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. 8
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coagulative necrosis (necrobiosis) of soft tissues
A
with surrounding palisaded histiocytes.




B




Bones and Joints 507
A




8-46. Rheumatoid arthritis (RA). A. Head of femur
shows pannus overgrowth (whitish nodules, top),
and the synovium (bottom) shows brownish nod-
ules due to a combination of lymphoid hyperplasia
and iron deposits secondary to hemorrhage. B. Syn-
ovitis in RA has produced a papillary appearance
to the synovial lining. (continued on next page)



B




508 Bones and Joints
C




D




8-46. (Continued) C. Low-power histology of the
hyperplastic synovium shows abundant lymphoid
tissue occupying the papillary infoldings. D. High-
power view of several lymphoid-¬lled papillary
folds. (continued on next page)




Bones and Joints 509
E




F




8-46. (Continued) E. Articular surface (top) shows
loss of articular cartilage beneath pannus over-
growth. F. Pannus overgrowth on articular surface
that has lost its cartilage layer, and the underlying
bone is eroded.




510 Bones and Joints
A B




C




8-47. Osteoarthritis (OA) is characterized by wearing
away of the articular cartilage of a joint. A. OA of
the femoral head. Scanty residual cartilage (arrow) is
seen as pinkish-colored areas elevated above the yel-
low-colored burnished bare bone. B. Fibrillated car-
tilage protrudes from the (top) edge of the central,
eroded articular surface of the head of femur. C. His-
tology of a ¬brillated cartilaginous excrescence. (con-
tinued on next page)




Bones and Joints 511
D E




F


*




8-47. (Continued) D. Transected head of femur
shows severe loss of cartilage (arrows). E. Bone is
forming the articular surface of most of this femoral
head. F. Histology of femoral head in OA shows
subtotal loss of the articular cartilage apart from a
small zone (arrow), which has a small subarticular
cyst at its right margin (*). (continued on next page)




512 Bones and Joints
G




8-47. (Continued) G. Bare bone on the articular sur-
H
face has become worn down and corresponds to
eburnated bone seen grossly in A. H. Very advanced
OA shows a large bone cyst due to a crack in the
bone that allowed synovial ¬‚uid to enter the bone.
Note the well-delineated, reactive bone surrounding
the cyst.




Bones and Joints 513
8-48. Fibrous histiocytoma of the synovium. 8-49. Fibroma of tendon sheath removed from the
wrist.




8-50. Well differentiated synovial chondrosarcoma
of the knee joint comprises numerous multinodular
cartilaginous tumors.




514 Bones and Joints
9 Diseases of the Spleen, Lymph Nodes,
and the Thymus Gland


A




9-1. Mechanical disruption of the spleen. A. Rup-
ture of the spleen and the splenic capsule in a
patient with infectious mononucleosis due to weak-
ening of the splenic trabecula and capsule by lym-
phocytic in¬ltration. B. Follicular hyperplasia of
spleen in infectious mononucleosis. C. Histology
shows follicular hyperplasia impinging on attenu-
ated trabecula. (continued on next page)



B C




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 515
D E




F




9-1. (Continued) D. The same spleen shows posi-
tive immunoperoxidase staining by labeled anti-
body against Epstein“Barr virus. E. Recent, circum-
scribed subcapsular hematoma (bottom left) after a
blow to the abdomen. F. Sliced spleen is seen to
contain an irregularly shaped, dark-colored
hematoma within its substance.




516 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
9-2. Reactive dif¬‚uent spleen due to infection. Note
the rounded edge and the watery-looking splenic cut
surface. (This is in contradistinction to chronic con-
gestion of the spleen, which exhibits a sharp cut
edge and a ¬rm, nondif¬‚uent cut surface.) On touch-
ing the cut surface of a reactive spleen, some of the
splenic tissue becomes attached to the glove. Note
that peritonitis does not cause a reactive spleen.




9-3. A. Gamna“Gandy body (localized area of cal-
cium and iron encrustation due to a prior localized
hemorrhage) within a reactive spleen is seen as a
circumscribed brown area within the soft, dif¬‚uent
splenic pulp. B. Healed “perisplenitis” (so-called
sugar icing of the spleen) comprises thickening of
the splenic capsule due to organization of previous
¬brin deposits on the peritoneal surface of the
spleen.




