Co-Director, University of the Incarnate Word School of Osteopathic Medicine
The small cell type contains a condensed nucleus; these cells are often located peripherally to the larger cells acne x lanvin cheap accutin 5 mg fast delivery. Some tumors contain a variable number of cells arranged in tubules acne cure best 40 mg accutin, often peripherally located within the lesion; the tubular cells are usually large and contain eosinophilic cytoplasm skin care natural remedies accutin 20mg mastercard. There typically is a lymphocytic infiltrate that has a scattered distribution throughout the tumor. Some tumors display pronounced degenerative changes, including fibrosis, and cyst formation. Some of the larger tumors are partially or totally necrotic, with only a thin rim of tumor cells. These comprise a broad and varied spectrum of tumors with diverse growth patterns and biologic potential. The following section discusses tumors traditionally classified as apocrine, eccrine, and mixed ductal types. Apocrine Adenocarcinoma (Excluding Extramammary Paget Disease and Ceruminous Carcinoma). Apocrine adenocarcinoma645-647 is a poorly documented and seldom-studied spectrum of adnexal adenocarcinomas that usually occur in the axilla or inguinal region of adults of either sex. In general, local recurrence and regional lymph node metastasis are relatively frequent, occurring in nearly half of the reported cases. Infiltrative growth characteristics have been especially helpful in cases with monomorphic cytologic features. Ultrastructurally, the primary and secondary apocrine carcinomas, especially the secondary lesions, show loss of differentiation compared with normal apocrine glands. Tubular and cribriform patterns of pleomorphic cells containing eosinophilic cytoplasm. Extramammary Paget disease650,651 is a type of adenocarcinoma in situ, often with some degree of apocrine differentiation, similar histologically to mammary Paget disease. The strict application of the term applies only to a type of adenocarcinoma that begins in situ in the epidermis. It is often multifocal and is unresponsive to conventional treatments for spongiotic dermatitides. Besides the essential histologic features of intraepidermal cells showing features of an apocrine adenocarcinoma, one may also observe pagetoid cells in adnexal epithelium. Small tubules may be seen in a few areas, in contrast to mammary Paget disease, in which intraepithelial tubules are rare. It may also be possible to differentiate some cases from secondary pagetoid spread by immunoperoxidase staining. Unfortunately, it is not always known at the time of initial diagnosis whether a dermal component or deepseated primary carcinoma is present and this can be difficult to sort out unless special methods are used. There are prominent epithelioid cells at the basal layer and scattered throughout the epidermis. The differential diagnosis is malignant melanoma,661 Bowen disease, the epidermal phase of neuroendocrine carcinoma,662 and pagetoid spread of visceral carcinomas.
Junctional Spitz nevi show the same epidermal attributes observed in the compound forms skin care olive oil buy accutin without a prescription. If skin care equipment suppliers order discount accutin online, however acne pregnancy discount accutin uk, the melanocytes are entirely spindle shaped and have a pushing border, the differential diagnosis from pigmented spindle cell nevus (Reed) is impossible; in fact, for this reason, the latter is regarded as a special type of Spitz nevus. Pigmented spindle cell nevus is considered to be a special type of spindle or large epithelioid cell nevus (Spitz). Clinically, pigmented spindle cell nevi are sharply demarcated, symmetric or irregular, and dark brown to black. They are usually less than 1 cm in diameter and tend to be discovered on the limbs, especially the thigh,883 of young women in the third decade. Histologically, the lesions are junctional or compound887 and are circumscribed not only at the peripheral epidermal theques but also at the deep dermal boundary. Although theques may be eliminated transepidermally, and solitary melanocytes may be observed within the epidermis in some cases, pagetoid spread is absent. Often the melanocytes have bizarre sizes and shapes, including this myoblastoid type. The nuclei of the epithelioid cells are vesicular with small but readily apparent nucleoli; pseudoinclusions,869 nuclear invaginations of cytoplasm,870 may or may not be observed in an individual cell, and none of these features is definitive for the diagnosis. The spindle-shaped cells often are uniform and closely apposed within a theque or nest. Within theques, the spindle cells often follow the line of the adjacent surface or adnexal epithelium. Cells of either type may be in mitosis; however, mitotic figures are usually sparse, usually normal, and, when present, usually found in the superficial areas of the lesion. Immunohistochemically, Spitz nevi are usually positive in the cytoplasm and nucleus when stained with S-100 protein. No epidermal component, but similar in cytology to the common type of Spitz nevus. Pigmented spindle cell nevus usually can be differentiated by making the observation of a symmetric lesion with well-circumscribed borders. Blue Nevus the blue nevus892-895 is a localized, congenital or acquired, melanocytic nevus that has a range of clinically blue hues and may grow in several patterns