Case Number : Case 1710 - 16 December - Dr Richard A Carr Posted By: Guest

As good preparation for the final weekend of shopping for the holiday season there is nothing better than one of Dr Richard A Carr's excellent and intriguing Spot Cases.

Cheers, Geoff Cross - DermpathPRO Projects

elastosis, elastic fibres in dermis, wonder if the the pink stuff in the histiocyte-like cells is engulfed elastotic material, irregularly hyperplastic epidermis. ?annular elastotic granuloma (have never seen one!) but the cells do have prominent nucleoli. would have done epithelial, histiocytic and some lymphoid markers to exclude a variant of SCC and Hodgkin's (given the history) and if that wouldn't have been conclusive, would have referred the case to Richard!!

I share some of the appreciations of Urmila. I thought this was a case of eccrine squamous metaplasia (link) secondary to chemotherapy. I am not sure if there are some Hodgkin cells but as Urmila, I though it is worth performing immunos to check for the presence of neoplastic cells. As for the histiocytes I dont know the kind exactly, they made me think of the ones seen in crystal storing histyocitosis. 

31 minutes ago, Raul Perret said:

I share some of the appreciations of Urmila. I thought this was a case of eccrine squamous metaplasia (link) secondary to chemotherapy. I am not sure if there are some Hodgkin cells but as Urmila, I though it is worth performing immunos to check for the presence of neoplastic cells. As for the histiocytes I dont know the kind exactly, they made me think of the ones seen in crystal storing histyocitosis. 

thanks for sharing your expert comments Raul, get to learn so much from you guys

Features of syringo-squamous metaplasia but need immunos to exclude neoplastic deposits of Hodgkin.

what about a granular cell tumor, with chemio regressive changes?

Here what I found in Requena and Kutzner book: Multiple cutaneous granular cell tumors in a child in remission for Hodgkin's disease.. / De Raeve L; Roseeuw D; Otten J. J Am Acad Dermatol 2002, Vol. suppl, No. 47, 2002, p. 180-182

i don't know if a granular cell tumour would respond to chemotherapy given for hodgkin's. and hence HD chemotherapy induced changes would seem unlikely. but a good suggestion I think (the epidermal changes would fit) and certainly worth considering.

Another thought is PEC-oma, but as second spot ( this because I don't know enough primary cutaneous PEComa... )

A very busy day, but at the end of the afternoon (my standard time is UTC–04:00) I save some minutes to take on the challenge of this Dr. Carr's intriguing spot case.

Eccrine squamous syringometaplasia is a well-known chemotherapy-associated eccrine gland reaction. Bleomycin-induced eccrine squamous syringometaplasia has already been described in patients undergoing ABVD regimen used in the first-line treatment of Hodgkin lymphoma. That said, I don’t know how to explain all those cells resembling eosinophils, including many atypical ones, which degranulate on collagen bundles to produce a flame figure-like area.

I think I would go for eccrine squamous syringo metaplasia. However, what intrigues me are the uni and binucleate cells with granular cytoplasm. I would interpret these as degenerative. Focal necrosis is noted, which is fine for ESSM. Would do some IHC in real life, EMA, MUM-1, CD15, S-100 and CD163. 

Diagnosis: Odd elastolytic granuloma-like reaction with pseudoepitheliomatous hyperplasia and eccrine squamous syringometaplasia (?chemotherapy agent induced).

Well done Urmila and Raul.