A B




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 517
B
A




C


9-4. A. Chronic congestion of the spleen (bottom) secondary to por-
tal hypertension in cirrhosis of the liver (top). Note the sharply
de¬ned cut edge of the spleen, the ¬rm-appearing cut surface, and
the prominent, thick-walled blood vessels. The congested spleen is
enlarged to rival the liver in size. B. Histology of a congested spleen
shows a very prominent red pulp with scanty lymphoid elements.
C. Severe transfusional siderosis of a spleen that has a very brown
cut surface. In siderosis, the iron deposits occur within the reticu-
loendothelial system, as opposed to hemochromatosis, in which the
iron deposits occur within the parenchymal cells. Hence, the spleen
is usually spared from siderosis in hemochromatosis.




518 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
A



9-5. Infarction of the spleen. A. Venous infarcts, due
to venular occlusion within the spleen, appear as
mottled, darker red areas (top right). Scanty true
infarcts due to arterial occlusion are noted as small
pale yellow areas (bottom center). B. Pale infarct in
a spleen (bottom) that is enlarged to the same size
as the liver (top) due to immune de¬ciency. (con-
tinued on next page)




B




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 519
C



9-5. (Continued) C. Multiple, pale yellow, well-
established infarcts of the spleen. D. Histology of a
splenic infarct (horizontal pale band center) shows
prominent neutrophilic in¬ltration at its top and
right borders. (continued on next page)




D




520 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
E




F




G

9-5. (Continued) E. Ruptured splenic infarct (left).
F. Healed infarct (top center, yellow-gray area) is
surrounded by a zone of pallor representing par-
tially ischemic, nonnecrotic splenic parenchyma.
G. Healed infarct (top left) has a peritoneal adhe-
sion on its overlying depressed capsular surface.




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 521
A




9-6. Sickle cell anemia. A. “Autosplenectomy” in a
B
patient with sickle cell anemia. Repeated infarc-
tions of the spleen have reduced it to a miniscule,
shrunken, nonfunctioning organ. B. Histology
shows abundant iron and calcium encrustations,
with no normal splenic tissue visible apart from a
small collection of lymphocytes (center).




522 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
9-7. Splenic abscess (bottom right) is about to rup-
ture. Only the outer portion of the spleen has been
¬xed, accounting for the lighter color of the core.
Omental adhesions are also present.




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 523
A




B




9-8. Granulomas in the spleen. A. Necrotizing gran-
uloma in the spleen due to histoplasma infection.
B. Histology of an encapsulated histoplasma granu-
loma in a spleen. (continued on next page)




524 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
C




D




9-8. (Continued) C. Multiple small nodules in the
spleen due to Candida albicans infection. Portion
of an infarct is seen (top right). D. Multiple pyemic
abscesses of the spleen in infective endocarditis.




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 525
A




B

9-9. Amyloidosis of the spleen. A. Note the charac-
teristic very sharp cut edge and the waxy-looking,
translucent cut surface of amyloidosis. The spleen
is hard at autopsy if the body has been refrigerated,
but at normal body temperature during life amyloid
has a soft consistency. B. Histology of the spleen
shows massive deposits of amyloid staining posi-
tively with the Congo red stain.




526 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
9-10. Myelo¬brosis: the ¬rm spleen has a diffuse dark
plum-colored appearance due to extramedullary
hematopoiesis.




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 527
A




B




C

9-11. Spleen in leukemia. A. Solitary neoplastic nodule in a patient
with chronic lymphocytic leukemia (CLL). B. CLL has produced
numerous ill-de¬ned tumor nodules on the splenic cut surface. C.
Chronic lymphocytic leukemia has produced numerous, small well-
de¬ned neoplastic nodules.


528 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
A




B




C

9-12. Lymphoma in the spleen. A. Nodular sclerosing Hodgkin dis-
ease in the spleen is seen as focally aggregated tumor nodules. B.
More advanced Hodgkin disease of the spleen. C. Histologic appear-
ance of a focal nodule of Hodgkin disease in the spleen. (continued
on next page)


Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 529
9-12. (Continued) D. Histology shows Hodgkin-type
giant cells in the lesion. E. Extensive replacement
of the spleen by a large cell, noncleaved follicular
lymphoma. The tumor shows the characteristic
“¬sh ¬‚esh” appearance strongly suggestive of a lym-
phoma. F. Small cell follicular lymphoma. The
extreme multiplicity of tumor nodules is more in
keeping with a lymphoma than with a secondary
carcinoma. The background splenic tissue appears
brown due to abundant iron deposits related to
D
multiple blood transfusions.




