| Abstract|| |
Introduction: We have aimed to evaluate the difference between the expression of p53, Ki-67, and laminin in keratoacanthoma and well-differentiated SCC (SCC) and to determine its importance in differential diagnosis. Methods: This study totally included 46 cases consisting of 23 cases with keratoacanthoma and 23 with SCC. As well as age, gender, localization, and diameter of the lesion, the expression of p53, Ki-67 and laminin was evaluated. Results: No statistically significant difference was found between KA and well-differentiated SCC in terms of diameter, age, and localization. There was a statistically significant difference between KA and well-differentiated SCC in terms of p53 and Ki-67 staining (P < 0.001). Increased expression of p53 and Ki-67 was found in well-differentiated SCC. A statistically significant correlation was present between the expression of p53 and Ki-67 in KA. A statistically significant difference was detected between KA and well-differentiated SCC in terms of laminin staining (P = 0.018). Increased laminin expression was determined in well-differentiated SCC. Conclusion: We have determined in this study that p53, Ki-67 and laminin may be used as adjuvant immunohistochemical markers in differential diagnosis of KA and well-differentiated SCC.
Keywords: Differential diagnosis, immunohistochemistry, keratoacanthoma, well-differentiated SCC
|How to cite this article:|
Turan G, Altun E, Aslan F, Kulahci O. The role of p53, Ki-67 and laminin expression in the differential diagnosis of keratoacanthoma and well-differentiated SCC. Indian J Pathol Microbiol 2019;62:561-5
|How to cite this URL:|
Turan G, Altun E, Aslan F, Kulahci O. The role of p53, Ki-67 and laminin expression in the differential diagnosis of keratoacanthoma and well-differentiated SCC. Indian J Pathol Microbiol [serial online] 2019 [cited 2020 Jun 6];62:561-5. Available from: http://www.ijpmonline.org/text.asp?2019/62/4/561/269084
| Introduction|| |
Keratoacanthoma (KA) is a rapidly progressing and self-regressing well-differentiated squamoproliferative skin lesion. It may be confused with squamous cell carcinoma (SCC) in its rapidly progressing term. It may be difficult to differentiate KA from well-differentiated SCC by histopathological examination. Also some studies have supported that KA may be a subtype of SCC. Therefore, there are a number of studies carried out to shed light on pathogenesis and differential diagnosis of these lesions in the literature., The KA cases with minimal lesions are the most commonly confused types of KA with SCC. SCC of skin is the second most common type of cutaneous malignancy. They usually develop as a result of exposure to high levels of UVB light and they are mostly observed in the areas that are exposed to sunlight such as face, neck, arms and hands. The etiology of SCC is multifactorial and chronic actinic damage has been considered as the most important risk factor especially in the fair-skinned individuals. The other risk factors are radiation, immunosuppressive agents, human papillomavirus (HPV), chemical carcinogens, chronic inflammation and chronic infection. P53 is an important transcription factor which plays a central role in the cell cycle regulation mechanisms., It is the most frequently altered gene in human cancers and its inactivation plays an important role in human carcinogenesis. P53 mutations were detected in more than half of all the tumors. Abnormal p53 expression was encountered in lichen planus, psoriasis, chronic dermatitis, lupus erythematosus and inflammatory disorders of squamous epithelium. P53 plays an important role in the control of cell proliferation. P53 is commonly found in cutaneous SCC., Ki-67, known as a marker protein of proliferation, is the most commonly used cell-cycle regulation protein among the immunohistochemical markers in squamoproliferative lesions., Laminin is one of the major glycoproteins of basement membrane. Tumor cells may bind to basement membrane by laminin receptors and thereby cause invasion and metastasis. Normal cells also express laminin receptors, however, these receptors usually concentrate on the surface of basement membrane since they bind to laminin on the basement membrane with a high level of affinity. Even though the number of the receptors increase in the tumor cells, these receptors spread through the cell. Increased laminin expression was found to be in correlation with invasion in many cancer types such as breast, colon, prostate, lung and ovarian cancers.,,,
| Methods|| |
This study included a total of 46 cases. including 23 cases with keratoacanthoma and 23 cases with well-differentiated SCC. The data were obtained from the archive of the department of pathology, in a tertiary care centre. The Hematoxylin-Eosin (H and E)-stain preparations of the cases were reevaluated by 2 pathologists. The keratoacanthoma and well-differentiated SCC cases were compared in terms of age, gender, clinical data such as diameter and localization of the lesion, macroscopic and microscopic characteristics, prevalence and staining patterns with p53, Ki-67 and laminin.