histologically. These range from a diffuse, symmetric population of dermal, pigmented, dendritic melanocytes (common type), to a mixed population of dendritic melanocytes and uniform epithelioid melanocytes with sclerotic stroma (mixed type), to epithelioid melanocytes with sclerotic stroma (cellular or epithelioid type). Conceptually, the nevi of Ota and Ito and the Mongolian spot are situated at the common blue nevus end of the histologic spectrum of blue nevi; however, these are clinically distinct lesions that are usually separated from localized forms of blue nevi. They may affect patients of either sex and may be discovered at any age, including birth. Histologically, the dendritic (common) blue nevi range from inconspicuous to obvious diffuse populations within the dermis. Minimal nesting of the melanocytes occurs, and the collagen within and around the lesion is typically similar to the adjacent nonlesional collagen. Occasionally they are hypomelanotic,904,905 and differentiation from dermatofibroma can be difficult. The usual differential diagnosis is with nevi of Ito and Ota and the Mongolian spot. On scanning magnification, cellular blue nevi are readily apparent, symmetric, and fibrotic. The deeper portions are often well circumscribed and can extend into the subcutis. Some may be locally destructive if fixed structures, such as bone, are in close proximity. When a dermal component is present, the melanocytic nests are closely apposed, are fascicular in their pattern of growth, and occupy the dermis minimally, usually to a depth of no more than the papillary dermis.
Despite their slow growth skin care quotes order accutin 10 mg on-line, chordomas are relentless neoplasms that usually present with extensive local infiltration and destruction of adjacent skin care forum buy accutin 30mg amex, often vital skin care 1 order generic accutin line, structures. More recent evidence suggests that optimal treatment may include photon or proton radiotherapy alone or, when possible, combined with gross total resection. The existence of chondroid chordoma distinct from lowgrade chondrosarcoma has been questioned, but there appear to be immunohistochemical differences that support the contention that chondroid chordoma is a distinct lesion. Dedifferentiation of chordomas to highgrade sarcomas occurs and includes transformation to fibrosarcoma, unclassified pleomorphic sarcoma, osteosarcoma, or chondrosarcoma. A, the neoplastic cells are epithelioid with vesicular nuclei and abundant, granular to vacuolated cytoplasm. The vacuolization corresponds to the presence of glycogen or mucus; when extensive it can produce a soap-bubble appearance, compressing the nucleus and creating the characteristic physaliferous cells; neoplastic cells are immunoreactive for (B) cytokeratin and (C) S-100 protein. Malignant Teratoma (Teratocarcinosarcoma) Malignant teratoma of the sinonasal tract is a rare tumor showing combined histologic features of carcinosarcoma and teratoma. The most common site of involvement is the nasal cavity; other sites of involvement include the ethmoid and maxillary sinuses. Histologically, malignant teratomas are characterized by a combination of epithelial and mesenchymal tissue components with very variable growth patterns. The teratoid components include "fetalappearing" clear cell squamous epithelium, organoid structures, or neural tissue in the form of neural rosettes and neurofibrillary matrix. The "fetal-appearing" clear cell squamous epithelium represents a characteristic histologic finding in this entity and is supportive evidence of the teratoid nature of this neoplasm, given its description in teratomas of other organ systems. More often, metastasis to the upper aerodigestive tract is part of widely metastatic disease. Although virtually every conceivable malignancy may metastasize to the upper aerodigestive tract, the most common primary tumor metastatic to this region is renal cell carcinoma. No sex predilection is seen; sinonasal polyps occur in all ages but are commonly seen in adults over 20 years of age and rarely seen in children younger than 5 years of age. Antrochoanal polyps are sinonasal polyps specifically arising from the maxillary antrum. The majority of antrochoanal polyps are single, unilateral lesions with associated nasal obstruction. Posterior extension from the maxillary sinus toward the nasopharynx may result in obstruction of the nasopharynx and clinical suspicion of a primary nasopharyngeal tumor. Antrochoanal polyps are often associated with bilateral maxillary sinusitis and may also be associated with more typical sinonasal polyps. Antrochoanal polyps are identical to other nasal polyps except for the presence of a stalk with attachment to the maxillary sinus. Histologically, the surface epithelium is composed of intact respiratory epithelium but may show squamous metaplasia. The stroma is markedly edematous and is noteworthy for the absence of mucoserous glands. A mixed chronic inflammatory cell infiltrate is present and is predominantly composed of eosinophils, plasma cells, and lymphocytes. The stroma contains bland-appearing fibroblasts and small to medium-sized blood vessels. Secondary changes include surface ulceration, fibrosis, infarction, granulation tissue, deposition of an amyloid-like stroma, osseous and/or cartilaginous metaplasia, glandular hyperplasia, granuloma formation, and atypical stromal cells.
