Seungkirl Ahn, PhD

• Assistant Professor in Medicine

https://medicine.duke.edu/faculty/seungkirl-ahn-phd

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Foci of hypercellularity are additionally generally noted throughout the dermal population of cells. Neural differentiation resembling neural tubules or pseudo-Meissnerian buildings may also occur. Congenital nevi with atypical options Archltectlral Disorder and Cytologlc Atypla All sorts of congenital nevi might exhibit various degrees of architectural and cytologic atypia of both the intraepidermal and dermal parts (Tables 27-14 and 27-15). Epithelioid cell lntraepidermal Pagetoid unfold in nevi Dermal Expansile nodule of epithelioid cells Epithelioid schwannoma 2. Spindle cell with schwannian or perineurial differentiation Dermal Neuroid spindle cell tumor (neurofibroma-like) Schwannoma 4. Specific mesenchymal "ectomesenchymal") differentiation Cartilage Lipoma Hemangioma 6. They are usually sharply outlined, symmetrical, spherical or oval, and sometimes exhibit easy to shiny floor. Most of those nodular mobile aggregates tend to present gradual transition (not abrupt) with the encompassing nevus. If cytological atypia is present, the melanocytes are often uniform and mitotic exercise in minimal. However, vital cytologic atypia, conspicuous mitotic activity (eg, as much as 25 mitoses per mm2), ulceration, and necrosis may be noticed in rare lesions. Hfstopathologlc Features Microscopic examination discloses nodules of uniform spindle cells with neuroid/schwann. Neither significant cytological atypia, mitotic exercise, nor necrosis is observed. Mitotic rate was thirteen per mm 2 � the patient had a historical past of other proliferative nodules and is alive and properly without any recurrence on longterm follow-up. The latter lesion may be asymptomatic or result in hydrocephalus (either the communicating or noncommunicating type), seizures, psychological retardation, different neurologic signs, or leptomeningeal melanoma. Meningeal biopsy could additionally be necessary to verify a prognosis of leptomeningeal melanoqtosis. I proliferations that always involve the papillary dermis, resulting in a compound news. Furthermore, careful examination reveals low-grade or no cytologic atypia of those cells. Virtually all of those proliferations are benign and represent mimics of melanoma. The overwhelming majority of theae nodular proliferations, notably within the neonatal period, are biologically benign mimics of melanoma. D4 Such tumors usually manifest cohesive mobile nodules distinctly completely different from the encircling nevus, substantial nuclear pleomorphism, necrosis, mitotic activity, and hanging cellularity. Melanomas creating in newborns and infants youthful than 1 yr ofage are extremely rare, and such a diagnosis must at all times be critically questioned. A prudent strategy is to ensure full surgical removing of such nodular lesions and to carefully monitor the affected person for recurrence or metastasis. The cells are closely crowded; have minimal cytoplasms; and comprise small round or slightly oval nuclei with dense, uniformly dispersed chromatin. The cells tackle the appearance oflymphoblastic lymphoma or comparable blastic" tumors. The distinction from melanoma pertains to the gradual mixing of the cellular nodule with the encompassing nevus. Necrotic cells, important cytologic atypia, and simply discovered mitotic exercise are additionally features suggesting melanoma. Nonetheless, age is a critical factor to be thought of within the analysis of these proliferations. A diagnosis of melanoma should be made with excessive caution in kids youthful than age 1 yr. De novo melanomas arising at start (congenital melanoma) or in prepubertal individuals.

