Giant keratoacanthoma of the nasal pyramid - diagnosis and treatment challenges

Keratoacanthoma (KA) is a benign tumor that originates in the pilosebaceous glands and closely resembles clinically and histopathologically with squamous cell carcinoma (SCC), is some cases being impossible to differentiate them resulting in speculation and controversies, especially because is considered to be a pseudoepitheliomatous hyperplasia. A 90 year-old female, from rural area presented to our hospital with a giant tumor located on the left side of the nasal pyramid penetrating the nasal vestibule as a 3 mm hole with elevated borders and the surface was covered by a hematic and honey colored crusts. The onset of the tumor was long by the patient could not tell the exact moment of the appearance of the tumor.

The patient reported that the tumor bled and grew in size, after a previous local trauma that took place a month earlier.

To confirm the diagnosis, we performed a incisional biopsy under local anesthesia.From our point of view the result of the histological exam was inconclusive, showing microscopic structure of ulcerated, hyperkeratotic papilloma with well represented chronic inflammatory infiltrate. So, we performed an native and post-contrast MRI showing a heterogeneous tumor located on the alar and triangles cartilages, with nasal invasion, mainly on the left side of the nasal septum; white matter in infra and supra-tentorial spaces, with no focal lesions or other changes that sugest recent vascular lesions or space-occupying processes; cerebral and cerebellar atrophy due to patient’s age; midline symmetrical ventricular system

Taking in consideration the advanced age of the patient and the medical history, the reparative plastic surgery department and otorhinolaryngology clinique advised against surgery and reccommended roentgen teraphy. The patient refused the treatment and we initiated isotretinoin 1mg/kg/day for 60 days. The evolution was spectacular, the tumor resorbed and the keratotic plug was removed leaving a retractile and atrophic scar and a lack of substance located on the left nostril.