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- 困惑？！面部肿物
最初看到切片时，第一印象是良性病变---即角化棘皮瘤，然而当看到大体标本又到病房详细询问病史后，改变了看法，认为用良性病变不好解释。从病变的发展过程看，很有可能是病变一开始是良性的，由于反复复发和人为刺激，使其发生恶变。
尽管边缘扩展型角化棘皮瘤可以长大到20cm，但据文献报道它最终还是在一年内逐渐自愈的，且可以在周边扩展的同时，中央部分愈合，且病变基底深度一般不会超过汗腺水平。如果病变持续发展，则应考虑低度恶性鳞状细胞癌的可能。
所以，最后的报告是：结合病变发展过程、大体形态及镜下病变浸润深度，考虑为低度恶性鳞状细胞癌。
- 博学之，审问之，慎思之，明辨之，笃行之。
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本帖最后由 于 2010-02-04 15:53:00 编辑
| 以下是引用xljin8在2010-1-22 5:37:00的发言： 低倍镜照片不太清晰，高倍镜非常好。 |
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本帖最后由 于 2010-02-04 15:50:00 编辑
此例就临床表现应该认为生物学行为是恶性，问题是与一般鳞状细胞癌的形态不符合。病理诊断主要鉴别诊断为：1）巨大刺激性炎症性脂溢性角化病，一般为直径3cm左右，无如此巨大和侵袭性临床过程；2）离心性边缘扩展型角化棘皮瘤，可大到20cm；3）特殊类型的鳞状细胞癌。因此鉴别诊断集中到此例是角化棘皮瘤还是角化棘皮瘤样鳞状细胞癌。现将 “AFIP， series 4, Nonmelanocytic tumors of the skin,p44,2006”有关角化棘皮瘤的鉴别诊断摘录如下， 供参考：
There is no known absolutely reliable means of distinguishing keratoacanthoma from squamous cell carcinoma. The current trend is to regard keratoacanthoma as a varriant form of squamous carcinoma, one that is capable of selfhealing, and to advocate complete if conservative removal of all such lesion. While we generally agree with this viewpiont, we still make a diagnosis of keratoacanthoma provided that certain conditions are met. There should be a clear-cut clinical description( preferably from a dermatologist) of a rapidly evolving crateriform lesion, with keratoacanthoma as the primary clinical diagnosis, and no history of immunosuppression. Adequate biopsy material should be submitted, allowing complete visualization of the lesion. Finally, the microscopic finding should be absolutely classic for keratoacanthoma. Otherwise, a diagnosis of squamous cell carcinoma with features of keratoacanthoma is preferred.
主要观点：
1）尚未认识到有绝对可靠的方法去鉴别角化棘皮瘤和鳞状细胞癌；
2）近年的趋势认为角化棘皮瘤是鳞状细胞癌的变型，它具有自愈性，主张即使为保守的完整切除也可治愈。
3）尽管同意上述癌的观点，假如符合某些条件，我们仍然诊断为角化棘皮瘤。
有典型的临床描述（最好是皮肤科医师）快速演进的火山口性病变；
临床最初诊断为角化棘皮瘤
无免疫抑制病史
活检标本适当，能完全观察到整个病变
显微镜下为典型的角化棘皮瘤形态
4）如果不符合上述几点，宁可诊断为具有角化棘皮瘤特点的鳞状细胞癌
There is no known absolutely reliable means of distinguishing keratoacanthoma from squamous cell carcinoma. The current trend is to regard keratoacanthoma as a varriant form of squamous carcinoma, one that is capable of selfhealing, and to advocate complete if conservative removal of all such lesion. While we generally agree with this viewpiont, we still make a diagnosis of keratoacanthoma provided that certain conditions are met. There should be a clear-cut clinical description( preferably from a dermatologist) of a rapidly evolving crateriform lesion, with keratoacanthoma as the primary clinical diagnosis, and no history of immunosuppression. Adequate biopsy material should be submitted, allowing complete visualization of the lesion. Finally, the microscopic finding should be absolutely classic for keratoacanthoma. Otherwise, a diagnosis of squamous cell carcinoma with features of keratoacanthoma is preferred.
主要观点：
1）尚未认识到有绝对可靠的方法去鉴别角化棘皮瘤和鳞状细胞癌；
2）近年的趋势认为角化棘皮瘤是鳞状细胞癌的变型，它具有自愈性，主张即使为保守的完整切除也可治愈。
3）尽管同意上述癌的观点，假如符合某些条件，我们仍然诊断为角化棘皮瘤。
有典型的临床描述（最好是皮肤科医师）快速演进的火山口性病变；
临床最初诊断为角化棘皮瘤
无免疫抑制病史
活检标本适当，能完全观察到整个病变
显微镜下为典型的角化棘皮瘤形态
4）如果不符合上述几点，宁可诊断为具有角化棘皮瘤特点的鳞状细胞癌
- xljin8