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Oral manifestations of the systemic situations may predate systemic findings in up to half of sufferers with Crohn disease. Orofacial granulomatosis has been attributed to an abnormal immune response to quite a lot of antigens, including food and meals components as well as cinnamon products. The epithelium is acanthotic, with leukocyte exocytosis and infrequently confluence of the rete ridges at the bases. There is edema of the papillary lamina propria, thinning of the suprapapillary epithelium, vascular ectasia, and a variable lymphoplasmacytic infiltrate, all options of psoriasiform mucositis. There is also an association with liver illnesses including sclerosing cholangitis. If the affected person presents with the triad of cheilitis granulomatosa, fissured tongue, and facial nerve palsy, the analysis ofMelkersson-Rosenthal syndrome applies. Some contemplate cheilitis granulomatosa alone because the oligosymptomatic form of Melkersson-Rosenthal syndrome. These granulomas often are current in small numbers and may be poorly shaped, so multiple sections may be needed earlier than they am be identified definitively. The surrounding tissues could also be edematous and comprise scattered continual inflammatory cells, often in a peri- or paravascular location. If salivary glands are present, granulomas should be sought inside the gland parenchyma. Stains for organisms are negative, and the granulomas should comprise no identifiable foreign materials Since the condition might wax and wane, the looks of granulomas will not be demonstrable in all patients. Differential Diagnosis the granulomas of orofacial granulomatosis are indistinguishable from these of Crohn disease, and the affected person should be evaluated for gastrointestinal signs and symptoms. Granulomas of sarcoidosis usually include asteroid our bodies and have a tendency to be well shaped. Granulomatosis with polyangiitis (Wegener granulomatosis) presents clinically with �strawberry gingivitis" and histologic options of pseudoepitheliomatous hyperplasia, vasculitis, geographic necrosis, abscesses, and a blended inflammatory infiltrate along with delicate granulomas. This is a standard situation caused by mucous extravasation and pooling in the interstitium because of traumatic disruption of the integrity of the excretory salivary duct. This condition was first described in the early 1970s, and its etiology was putatively ascribed to a hypersensitivity reaction to a element of chewing gum. Superficial mucoceles are 2 to three mm blisterlike lesions situated on the exhausting and soft palate. In the unique chewing gum-associated circumstances, there was concomitant cheilitis and glossitis. A portion of the salivary duct, typically exhibiting squamous metaplasia, the epithelium is markedly hyperplastic with spongiosis and generally superficial microcyst and pustule formation in a psoriasiform sample. Dilated capillaries and scattered lymphocytes are noted in areu the place the plasma cell infiltrate is less dense. Papillary buildings comprising small vascular channels and fibroblasts protrude into the lumen. The absence of proliferation ofductal, myoepithelial, epidermoid, mucous, or pricey cells differentiates a mucocele from a neoplastic course of. Neaotizing sialometaplasia Neaotizing sialometaplasia is an unusual inflammatory situation characterized by ulceration of the mucosa overlying infarcted salivary glands. It could additionally be confused with a malignant course of because of fast onset, the scientific appearance, and histopathology. A cyst-like cavity is crammed with mucus and surrounded by granulation tissue and histiocytes. Olnlcal Features could additionally be current at the periphery, and the associated minor salivary glands exhibit varying levels of persistent irritation, ductal ectasia, acinar atrophy, and interstitial fibrosis (all signs of obstruction). In late phases, only a nodule of granulation tissue with occasional muciphages remains. Synovium-like villous projections could additionally be current, and condensations of mucous results in myxoglobulosis. The mucosa of the posterior onerous palate and associated glands is affected in 70% to 80% of patients, with two-thirds of instances occurring unilaterally. The lesion normally begins as a swelling that ulcerates inside days; pain could or will not be present After a couple of weeks, the mass of necrotic salivary gland tissue exfoliates, and speedy therapeutic ensues.