Clinical and histopathological assessment
The cases containing keratin in the center and papillated surface definitely without invasion in the basement of the lesion were classified as KA cases while the cases including atypical and invasive areas in the depth of the lesion as well as keratoacanthoma-like appearance were identified as well-differentiated SCC [Figure 1]a and [Figure 1]e. The cases were evaluated in terms of age, gender, localization, and diameter of the lesion.
|Figure 1: a-h. (a); keratoakantom H and E (10×), (b); in KA, expression of Ki-67 is seen in the peripheral basal and supra-basal layers of the lesion (10×), (c); in KA, expression of p53 is seen in the peripheral basal and supra-basal layers of the lesion (10×), (d); focal and weak cytoplasmic staining with laminin was in KA (10×), (e); well-differentiated SCC H and E (10×), (f); In SCC, expression of Ki-67 is seen as a diffuse pattern showing positive nuclear staining through the full thickness of the lesion (10×), (g); in SCC, of p53 is seen as a diffuse pattern showing positive nuclear staining through the full thickness of the lesion (10×), (h), Increased cytoplasmic staining with laminin was in the tumor islands of the well-differentiated SCC (10×)|
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Immunohistochemical staining and evaluation
The Hematoxylin-Eosin (H and E)-stain preparations of the cases were reevaluated and the appropriate paraffin blocks were selected. 2 pieces of 4 μm-thick slices were obtained from each paraffin block to perform immunohistochemical staining procedures of the paraffin blocks on the adhesive slides. 3 slices were prepared from the paraffin blocks of each patient to test p53 (clone: DO–7, ScyTek, 1:50 dilution, Utah, USA), Ki-67 (clone: polyclonal, ScyTek, 1:50 dilution, Utah, USA) and laminin (clone: ab2508; Abcam, 1:100 dilution, Cambridge, MA). In the next stage, all the steps of staining procedure were performed using the automatic immunohistochemistry staining device Benchmark XT (Ventana Medicalsystem inc, Tuscon, AZ), including deparaffinization and antigen retrieval (CCL, Standard). Antigenic staining procedure was carried out with peroxidase-labeled Streptavidin-biotin kit and diaminobenzidine chromogen. Mayer's Hematoxylin was used for staining the basement. Normal epidermis and skin patches neighboring the lesion was accepted as positive internal controls for p53 and Ki-67 while positive internal controls for laminin were basement membrane-surrounding vessels. The stained preparations were assessed by an identical observer.
Immunohistochemical stainings for Ki-67 and p53 were assessed by counting the nuclear stainings. Nuclear staining of 10% and below were accepted as (1+) weak, 10-50% were (2+) moderate, 50% and above were accepted (3+) severe staining.
In the assessment of cytoplasmic staining with laminin, cytoplasmic staining of 10% and below were accepted as (1+) weak, 10-50% were (2+) moderate, 50% and above were accepted as (3+) severe staining.
The correlation between age, gender, localization and diameter of the lesion as well as the correlation with p53, Ki-67 and laminin expression in KA and well-differentiated SCC cases were statistically analyzed. The study data were analyzed using SPSS software (Version 15.0; SPSS Inc, Chicago, IL, USA). Pearson's Correlation Test was used for comparisons. The P < 0.05 value was accepted as the significance level.
