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557 Pages·2012·80.056 MB·English
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Atlas and Synopsis of Lever’s Histopathology of the Skin THIRD EDITION LWBK1083-FM.indd 1 19/06/12 10:13 PM David E. Elder, MB, ChB, FRCPA Professor of Pathology and Laboratory Medicine Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Rosalie Elenitsas, MD Professor of Dermatology and Dermatology in Pathology and Laboratory Medicine Director of Dermatopathology Department of Dermatology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Adam I. Rubin, MD Assistant Professor of Dermatology Assistant Professor of Dermatology in Pediatrics Assistant Professor of Dermatology in Pathology and Laboratory Medicine Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Michael Ioffreda, MD Associate Professor of Dermatology and Pathology Penn State Milton S. Hershey Medical Center Hershey, Pennsylvania Jeffrey Miller, MD Professor of Dermatology Penn State Milton S. Hershey Medical Center Hershey, Pennsylvania O. Fred Miller III, MD Emeritus Director Department of Dermatology Geisinger Medical Center Danville, Pennsylvania LWBK1083-FM.indd 2 19/06/12 10:13 PM THIRD EDITION Atlas and Synopsis of Lever’s Histopathology of the Skin LWBK1083-FM.indd 3 19/06/12 10:13 PM Senior Executive Editor: Jonathan W. Pine, Jr. Senior Product Manager: Emilie Moyer Senior Manufacturing Manager: Benjamin Rivera Director of Marketing: Caroline Foote Senior Designer: Stephen Druding Production Service: Aptara, Inc. © 2013 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com 2nd edition © 2007 by Lippincott Williams & Wilkins, a Wolters Kluwer business; 1st edition © 1999 by Lippincott Williams & Wilkins All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. gov- ernment employees are not covered by the above-mentioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data Atlas and synopsis of Lever’s histopathology of the skin / David E. Elder ... [et al.]. — 3rd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4511-1344-0 (alk. paper) I. Elder, David E. II. Lever’s histopathology of the skin. [DNLM: 1. Skin Diseases—pathology—Atlases. 2. Skin–pathology—Atlases. 3. Skin Diseases—diagnosis—Atlases. WR 17] 616.5’071—dc23 2012022575 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of informa- tion relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascer- tain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1 LWBK1083-FM.indd 4 19/06/12 10:13 PM BRIEF CONTENTS How to Use the Pattern Classification System in This Book vii Detailed Contents xi Preface xix Preface to the First Edition xxi Acknowledgments xxiii Introduction xxv I Disorders Mostly Limited to the Epidermis and Stratum Corneum 1 II Localized Superficial Epidermal or Melanocytic Proliferations 17 Disorders of the Superficial Cutaneous Reactive Unit 73 III IV Acantholytic, Vesicular, and Pustular Disorders 159 V Perivascular, Diffuse and Granulomatous Infiltrates of the Reticular Dermis 209 VI Tumors and Cysts of the Dermis and Subcutis 311 Inflammatory and Other Benign Disorders of Skin Appendages 449 VII VIII Disorders of the Subcutis 491 Index 525 v LWBK1083-FM.indd 5 19/06/12 10:13 PM LWBK1083-FM.indd 6 19/06/12 10:13 PM HOW TO USE THE PATTERN CLASSIFICATION SySTEM IN THIS BOOK Introduction to the V. Perivascular, Diffuse, and Granulomatous Infiltrates Pattern Classification System of the Reticular Dermis VI. Tumors and Cysts of the Dermis and Subcutis In this atlas, diseases are classified not by the usual patho- VII. Inflammatory and Other Benign Disorders of Skin physiologic classification but according to a pattern clas- Appendages sification. In this pattern classification, the diseases are VIII. Disorders of the Subcutis classified as listed below: When looking at a microscopic slide of an unknown • Location in the skin—low power features—specified disorder using this book, the first approach is to deter- with Roman numerals (I, II, III, and so forth) and used mine what part of the skin is primarily involved in that as chapter titles throughout the book. process. • Morphologic patterns—medium power features— specified with uppercase letters (A, B, C, and so forth) Pattern and red headings throughout the book. • Cell types—high power features—specified with Arabic Next, the relevant sections of the book can be scanned in numerals (1, 2, 3, and so forth) and green headings an effort to identify the predominant pattern of the throughout the book. abnormality. This can be done by scanning the table of • Representative disorders—individual diagnoses are in