Pyogenic Granuloma Recurrent with Satellite Lesions ROGER K. ALLEN, M.D., LTC., M.C., AND O. G. RODMAN, M.D., COL., M.C.
Pyogenic granuloma recurrent with satellite lesions is an uncommon clinical entity. The condition occurs most often on the back o f young individuals and runs a benign course. A case is presented and the literature is reviewed.
INTRODUCTION g r a n u l o m a recurrent with satellite lesions is a rare, but distinct clinical entity that occurs most commonly on the back, especially over the scapular areas.1 To date, 28 patients have been described with the phenomena.1_6a In this report, an additional patient with this unusual clinical picture is described and the literature on it is reviewed.
P y o g e n ic
REPORT OF A CASE
The patient, a 9-year-old white boy, was first seen on the Dermatology Service of the Department of Medi cine of the Walter Reed Army Medical Center in No vember, 1976. He had numerous red papules, 1-4 mm in size, on the back, just to the left of the right scapula (Fig. 1). The papules were arranged in satellite fashion about a well-healed horizontal scar (Fig. 2) from a previ ous biopsy. The clinical history revealed that a nontender, ulcer ated, erythematous papule arose on the upper, right side of his back in October, 1975 and grew into a nodule 1.5 cm in size by December, 1975, at which time it was shaved and electrodesiccated at another medical facility. By January, 1976 the lesion recurred together with numerous satellite lesions that devel oped in a radius of 6 cm around it. Biopsies in toto of the recurrent lesion and of several satellite lesions Dr. Allen is Chief, Dermatology Service, Department of Medi cine, Ireland Army Hospital, Fort Knox, Kentucky. Dr. Rodman is Chief, Dermatology Service, Department of Medi cine, Walter Reed Army Medical Center, Washington, D.C. Address reprint requests to Dr. Allen, Dermatology Service, De partment of Medicine, Ireland Army Hospital, Fort Knox, Ky. 40121.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
490
J. Dermatol. Surg. Oncol. 5:6 June 1979
were taken in July, 1976 at that other medical facility. Nothing more was then done there. In November, 1976 when we saw the patient at the Walter Reed Army Medical Center he had a wellhealed linear scar to the left of the right scapula and numerous erythematous papules, 1-4 mm in diameter, and a few larger lesions scattered about it in satellite fashion. The patient was otherwise healthy and noth ing abnormal was uncovered on complete physical and routine laboratory examinations. The report of the original biopsy was obtained and it confirmed that the primary lesion had been a typical pedunculated granuloma pyogenicum. Biopsies of two papules were then taken. Routinely processed with hematoxylin and eosin, they revealed fairly well circumscribed nodules covered by flattened epidermis. The nodules contained numerous newly formed, variably dilated capillaries with prominent endothelial cells in a stroma that was edematous (Figs. 3, 4, and 5). Following the biopsies, nothing more was done be yond follow-up for one year, during which time the remaining satellite lesions were observed to resolve spontaneously. DISCUSSION
Granuloma pyogenicum generally occurs and persists as a single lesion. The solitary lesion usually consists of a rapidly growing, red, sessile or pedunculated nodule with a soft, smooth surface that may become ulcerated. Its size ranges from 0.5 to 2 cm in diameter and its commonest location is on the gingiva, lips, face or fingers, but no site on the skin is exempt7. Preg nancy often precipitates the development of the soli tary lesion, and it has even been referred to as “ the tumor of pregnancy.“ 8 In contrast to this usual clinical presentation of granuloma pyogenicum as a solitary lesion are the rare
ALLEN AND RODMAN
FIGURE 3. Low-power view o f the histology o f a representa tive satellite lesion showing the flattened epidermis and nu merous newly form ed capillaries with prominent endothelial cells within edematous stroma. (H & E, x l9 )
FIGURE 1. Clinical appearance o f a patient with granuloma pyogenicum recurrent with satellite lesions.
FIGURE 4. Higher power view o f Fig. 3. (H & E, x35)
S' I
4
FIGURE 2. Close-up view o f the patient pictured in Fig. I showing the satellite arrangement o f the lesions around a scar from excision o f an original granuloma pyogenicum.