The Ethical Approval of the study (Ethical Approval No: 153, dated 26th September, 2018) was received from Faculty of Medicine, Clinical Researches Ethics Committee to carry out the study.
| Results|| |
This study totally included 46 cases including 23 patients with keratoacanthoma and 23 with SCC. The ages of the cases ranged between 22 and 87 years (mean value ± SD: 62.13 ± 14.08 years). The study group was composed of 24 male (52.2%) and 22 female (47.8) patients. The present study included 8 male and 15 female cases with keratoacanthoma, and 16 male and 7 female with well-differentiated SCCs. There was a statistically significant difference between the two lesions in terms of gender (P < 0.001). It was determined that keratoacanthoma was more common between females whereas well-differentiated SCC was more frequently found between males. The diameter of the cases ranged between 80 and 200 mm (averagely 11.5 mm). No statistically significant difference was found between KA and well-differentiated SCC in terms of diameter, age, and localization (P = 0.18, P= 0.19, P= 0.22). A statistically significant difference was found between KA and well-differentiated SCC in terms of p53 and Ki-67 stainings (P < 0.001) [Table 1] and [Table 2]. SCC specimens revealed the whole layer and diffusely staining with p53 and Ki-67 whereas KA specimens demonstrated staining of the peripheral basement and supra-basement layers [Figure 1]b, [Figure 1]c and [Figure 1]f, [Figure 1]g. A statistically significant correlation was present between the expression of p53 and Ki-67 in KA. In addition, a statistically significant difference was detected between KA and well-differentiated SCC regarding cytoplasmic staining of laminin (P = 0.018) [Table 3]. An increased laminin expression was encountered in well-differentiated SCC. Increased cytoplasmic staining with laminin was encountered in the tumor islands of the well-differentiated SCC whereas focal and weak cytoplasmic staining with laminin was encountered in KA [Figure 1]d and [Figure 1]h.
|Table 2: Ki-67 expression in keratoacanthoma and squamous cell carcinoma|
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|Table 3: Laminin expression in keratoacanthoma and squamous cell carcinoma|
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| Discussion|| |
Keratoacanthoma is a rapidly progressing skin tumor and is observed more frequently in the sunlight-exposed areas of the body. It is considered to be originating from follicular infundibulum. KA has some subtypes. Solitary KA is the most commonly observed form. It is usually associated with intense UVB exposure. Therefore, it is monitored in the damaged skin by sunlight, especially face, forearm, wrist and dorsal hand. Lesions may be multiple. The incidence of keratoacanthoma was higher in females than males in our study although it has been reported to be observed more commonly in male patients (2-3:1) in the literature. Its incidence increases by age and it is mostly encountered in the 6th or 7th decade. The mean age of the cases in our study was 62 years old. Solitary keratoacanthoma has a shape of regular and hemispheric papule and it transforms to a circular or ovoid-shaped and commonly skin-colored umbilical nodule sized 1-2 cm in diameter including a keratin-filled crater in the center by growing rapidly within a few weeks. Pigmentation is extremely rare. The lesions larger than 3 cm in diameter are termed as giant keratoacanthoma in some studies. Keratoacanthomas usually reach their full-size within 6-8 weeks and spontaneously regress in a time interval shorter than 6 months. There is a crater filled with irregularly shaped keratin in the center in a fully developed keratoacanthoma. Epidermis extends like a lip over the edge of the crater. Irregular epidermal proliferations which progress upwardly through the crater at the basement and downwardly through crater basement are observed. Even though epithelium may be mildly pleomorphic, a typical keratoacanthoma frequently has a frequently palely stained, eosinophilic and vesiculated cytoplasm and shows remarkable keratinization. There are numerous keratin pearls and these demonstrate complete keratinization in the center. The interior elastic fibers and remarkable solar elastosis are known as characteristic findings. An accurate differentiation cannot be achieved by the presence of these characteristics. The cases with deep infiltrative growth patterns, perineural invasion, and vascular involvement have also been reported. Such lesions are more frequently located at the head, especially lips and nose. Exoendophytic lesion including