E




F




530 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
9-13. Metastatic renal cell adenocarcinoma in the
spleen. The most common metastatic tumors in the
spleen are due to cancers of the lung and breast,
malignant melanoma, and leukemia.




9-14. Spleen in Langerhans cell histiocytosis (histio-
cytosis X) shows a diffuse nodular, reticular pattern.




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 531
A



9-15. A. Pulmonary hilar and bronchopulmonary
lymph nodes contain metastatic tumor. B. Histology
of a lymph node in¬ltrated by metastatic undiffer-
entiated ductal carcinoma of the breast. (continued
on next page)




B




532 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
9-15. (Continued) C. Hilar nodes show residual car-
bon deposits within the metastatic lung cancer.
D. Caseous tuberculous hilar lymph nodes in the
lymph node component of a primary tuberculous
complex of the lung. Note the prominent perinodal
C
¬brosis.




D




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 533
A B

9-16. Radical dissection of deep cervical lymph
nodes for metastatic carcinoma. A. Picture shows an
undissected chain of tumor-in¬ltrated neck lymph
nodes. B. Massive in¬ltration by metastatic carci-
noma in cervical nodes has spread beyond the
nodes to produce a fused tumor mass. (continued
on next page)




534 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
D
C




E

9-16. (Continued) C. Necrotic metastatic squamous
carcinoma in nodes. D. Histology of the same node
shows keratinizing squamous carcinoma with necro-
sis (lower left). E. Totally necrotic metastatic squa-
mous carcinoma after irradiation appears white in
color due to a granulomatous response to the keratin.




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 535
A




B




9-17. A. Metastatic colon cancer in peripancreatic
lymph nodes (arrow). B. Nodal histology shows sec-
ondary adenocarcinoma in a desmoplastic stroma.
(continued on next page)




536 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
C




E
D




9-17. (Continued) C. Mesenteric nodes in¬ltrated by
lymphoma show a ¬‚eshy, swollen appearance.
D. Enlarged lymph node due to malignant follicu-
lar lymphoma. E. Histology shows a follicular lym-
phoma composed of a mixture of small and large
cells.




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 537
A




9-18. A. Hyperplastic thymus in an adult with
myasthenia gravis that contained lymphoid follicles
with germinal centers. B. Thymic cyst that had con-
tained clear ¬‚uid. C. Thymoma that is still con¬ned
to the thymus gland. (continued on next page)



B C




538 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
D




9-18. (Continued) D. Close-up view of the same
tumor. Note the ¬‚eshy, lobulated appearance of the
lesion. E. Histology of an epithelial thymoma shows
a mixture of neoplastic epithelial cells and reactive
lymphocytes. Prognosis of a thymoma depends
more on the degree of in¬ltration found by the sur-
geon than on the histology.



E




Diseases of the Spleen, Lymph Nodes, and the Thymus Gland 539
9-19. Malignant thymoma presenting as a solid
white tumor that is in¬ltrating through the external
margins of the thymus gland.




540 Diseases of the Spleen, Lymph Nodes, and the Thymus Gland
10 Pituitary, Carotid Body, Thyroid
Gland, and Adrenals


A




10-1. A. Suprasellar extension of a pituitary adenoma (X).
B. Prolactin-secreting pituitary adenoma (right) has led to lac-
tating breast tissue (left). C. Histology of a pituitary adenoma.

B




C




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 541
B
A



10-2. A. External appearance of a carotid body
tumor that is a type of paraganglioma arising in the
carotid artery body. B. Opposite side of the resected
carotid body tumor includes a portion of the exter-
nal carotid artery (top). C. Histology of the carotid
body tumor exhibits the classical organoid pattern
of a paraganglioma. Some cellular atypism is appar-
ent in this benign tumor.




C




542 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
A




B




10-3. A. Hypoplastic left lobe (right) of the thyroid
C
gland. B. This thyroid gland shows marked symmet-
ric atrophy. C. Histology of the atrophic gland
shows a healed thyroiditis.