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Metastatic tumors additionally embrace melanomas, sarcomas, and cutaneous involvement by hematopoietic malignancies. As detailed elsewhere in this chapter, the age and gender of the affected person and the situation, distribution, and clinical look of the metastasis are of statistical worth in identifying a main tumor. Caution in interpretation is necessary in this space as a outcome of patients might develop multiple major malignancy, and a cutaneous metastasis may be the presenting signal of a beforehand occult major lesion. Many carcinomas, together with renal cell carcinoma, endometrial adenocarcinoma, thyroid follicular carcinoma, and a lot of spindle cell carcinomas categorical vimentin, which limits the diagnostic utility of vimentin expression as a marker of mesenchymal differentiation. In basic, the more particular melanocyte markers are probably to label a considerably smaller proportion of spindle cell or desmoplastic lesions than do the less particular melanoma markers. Some of those markers are discussed below at the aspect of their related malignancies. Nodules are the most typical scientific presentation of breast cutaneous metastases; they vary in dimension from 1 to three cm and are located within the dermis or subc:utis. Infiltration of tumor cells in a single file between dermal collagen bundles ends in a resemblance to granuloma annulare. Cytological atypia and intracytoplasmic duct formation are higher seen at excessive energy. Differential Diagnosis the various patterns of breast carcinoma every have their very own listing of circumstances from which a cutaneous metastasis have to be distinguished. A history of major breast carcinoma is useful, but patients can have a couple of malignancy, so care should be taken not to overlook alternative cutaneous primary or metastatic tumors. A major ductal eccrine adenocarcinoma may be thought-about when solid cords, tubules, and lumina formation are famous (see Chap. When single-file rows or cords of deeply basophilic cells predominate, one could have to contemplate major Merkel cell or metastatic neuroendocrine carcinoma, hematolymphoid malignancies, sclerosing or morpheaform basal cell carcinoma, and malignant sweat gland tu. Epidennotropic metastases have additionally been reported from primary websites aside from breast, including the prostate, colon, and skin. Cutaneous adenocarcinomas could be taken as major in circumstances in which an in situ part may be demonstrated. Lung carcinoma In older case sequence, cutaneous metastases from lung carcinoma represent 12% to 24% of cutaneous metastases in males and 2% to 4% in ladies. More latest collection have shown a rise in cutaneous metastases from lung most cancers in women, reflecting the rising incidence of main lung cancer in women. Other much less common shows embody ulcerated nodules, scarring alopecia, and zosteriform and erysipelas-like lesions. Metastases of bronchioalveolar and mucoepidermoid carcinomas, adenoid cystic carcinoma, carcinoid tumors, pleural mesothelioma, well-differentiated fetal adenocarcinoma, and pulmonary sarcomas are much less commonly seen. The tumor cells are dispersed in sheets and islands of epithelial cells with various degrees ofkeratinization and intercellular bridges, often with solely a small variety of whorls of squamous cells (pearls). More atypical features of the keratinizing cells could embrace large, weird cells, spindle cells, and clear cells with ample mitotic figures. The tumor cells are inclined to have pleomorphic, hyperchromatic nuclei with numerous mitotic figures. Pulmonary adenocarcinoma can exhibit an epidennotropic pattern of pores and skin metastasis, mimicking Paget disease and different main intraepidermal neoplasia. The giant cell variant has monster cells with bizarre nuclei and cells that frequently include leukocytes. The clear cell variant is composed of sheets and islands of clear cells without different forms of differentiation. Squamous cell carcinomas metastatic from the oral cavity are sometimes higher differentiated than those metastatic from the lung. Most adenocarcinomas metastatic to the pores and skin originate from the big intestine, lung. Those from the large intestine are sometimes higher differentiated than these from the lung. Metastatic colonic adenocarcinomas often show well-formed mucinous glandular epithelium and even giant pools of mucin with a small amount of epithelium and hence resemble mucinous carcinoma of the skin and metastatic mucinous carcinoma from the breast Mucinou. The signet ring cells commonly related to adenocarcinoma of the stomach are seen only often in metastases from the lung. Cutaneous metastatic lesions of undifferentiated kind are often from the breast or lung and less typically from the stomach, liver, or urinary bladder.

