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Case Number : Case 857 - 30th 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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50 year old female with a shave biopsy from right upper thigh.

Case posted by Dr. Mark Hurt.


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Robledo F. Rocha

Posted

Scanning magnification points to a small exophytic tumor without neoplastic involvement of the stalk. Those findings, in addition to the marked nuclear pleomorphism, make me think of atypical fibroxanthoma. Since this is a diagnosis of exclusion and sun-protected skin of the limb is a rare location, others anaplastic sarcomatoid tumors must be first ruled out, including nodular melanoma, a tumor much more commonly found at this site in a woman in her fifties.

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Sasi Attili

Posted

[quote name='Robledo F. Rocha' timestamp='1380548747']
Scanning magnification points to a small exophytic tumor without neoplastic involvement of the stalk. Those findings, in addition to the marked nuclear pleomorphism, make me think of atypical fibroxanthoma. Since this is a diagnosis of exclusion and sun-protected skin of the limb is a rare location, others anaplastic sarcomatoid tumors must be first ruled out, including nodular melanoma, a tumor much more commonly found at this site in a woman in her fifties.
[/quote]

Agree

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Dr. Mona Abdel-Halim

Posted

The lesion is polypoidal, well circumscribed, dermal lesion. I do not think this fits with pleomorphic sarcoma. The lesion not in a sun exposed site, I think this R/O AFX. I thought of malignant giant cell tumor of soft tissue. It is usually subcutaneous but I read that dermal and polypoidal lesions have been reported.


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Guest Romualdo

Posted

Atypical fibrous histiocytoma of the skin. IHQ is necessary. Clear margins and follow-up are in order, since there is a small risk of recurrence and metastasis.

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Mark A. Hurt MD

Posted

Here are additional images. I hope they help toward a diagnosis:

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/Case857_Image%2009.jpg[/img]
[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/Case857_Image%2010.jpg[/img]
[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/Case857_Image%2011.jpg[/img]
[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/Case857_Image%2012.jpg[/img]
[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/Case857_Image%2013.jpg[/img]

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Guest Jim Davie MD

Posted

I would add to the differential: Dermatofibroma, Monster-cell variant (DF with Monster Cells).

I agree that this is a fibrohistiocytic neoplasm with very unpleasant nuclei and foamy cytoplasm, resembling AFX. There is overall pattern of multinucleate giant cells, some with osteoclast-like or Touton-type foamy cytoplasmic features, and thickened keloidal collagen bundles. No tumor necrosis, ulceration, or solid growth pattern. Location on non-actinic site, overall symmetry, and low mitotic activity would support DFMC, if the rare mitoses in the above photos are representative of the true mitotic density of the neoplasm.

Immunostains would be worthwhile to help rule out Spitzoid or rare cutaneous leiomyosarcomas that show convincing AFX-like cytologic features.

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Dr. Hafeez Diwan

Posted

AFX. If this were a melanoma, I would expect S-100 to be positive. I reported an AFX with positive HMB45 about 8 years ago (the patient is alive and well), which was S-100 negative. Atypical fibrous histiocytoma/dermatofibroma with monster cells would be in my differential.

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Mark A. Hurt MD

Posted

Kudos to everyone for AFX, and to Hafeez for his article.

Here is my diagnosis:

SKIN, RIGHT UPPER THIGH, SHAVE BIOPSY :
[b]-- ATYPICAL FIBROXANTHOMA (SUPERFICIAL PLEOMORPHIC SARCOMA)[/b]
[b]WITH EXPRESSION OF HMB45 AND MELAN-A) *[/b]
[indent=1][b]COMMENT:[/b] This unusual presentation of atypical fibroxanthoma has been described in one other case in 2004. The case under consideration in this report looks virtually identical to the one published. The presence of HMB45 and Melan-A in the face of negative S100 protein and negative SOX10, militates against this being an authentic melanocytic lesion.[/indent]

Reference:

Smith-Zagone MJ, Prieto VG, Hayes RA, Timperman WW Jr, Diwan AH. HMB-45 (gp103) and MART-1 expression within giant cells in an atypical fibroxanthoma: a case report. J Cutan Pathol. 2004 Mar;31(3):284-6. PubMed PMID: 14984584.

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