histopathologically central keratin, presence of epithelial lips on the edges, keratinocytes with wide and pale-colored cytoplasm, presence of intra-lesional intraepithelial abscess, absence of anaplasia, presence of a distinct border between tumor and stroma, and absence of stromal desmoplasia are the signs for KA, whereas especially endophytic growth pattern, presence of frequent ulceration, rareness of the intraepithelial abscesses, high frequency of anaplasia, indistinct border between tumor and stroma and presence of stromal desmoplasia with keratinized crater are accepted as the signs for SCC. KA and SCC are two tumoral lesions with different prognosis which could not be easily differentiated in all cases according to their clinical behaviors and histopathological characteristics. The etiopathogenesis of KA has not been entirely clarified yet., Various immunohistochemical markers have been used to perform differential diagnosis between keratoacanthoma and SCC in many studies.,
Recep et al. have detected higher levels of p53 and Ki-67 expression in the well-differentiated SCC than KA in their study. We have encountered increased p53 and Ki-67 expression in the SCC in also our study, which is compatible with the literature. Batinac et al. have investigated Ki-67 and p53 expression in various non-neoplastic (normal skin, psoriatic skin) and neoplastic skin lesions (keratoacanthoma, SCC, basal cell carcinoma) and found a difference between the groups in terms of gene expression at the end of the study. They have reported that the expression of p53 protein increased especially in the neoplastic skin lesions.
Lu et al. have evaluated staining intensity and patterns of p53, p21, PCNA and Ki-67 in the premalignant and malignant skin lesions in their study. They have encountered moderate staining with p53 in 83.3% of the keratoacanthoma cases, whereas weak, moderate and severe staining with p53 was determined in 60%, 83.3% and 71.4% of the cases with SCC, respectively. Connolly et al. have evaluated immunohistochemical staining pattern with bcl-2, Ki-67, and p53 in subungual KA and subungual SCC in their study. They have encountered staining with Ki-67 in some cases of SCC whereas they have monitored no staining in KA. They have also detected increased staining with p53 in SCC and reported that Ki-67 and p53 could be useful in differential diagnosis of subungual KA and subungual SCC. Also, we have determined in our study that the differences between Ki-67 and p53 expression could be useful in differential diagnosis of KA and well-differentiated SCC, which is consistent with the literature.
Cain et al. have evaluated immunohistochemical p53 and PCNA expressions for differential diagnosis between KA, well-differentiated SCC and keratoacanthoma-like SCC and reported that use of those expressions was helpful in differentiating keratoacanthoma from well-differentiated SCC whereas those expressions provided no benefit in differentiating keratoacanthoma from keratoacanthoma-like SCC.
Oh et al. have evaluated p27 and Ki-67 expression in Bowen's disease, actinic keratosis, and SCC. They have monitored staining with Ki-67 in basal and parabasal cells in normal skin and actinic keratosis, whereas they have detected diffuse staining in the whole epithelial layer in SCC and Bowen's disease. We have observed the whole layer and diffuse staining with Ki-67 in SCC in our study.
Tiina T Kuivanen et al. have determined in their study that laminin-5 was stained in squamous and basal cell carcinoma. Dos Santos et al. have found cytoplasmic staining with laminin in all the cases of microinvasive SCC and well-differentiated SCC. We have also detected increased laminin expression in well-differentiated SCC, which is consistent with the literature. We have observed very weak focal staining with laminin in the cases of keratoacanthoma. In light of these results, we have concluded that laminin can be used in differential diagnosis between keratoacanthoma and well-differentiated SCC.
In conclusion, the differential diagnosis of KA and well-differentiated SCC can be difficult in some cases due to the similarities in the histopathological findings. The results of the research presented in this paper led us to conclude that an examination of p53, Ki-67 and laminin expression can be useful in the differential diagnosis between KA and well-differentiated SCC.
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Conflicts of interest
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Department of Pathology, Faculty of Medicine, Balikesir University, Balikesir
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]