Keratoacanthoma
Encyclopedia
Keratoacanthoma is a common low-grade (unlikely to metastasize or invade) skin tumour that is believed to originate from the neck of the hair follicle
. Many pathologists consider it to be a form of squamous cell carcinoma
(SCC). The pathologist often labels KA as "well-differentiated squamous cell carcinoma, keratoacanthoma variant", because about 6% of KA manifest itself as squamous cell carcinoma when left untreated. KA is commonly found on sun-exposed skin, and often is seen on the face, forearms and hands. The defining characteristic of KA is that it is dome-shaped, symmetrical, surrounded by a smooth wall of inflamed skin, and capped with keratin scales and debris. It always grows rapidly, reaching a large size within days or weeks, and if untreated will starve itself of nourishment, necrose (die), slough, and heal with scarring. While some pathologists classify KA as a distinct tumor and not a malignancy, enough clinical and histological KA do progress to invasive and aggressive squamous cell cancers, therefore prompt and aggressive treatment is required. In reality, the defining characteristics of a KA can not be found when only a small fragment of a large KA is submitted for pathology review. If the keratin debris is submitted, no diagnosis can be made. If a deep core or peripheral deep wedge is performed, a squamous cell carcinoma is often noted. Only when almost the entire structure is submitted, can a true diagnosis of a KA be made. This further complicates the distinction between a clinical diagnosis of a KA and the pathologic diagnosis of a KA vs a squamous cell cancer.
A skin biopsy
must be performed to confirm the diagnosis. Unfortunately, a shave biopsy will often reveal only keratin fragments. A deep punch biopsy will often reveal a well differentiated, mildly atypical, squamous cell suggestive of an actinic keratosis or a squamous cell carcinoma. Only when the pathologist has access to the entire lesion (not practical in many circumstances) can a correct diagnosis be made. From a practical standpoint (insurance reimbursement), the correct diagnosis should be "well differentiated squamous cell carcinoma, keratoacanthoma variant". This is especially important for facial and nasal KA's, as it allows the surgeon to treat the tumor with the proper respect it deserves, with margin-controlled surgery like Mohs surgery
.
Correct diagnosis often requires communication between the surgeon and the pathologist. Many pathologists are still under the impression that keratoacanthomas are benign growths that do not require surgery. Unfortunately, when the lesion appears on the nose, face, or hands it often grows to marble or golf ball size before necrosing, and leaving a sizable crater in the process. From a practical standpoint, the correct diagnosis of low grade squamous cell carcinoma should be rendered after communication between the surgeon and pathologist, as the tumor is often much more aggressive and the morbidity is much higher than the relatively benign basal cell carcinoma
.
allows for good margin control with minimal tissue removal; unfortunately, many insurance companies require the correct diagnosis of a malignancy before allowing such procedure. Recurrence after electrodesiccation and curettage is common, and usually can be identified and treated promptly with either further curettage or surgical excision. Allowing the KA to grow and necrose spontaneously is not acceptable in today's standard of care.
Hair follicle
A hair follicle is a skin organ that produces hair. Hair production occurs in phases, including a growth phase , and cessation phase , and a rest phase . Stem cells are principally responsible for the production of hair....
. Many pathologists consider it to be a form of squamous cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma , occasionally rendered as "squamous-cell carcinoma", is a histologically distinct form of cancer. It arises from the uncontrolled multiplication of malignant cells deriving from epithelium, or showing particular cytological or tissue architectural characteristics of...
(SCC). The pathologist often labels KA as "well-differentiated squamous cell carcinoma, keratoacanthoma variant", because about 6% of KA manifest itself as squamous cell carcinoma when left untreated. KA is commonly found on sun-exposed skin, and often is seen on the face, forearms and hands. The defining characteristic of KA is that it is dome-shaped, symmetrical, surrounded by a smooth wall of inflamed skin, and capped with keratin scales and debris. It always grows rapidly, reaching a large size within days or weeks, and if untreated will starve itself of nourishment, necrose (die), slough, and heal with scarring. While some pathologists classify KA as a distinct tumor and not a malignancy, enough clinical and histological KA do progress to invasive and aggressive squamous cell cancers, therefore prompt and aggressive treatment is required. In reality, the defining characteristics of a KA can not be found when only a small fragment of a large KA is submitted for pathology review. If the keratin debris is submitted, no diagnosis can be made. If a deep core or peripheral deep wedge is performed, a squamous cell carcinoma is often noted. Only when almost the entire structure is submitted, can a true diagnosis of a KA be made. This further complicates the distinction between a clinical diagnosis of a KA and the pathologic diagnosis of a KA vs a squamous cell cancer.