Syndromes
Intellectual disability (only present in some types of the condition)
The victim is unconscious, is experiencing convulsions, has multiple injuries, appears to be in any distress, or is not lucid.
Anyone who has symptoms of infectious mononucleosis, but has negative test results for mononucleosis and Epstein Barr virus
Anionic surfactants (soaps)
Fever
Heredity and disease
High erythrocyte sedimentation rate (ESR)
Vomiting
Who have conditions such as diabetic neuropathy or polyarteritis nodosa
Speech difficulty (rare)
Clinical Features Most granular cell tumors arise in the skin or subcutaneous tissue of middle-aged adults with a slight female predominance skin care collagen accutin 20 mg without a prescription. Virtually any anatomic site may be affected skin care with peptides discount accutin 30mg fast delivery, but the trunk (including vulva) and the tongue are perhaps the most common acne vs pimples best purchase for accutin. Lesions in the breast,112 esophagus,113 colon,114 larynx (see Chapter 4) and a wide range of other visceral locations are well recorded; however, origin within skeletal muscle is relatively infrequent. Up to 10% of patients with granular cell tumor have multiple lesions,111,115,116 and this phenomenon appears to be more common in blacks. In most cases the tumor is slowly growing, is rarely tender, and usually measures less than 3 cm in maximum dimension. The local recurrence rate in benign lesions is less than 5% and usually reflects incomplete excision. Histologic Features Granular cell tumors have a remarkably uniform appearance, irrespective of their location. Circumscription is variable, and up to 50% of cases have poorly defined or infiltrative margins. They are large, rounded, or polygonal and have copious, finely granular, eosinophilic cytoplasm. Tumor cell nuclei are small, centrally situated, and usually pyknotic or hyperchromatic, although in some cases they appear vesicular. Some lesions show scattered mitoses or mild nuclear atypia, which often appears degenerative. Note the typically hyperchromatic small nuclei and finely granular cytoplasm with occasional eosinophilic droplets. Overlying epidermal or mucosal hyperplasia, sometimes pseudoepitheliomatous in degree, is common, especially in oral lesions. This lesion from a neonate shows more numerous vessels and inflammatory cells than are usual in adult cases. Superficially located examples are commonly associated with acanthosis or pseudoepitheliomatous hyperplasia of the overlying squamous epithelium. Ultrastructurally, as already mentioned, granular cells contain numerous secondary lysosomes containing prominent myelin figures. In addition, tumor cells show a variably complete external lamina and multiple cytoplasmic processes. Differential diagnosis in most cases presents no problem other than considering the possibility of other tumor types showing granular cell change, as discussed earlier. Some tumors may have to be distinguished from adult rhabdomyoma, histiocytoid carcinoma. Also known as congenital epulis, this is a very uncommon lesion that presents as a polypoid swelling most often situated over the lateral alveolar ridge, especially of the maxilla. Over time these lesions tend to reduce in size, and they seem not to recur after excision. Histologically, they are composed of cells essentially identical to those in the adult neuroectodermal type. Immunohistochemically,121,122 these lesions are S-100 protein negative and show no evidence of any specific differentiation; by electron microscopy122,123 the cells have no external lamina and show partially histiocytic features.
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