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Lower 5 intercostal vessels and nerves pass between costal origins of diaphragm and transversus abdominis. The 2nd intercostal area lies under this cartilage and is used for counting the intercostal spaces for the place of heart, lungs and liver. Ans: the sternum is single median line bone in the anterior part of the thoracic cage. Its upper part, manubrium is wider and contains two plates of compact bone with intervening cancellous bone. During sternal puncture, a thick needle is pierced through the skin, fascia and anterior plate of compact bone until it reaches the bone marrow in the cancellous bone. Three giant openings within the diaphragm are at ranges of which of the following thoracic vertebrae All the following buildings course through the inlet of thorax in the median airplane, except: a. Main openings within the thoracoabdominal diaphragm, together with their levels and contents d. The quantity may be elevated by improvement of a cervical or a lumbar rib; or the number could also be decreased to 11 by the absence of the twelfth rib. The spaces are deeper in entrance than behind, and deeper between the higher than between the decrease ribs. The obliquity reaches its maximum on the ninth rib, and thereafter it steadily decreases to the twelfth rib. According to articulations with sternum the ribs are true and false: the primary 7 ribs which are linked through their cartilages to the sternum are known as true ribs, or vertebrosternal ribs. Out of those, the cartilages of the eighth, ninth and tenth ribs are joined to the next greater cartilage and are often identified as vertebrochondral ribs. The anterior ends of the eleventh and twelfth ribs are free and are called floating ribs or vertebral ribs. According to morphological features the ribs are atypical and typical: the first two and last three ribs have special options, and are atypical ribs. The anterior sternal end is oval and concave for articulation with its costal cartilage. Its medial half is articular and forms the costotransverse joint with the transverse process of the corresponding vertebra. The shaft is flattened so it has two surfaces-outer and inside; and two borders-upper and decrease. This surface is marked by a ridge which is steady behind with the lower border of the neck. The thoracolumbar fascia and the lateral fibres of the sacrospinalis muscle are connected to the angle. It articulates with the transverse process of first thoracic vertebra to kind the costotransverse joint. The higher floor is marked by two shallow grooves, separated close to the internal border by the scalene tubercle. The higher a half of the first digitation of the serratus anterior, just behind the groove for the subclavian artery. For the shaft there are solely two secondary centres, one for the pinnacle and the opposite for the tubercle. These secondary centres seem at puberty and unite with remainder of bone after 20 years. Second Rib Features 1 Anteriorly, the neck is related from medial to lateral facet to: a. The eighth cervical nerve three the anterior groove on the superior floor of the shaft lodges the subclavian vein, and the posterior groove lodges the subclavian artery and the lower trunk of the brachial plexus. The attachment of the costoclavicular ligament on the anterior finish behind the subclavius. The insertion of the scalenus medius on the elongated rough area behind the groove for the subclavian artery. Attachments 1 the rough tubercle on the outer floor gives origin to 1� digitations of the serratus anterior muscle. The angle and costal groove are poorly marked within the eleventh rib and are absent within the twelfth rib. Attachments and Relations of the Twelfth Rib 3 the following are hooked up to the outer surface.

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The measurement of the nuclei tends to diminish as melanocytes strategy the base of the lesion, which is normally ill defined. Histologically, whereas desmoplastic Spitz nevi are likely to be small, well-circumscribed, superficial lesions. These fascicles are probably to have a reasonably uniform and symmetric spacing and measurement throughout the epidermis and are often vertically or concentrically oriented. Their nuclei are equal in dimension or smaller than the nuclei of adjoining keratinocytes. Heavy pigmentation may contain the adjacent keratinocytes, cornified layer, and papillary dermis. The lesions could contain mobile aggregates or nodules of melanocytes that substitute the papillary dermis without maturation. Rigorous molecular characterization of such neoplasms is crucial for definitive classification, if this is possible. Even with hanging pagetoid spread in some lesions, the previous options argue strongly in favor of a benign course of, particularly if present in a younger individual and on a web site such because the thigh. Nonetheless, a few of these tumors are fairly difficult because of massive measurement, conduent cellular aggregates, absence of maturation, and highgrade cytologic atypia. As a outcome, the biologic potential of a small minority of such lesions could additionally be tough to predict. In deep penetrating nevus, the fascicles are often extra cellular and extra carefully aggregated (with less intervening dennal collagen) in a wedge-shaped (or V-shaped) structure. The spindle cells are aligned along the neurovascular plexus of blood vessels and nerves (and pores and skin appendages). The cells contain fantastic granular melanin and monotonous nuclei with dispersed chromatin. In contrast to deep penetrating nevus, plexiform spindle cell nevus is defined solely by plexiform architecture