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• W3012496513 abstract "To the Editor: Collagenous spherulosis (CS) is an entity that was first described by Clements et al1 in the breast. CS can be incidentally detected in surgical specimens of other lesions in the breast including papilloma, ductal hyperplasia, sclerosing lesions of the breast, and lobular carcinoma in situ and is a common morphologic pitfall for residents and novice pathologists in breast pathology.2 Because the spherules may fill the lumens either partially or completely, the resulting pseudocribriform pattern may bring atypical ductal hyperplasia, ductal carcinoma in situ, or adenoid cystic carcinoma into the differential diagnostic considerations.1 Although CS is a common entity in breast biopsy specimens, there have been only rare reports of cutaneous lesions with this finding. It has been described in syringoma, chondroid syringoma, cutaneous schwannoma, and basal cell carcinoma.3–6 We are describing this rare and incidental finding in a case of benign lichenoid keratosis (BLK) of the medial aspect of the lower leg of a 77-year-old woman. The patient had a prolonged history of a solitary pink flat-topped papule over the right lower leg (Fig. 1). The clinical differential diagnoses were actinic keratosis, basal cell carcinoma, and squamous cell carcinoma. A biopsy was performed, and the microscopic findings revealed a dense lichenoid band of lymphocytes and histiocytes with obscuration of the dermal–epidermal junction. There was vacuolar interface change and scattered apoptotic keratinocytes. There were large eosinophilic globules in the basal layers of the epidermis, which we initially thought were civatte bodies or colloid bodies that are a common finding in interface dermatitides such as BLK7 (Fig. 2). However, upon high-power examination, it became apparent that these eosinophilic globules were larger and more fibrillar as compared to the more homogenous and dense-appearing civatte bodies. The fibrils within the spherules were arranged in a radiating star-shaped configuration similar to the findings described in CS lesions of the breast1 (Fig. 3). We performed a trichrome stain to confirm our findings and the eosinophilic globules stained blue, which supports the collagenous nature of the eosinophilic globules (Fig. 4).FIGURE 1.: Solitary pink flat-topped papule over the right lower leg.FIGURE 2.: Low magnification of BLK with CS (×40).FIGURE3.: High magnification of eosinophilic fibrillar globules consistent with CS (×400).FIGURE 4.: Trichrome stain revealing blue staining of the CS globules (×200).Because of the fibrillary nature of the spherules, an important differential diagnosis to CS in the skin could be calcium oxalate crystal deposition, as may be seen in patients receiving hemodialysis. The calcium oxalate crystals fail to stain with von Kossa stain, which makes this distinction more difficult. Some authors have suggested polarizing microscopy to differentiate CS from calcium oxalate crystals. Although collagen fibers of CS show weak birefringence under polarization (Fig. 5), the oxalate crystals are strongly birefringent making the distinction possible.3 Few other authors have demonstrated the presence of CS in salivary gland tumors and have advocated a distinction between collagenous spherules and collagenous crystalloids. The latter are rich in collagen types I and III, whereas the former contain varying amounts of type IV collagen, laminin, elastin, and acidic mucins.8,9 Our case showed focal areas with fibrillary CS in an unequivocal background of BLK, but more extensive areas with a laminated appearance can be mistaken as keratin pearls as exemplified by a case of borderline endometrioid tumor of the ovary described by Treilleux et al10 where CS was initially erroneously identified as squamous metaplasia, and the lesion was initially upstaged to an endometrioid carcinoma. This could be a potential diagnostic pitfall in skin because this confusion might lead to an erroneous diagnosis of invasive squamous cell carcinoma in the background of a lichenoid actinic keratosis.FIGURE 5.: High magnification of fibrillar globules showing weak birefringence under polarized microscopy (×400).This report is aimed to strengthen the argument that CS is a finding that is not limited to the breast and can be seen in various skin lesions. Dermatopathologists should be aware of the presence of this change because it is a potential diagnostic pitfall that can lead to disastrous consequences." @default.
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• W3012496513 date "2020-03-06" @default.
• W3012496513 modified "2023-09-28" @default.
• W3012496513 title "Collagenous Spherulosis in Benign Lichenoid Keratosis—Breaking the Monopoly of Breast Lesions" @default.
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• W3012496513 doi "https://doi.org/10.1097/dad.0000000000001623" @default.
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