Classification
Keratoacanthomas (molluscum sebaceum) may be divided into the following types:- Giant keratoacanthomaGiant keratoacanthomaGiant keratoacanthomas are a cutaneous condition, a variant of keratoacanthomas, which in some instances may reach dimensions of several centimeters....
- Keratoacanthoma centrifugum marginatumKeratoacanthoma centrifugum marginatumKeratoacanthoma centrifugum marginatum is a cutaneous condition, a variant of keratoacanthomas, which is characterized by multiple tumors growing in a localized area.- See also :* Keratoacanthoma* Nail anatomy* List of cutaneous conditions...
- Multiple keratoacanthomasMultiple keratoacanthomasMultiple keratoacanthomas is a cutaneous condition, a variant of keratoacanthomas, which is characterized by the appearance of multiple, sometimes hundreds of keratoacanthomas....
(Ferguson Smith type of multiple self-healing keratoacanthomas, Multiple keratoacanthomas of the Ferguson-Smith type) - Generalized eruptive keratoacanthomaGeneralized eruptive keratoacanthoma220px|thumb|right| Picture of the face of a patient Generalized eruptive keratoacanthomas of GrzybowskiGeneralized eruptive keratoacanthoma is a cutaneous condition, a variant of keratoacanthomas, characterized by hundreds to thousands of tiny follicular keratotic papules over the entire body.-...
(Generalized eruptive keratoacanthoma of Grzybowski) - Subungual keratoacanthoma
Etiology
The tumors usually occur in older individuals (mean age 64 years old). Like squamous cell cancer, data suggests ultraviolet light from the sun causes the development of KA. Just like its close relative, the squamous cell cancer, sporadic cases have been found co-infected with the human papilloma virus (HPV).Diagnosis
Diagnosis is best done with clinical exam and history. It presents as a fleshy, elevated and nodular lesion with an irregular crater shape and a characteristic central hyperkeratotic core. Usually the patient will notice a rapidly growing dome-shaped tumor on sun-exposed skin.A skin biopsy
Skin biopsy
Skin biopsy is a biopsy technique in which a skin lesion is removed and sent to the pathologist to render a microscopic diagnosis. It is usually done under local anesthetic in a physician's office, and results are often available in 4 to 10 days. It is commonly performed by dermatologists. Skin...
must be performed to confirm the diagnosis. Unfortunately, a shave biopsy will often reveal only keratin fragments. A deep punch biopsy will often reveal a well differentiated, mildly atypical, squamous cell suggestive of an actinic keratosis or a squamous cell carcinoma. Only when the pathologist has access to the entire lesion (not practical in many circumstances) can a correct diagnosis be made. From a practical standpoint (insurance reimbursement), the correct diagnosis should be "well differentiated squamous cell carcinoma, keratoacanthoma variant". This is especially important for facial and nasal KA's, as it allows the surgeon to treat the tumor with the proper respect it deserves, with margin-controlled surgery like Mohs surgery
Mohs surgery
Mohs surgery, also known as chemosurgery, created by a general surgeon, Dr. Frederic E. Mohs, is microscopically controlled surgery used to treat common types of skin cancer. It is one of the many methods of obtaining complete margin control during removal of a skin cancer using frozen section...
.
Correct diagnosis often requires communication between the surgeon and the pathologist. Many pathologists are still under the impression that keratoacanthomas are benign growths that do not require surgery. Unfortunately, when the lesion appears on the nose, face, or hands it often grows to marble or golf ball size before necrosing, and leaving a sizable crater in the process. From a practical standpoint, the correct diagnosis of low grade squamous cell carcinoma should be rendered after communication between the surgeon and pathologist, as the tumor is often much more aggressive and the morbidity is much higher than the relatively benign basal cell carcinoma
Basal cell carcinoma
Basal-cell carcinoma is the most common type of skin cancer. It rarely metastasizes or kills. However, because it can cause significant destruction and disfigurement by invading surrounding tissues, it is still considered malignant. Statistically, approximately 3 out of 10 Caucasians may develop a...
.
Treatment
On the trunk, arms, and legs, electrodesiccation and curettage often suffice. Excision of the entire lesion is often required if one wants to confirm the clinical diagnosis of keratoacanthoma. On the nose and face, Mohs surgeryMohs surgery
Mohs surgery, also known as chemosurgery, created by a general surgeon, Dr. Frederic E. Mohs, is microscopically controlled surgery used to treat common types of skin cancer. It is one of the many methods of obtaining complete margin control during removal of a skin cancer using frozen section...
allows for good margin control with minimal tissue removal; unfortunately, many insurance companies require the correct diagnosis of a malignancy before allowing such procedure. Recurrence after electrodesiccation and curettage is common, and usually can be identified and treated promptly with either further curettage or surgical excision. Allowing the KA to grow and necrose spontaneously is not acceptable in today's standard of care.