and spindle cell cytomorphology. Spitz melanoma often presents as a altering or enlarging amelanotic or pigmented plaque, papule, or nodule on the ex:trem� ities or trunk however could happen at any website.! Other features suggesting melanoma are massive dimension (often >6 mm and particularly> 1 cm in diameter). Additional options in the epidermal component suggesting melanoma embody asymmetry; poor circumscription; effacement/consumption of the dermis; ulceration; enlarged, irregular, and confluent nests; and pagetoid melanocytosis. An elevated mitotic rate (>6 mitoses/mm2 in a baby aged >l yr or >2 mitoses/mm2 in an adult328. These lesions are current at delivery but normally spontaneously regress by age 3 to four years. Mongolian spots are observed primarily in Asians and Africans401-403 and show no intercourse predilection. Brownish lentigo-like lesions and bluish papules or nodules are often related to nevus of Ota. The bluish look of those varied lesions is primarily associated to the depth of melanin in the dermis and the Tyndall phenomenon. The longer wavelengths of seen gentle penetrate the reticular dermis and are absorbed by the melanin. However, the shorter wavelengths representing the bluish part of Nevus fuscoceruleus zygomaticus Synonyms: Acquired nevus of Ota-like macules, sun nevus. Clinical Features the devdopment of bilateral bluish macules in the zygomatic areas of the face has primarily been reported in Chinese and Japanese women. Differential Diagnosis the time period "dermal melanocyte hamartoma" describes a small number of developmental abnormalities usually current at birth and exhibiting intensive involvement of the skin. Rarely, in brownish areas, dermal melanocytes are located very near the epidermis, or basilar melanocytic hyperplasia and basal-layer hypermelanosis are current, or each. In dermal melanocyte hamartoma, there may be aggregation of these cells about sebaceous glands, eccrine ducts, blood vessels, and cutaneous nerves.

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Intact trematodes are seldom found in these lesions but when discovered are characterised by typical trematode tegument and parenchyma. Differential Diagnosis Early fascioliasis could additionally be accompanied by fever, stomach ache, urticarial rash, and excessive peripheral eosinophilia. Itchy pores and skin tracks resembling those ofcutaneous larva migrans or paragonimiasis could accompany this syndrome. Histopathologic Features In biopsies of skin nodules, Paragonimus can often be differentiated from these brought on by Fasciola primarily based on the shape of the tegumental spines (sharp and ere<:t in Paragonimus. These distinctions are necessary as a outcome of completely different trematode species require totally different therapies. As with paragonimiasis, there are antibody detection assays out there for this illness. The inset exhibits the variations between the tegumental spines of Fascio/a hepatica A) and Paragonimus species (8) (H&E, 40x; insets at 500x). Schistosomiasis is a widespread persistent endemic an infection by sexually dimorphic trematodes. Schistoso:miuis is likely one of the leading causes of morbidity and mortality amongst parasitic diseases, together with malaria and amebiasis. More rarely, an identical rash happens quickly after publicity to cercariae of any of the major human-adapted schistosomes. During its early prepatent stage, schistosomiasis is diagnosable solely by antibody detection. Most lesions have been seen within the perianal and scrotal area however hardly ever also within the periumbilical area. Differential Diagnosis Differentiation of acute cercarial dermatitis from other allergic and pruritic dermatitides must be made by medical presentation and epidemiologic knowledge. Patients with continual lesions containing schistosome eggs in the skin may shed eggs within the stool or urine or present with other medical proof of urinary or visceral schistosomiasis. Eggs tend to be shed in low numbers, and a number of stool specimens ought to be collected and focus procedures employed. The solely helminth eggs in skin biopsy specimens which might be comparable in dimension to these of Schistosoma spp. Cercarial skin rashes, whether by zoonotic or human-adapted species, are more often localized than generalized and are more extreme in sufferers with repeated exposure. Only 2 studies with histopathological examination of skin lesions have been printed. Around the dying schistosomulae, there was exocytosis and formation of eosinophil-enriched microabscesses. Dermal schistosome egg deposits current as mildly inflamed subcutaneous nodules or tumor-like plenty which might be tender but not painful with little or no erythema. These eggs measure as a lot as one hundred fifty pm in size relying on the species and contain an outlined miracidiwn (first-stage larva). The inset shows a close-up of 1 of the eggs demonstrating the attribute lateral backbone (H&:E, 100x; inset 400x). Diroftlaria ursi-like parasites acquired by people in the northern United States and Canada: report of two instances and a brief evaluation. Serological prognosis of North American paragonimiasis by Western Blot utilizing Paragonimus kellicotti grownup worm antigen. Atlas of Fundamental Infectious Disease Histopathology: A Guide for Daily Practice. The emergence of zoonotk Onchocerca lupi an infection within the United States-a case series. Human streptocerciasis: a clinicopathologic examine of 40 Africans (Zairians) together with identification of the adult filaria. There is considerable overlap between what one may consider a cyst and what one would possibly think about an appendageal tum.