FIGURE 5. Still higher power view o f Fig. 3. (H & E, x440)
J. Dermatol. Surg. Oncol. 5:6 June 1979
491
PYOGENIC GRANULOMA RECURRENT
Table 1 Salient Differential Features of Certain Cutaneous Angiopathies
Characteristics Ages of patients Sex distribution Predominant location on body
Rate of development Relation to trauma Spontaneous regression Biologic behavior Histopathology
Usually the young, but any age may be affected Equal In and around mouth, on face and on hands Rapid Often Sometimes Benign Eroded, pedunculated lesion of newly formed capillaries with prominent endothelial cells imbedded in an edematous stroma with an epidermal collarette.
cases of small angiomatous satellite lesions that de velop in multiplicity following excision or irritation of a primary growth.9The initial lesion in such instances is identical in appearance to a simple, solitary pyogenic granuloma. When this primary lesion is traumatized by cauterization or curettage, or is surgically excised, satellite lesions appear around the primary site, in which, moreover, the original neoplasm may recur be fore or simultaneously with the satellites. The time interval between these events may vary from one week to four months or more. In some cases satellitosis is reported to have occurred without a history of distur bance of the primary lesion. Satellite lesions tend to be smooth and bright red in color, and in size range from 1 mm to 1 cm in diameter. They are said to be larger and more numerous when in close proximity to the origi nal, solitary lesion or the site of its extirpation. Most cases are reported to have occurred on the back over a scapula, but occasionally on the face. The patients are in the main under 25 years of age. In most cases, recur rent satellites were either excised or destroyed by cautery and did not return. In several cases in which no treatment was accorded, including the present case, the lesions resolved slowly and spontaneously over a course of several months. In histopathology, original lesions tend to be pedun culated and frequently ulcerated, and to show pro liferating angiomatous tissue of the kind usually found in pyogenic granulomas. Recurrent lesions usually are sessile and have intact surfaces. The smallest of recur rent papules closely simulate simple capillary heman giomas and lack the usual structural features of typical pyogenic granulomas. Some large recurrent nodules have certain unusual features, namely, angiomatous
492
Pyogenic granuloma with satellite lesions
Solitary pyogenic granuloma
J. Dermatol. Surg. Oncol. 5:6 June 1979
Simple capillary hemangioma
Usually under 25
Infants
Equal Trunk, especially back and scapular regions
Equal On head most commonly, but may occur on any site of the body. Rapid No Usually Benign Proliferation of large endothe lial cells into cords and channels; later fibrosis.
Rapid Often Sometimes Benign Primary lesion similar to solitary pyogenic granuloma with satel lite lesions that are sessile and often resembling capillary hemangiomas.
proliferation that extends deep and reaches the sub cutaneous fat and intraluminal projections of en dothelium, but no intraluminal shedding of cells. In differential diagnosis of an acquired angiopathy like pyogenic granuloma recurrent with satellite le sions, the following condition must be considered: simple capillary hemangiomas,7 angiolymphoid hyperplasia with eosinophilia10, malignant angioendothelioma7,11, papular angioplasia12, and Kaposi’s sarcoma. Table 1 summarizes salient features of each. The pathogenesis of the satellitosis of granuloma pyogenicum is unknown. Most authors hold the view that the phenomenon is a vascular disturbance triggered by trauma which is known to be followed by neoangiogenesis in the process of natural repair. Some authors have even suggested the term “ post traumatic angioma’’ for the phenomenon in point.13,14
1. 2. 3.
4.
5. 6.
6a.
REFERENCES Frain-Bell, W. Multiple pyogenic granulomata. Br. J. Der matol. 70:428-429, 1958. Evans, C. D., and Warin, R. P. Pyogenic granuloma with local recurrences. Br. J. Dermatol. 69:106, 1957. Coskey, R. J., and Mehregan, A. H. Granuloma pyogenicum with multiple satellite recurrences. Arch. Dermatol. 96:71-73, 1967. Warner, Joyce, and Wilson Jones, E. Pyogenic granuloma re curring with multiple satellites: a report of 11 cases. Br. J. Dermatol. 80:218-227, 1968. Hare, P. J. Granuloma pyogenicum. Br. J. Dermatol. 83:513— 515, 1970. Zaynoun, S. T., Juljulian, H. H., and Kurban, A. K. Pyogenic granuloma with multiple satellites. Arch. Dermatol. 109:689691, 1974. Fisher, I. Recurrent multiple pyogenic granuloma with multiple
A LLEN AND RODMAN
Kaposi's sarcoma Highest incidence in 5th, 6th, and 7th decades 9M : IF Distal lower extremities Slow No No Malignant Vascular cords; lumina con taining spindle-shaped fibroblastic cells; vascular slits with extravasated red blood cells.
