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Building Blocks of Dermatopathology

BAD DermpathPRO Learning Hub: Basics of Immuno

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Case Number : IM0006 Dr. Richard Carr

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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49 years-old male. Inflammatory macule ?eczema ?psoriasis.

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Dr. Mona Abdel-Halim - Bowen's disease.
Dr. Richard Carr - Thanks Mona. The anatomical site is glans penis I think.
Dr. Mona Abdel-Halim - If so, then it will be erythroplasia of Queyrat !!!!!
Mark A. Hurt MD - SCCIS unless there is some compelling reason to think this could be a sequla of treatment (i.e., some type of drug reaction)
Guest Bansal - Dysplasia / PeIN but unsure of grading. In real-life, would take more levels and show to colleagues.
Robledo F. Rocha - Differentiated penile intraepithelial neoplasia (PeIN), probably arising in the setting of a long-term dermatitis.
I prefer the simplified nomenclature for penile preinvasive lesions proposed by Antonio Cubilla et al (Morphological characterization and distribution of penile precancerous lesions using a simplified nomenclature. A study of 198 lesions in 115 patients. Lab Invest 2008;88:696A). Edited April 26, 2013 by Guest
Guest Rodrigo restrepo - Differentiated PeIN

Guest Jim Davie MD - Agree with SCC in situ / Bowen's disease / Erythoplasia of Queyrat (The tree of nomenclature needs pruning!)
- Low power image (top left): shows increased pleomorphism and nuclear/cytoplasm volumes, compared to the 'normal' epidermis on the left, and what look like sparse bizarre giant keratinocytes and deeply eosinophilic necrotic keratinocytes in the upper reaches. [very useful image].
- Medium and high power images (top right, lower right): show mitotic figures at all levels, coarse parakeratosis, dyskeratosis, and prominent nucleoli. There is aberrant multinucleation. Edited April 26, 2013 by Jim Davie MD
Dr. Richard Carr - Thank you all for the contributions. I must say that the contributors today all made light work of a difficult case which is very impressive. I am saying this so that any visitors new to dermatopathology (the neophytes) will not be disheartened!! Immunostaining can be exceedingly useful in this setting.In view of the comments above I e-mailed to Dr Cubilla as follows:

Dear Dr Cubilla,
I would be most interested on your opinion on the case I posted today for Phillip Mckee's website - the spot diagnosis of the day. I reported it as conventional [high grade] PeIN because of strong p16 and what I interpreted as focal koilocytosis. I thought the lichenoid reaction was limited to the neoplastic epithelium and was therefore secondary but I would be most grateful for your thoughts.
Richard Carr

Dr Cubilla responds: I would favor this lesion to be a Penile Intraepithelial Neoplasia,basaloid over Diff. PeIN. Cells are rather uniform, surface is parakeratotic with isolated superficial koylocytotic cells. I expect this lesion to be p16 Ki 67 positive. Thanks for calling my attention to this intersting case. Antonio Cubilla.

Additional notes (Dr Carr): Abrupt full thickness p16 with Ki67 at all levels coincides with the inflammatory infiltrate (on the right half of image 1)

I will ask the DermpathPro team to post the additional immunos for your interest. Regards to all and enjoy your weekends
Guest Bansal - Thanks Richard, very useful.
Dr. Mona Abdel-Halim -Thanks for the Immunos , very nice

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