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Both cyst and trophozoite levels exist in nature and are identifiable in tissue sections. Transmission occurs through the respiratory mucosa or contamination of skin lesions; unfold is hematogenous. Acanthamoeba and Balamuthia infections are increased in contact lens wearers and immunocom promised hosts. Cutaneous an infection, with or without involvement of different sites, has been sometimes reported in strong organ transplant recipients. Lesions could also be painful or nontender, indurated, violaceous to erythematous, and should progress to draining pustules and ulcers. The ulcers are poorly demarcated; have elevated borders, usually with an eschar; and ultimately heal. Reported sites embrace the trunk, face, and extremities; several instances have been disseminated and have occurred in transplant sufferers; secondary bacterial infection is also reported. Mild perivascular inflammation with lymphocytes and scattered histiocytes could progress to necrotizing granulomatous inflammation. A neutrophilic infiltrate may be present in the pustules, acute ulcers, and abscesses. Deep dermal and subcutaneous lesions are characterised by a marked cellular response consisting of histiocytes, lymphocytes, plasma cells, eosinophils, and scattered big cells, often with a leukocytoclastic vasculitis. Variable numbers of organisms are seen throughout the lesion and often surround dermal vessels. Most of these can be dominated out by biopsy, direct examination, or tradition ofmaterial from the lesion. Acanthamoeba cysts could additionally be confused with Blastomyces dermatitidis; the yeasts are slightly smaller and have broad-based budding and multiple nuclei and lack the distinguished karyosome of the amoebae. The zygospore ofBasidiobolus ranarum, when seen in isolation in tissue, can mimic the looks of trophozoites of Acanthamoeba or Balamuthia species; the differential prognosis requires identification of the opposite fungal parts. Macrophages could also be confused with trophozoites, however nuclear morphology and immunohistochemical stains can be utilized as diagnostic aids. Risk components for illness include very young age (neonates); pregnancy and postpartum. Cutaneous involvement results from several mechanisms, including direct extension ofa bowel an infection to the anogenital region; at websites of perforation or fistul. Rare instances of major inoculation of the pores and skin of the orbit, face, and legs are reported from contact with contaminated materials. Rapid, deadly unfold has been reported in younger patients and those with compromised immune standing. Tissue destruction and granulation of the anoperineal area because of Entamoeba hi$tolytica infection. Superficial lesions usually have concomitant visceral lesions with contiguous spread or perforation. The ulcer has a neaotic base with acute and chronic irritation, granulation tissue, and edema (see Table 23-5). Varying levels of acanthosis and papillomatosis are present on the epithelial margin. Deep lesions have deep dermal and subcutaneous liquefaction neaosis with suppuration and vasculitis. They measure 15 to 25 �m, have fine granular cytoplasm and phagocytized erythrocytes, and are usually isolated from the surrounding tissue by a small space (shrinkage artifact). The nucleus is small and round with a uniform blue ring of chromatin along the nuclear membrane; it will not be seen in all sections. Material from the ulcer edge can be examined immediately using iron hematoxylin or trichrome stain. Note the shortage of cohesion, the thin rim of nuclear chromatin, and the eiythrophagocytosis. Granulomatous irritation, may have caseous necrosis in bursa Severity of pores and skin lesions associated to depth of invasion Organisms in areas of necrosis Diagnostic options embody Size (P. Use of topical steroids could predispose some people to a localized skin lesion.

