PMC3081488_01
Right posterior auricular swelling with a healed curvilinear scar (thin arrow) over the scalp; Note another irregular healed scar at the right parieto-occipital region (thick arrow)
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On examination, there was a 2.5 x 2 cm hemispherical swelling in the right post-auricular region, with an overlying scar of the previous split-skin grafting [Figure 1]. A linear well-healed scar was also noted in the right parieto-occipital region [Figure 1].
CT scan shows soft tissue mass with uninvolved mastoid bone
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To evaluate the underlying bone involvement and the exact extent of tumour, radiological workup was done with X-ray skull and computed tomography (CT) scan which showed no bone involvement [Figure 2].
Mastoid bone shaved for a better surgical clearance
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The underlying mastoid was shaved as a precautionary measure [Figure 3].
Skin with tumour islands in the dermis arranged in lobular and diffuse pattern (H and E, 20x)
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The tumour cells were arranged as islands, in lobular and diffuse pattern [Figures 4 and 5a].
a- Tumour cells arranged in lobules with a few showing keratinization (H and E, 40x); b- Individual tumour cells are polygonal with some showing clearing of cytoplasm and keratinization (H and E x 40); c: Islands of clear tumour cells showing nuclear pleomorphism and mitotic activity (H and E, 100x); d: Neoplastic cells show abrupt keratin production (H and E, 40x)
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The tumour cells were arranged as islands, in lobular and diffuse pattern [Figures 4 and 5a]. Neoplastic cells were oval to polygonal with abundant cytoplasm and many showed individual cell keratinization [Figure 5b]. The predominant population of tumour cells showed clearing of cytoplasm with high nucleo-cytoplasmic ratio, nuclear hyperchromasia and moderate nuclear pleomorphism [Figure 5b and c]. Tumour lobules showed abrupt keratinization [Figure 5d] and calcification [Figure 6].
Tumour nests showing basophilic areas of calcification (H and E, 100x); Inset shows islands of pleomorphic tumour cells with many mitotic figures, a few of which appear atypical (H and E, 200x)
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Tumour lobules showed abrupt keratinization [Figure 5d] and calcification [Figure 6]. Numerous mitotic figures were also noted [Figure 6 inset].
One year postoperative image showing healed scar
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One year after the surgery, patient is doing well with no recurrence [Figure 7].