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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 1002 - 25th April 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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F36. Lesion on breast received from GP with no other information. Referred due to mitotic rate (20 mitotic figures).

Case posted by Dr. Richard Carr.


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If there are, indeed, 20 mitoses per lesion and these are in dermal melanocytes (which they appear to be in the lower left photo), then this is a melanoma, period, no matter what the lesion looks like.

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Dr. Mona Abdel-Halim

Posted

The lesion is completely banal and innocent to me, I even could not think of nevoid melanoma. The mitotic figures demonstrated are in the upper half of the dermis. If all are there, I do not find any problem. Mitoses do occur in nevi. May be the lady is pregnant, where increased proliferation of nevi occur. Plus, breast is one of the atypical site nevi... I have also come across this article which might be beneficial

http://bpa-pathology.com/uploads/file/docs/Frequent%20Mitotic%20Activity%20in%20Banal%20Melanocytic%20Nevi...-%20KGlatz%20et%20all%20-%20Am%20J%20Dermatopathol%202010.pdf

Would love to read comments of others who r more expert in melanocytic lesions than me...

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nick turnbull

Posted

Looks very benign at scanning magnification, and there is no obvious phoenotype change or expansion of the papillary dermis (or COE),matures with depth etc. while the mitoses rate is anxiety provoking I wonder if its benign

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The lesions is simetric in many aspects and there´s maturation. I also believe this is a mitotically active dermal nevus without malignant behavior. Immunostains with HMB-45 and ki-67, which will probably demonstrate higher index in the superficial dermis, might be helpfull.

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Dr. Richard Carr

Posted

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE1002_RAC6781x10_Ki67_Label.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE1002_RAC6781x10b_Ki67_Label.jpg[/img]

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Low ki-67 in the basis of the lesion: Mitotically active dermal nevus, but I would not report like this to not confuse the clinician. I would call it Dermal nevus.

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Robledo F. Rocha

Posted

I’d call this nevoid melanoma. In addition to the high mitotic index highlighted by Ki-67 immunostain, in the deeper reaches one can find some mitotic figures, some subtle pleomorphic cells with hyperchromatic and enlarged nuclei around an eccrine coil, and a well demarcated pushing lower border. Also, on scanning magnification, the lesion appears more expanded on the right half, but this asymmetry may be an artifact. Anyway, a careful scrutiny of other fields and levels of sectioning will confirm or not this as a nevoid melanoma or a mitotically active Unna’s nevus.

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Guest Romualdo

Posted

[quote name='I. Abdul-kadir' timestamp='1398424523']
If there are, indeed, 20 mitoses per lesion and these are in dermal melanocytes (which they appear to be in the lower left photo), then this is a melanoma, period, no matter what the lesion looks like.
[/quote]
I think this mitotic count is incompatible with a benign melanocytic nevus.

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Dr. Richard Carr

Posted

The 20 mitotic figures were in 6 cross sections amounting to a total area of 60 mm2. Does this information change your thinking. All mitoses were in the superficial half of the lesion.

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Guest Romualdo

Posted

Yes, a little more than 3 mitotic figures per histologic section, all located in the superficial part of a lesion that looks like benign is not so terrible! I change my mind!

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Mark A. Hurt MD

Posted

It looks like a Miescher's nevus. I am skeptical about melanoma in this case, but I have, with enthusiasm, submitted similar cases for genomics, and almost to a case, the genotype has shown no gains or losses. Is this patient pregnant (as Mona suggested)? Also, phh3 might be more useful than ki67 in such a case.

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Dr. Richard Carr

Posted

Thanks Mark for the additional comment. This was a referred case with no history unfortunately. I reported it as follows: This is indeed the most mitotically active benign naevus I have seen to date. In total, I counted 20 mitotic figures in 6 individual cross sections, amounting to an area of approximately 60mm2. This gives a mitotic rate of far less than 1 per mm, which is in fact low. All of the mitotic figures are superficial and the naevus is otherwise typical, although having rather active appearances, as can be seen in lesions
from the breast. Excision is close, but probably complete, and certainly a wait and watch can be adopted.

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