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The scalp is the most common cutaneous web site of involvement of metastatic leiomyosarcoma. Benign Triton tumors comprise muscle elements intimately associated with nerve fibers. Rhabdomyomas in childhood show relatively immature skeletal muscle rather than well-formed striated muscle fibers. Malignant tumors are far more widespread than benign tumors, and benign tumors might have immature features suggesting a malignant lesion. Histopathologic Features Boys <5 years Head and neck Histopathologic Features Histologically, these tumors show round, fusiform, or strap-like rhabdomyoblasts within a vascularized fibrous stroma. Differential Diagnosis Immature skeletal muscle No mitoses or atypia Differential Diagnosis Rhabdomyosarcoma Rhabdomyomatous mesenchymal hamartoma solitary or a number of. Some instances may be quite cellular, and areas resembling grownup rhabdomyoma with giant ganglion-like cells or "spider" cells may be present. Molecular Genetics the principle differential analysis contains embryonal (botryoid) rhabdomyosarcoma and benign fibroepithelial polyps. Embryonal rhabdomyosarcoma is a rapidly rising malignancy of young ladies consisting of principally primitive mesenchymal cells with restricted muscle maturation, with a subepithelial condensation of neoplastic cells referred to because the "cambium" layer. The lack of hanging nuclear atypia is the one most important criterion for distinguishing rhabdomyoma from rhabdomyosarcoma. Adult rhabdomyoma has a uniform population of enormous polygonal cells with abundant, deeply eosinophilic cytoplasm with scattered "spider" cells. Occasional spider cells with clear cytoplasm and thin strands of material extending from the nucleus to the cytoplasmic membrane are current. Crossstriations, glycogen vacuoles, disorderly filamentous arrays, and crystalline materials may be recognized within the cytoplasm. Polygonal tumor cells with abundant eosinophilic and focally vacuolated cytoplasm. Granular cell tumors are composed of slightly smaller cells with a lot smaller nuclei and nucleoli. Hibemomas could resemble rhabdomyomas because of their eosinophilic, granular to vacuolated cytoplasm. It occurs most incessantly within the deep tissues of the head and neck or urogenital viscera in patients younger than 10 years of age. Evidence of myogenesis is characterised by small amounts of eosinophilic cytoplasm that could be present to one aspect of the cell, or the cytoplasm could also be extra profuse, giving rise to spherical, tadpole-, or strap-shaped rhahdomyoblasts. When submucosal, the lesion could current as a polypoid mass protruding into a lumen, and there could additionally be a "cambium� layer characterized by increased cellularity immediately beneath the epithelium. Focal anaplastic options could additionally be seen as nicely as bizarre multipolar mitotic figures. However, a recent literature evaluation that included 33 main cutaneous cases discovered a slight feminine preponderance. Primitive mesenchymal cells with scattered ovoid and spindled rhabdomyoblasts exhibiting extra plentiful eosinophilic cytoplasm. Rhabdomyoblastic heterologous differentiation could additionally be seen in a wide range of neoplasms. The cells may have a hobnail appearance and are discohesive, with isolated cells mendacity freely within the "alveolar" areas. Multinucleated cells with the nuclei forming a peripheral �wreath" are a characteristic finding. Greater emphasis has been placed on the nuclear somewhat than the architectural options. As mentioned beforehand, focal heterologous rhabdomyoblastic differentiation may be seen with a wide range of tumors, including dedifferentiated liposarcoma, malignant peripheral nerve sheath tumor, and carcinosarcoma. Pleomorphic dermal sarcoma can present expression of smooth muscle actin however lacks expression of skeletal muscle markers. Molecular Genetics Cytogenetically, these tumors lack r~g tumor-specific translocations and as a substitute show quite a lot of chromosomal gains and losses. In children, the paratesticular area is the most common website of involvement for tumors with spindle cell morphology. The sclerosing morphology is ~n mostly within the limbs in both young and old patients. Hlstopathologfc Features the differential diagnosis consists of pleomorphic leiomyosarcoma.

References

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