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 543
A




B




10-4. Chronic autoimmune (Hashimoto) thyroiditis.
A. External surface of an enlarged, nodular-appearing
thyroid gland. B. Cut surface of a lobe of thyroid
gland in Hashimoto thyroiditis shows a lobulated
arrangement. (continued on next page)




544 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
C




10-4. (Continued) C. Histology of Hashimoto disease
shows massive lymphocytic in¬ltration between
atrophic follicles. D. High-power view of Hashimoto
disease showing a germinal center in the lymphoid
in¬ltrate.



D




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 545
B
A




C




10-5. A. Thyroid gland in subacute lymphocytic thy-
roiditis shows muted zones of increased tissue den-
sity in an otherwise normal-appearing gland. B. His-
tology shows lymphocytic in¬ltration with follicular
germinal center formation but no ¬brosis or Hürthle
cell metaplasia such as occurs in Hashimoto thy-
roiditis. C. Aspergillus abscess (right) of the left lobe
of the thyroid gland. The thyroid gland is often
affected in disseminated aspergillosis.




546 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
A




10-6. A. Colloid goiter (i.e., the phase of colloid
involution of a diffuse nontoxic [simple] goiter in a
geographic area of iodine de¬ciency). The colloid
goiter shows early signs of transformation into a
multinodular goiter. B. External aspect of a multin-
odular goiter. C. Cut surface of a multinodular goi-
ter shows multiple nodules of varying sizes with
cyst formation in areas. (continued on next page)



B




C




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 547
D




E




10-6. (Continued) D. Histology of multinodular goi-
ter shows a portion of one of the hyperplastic nod-
ules. E. Multinodular goiter with more abundant
cysts and a calci¬ed white nodule (arrow). (contin-
ued on next page)




548 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
F




G




10-6. (Continued) F. Advanced multinodular goiter
with abundant cysts and much ¬brosis following
involution of hyperplastic nodules. Focal calci¬ca-
tion (arrow) appears yellow in color. G. Histology
con¬rms the calci¬cation (bottom left).




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 549
A




B




10-7. Thyrotoxicosis/diffuse hyperplasia of the
C
thyroid gland (Graves™ disease). A. The external sur-
face of the diffusely enlarged thyroid gland shows
a prominent vascularity and an erythematous
parenchyma. B. The cut surface of the thyroid gland
shows a hyperemic, meaty, shiny appearance.
C. Histology of Graves™ disease showing resorption-
induced scalloping of the margins of the colloid.
Hyperplastic papillary epithelial infolding results
from the lining cells becoming columnar in shape
and increased in number. Pretreatment of the gland
may alter its morphology.




550 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
A




B




C




10-8. A. Follicular adenoma of the thyroid gland
has a well-demarcated border surrounded by a thin
¬brous capsule. B. This follicular adenoma shows
some degeneration and focal calci¬cation of the
lesion. C. Histology of a well-differentiated follicu-
lar adenoma showing a capsule separating the ade-
noma (bottom) from the normal thyroid tissue (top).




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 551
A



10-9. Papillary carcinoma of the thyroid gland. A.
Macroscopic appearance of papillary cancer (X) of
the thyroid gland comprises a ¬brous-looking area
within the gland. B. Fine-needle aspiration of the
papillary cancer reveals epithelial cells with
nuclear grooves (arrows). C. Typical vacuolated
(“orphan Annie”) nuclei of a papillary cancer of the
thyroid.




B




C




552 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
10-10. A. Follicular carcinoma of the thyroid gland appearing
as a well-circumscribed nodule. B. Minimally invasive follicu-
lar carcinoma has been surgically resected. Note the inked
resection margins. C. Histology of an invasive follicular carci-
noma showing the neoplasm invading through the ¬brous cap-
sule (arrow).




A




B




C




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 553
A




B C




10-11. A. Medullary carcinoma of the thyroid gland
shows its typical features of an unencapsulated, cir-
cumscribed, solid-looking, gray-white tumor mass.
B. Whole mount section of a medullary carcinoma
showing masses of tumor cells separated by a col-
lagenous stroma. C. Higher power reveals amyloid
production by the tumor cells.