Papular angioplasia
Angiolymphoid hyperplasia with eosinophilia
Middle-aged or older (rarely infants and children) Males Face and scalp
Elderly individuals
Young adults
Equal Face and scalp
Equal Head and neck
Rapid No Sometimes Benign Atypical vascular proliferation in dermis; capillary lumina lined by large protruding endothelial cells.
Moderately rapid or slow No No Benign Dermal and/or subcutaneous endothelial proliferation; exten sive infiltrate of lymphocytes, histiocytes and eosinophils.
satellites: features of Masson’s hemangioma. Cutis 20:201205, 1977. 7. Leyden, J. J., and Master, G. H. Oral cavity pyogenic granuloma. Arch. Dermatol. 108:226-228, 1973. 8. Lever, W. F., and Schaumburg-Lever, G. Histopathology of the Skin. 5th ed., Philadelphia, J. B. Lippincott Co., 1975, pp. 596-597. 9. Juhlin, L., Hjertquist, S.-O., Ponten, J., and Wallin, J. Dis seminated granuloma pyogenicum. Acta Derm. Venereol. (Stockh.) 50:134-136, 1970. 10. Wells, G. C., and Whimster, I. W. Subcutaneous angiolym-
Malignant angioendothelioma
Moderately rapid No No Highly malignant Anastomosing vascular channels; cords of atypical endothelial cells.
phoid hyperplasia with eosinophilia. Br. J. Dermatol. 81:1-15, 1969. 11. Bardwil, J. M., Mocega, E. E., Butler, J. J., and Russin, D. J. Angiosarcomas of the head and neck region. Am. J. Surg. 116:548-553, 1968. 12. Wilson-Jones, E., and Marks, R. Papular angioplasia. Arch. Dermatol. 102:422-427, 1970. 13. Foldvari, F. Post-traumatic angioma. Br. J. Dermatol. 47:463467, 1935. 14. Ryan, T. J., and Kurban, A. K. New vessel growth in the adult skin. Br. J. Dermatol. 82(Suppl. 5):92-98, 1970.
J. Dermatol. Surg. Oncol. 5:6 June 1979
493
Pyogenic granuloma recurrent with satellite lesions is an uncommon clinical entity. The condition occurs most often on the back o f young individuals and runs a benign course. A case is presented and the literature is reviewed.
INTRODUCTION g r a n u l o m a recurrent with satellite lesions is a rare, but distinct clinical entity that occurs most commonly on the back, especially over the scapular areas.1 To date, 28 patients have been described with the phenomena.1_6a In this report, an additional patient with this unusual clinical picture is described and the literature on it is reviewed.
P y o g e n ic
REPORT OF A CASE
The patient, a 9-year-old white boy, was first seen on the Dermatology Service of the Department of Medi cine of the Walter Reed Army Medical Center in No vember, 1976. He had numerous red papules, 1-4 mm in size, on the back, just to the left of the right scapula (Fig. 1). The papules were arranged in satellite fashion about a well-healed horizontal scar (Fig. 2) from a previ ous biopsy. The clinical history revealed that a nontender, ulcer ated, erythematous papule arose on the upper, right side of his back in October, 1975 and grew into a nodule 1.5 cm in size by December, 1975, at which time it was shaved and electrodesiccated at another medical facility. By January, 1976 the lesion recurred together with numerous satellite lesions that devel oped in a radius of 6 cm around it. Biopsies in toto of the recurrent lesion and of several satellite lesions Dr. Allen is Chief, Dermatology Service, Department of Medi cine, Ireland Army Hospital, Fort Knox, Kentucky. Dr. Rodman is Chief, Dermatology Service, Department of Medi cine, Walter Reed Army Medical Center, Washington, D.C. Address reprint requests to Dr. Allen, Dermatology Service, De partment of Medicine, Ireland Army Hospital, Fort Knox, Ky. 40121.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
490
J. Dermatol. Surg. Oncol. 5:6 June 1979
were taken in July, 1976 at that other medical facility. Nothing more was then done there. In November, 1976 when we saw the patient at the Walter Reed Army Medical Center he had a wellhealed linear scar to the left of the right scapula and numerous erythematous papules, 1-4 mm in diameter, and a few larger lesions scattered about it in satellite fashion. The patient was otherwise healthy and noth ing abnormal was uncovered on complete physical and routine laboratory examinations. The report of the original biopsy was obtained and it confirmed that the primary lesion had been a typical pedunculated granuloma pyogenicum. Biopsies of two papules were then taken. Routinely processed with hematoxylin and eosin, they revealed fairly well circumscribed nodules covered by flattened epidermis. The nodules contained numerous newly formed, variably dilated capillaries with prominent endothelial cells in a stroma that was edematous (Figs. 3, 4, and 5). Following the biopsies, nothing more was done be yond follow-up for one year, during which time the remaining satellite lesions were observed to resolve spontaneously. DISCUSSION
