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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 803 - 16th July 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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Case posted by Dr. Mark Hurt.


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Guest Romualdo

Posted

In situ superficial spreading melanoma.

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Robledo F. Rocha

Posted

Assymetric junctional and pagetoid proliferation of atypical epithelioid melanocytes with nested and lentiginous growth patterns. I would call this superficial spreading melanoma, in-situ stage.
Is the site a man's back or a woman's leg?

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Guest Rodrigo Restrepo

Posted

Agree, superficial spreading melanoma.

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[color=#1C2837][font=arial, verdana, tahoma, sans-serif][size=4]Superficial spreading melanoma.[/size][/font][/color]

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Asymmetric junctional nests and atypical lentiginous proliferation. Also pagetoid extension at the center and at the borders of the lesion. No doubt Superficial Spreading Melanoma, in situ.

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Guest Dr. Francisco Vílchez

Posted

Agree, superficial spreading melanoma.

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Guest DR. Engin Sezer

Posted

Nested melanoma [i]in situ[/i]

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Sasi Attili

Posted

For some reason I am not so malignant on this one. The cells have a epithelioid morphology with nesting and single cell ascent in the center of the lesion. However the cells seems to be getting smaller with ascent.

Atypical special site naevus (depending on CPC) or an epidermal Spitz, would be what I would favour. I would however what to see the lesion excised completely.

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Guest Marcia

Posted

Melanoma in situ, superficial spreading type.

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Dr. Richard Carr

Posted

This lesion is relatively well nested, predominantly junctional (definitely a few cells in the papillary dermis (middle left). Some spitzoid morphology and focal pagetoid spread. I agree with Sasi we might accept many of these features in some special site naevi. Clinical correlation is obviously important but assuming these images are representative (i.e. a small lesion of around 4mm diameter) I would label as an atypical / odd small predominantly junctional and pagetoid Spitzoid lesion without overtly worrying features for outright melanoma and provided it is completely excised no further management required. It falls into a grey area of small superficial atypical lesions that are hard to classify / predict their biology and given the arbitrary features I often don't label them - i.e. I admit defeat but take a practical approach as provided they have been examined carefully (with additional levels to rule out a proper "invasive" melanoma) and removed in their entirety there is no chance of any adverse outcome to the patient for this lesion! There is an inverse relationship between size and difficulty of diagnosis in such cases.

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Dr. Mona Abdel-Halim

Posted

I am also not with malignant here, more with atypical site nevus

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Mark A. Hurt MD

Posted

Here is the Melan-A stain. Does it change your diagnosis? I'll post my diagnosis at 14:00 CDT.

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE803F7_B035531_Melan-A_700.jpg[/img][img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE803F8_B035531_Melan-A_700.jpg[/img]

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Guest Jim Davie MD

Posted

In the absence of clinical context, I agree this would favor melanoma in situ, with the differential including a special site (likely vulvar/genital) nevus.
Features favoring malignant: lentiginous predominance, pagetoid downwards spread, asymmetric pagetoid scatter over non-nested lentiginous junctional zones, asymmetric pigment distribution, pleomorphism of nest size and shape, high-grade atypia with dusty grey cytoplasm, variable nuclear hyperchromatism, randomly prominent nucleoli, thick nuclear membranes. Overall asymmetry, with rete peg irregularity in size/position.

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Mark A. Hurt MD

Posted

My diagnosis was melanoma in situ (pagetoid).

The patient is a 39 year-old woman with an 8mm diameter macule.

The findings that led to my diagnosis included the internal heterogeneity of pattern, large and small theques not spaced uniformly, and foci of pagetoid melanocytes in a pagetoid pattern. These findings were accentuated with Melan-A. In many melanomas in situ, I find that there is colonization of the suprapapillary plates, which is less prominent here.

I tend to stay away from phrases such as "superficial spreading melanoma," as melanomas with a pagetoid pattern [i]and [/i]lentiginous melanomas both "spread" superficially, so that phrase doesn't differentiate them. Of course, some if not many melanomas in situ contain both pagetoid [i]and [/i]lentiginous patterns, in my experience.

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Sasi Attili

Posted

This is a tricky case for which there would be a wide range of opinions. I suspect there might be a East/ West divide as to what this lesion is called. Most people in the UK I think might not go as far as calling this a melanoma. Wolter Mooi gave an excellent lecture at the recently concluded BAD meeting in Liverpool, talking exactly on this issue. He favoured the term 'Uncertain Malignant Potential' for these tumours which are thin and the certainty of malignancy is difficult to assess, in view of the large number of cases that would be necessary to achieve statistical significance!

Obviously this is a debatable topic and I am not sure we will ever find an answer to this question. [b]However if you call this malignant, you can never be wrong [/b][i](apart from colleagues who might disagree)[/i][b]!! [/b]So it is a safe bet to err on the side of caution and this is the approach most pathologists might take.

On a slightly different note, Wolter Mooi has a melanocyte slide set that is accessible for free online and I would recommend checking out: [url="http://melanocytepathology.com/"]http://melanocytepathology.com/[/url].

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Mark A. Hurt MD

Posted

I don't think it is strictly and East/West issue, as many in the States use the phrase "uncertain malignant potential." In my way of thinking, however, one doesn't diagnose a potential. Rather, one evaluates morphological data and establishes criteria for what a thing is. The end product of that process is a diagnosis. Once one has decided what the thing is based on the criteria (assuming the criteria are legitimate), its potential is known, because the potential is [i]part [/i]of what the thing is.

That said, there is always room -- many reasons -- for being uncertain, but what one is uncertain [i]about [/i]is not the potential but rather the diagnosis.

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Guest Romualdo

Posted

Thanks Dr. Sasi for divulgating this excellent site!

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Sasi Attili

Posted


If one thinks about it, even a normal cell has the 'potential' to become malignant. A melanoma cell has to after all arise from a normal cell. In my opinion it is the statistical chance that the potential can manifest, that is important. One can be certain about the malignant potential of even a normal cell i.e. it has the potential. It is the chance of the potential manifesting, that is debatable. This assumes clinical significance in the case so called early melanoma's. I think the diagnosis of an early melanoma has too many variables and subjective criteria, for it to be called a defined 'diagnosis'. That is where all the problem arises. Your statement 'assuming the criteria are legitimate' aptly sums it up.

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Mark A. Hurt MD

Posted

I'm working on a blog to address some of the issues raised here.

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