In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 901 - 2nd December Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
Submitted Date :
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The patient is an 85 year old white man with a history of a lesion that was excised from the nose, with known outcome. He was treated. A shave biopsy of a keratotic, pink papule arising in the flat used to close the nose defect, present for three months, is taken from the nose.

Case posted by Dr. Mark Hurt


User Feedback


Guest Maria George

Posted

Recurrent malignant melanoma is my favorite here however others need to be excluded by IHC.

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Dr. Richard Carr

Posted

Friday's case was a metastasis from the colon (CDX2, CEA positive). Apologies for delay, long day in Paris!

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Mark A. Hurt MD

Posted

Note: in the history, it should be "flap" not "flat."

Let me state it better:

The patient is an 85 year old white man with a history of a lesion that was excised from the nose. The outcome was known, and he was treated. The specimen for your review is a shave biopsy of a keratotic, pink papule, present for three months, arising in the flap used to close the nasal defect.

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I also think it is a recurrent Melanoma. If there is no history, immunohistochemistry is mandatory.

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Robledo F. Rocha

Posted

Pleomorphic recurrence of melanoma or squamous cell carcinoma.

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Guest Jim Davie MD

Posted

I favor a high-grade squamous carcinoma. There is high-grade atypia at the junction, most pronounced / best seen in the first low-power image (right edge). Given the epidermal atypia, and clinical history, there is consideration that this tumor is an 'import' from the flap, and not original to the nose.

To add to the above differential of SCC vs. melanoma, less likely would be:
1. Epithelioid angiosarcoma ( given other images, it seems that the red cells in last photo are most likely artefactual to procedure, but some appear placed within intracellular lumens. )
2. High grade sebaceous carcinoma (the vacuolar clear-cell changes seem more consistent with that commonly seen in poorly differentiated SCC / Bowen's disease).

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Dr. Mona Abdel-Halim

Posted

I also thought of recurrent sebaceous carcinoma, but the vague nested nature of the tumor masses made me favor melanoma. I have realized the atypia of the basal layer but explained it by actinic keratosis in the flap, the tumor masses did not look like squamous cell carcinoma to me, but it is of course a possibility... I still feel it is a recurrence of the original tumor.. Lovely case...

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Dr. Richard Carr

Posted

Don't forget metastasis (from a systemic primary) is also a possibility. What looks like nesting pattern may be intra-vascular tumour. Certainly some endothelial looking cells noted around some nests. Agree should consider all of the above (including angiosarcoma).

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Eman El-Nabarawy

Posted

Favor recurrent sebaceous carcinoma with a DD of melanoma.

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Mark A. Hurt MD

Posted

Here are some additional images:

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE901_Image%2007.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE901_Image%2008.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE901_Image%2009.jpg[/img]

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Mark A. Hurt MD

Posted

The diagnosis was Merkel Cell Carcinoma. This is either a persistent primary or a local metastasis. Here are the details:

[b]-- MERKEL CELL CARCINOMA (NEUROENDOCRINE CARCINOMA)[/b]

[b]COMMENT[/b]: I have reviewed the prior lesion from this site "neuroendocrine carcinoma (Merkel cell carcinoma)”, and I agree with the diagnosis rendered in that case.

Micro:

This lesion from the nose consists of a proliferation of deeply basophilic cells with considerable nuclear pleomorphism. The nucleoli have a granular quality to them with small nucleoli in them for the most part. There are many mitotic figures, including abnormal ones. There is an solar keratosis over the lesion. In one area, the dermal cells abut the epidermis but they do not appear to extend into the epidermis. There is also a considerable amount of acantholysis of the lesion. I am not completely convinced that there is intralymphatic or intravascular embolization of the lesion. I am not able to identify any embolization clearly on the H & E sections, although there are a few areas suggestive of that phenomenon. I am not able to prove it with D2-40, CD31, or CD34, as those markers highlight vessels but they don't appear to stuffed with tumor. The immunophenotype is that of strong Cam 5.2 positivity with paranuclear dots. CK 20 is also strongly positive in a similar pattern to Cam 5.2. Synaptophysin and chromogranin are both positive in the lesion. Melan-A, S-100 protein, CK7, TTF1, and p63 are all negative, and all contain internal control.

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