Granuloma pyogenicum generally occurs and persists as a single lesion. The solitary lesion usually consists of a rapidly growing, red, sessile or pedunculated nodule with a soft, smooth surface that may become ulcerated. Its size ranges from 0.5 to 2 cm in diameter and its commonest location is on the gingiva, lips, face or fingers, but no site on the skin is exempt7. Preg nancy often precipitates the development of the soli tary lesion, and it has even been referred to as “ the tumor of pregnancy.“ 8 In contrast to this usual clinical presentation of granuloma pyogenicum as a solitary lesion are the rare
ALLEN AND RODMAN
FIGURE 3. Low-power view o f the histology o f a representa tive satellite lesion showing the flattened epidermis and nu merous newly form ed capillaries with prominent endothelial cells within edematous stroma. (H & E, x l9 )
FIGURE 1. Clinical appearance o f a patient with granuloma pyogenicum recurrent with satellite lesions.
FIGURE 4. Higher power view o f Fig. 3. (H & E, x35)
S' I
4
FIGURE 2. Close-up view o f the patient pictured in Fig. I showing the satellite arrangement o f the lesions around a scar from excision o f an original granuloma pyogenicum.
FIGURE 5. Still higher power view o f Fig. 3. (H & E, x440)
J. Dermatol. Surg. Oncol. 5:6 June 1979
491
PYOGENIC GRANULOMA RECURRENT
Table 1 Salient Differential Features of Certain Cutaneous Angiopathies
Characteristics Ages of patients Sex distribution Predominant location on body
Rate of development Relation to trauma Spontaneous regression Biologic behavior Histopathology
Usually the young, but any age may be affected Equal In and around mouth, on face and on hands Rapid Often Sometimes Benign Eroded, pedunculated lesion of newly formed capillaries with prominent endothelial cells imbedded in an edematous stroma with an epidermal collarette.
cases of small angiomatous satellite lesions that de velop in multiplicity following excision or irritation of a primary growth.9The initial lesion in such instances is identical in appearance to a simple, solitary pyogenic granuloma. When this primary lesion is traumatized by cauterization or curettage, or is surgically excised, satellite lesions appear around the primary site, in which, moreover, the original neoplasm may recur be fore or simultaneously with the satellites. The time interval between these events may vary from one week to four months or more. In some cases satellitosis is reported to have occurred without a history of distur bance of the primary lesion. Satellite lesions tend to be smooth and bright red in color, and in size range from 1 mm to 1 cm in diameter. They are said to be larger and more numerous when in close proximity to the origi nal, solitary lesion or the site of its extirpation. Most cases are reported to have occurred on the back over a scapula, but occasionally on the face. The patients are in the main under 25 years of age. In most cases, recur rent satellites were either excised or destroyed by cautery and did not return. In several cases in which no treatment was accorded, including the present case, the lesions resolved slowly and spontaneously over a course of several months. In histopathology, original lesions tend to be pedun culated and frequently ulcerated, and to show pro liferating angiomatous tissue of the kind usually found in pyogenic granulomas. Recurrent lesions usually are sessile and have intact surfaces. The smallest of recur rent papules closely simulate simple capillary heman giomas and lack the usual structural features of typical pyogenic granulomas. Some large recurrent nodules have certain unusual features, namely, angiomatous
492
Pyogenic granuloma with satellite lesions
Solitary pyogenic granuloma
J. Dermatol. Surg. Oncol. 5:6 June 1979
Simple capillary hemangioma
Usually under 25
Infants
Equal Trunk, especially back and scapular regions
Equal On head most commonly, but may occur on any site of the body. Rapid No Usually Benign Proliferation of large endothe lial cells into cords and channels; later fibrosis.