554 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
A




10-12. A. All four parathyroid glands are enlarged
due to hyperplasia. This is in contradistinction to
an adenoma of a single parathyroid gland, which
would produce atrophy of the other three glands.
B. Parathyroid adenoma has enlarged this parathy-
roid gland. C. Histology shows a proliferation of
chief (clear) cells comprising the parathyroid ade-
noma.



B




C




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 555
A



10-13. A. Mild hemorrhage into the adrenal glands.
B. Massive, bilateral, intraadrenal hemorrhage. Por-
tions of the adrenal cortices have been destroyed.
The patient died of shock. In Waterhouse“
Friderichsen syndrome, the entire adrenal gland
may undergo hemorrhagic infarction (e.g., in asso-
ciation with meningococcal septicemia). C. Histol-
ogy of hemorrhagic infarction of the adrenal gland
in a neonate.




B




C




556 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
A



10-14. A. Atrophy of both adrenal glands due to
B
corticosteroid therapy. B. Histology shows attenua-
tion of all three zones of the adrenal cortex.




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 557
A B




10-15. A. Extensive hyperplasia of the adrenal cortex. B. Ade-
nomatous hyperplasia of the adrenal cortices: the cortices show
diffuse widening with focal, nodular excrescences that are
quite marked in areas. (continued on next page)




558 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
C D




E




10-15. (Continued) C. Histology of focal nodular
F
hyperplasia of the adrenal cortex. D. Adrenal corti-
cal adenoma has a yellow color due to the high
lipid content of its component cells. E. Histology of
the junction between adenoma (bottom) and normal
cortex (top). F. Multiloculated adrenal cyst of uncer-
tain origin. The lesion may be a pseudocyst second-
ary to degeneration of a benign neoplasm or due to
resolution of an intraadrenal hemorrhage.




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 559
10-16. Carcinoma of the adrenal cortex presenting
as a large, ¬‚eshy partially necrotic tumor that has
completely effaced the adrenal gland.




560 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
A




B

10-17. A. Bisected adrenal gland contains a pheochro-
mocytoma in its central, medullary region. A second
smaller adjacent tumor nodule is also noted. B. Bilat-
eral pheochromocytomas of the adrenal glands. (con-
tinued on next page)




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 561
C



10-17. (Continued) C. This large pheochromocy-
toma shows extensive necrosis and cystic degener-
ation. D. Histology of a pheochromocytoma (bot-
tom) showing an organoid growth pattern. The
adrenal cortex (top) appears compressed.




D




562 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
A




10-18. A. Neuroblastoma of the adrenal cortex of a
B
young child. B. Histology of neuroblastoma show-
ing nested groups of small, regular-size, dark tumor
cells. (continued on next page)




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 563
C




10-18. (Continued) C. Treated neuroblastoma has
D
evolved into a ganglioneuroblastoma of the adrenal
gland that shows focal necrosis (yellow area) and
extensive hemorrhage (dark red areas). D. Histology
of ganglioneuroblastoma shows ganglion-like cells
emerging from a background of small neuroblasts.




564 Pituitary, Carotid Body, Thyroid Gland, and Adrenals
A




10-19. Metastatic tumors in the adrenal glands.
A. Metastatic, partly necrotic, bronchial carcinoma
in both adrenal glands. Lung cancer has a special
af¬nity to spread to the adrenals. B. Metastatic
malignant melanoma in a surgically resected (note
the inked margins) adrenal gland.



B




Pituitary, Carotid Body, Thyroid Gland, and Adrenals 565
11 Skin and Soft Tissues




A




B

11-1. A. Multiple areas of ulceration of the skin due
to an unidenti¬ed fungal infection that required
surgical excision for a cure. B. Fungal methenamine
silver stain shows branching fungal elements invad-
ing the epidermis from the dermis.




566 Skin and Soft Tissues
11-2. Chronic ischemic ulcer of the lower leg due
to peripheral arterial narrowing by atherosclerosis.
Note the sloping edge of the ulcer, and no sign of
infection is evident. The red color of the ulcer base
is due to the presence of granulation tissue.




11-3. Decubitus ulcer (“bed sore”) due to pressure
in a paralyzed patient. Such lesions are now
regarded as indicative of inadequate nursing care
and are noti¬able in many states. The ulcer has pen-
etrated as deep as the sacrum in its central portion.
Treatment by surgical debridement will greatly
increase the area of skin loss.




