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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 906 - 9th December Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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The patient is a 34 year old woman with an excision of a lesion on the right upper back.

Case posted by Dr. Mark Hurt


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Sasi Attili

Posted

Presuming this is the worse it gets on all levels through the specimen- I think, this is something I would do S100/ Melan A stains to see if there is a true melanocytic proliferation or if the pigmentation is simply within the keratinocytes. Early flat/ reticulated pigmented BCP can often overlap (or be difficult to distinguish) from a solar lentigo. Histo is reminiscent of that.

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My first thought was a Becker nevus.

I can see some epidermal hyperplasia with anastomosing rete ridges and basal hyperpigmentation.

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Robledo F. Rocha

Posted

Hyperpigmented rete ridges that are too elongated and anastomosing, accompanied by some basophilic elastic fibers, make me think of solar lentigo evolving into reticulated seborrheic keratosis. Patient and clinical dermatologist, maybe concerned with the grossly modifications brought by this process, have decided to remove the lesion.
I didn’t see significant increased numbers of melanocytes, so that pigmented cell are keratinocytes to me.

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Dr. Mona Abdel-Halim

Posted

Solar lentigo starting to evolve into retic seb K, do not c nests to think of a junctional nevus..

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Mark A. Hurt MD

Posted

Here are some additional images. My diagnosis at 14:00 Central Standard Time (St. Louis, MO).

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE906_Image%2006.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE906_Image%2007.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE906_Image%2008.jpg[/img]

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Dr. Mona Abdel-Halim

Posted

I think the second Melan A is highlighting nests that I did not perceive on H&E, this will make it a lentiginous junctional nevus.

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Sasi Attili

Posted

Wow. Impressive lentiginous melanocytic proliferation. It does look benign, but I am not sure it fits into the category of 'junctional nevus'. I am not convinced that the nest in the dermis is indeed dermal and not just a cross cut rete ridge. I don't see any pagetoid spread at all to call this lesion definitely malignant, though the melanocytic proliferation is quite confluent. Tough call. I would however favour this being within the Benign Junctional Nevus spectrum.

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Dr. Richard Carr

Posted

Junctional / lentiginous naevus ("jentigo")

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Guest Jim Davie MD

Posted

Lentiginous compound nevus. I think at least some of the sparse superficial Melan-A positive cells near the junction may be actual dermal melanocytes rather than tangential sections of rete. The junctional melanocytes cluster along tips of rete pegs, and predominantly spares the intra-rete zones. No high-grade atypia...melanocytes are predominantly small with rounded/hyperchromatic nuclei. ( There is background of subtly lighter-brown, non-staining heavily pigmented keratinocytes and focally aggregated melanophages ).

Clinically, I think it would have been any darkly pigmented lesion, such as dark area in a nevus spilus (r/o MM), or inkspot lentigo.

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Mark A. Hurt MD

Posted

My diagnosis was lentiginous melanocytic nevus.

I agree with Jim that there are a few melanocytes in the dermis, and I second Sasi's "wow," as the Melan-A really brings out the silhouette of this lesion, especially small theques in the epidermis, which, no doubt, led to Richard's "jentigo" diagnosis.

In contrast with melanomas in situ, there is consistent sparing of the suprapapillary plates in this lesion, which is a finding not emphasized very much in the literature, but which I find very helpful, especially in small biopsies.

One dermatologist with whom I work sends very small biopsies that are targeted with a dermatoscope. Melan-A helps me greatly with these lesions, which, 10 years ago I would have never received. In those days, the biopsies were larger, and the entire lesion was contained in most of them. Not so today.

In any event, thank you all for your responses.

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