contents, or by scanning the images in order to find ones blue headings throughout the book, with a clinical sum- that look similar to the image under the microscope. This mary and histopathology given for each. process may seem difficult at first; however, this pattern It is assumed that basic pathologic processes like sup- recognition method has the potential to lead quite rapidly puration, granulomatous inflammation, and neoplasia can to the section that contains the disease in question. In be recognized by the reader. these Roman numeral-designated sections, the various In this atlas, the cutaneous diseases are listed in mor- patterns that may occur in the various locations are desig- phologic categories based on their location in the skin, nated by capital letters, A, B, C, and so forth. These patterns their architectural patterns, and their cytology. The list of differ from one location to another. For example, within diseases in each morphologic category serves as a differen- the very important group of inflammatory disorders of the tial diagnosis for unknown disorders that present with the superficial cutaneous reactive unit, the patterns include attributes of that category. The diseases are listed in rough reactions involving the epidermis such as spongiosis, order of their expected frequency in an average dermato- which is a basic pattern of the very common eczematous pathology practice. In this atlas, representative disorders in disorders; reactions involving these highly reactive super- each category are briefly described and illustrated. More ficial vessels such as perivascular lymphocytic inflamma- detailed discussions of most of these and the other lesions tion, which is common in many diseases; reactions at the in the lists can be found in the parent volume. For more dermal epidermal interface such as vacuolar or lichenoid information on the classification system, see the Introduc- patterns, and changes in the interstitium such as sclerosis tion on page xxv. to name a few. All of these patterns have their own associations which are redundant and not specific. For Location There are eight specified locations, which are assigned *Some of these “locations” also combine patterns where these have par- Roman numerals I through VIII, as follows:* ticularly broad significance. For example, “II Localized Superficial Epi- dermal or Melanocytic Proliferations,” “IV Epidermal Acantholytic, I. Disorders Mostly Limited to the Epidermis and Vesicular, and Pustular Disorders,” “V Perivascular, Diffuse, and Granu- Stratum Corneum lomatous Infiltrates of the Reticular Dermis” are all terms that combine II. Localized Superficial Epidermal or Melanocytic a location and one or more patterns, namely proliferations of cells to Proliferations form plaques or superficial nodules (II), separation of epidermal cells either from each other or from the underlying dermis to form spaces III. Disorders of the Superficial Cutaneous Reactive termed vesicles, bullae, or pustules (IV), granulomas which are collec- Unit tions of epithelioid histiocytes (V) or tumors which are mass lesions IV. Acantholytic, Vesicular, and Pustular Disorders formed by neoplastic cells (VI), and so on. vii LWBK1083-FM.indd 7 19/06/12 10:13 PM viii How to Use the Pattern Classification System in This Book example, a lichenoid pattern, discussed in section IIIF can Granulomas be shared by lichen planus (its prototypic disorder), a lichenoid drug reaction, a lichenoid actinic keratosis, and other conditions. As is often the case in dermatopathology, the term “lichenoid” is not intuitive histologically but is derived from the clinical appearance of the lesion and from clinical terminology. Cell Type The third level of classification is by cell type, designated by Arabic numerals 1, 2, 3, and so forth. The cell types in question in the same superficial inflammatory disorders discussed above include among others lymphocytes only (e.g., lichen planus which is section IIIF1), lymphocytes Example Figure 2. Same lesion at medium power reveals gran- with eosinophils (e.g., lichenoid drug eruption IIIF2a), ulomas (morphologic pattern). Within Section VIII, refer to Sec- lymphocytes with plasma cells (e.g., syphilis IIIF2b), or in tion C7 “Lobular Panniculitis Without Vasculitis” and in Section other patterns the cytologic choices might include neutro- D6 “Mixed Lobular and Septal Panniculitis, Granulomatous.” phils predominating (e.g., Sweet’s syndrome VC2), eosino- phils predominating (e.g., Well’s syndrome VC6), and so on. Neoplasms also often have quite specific cytology. such as tuberculosis and