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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 934 - 21st January Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
Submitted Date :
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The patient is a 53-year-old woman with a punch biopsy of a 1.0 x 0.6 cm irregularly hyperpigmented and pink plaque taken from the left calf.

Case posted by Dr. Mark Hurt


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Guest Saleem Taibjee

Posted

I wondered about a subtle bowenoid lesion, I don't think there is a melanocytic proliferation. Might also want a PAS to rule out dermatophyte.

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Eman El-Nabarawy

Posted

Bowen's disease vs large cell acanthoma.

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Dr. Mona Abdel-Halim

Posted

Difficult case. The scanning image shows that the right side is different from the left side. Maybe the biopsy was taken from both the hyperpigmented (right side) and the pink (left side)???? I am thinking of a subtle Bowen's developing in collision or within a lentigo?? Need Melan stain to confirm the nature of the increased pigmentation on the right side. Need proliferation markers to assess the subtle bowenoid changes. Interesting case..

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Sasi Attili

Posted

agree with Mona.....Subtle Bowens. But would like to see a Melan-A, to be on the safe side.

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Mark A. Hurt MD

Posted

Below are more H&E images. The immunos will follow later.

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE934_Image%2009.jpg[/img]

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE934_Image%2010.jpg[/img]

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Guest Maria George

Posted

Pigmented Actinic keratosis is also a possibility here.

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Eman El-Nabarawy

Posted

Actinic keratosis (atrophic and bowenoid types) vs actinic keratosis with Bowen's disease.

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Guest Jim Davie MD

Posted

I favor atypical junctional melanocytic proliferation with pagetoid scatter, rule out MMIS.

I see variably atypical and/or enlarged epithelioid cells at the junction, and also in the epidermis with high-level pagetoid scatter. There is parakeratosis (with flattened hyperpigmented cells embedded therein) and reactive keratinocyte changes that may suggest a non-neoplastic etiology (such as previous trauma) for melanocyte scatter.

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Mark A. Hurt MD

Posted

Below are the immunos. Do they change your diagnosis? I'll post my diagnosis at 20:00 GMT

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE934_Image%2011.jpg[/img]
[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE934_Image%2012.jpg[/img]
[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE934_Image%2013.jpg[/img]
[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/CASE934_Image%2014.jpg[/img]

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Guest Dr.Yüksel Okumuş

Posted

In addition to epidermal Bowenoid features, is there dermal hamartomatous (smooth muscle proliferation) and nevus lipomatosus like changes ? Especially at the right side, increased basal layer pigmentation, hyperkeratosis and elongation of rete ridges maybe the signs of Becker’s melanosis, although the localization and the patient age is contrary.

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Eman El-Nabarawy

Posted

Melanoma in situ in collision with Bowen's disease.

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Dr. Mona Abdel-Halim

Posted

So after the Immunos, Bowen's in collision with a melanom in situ..

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Guest Jim Davie MD

Posted

My opinion:
1. [b]MMIS[/b]. The large epithelioid cells at the junction and pagetoid within the dermis stain with Melan-A. The flattened hyperpigmented cells embedded in the parakeratosis are also strongly Melan-A positive, as expected. There is downwards pagetoid extension along adnexa.
2. [b]Incidental clonal-pattern SK[/b]. I think it's too discrete and well-circumscribed to be Bowen's. Ki67 (and mitotic activity) can be deceitfully high in SKs.

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Mark A. Hurt MD

Posted

Here is my diagnosis:

SKIN, LEFT CALF, PUNCH BIOPSY:
[b]-- MELANOMA IN SITU, PAGETOID (Tis)[/b]
[b] IN CONJUNCTION WITH FOCAL SQUAMOUS CELL CARCINOMA IN SITU*[/b]

To Jim's point about the clonal SK, in my experience, I have seen this pattern of staining with thin Bowen's disease, but usually clonal SK really is clonal, i.e., multifocal and nested. I have seen now a number of examples of thin lesions of Bowen's disease that are identical to the pattern above. So, I think it really is Bowen's disease with MMIS.

I found this example to be important because MMIS can be very subtle. I have to wonder how many of these I missed completely in the years before immunostaining when Melan-A was widely available. I shudder to think of how many.

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