Rapid Often Sometimes Benign Primary lesion similar to solitary pyogenic granuloma with satel lite lesions that are sessile and often resembling capillary hemangiomas.
proliferation that extends deep and reaches the sub cutaneous fat and intraluminal projections of en dothelium, but no intraluminal shedding of cells. In differential diagnosis of an acquired angiopathy like pyogenic granuloma recurrent with satellite le sions, the following condition must be considered: simple capillary hemangiomas,7 angiolymphoid hyperplasia with eosinophilia10, malignant angioendothelioma7,11, papular angioplasia12, and Kaposi’s sarcoma. Table 1 summarizes salient features of each. The pathogenesis of the satellitosis of granuloma pyogenicum is unknown. Most authors hold the view that the phenomenon is a vascular disturbance triggered by trauma which is known to be followed by neoangiogenesis in the process of natural repair. Some authors have even suggested the term “ post traumatic angioma’’ for the phenomenon in point.13,14
1. 2. 3.
4.
5. 6.
6a.
REFERENCES Frain-Bell, W. Multiple pyogenic granulomata. Br. J. Der matol. 70:428-429, 1958. Evans, C. D., and Warin, R. P. Pyogenic granuloma with local recurrences. Br. J. Dermatol. 69:106, 1957. Coskey, R. J., and Mehregan, A. H. Granuloma pyogenicum with multiple satellite recurrences. Arch. Dermatol. 96:71-73, 1967. Warner, Joyce, and Wilson Jones, E. Pyogenic granuloma re curring with multiple satellites: a report of 11 cases. Br. J. Dermatol. 80:218-227, 1968. Hare, P. J. Granuloma pyogenicum. Br. J. Dermatol. 83:513— 515, 1970. Zaynoun, S. T., Juljulian, H. H., and Kurban, A. K. Pyogenic granuloma with multiple satellites. Arch. Dermatol. 109:689691, 1974. Fisher, I. Recurrent multiple pyogenic granuloma with multiple
A LLEN AND RODMAN
Kaposi's sarcoma Highest incidence in 5th, 6th, and 7th decades 9M : IF Distal lower extremities Slow No No Malignant Vascular cords; lumina con taining spindle-shaped fibroblastic cells; vascular slits with extravasated red blood cells.
Papular angioplasia
Angiolymphoid hyperplasia with eosinophilia
Middle-aged or older (rarely infants and children) Males Face and scalp
Elderly individuals
Young adults
Equal Face and scalp
Equal Head and neck
Rapid No Sometimes Benign Atypical vascular proliferation in dermis; capillary lumina lined by large protruding endothelial cells.
Moderately rapid or slow No No Benign Dermal and/or subcutaneous endothelial proliferation; exten sive infiltrate of lymphocytes, histiocytes and eosinophils.
satellites: features of Masson’s hemangioma. Cutis 20:201205, 1977. 7. Leyden, J. J., and Master, G. H. Oral cavity pyogenic granuloma. Arch. Dermatol. 108:226-228, 1973. 8. Lever, W. F., and Schaumburg-Lever, G. Histopathology of the Skin. 5th ed., Philadelphia, J. B. Lippincott Co., 1975, pp. 596-597. 9. Juhlin, L., Hjertquist, S.-O., Ponten, J., and Wallin, J. Dis seminated granuloma pyogenicum. Acta Derm. Venereol. (Stockh.) 50:134-136, 1970. 10. Wells, G. C., and Whimster, I. W. Subcutaneous angiolym-
Malignant angioendothelioma
Moderately rapid No No Highly malignant Anastomosing vascular channels; cords of atypical endothelial cells.
phoid hyperplasia with eosinophilia. Br. J. Dermatol. 81:1-15, 1969. 11. Bardwil, J. M., Mocega, E. E., Butler, J. J., and Russin, D. J. Angiosarcomas of the head and neck region. Am. J. Surg. 116:548-553, 1968. 12. Wilson-Jones, E., and Marks, R. Papular angioplasia. Arch. Dermatol. 102:422-427, 1970. 13. Foldvari, F. Post-traumatic angioma. Br. J. Dermatol. 47:463467, 1935. 14. Ryan, T. J., and Kurban, A. K. New vessel growth in the adult skin. Br. J. Dermatol. 82(Suppl. 5):92-98, 1970.
J. Dermatol. Surg. Oncol. 5:6 June 1979
493