fungal infections should be The addition of the cytologic classifier to the location excluded and diagnosis is therefore a clinicopathologic and pattern classifiers can often lead to a very narrow exercise. Turning to Section VIII “Disorders of the Subcu- differential diagnosis or even a specific diagnosis. tis,” granulomas involving the subcutaneous fat lobules are mentioned in Section C7 “Lobular Panniculitis Without Example Vasculitis,” and in Section D6 “Mixed Lobular and Septal Panniculitis, Granulomatous.” In Section C7, Subcutane- As an example, in Example Figures 1, 2, and 3, a lesion is ous Sarcoidosis is listed as the prototypic example, and the illustrated that was submitted with the history “subcutane- following conditions are listed in the differential diagnosis: ous nodule, rule out malignancy.” At scanning magnification (Example Figure 1), an erythema induratum/nodular vasculitis (if vasculitis is irregular mass is seen in the subcutis. At medium and high inapparent) power (Example Figures 2 and 3), collections of epitheli- subcutaneous granuloma annulare/pseudorheumatoid oid histiocytes constituting granulomas are recognized, nodule and there are scattered giant cells. Epithelioid cell granulo- rheumatoid nodules mas without necrosis and usually with giant cells are char- subcutaneous sarcoidosis acteristically seen in sarcoidosis. However, other conditions mycobacterial, fungal, and other infections Example Figure 1. Lesion shown at low power, revealing an Example Figure 3. Same lesions at high power magnification irregular mass in the subcutis (location). Refer to Section VIII, shows giant cells (cell types). Refer to Section C7, Subcutaneous “Disorders of the Subcutis.” Sarcoidosis. LWBK1083-FM.indd 8 28/06/12 4:07 PM How to Use the Pattern Classification System in This Book ix Crohn’s disease condition for each subsection is italicized in these lists, as epithelioid sarcoma an additional diagnostic reference point. Consideration of this list, with reference if necessary Advantages of Using the Pattern to photomicrographs and descriptions of the listed enti- Classification System ties elsewhere in the book (aided by the index or online search functions) suggests that sarcoidosis is the most We have found in practice that trainees who use this sys- likely diagnosis. A phone call to the clinician suggesting tem can develop more comprehensive differential diagno- the possibility of sarcoidosis leads to further investiga- ses as they preview cases for sign out with their teachers. tion, and the information that the patient has been Similarly, experienced dermatopathologists can use the coughing and has characteristic changes on a chest book to ensure that their differential diagnostic consider- X-ray. Acid-fast stains are negative, and a presumptive ations are complete, and also to illustrate to their trainees diagnosis of sarcoidosis can be considered to be estab- the range of lesions that can have morphology similar to lished. In this way, the recognition and accurate inter- that which is visualized under the microscope. pretation of histologic findings in an unknown case can We hope and expect that using these principles will lead to the establishment of the diagnosis of an impor- increase the value of the sign-out process as a learning tant systemic disease. experience, and ultimately may make itself redundant as Even if a specific diagnosis cannot be made, it is always the patterns become ingrained into the experience of the useful to generate a differential diagnosis which can be learner, who may then begin to recognize diseases like correlated with the clinical impressions, often leading to a lichen planus, lupus profundus, bullous pemphigoid, specific diagnosis based on clinicopathologic correlation. superficial spreading melanoma, and so on in a flash of In this book, conditions that may be considered in the dif- recognition or “gestalt,” similar to the manner in which old ferential diagnosis are listed at the end of each section, and friends can be rapidly picked out of a crowd of otherwise these lists may serve as the basis for writing a pathology generally similar human beings. When this stage is report that considers, as completely as possible, the range reached, our work can be considered to be done and a life- of possibilities for any given case. The “prototypic” (i.e. time of continued learning, useful productivity, and fun, most characteristic and often one of the most common) will follow. LWBK1083-FM.indd 9 19/06/12 10:14 PM LWBK1083-FM.indd 10 19/06/12 10:14 PM

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