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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 851 - 20th September 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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85 Year old Male, Papule on scalp.


Case posted by Dr. Richard Carr.


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BCC

D.D:BCC vs Trichoblasroma ( basaloid variant)

The strong anf diffuse positivity of BerEP4 is typical of BCC and not basalod trichoblastoma in which it is focal and weak

Althogh a papillary mesenchymal body is seen, the seperation artifact is between the tumor and the fibromyxoid stroma which is a feature typical of BCC and not Trichoblastoma

BCC with sarcomatous differentiation is a good catch from Engin

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Guest Romualdo

Posted

Cutaneous carcinosarcoma with carcinoma component represented by basal cell carcinoma.

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Dr. Mona Abdel-Halim

Posted

Carcinosarcoma, epithelial component is BCC

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Agree, a rare case of cutaneous carcinossarcoma with the epithelial component composed of BCC.

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Arti Bakshi

Posted

would probably do some more immunos to see if the spindle cell component stains with anything specific.
But otherwise agree with carcinosarcoma.

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Robledo F. Rocha

Posted

Just to make something different, I gonna use a synonym: metaplastic basal cell carcinoma. The sarcomatoid component is probably originated from the epithelial one.

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Guest Jim Davie MD

Posted

[size=4][font=arial,helvetica,sans-serif]This looks like a superficial and nodular BCC.

Although there is aberrant mitoses in the surrounding stroma, this stroma appears to be well circumscribed and completely/concentrically distributed around basaloid tumor nodules, with absence of asymmetric infiltration/extension into the surrounding dermis, and absence of chronic host inflammatory reaction. This is a low-power histology pattern I would [i]not [/i]expect of a sarcomatous/spindle cell degeneration of a epidermal carcinoma.

Nevertheless, it pays to be cautious. Any case with this kind of atypical spindled stroma deserves an additional stain for high molecular weight cytokeratin such as CK5, and/or 34betaE12 (covers HMW cytokeratins 1,5,10, and 14), or P63 to help exclude the worst-case scenario of a spindle-cell/poorly differentiated carcinoma. [/font][/size][font=arial, helvetica, sans-serif][size=4]Some spindle cell carcinomas will be negative for these markers, notwithstanding. [/size][/font][font=arial, helvetica, sans-serif][size=4] ( Pancytokeratin AE1/AE3 is very unreliable and insensitive as a carcinoma marker in this scenario ). [/size][/font]

[size=4][font=arial,helvetica,sans-serif]An EMA stain would be useful to exclude a sneaky Merkel cell carcinoma masquerading as BCC or SCC, as MCC is usually simultaneously positive for EMA and BerEP4, unlike BCC (BerEP4 positive only) or SCC (EMA positive only). [/font][/size]

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Guest Saleem Taibjee

Posted

Agree, BCC with malignant sarcomatoid component. Prognosis should be good.

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Dr. Richard Carr

Posted

I reported this case as follows: Nodular basal cell carcinoma with tight peritumoural sarcomatoid
element, the latter of doubtful clinical significance. Depth 1.8mm (it was a superficial shave biopsy)

I recorded the IHC (for academic interest) in my slide collection database (See Mark's blogs on filing references) as follows:
Epithelium diffuse BerEP4, Pank, 34BE12, p63, Ki67 50%; p53++80%; EMA neg
Stroma: Neg for BerEP4, Pank, 34BE12, p63 & EMA; Ki67 10%; p53+20%.

Interestingly we reported a cutaneous sarcoma NOS on his scalp last year (fully excised) and he has had multiple H&N NMSC's. I suppose there is a differential diagnosis of a recurrence / cutaneous metastasis of the previous cutaneous sarcoma NOS and collision with BCC.

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Mark A. Hurt MD

Posted

Enlightening case, Richard. I agree with your diagnosis. This is a very uncommon phenomenon in my experience.

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Guest Jim Davie MD

Posted

[quote name='Dr. Richard Carr' timestamp='1379739766']
I reported this case as follows: Nodular basal cell carcinoma with tight peritumoural sarcomatoid
element, the latter of doubtful clinical significance. Depth 1.8mm (it was a superficial shave biopsy)

I recorded the IHC (for academic interest) in my slide collection database (See Mark's blogs on filing references) as follows:
Epithelium diffuse BerEP4, Pank, 34BE12, p63, Ki67 50%; p53++80%; EMA neg
Stroma: Neg for BerEP4, Pank, 34BE12, p63 & EMA; Ki67 10%; p53+20%.

Interestingly we reported a cutaneous sarcoma NOS on his scalp last year (fully excised) and he has had multiple H&N NMSC's. I suppose there is a differential diagnosis of a recurrence / cutaneous metastasis of the previous cutaneous sarcoma NOS and collision with BCC.
[/quote]

A great case! It would be interesting to compare the atypical stroma of this tumor to the previous one, and possibly to other tumors, to see if there is similarity. That may shed light on the significance of the cytologic features in differentiating sarcoma from a pseudosarcomatous stroma (which I favor more strongly than before, in light of the helpful negative IHC stains).

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