Skin and Soft Tissues 567
A
B




11-4. A. Atrophy of the pulp of the ¬ngertips in a
patient with systemic sclerosis (scleroderma). B. A
section of skin (right) of the same patient shows
severe luminal narrowing of the dermal blood ves-
sels due to intimal ¬brosis.




11-5. Dry gangrene of two toes in a diabetic patient
with severe arterial atherosclerosis. Thickened base-
ment membranes of small blood vessels plus a
reduction in the number of small arteries con-
tributes to the ischemia in diabetic individuals.




568 Skin and Soft Tissues
11-6. Necrotizing fasciitis of the left lower leg (bot-
tom). Both the skin and the subcutaneous tissues
and fascial sheets are rendered necrotic by a bacte-
rial (commonly streptococcal) infection. The lesion
carries a high mortality rate.




11-7. Supernumery (accessory) digit excised from 11-8. Skin tag (acrochordon) comprises a ¬broepithe-
ulnar side of little ¬nger. A thin stalk linked the lial polyp that forms in skin creases. It is more com-
accessory digit to the ¬nger. The extra digit may be mon in women and increases in incidence with age.
excised or tied off at the base of the stalk soon after
birth. The condition may be familial.




Skin and Soft Tissues 569
11-9. Two keloids removed from a person of
African descent who developed this exaggerated
scar formation at the site of piercing of the ear
lobes. Histologically, the lesion shows dense, larger
than normal collagen bundles. The keloid scar is
larger in size than the original injury.




11-10. Epidermoid cyst removed from beneath the
skin (top) comprises a smooth epithelial cystic cav-
ity that contains inspissated keratinous material.




570 Skin and Soft Tissues
B
A

11-11. A. Nevus sebaceous is a localized lump
made up of a hyperplasia of sebaceous glands with
overlying epithelial hyperplasia. B. Histology of the
lesion shows it to be composed of hyperplastic
sebaceous glands underlying acanthotic epidermis.




11-12. Seborrheic keratosis is the most common
benign tumor in elderly individuals and comprises
an area of epithelial cellular proliferation. It is less
common in darkly pigmented races. Lesser“Tr©lat™s
sign is the association of multiple eruptive sebor-
rheic keratoses with an internal malignancy.




Skin and Soft Tissues 571
11-13. Congenital nevus. A. Congenital nevome-
lanocytic nevus (CNN), also termed “congenital
giant hairy nevus,” covers a large portion of this
man™s surface area. CNN has a serious risk for devel-
opment of a malignant melanoma, which eventu-
ated in this patient. B. Mixed CNN and neuroecto-
dermal tumor that showed a mixed proliferation of
melanocytes and neuroid (Schwannian) elements.
The surface has a bosselated, nonpigmented appear-
A
ance. (continued on next page)




B




572 Skin and Soft Tissues
C




D E

11-13. (Continued) C. Cut surface of the nevus
shows a ¬brous-looking lesion containing scanty
areas of pigmentation. D. Histology of this same
nevus shows neuroid elements. E. Focal area of the
same nevus showing pigmented melanocytes.




Skin and Soft Tissues 573
11-14. Intradermal nevus. In this lesion, the
melanocytes lie within the dermis and have a lower
potential for malignant change because no junc-
tional activity is present.



11-15. Skin cancer. A. Basal cell carcinoma (“rodent
ulcer”) shows a central ulcerated area surrounded
by nodular, heaped-up edges of tumor growth. B. In¬l-
trating squamous carcinoma of the skin shows ele-
vation of the skin surface with minimal ulceration.
Focal yellow areas of keratinization are noted.
(continued on next page)

B
A




574 Skin and Soft Tissues
D




C




E




11-15. (Continued) C. Pro¬le of a bisected squamous
carcinoma of the skin showing the characteristic
¬‚aky appearance of a squamous carcinoma. Black
ink marks the resection lines. D. Nodular malignant
melanoma showing asymmetry of the lesion and
irregular growth extensions on its border. The cen-
ter of the lesion is hypopigmented compared to the
edge. E. Histology of the nodular melanoma shows
malignant melanocytes packing the dermis. The
vertical depth of the lesion is important with regard

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