency to spontaneously regress. Historically, KAs have been considered a variant of cutaneous squamous cell carcinoma (cSCC) and are often reported as KA-type cSCC. However, the penchant for regression has led many to categorize KAs as biologically benign tumours with distinct pathophysiological mechanisms from malignant cSCC. The clinical and histopathological similarities between KA and cSCC, particularly the well-differentiated variant of cSCC, have made definitive differentiation difficult or impossible in many cases. The ambiguity between entities has led to the general recommendation for surgical excision of KAs to ensure a potentially malignant cSCC is not left untreated. This current standard creates unnecessary surgical morbidity and financial strain for patients, especially the at-risk elderly population. There have been no reports of death from a definitive KA to date, while cSCC has an approximate mortality rate of 1·5%. Reliably distinguishing cSCC from KA would shift management strategies for KAs towards less-invasive treatment modalities, prevent unnecessary surgical morbidity, and likely reduce associated healthcare costs. Herein, we review the pathophysiology and clinical characteristics of KA, and conclude on the balance of current evidence that KA is a benign lesion and distinct from cSCC.Keywords:
Keratoacanthoma
Pathophysiology
The authors' aim in this study is to discuss and review, from the presentation of a keratoacanthoma case with a clinical diagnosis of squamous cell carcinoma, the clinical and histologic criteria for a differential diagnosis between these two lesions, as well as to analyze the factors presumably involved in keratoacanthoma formation.
Keratoacanthoma
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Keratoacanthoma
Verrucous carcinoma
Foot (prosody)
Skin grafting
Surgical excision
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A case of primary cutaneous hyalohyphomycosis in a healthy individual is presented. The initial clinial impression was kerato‐acanthoma or squamous cell carcinoma. Upon excision, the lesion proved to be an example of cutaneous hyalohyphomycosis due to an unidentified, non‐pigmented fungal organism. The lesion was completely excised, and the patient was treated with saturated solution of potassium iodide. To date, there has been no evidence of recurrence. The clinical, histologic and mycologic aspects of hyalophyphomycosis are discussed.
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To the Editor.— The treatment of keratoacanthoma (KA) with fluorouracil cream administered by the intralesional1,2and topical routes at concentrations of 20%3and 5%4,5has been reported. When treating these lesions without histologic confirmation, the following criteria are suggested to preclude the misdiagnosis of squamous cell carcinoma: (1) characteristic morphology of the keratoacanthoma, (2) history of growth of the lesion to its ultimate size within four to six weeks, and (3) prompt response of the lesion to fluorouracil treatment with at least 60% to 70% involution during a two-week treatment period.4We describe a patient with such a lesion that initially responded to fluorouracil therapy only to recur three weeks after completion of therapy. An excisional biopsy specimen at that time revealed a poorly differentiated squamous cell carcinoma. Report of a Case.— A 76-year-old man presented with a three- to four-week history of a rapidly growing
Keratoacanthoma
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Keratoacanthoma is a common skin lesion of the head and neck region, particularly of the central face. Although it is a benign tumor, it may mimic a well-differentiated squamous cell carcinoma in its clinical and particularly its histologic appearance. Two cases of squamous cell carcinoma are presented in which the histologic diagnosis of keratoacanthoma was made. Serious errors in treatment may arise from reliance on the histologic characteristics alone. Conservative treatment of keratoacanthomas should be avoided. Prompt and total excision is the treatment of choice.
Keratoacanthoma
Surgical excision
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Keratoacanthoma (KA) is a benign epithelial proliferative lesion which frequently occurs on the sun exposed areas of the skin.KA originates within the pilosebaceous apparatus of the skin and may be solitary or multiple.Solitary KA can be difficult to differentiate from squamous cell carcinoma (SCC) both clinically and microscopically.However, the clinical course of the lesion and its ability to self involute makes it a distinct clinical entity.Solitary KA appears on the vermilion border of the lower lips with some frequency.A case of keratoacanthoma involving the upper lip is reported presenting as an exophytic growth that resolved after excisional biopsy.Photographic documentation of the case along with relevant management protocol is discussed.The article emphasizes the significance of recognizing such lesion and discriminating it from SCC thus carrying diagnostic and therapeutic implications.However, in case of dilemma it is prudent to assume that the lesion is SCC unless proved otherwise clinically or histologically.
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An 81-year-old man had a keratotic eyelid lesions for 20 years. He eventually sought treatment by ophthalmic plastic surgery. Clinically, the lesion resembled a keratoacanthoma. Findings from histologic examination of the excision biopsy specimen showed a squamous cell carcinoma. The lesion was completely excised. This case demonstrates the difficulty in making a correct clinical diagnosis of a keratotic eyelid lesion. Performing a histologic examination of nonregressed keratotic lesions is essential to exclude a squamous cell carcinoma.
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This article reports the results of a clinicopathologic study of 44 keratoacanthomas of the eyelid. This tumor characteristically has a rapid development and presents as a hemispherical elevated lesion with a keratinfilled central crater. There is some predilection for the lower lid. Clinically the lesion is most often confused with basal cell carcinoma, but it may resemble a variety of other epithelial tumors. In the past keratoacanthoma has often been clinically and pathologically interpreted as squamous cell carcinoma. The lesion is benign, and although it may undergo spontaneous regression, we feel that simple excision at an early stage is the treatment of choice in most cases. The pathogenesis is not established.
Keratoacanthoma
Pathogenesis
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Although keratoacanthoma regresses spontaneously, treating physicians seldom allow these lesions to progress through their natural course. We describe two cases of skin lesions, the first being a keratoacanthoma, which enlarged rapidly and then involuted with minimal scarring. The second lesion was initially misdiagnosed and failed to respond to medical management. An accurate diagnosis of squamous cell carcinoma was not made until the lesion had become deeply invasive. These two lesions have helped clarify our thoughts about the observation of keratoacanthomas, the need for frequent patient follow-up when a lesion is not surgically ablated, and the importance of providing the pathologist with an adequate biopsy specimen for diagnostic purposes.
Keratoacanthoma
Skin lesion
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