Case Number : Case 41 Posted By: Guest

Phillip McKee - Overseas consultations (USA) Wrote:

Please excuse the obvious spelling mistakes in the previous post!

Submitted on 05/08/2010 21:30
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Phillip McKee - Overseas consultations (USA) Wrote:

This is quite a difficult case. Although it was originally signed out as a basi-squamous carcinoma, I think that Richard's suggestion on a squamous morular and tricholemmal variant of "keratotic nodular BCC deserves serious consideration. Unforunately I cannot find the original slide from which this filed comes from so the diagnosis is a bit open-ended. This is a great example of how much we can learn from each other.

Submitted on 05/08/2010 21:29
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Wayne Grayson - (Johannesburg, South Africa) Wrote:

I think the features are probably most in keeping with a basosquamous carcinoma.

Submitted on 05/08/2010 17:49
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Rodrigo Restrepo - UPB (Colombia) Wrote:

My opinion is keratotic basal cell carcinoma

Submitted on 05/08/2010 14:56
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Phillip McKee - Overseas consultations (USA) Wrote:

Many thanks for all of your helpful comments particularly Richard who has given us a highly educational reply. I will have to check the original section to see if what he has said applies. Unfortunately, here is Sedona, Arizona, I work solely with H/E-stained sections and do not have access to immunohistochemistry. More later.

Submitted on 05/08/2010 13:51
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richard carr - warwick (UK) Wrote:

BerEP4 and EMA can also highlight nicely the rare cases of collision of BCC and SCC (however the H&E usually does show an abrupt junction between the tumours difficult to assess in this field but unlikely I think).

Submitted on 05/08/2010 11:02
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richard carr - Warwick (UK) Wrote:

sorry 5th line from end of my post should have said: BCC "unusually" (although ductal and squamous morular are surprisingly common if you look for it).

Submitted on 05/08/2010 10:58
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Richard Carr - Warwick (UK) Wrote:

This case it a bit up my street!! We have the typical features of a nodular basal cell carcinoma showing the interesting features of squamous, slighly, morular (rounded ball like) differentiation and tricholemmal keratinisation within the centre of otherwise typical nodular islands. So for me this is not a malignant squamous component (basosquamous carcinoma) but rather a squamous morular and tricholemmal variant of "keratotic nodular BCC". I am very interested in squamous morular change. We have seen it in hidradenoma, porocarcinoma, tricholemmoma, inverted follicular keratosis, KA, "follicular" SCC so it is not specific but in BCC it is also often accompanied by a clear cell (and squamous morular pattern) easily confused with hidradenoma (I know this from getting it wrong!) The immunos can be very helful in sorting BCC: basosquamous variant(always positive for BerEP4 in the basaloid component and negative for EMA in the basaloid component) from basaloid SCC (usually negative or only very focally positive for BerEP4 in the basaloid component and often EMA positive). Very rarely we find the H&E features and immunos do not allow us to separate the two i.e. BCC (with basosquamous component) v's SCC (basaloid). So these very few cases could be called "basosquamous carcinomas NOS" and treated as for SCC. Incidentally we are seeing a lot of tumours we now believe to be follicular SCC that have mainly tricholemmal keratinisation and a few of these have had basaloid peripheries. This raises the interesting idea that tumours showing differentiation of different parts of the hair follicle may well show several lines of follicular (and of course sebaceous or apocrine differeniation). In the case of BCC usually it may show tricholemmal, inner root sheath, ductal and sebaceous differentiation. What we are calling follicular SCC tend to be more tricholemmal in nature and are usually completely BerEP4 negative. But a few cases with overlap features are to be expected. Hope I am in the right ball park!

Submitted on 05/08/2010 10:54
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Ralph M - Trainee (UK) Wrote:

Hello all, I think this could be a Merkel cell carcinoma with divergent differentiation (atypical squamous component)

Submitted on 05/08/2010 10:07
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Eman El-Nabarawy - Dermatology Department,Faculty of Medicine, Cairo university. (Egypt) Wrote:

After revising text.My DD: Keratotic BCC, Basosquamous cell carcinoma.

Submitted on 05/08/2010 06:32
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M N Mahmood - UAH (Edmonton, Canada) Wrote:

Basosquamous carcinoma.

Submitted on 05/08/2010 05:39
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Mona Abdel-Halim - Dermatology Department, Faculty of Medicine, Cairo University (Egypt) Wrote:

Basaloid islands with peripheral pallisading in many of them. There is also a keratinous cyst. The most striking feature is the presence of an island with squamous differentiation showing squamoid cells with copious esinophilic cytoplasm. I think this is a basosquamous carcinoma or a keratotic BCC.

Submitted on 05/08/2010 05:23
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Eman El-Nabarawy - Dermatology Department,Faculty of Medicine, Cairo university. (Egypt) Wrote:

I will go for Basosquamous cell carcinoma.

Submitted on 05/08/2010 04:31
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Marcela Saeb Lima - MSL Dermatopato (Mexico City) Wrote:

Most of it is a basaloid neoplasm with palisaded at the periphery, and some cystic spaces, with focal squamous change with trichelimmal keratinization... originating from the folliculosebaceous units. Interesting cause it could be a basal cell carcinoma with keratotic changes. Nice case Phillip!!

Submitted on 05/08/2010 04:28
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Eduwiges Martínez Luna - Hospital Gea González (trainee) (Mexico City) Wrote:

Maybe, basal-scamous cell Carcinoma

Submitted on 05/08/2010 03:04
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Yvonne Bury - (UK) Wrote:

Oh that's really difficult, seems to be a very complex lesion, they look like abortive hairfollicles, there are cysts, sebacous glands, squamous differentiation, the whole spectrum set in an inflammatory stroma. Don't know what this is, I suggest basaloid follicular hamartoma, but that's probably wrong. Will think about it again tomorrow.

Submitted on 05/08/2010 00:54
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Juan Carlos Garcés - Hospital Oncológico / Hospital Luis Vernaza (Guayaquil Ecuador) Wrote:

Good evening sir... Could be keratotic basal cell carcinoma?

Submitted on 05/08/2010 00:44
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