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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 1038 - 16th June 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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The patient is a 13 year old boy with excisions with margin exam of darkening lesions, present six months, taken from the left, upper aspect of the back.

Case posted by Dr. Mark Hurt.


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amiratawdy

Posted

is it possible to be a minimal deviation melanoma? ki67 and HMB45 are needed

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Dr. Mona Abdel-Halim

Posted

This is a somehow difficult lesion. Fairly circumscribed, yet asymmetrical. The lesion appear nicely maturing. However, I am worried about this expansile nodule that is sharply delineated from the rest of the nevus in the background. It reminded me of proliferation nodules in congenital nevi. From the history, I understood that the patient presents with darkening lesions of 6 months. Does this mean multiple lesions? Are the darkening lesions arising de novo or on top of another lesion in the background, ? Congenital nevus? and has been present for 6months? Cytologically, the cells of this nodule do not look like typical epithelioid melanoma cells, yet they show prominent nucleoli and are different than the background dermal nevocytic cells, but they show no mitotic activity. It does not fit in clonal or (inverted type A) nevus. There is an isolated typical mitosis in the background dermal component, I do not think it is worrisome because the patient is a child (13 years) and I think this is expected in such age.
What is worrying me is this dermal nodule!!!!!
If these are lesions developing within a giant congenital nevus, I will consider it proliferation nodules.
If they are arising de novo, then may be it is better to describe this lesion as MELTUMP and do further work including IHC and genetic studies?? Waiting to read expert opinions...

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Robledo F. Rocha

Posted

A late proliferative nodule arising within a congenital melanocytic nevus.

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I don´t think this is a melanoma. I agree with Robledo, proliferative nodule arising in a congenital nevus.

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Guest Romualdo

Posted

Agree with Dr. Richard Carr: clonal nevus.

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Eman El-Nabarawy

Posted

Agree with Dr Abdul-Kadir: Nevoid melanoma.

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Mark A. Hurt MD

Posted

In short, the diagnosis was melanoma. Below is the process of thought I went through on the case. Thanks, everyone for participating in a very difficult case diagnostically (at least by H&E)….

MAH


SKIN, LEFT UPPER BACK , EXCISION :

-- COMPOUND MELANOCYTIC PROLIFERATION WITH FEATURES OF A
SUPERFICIAL CONGENITAL MELANOCYTIC NEVUS*
COMMENT: I am not completely certain about the nature of this lesion, although I strongly favor a melanocytic nevus in this case. This point of view is also shared by one of my colleagues. Another colleague regards it as a compound melanocytic nevus. Still, another colleague raised the issue of the slightly unusual cytopathology of some of these melanocytes and suggested the possibility that CGH might be of value in this case to understand better the genome of this lesion. I concur that either CGH or FISH technology might aid to classify this lesion more definitively.

[u]Follow-up Excision[/u]

SKIN, LEFT UPPER BACK , EXCISION :

-- SCAR, POST SURGICAL, NO RESIDUAL MELANOCYTIC LESION IDENTIFIED
COMMENT: Although I had initially thought that the prior lesion that led to this excision was a melanocytic nevus, I was not completely certain of that diagnosis and suggested that be sent for comparative genomic hybridization or fluorescent in situ hybridization, which was done. The results of that examination indicated a loss in chromosome 6q on the fluorescent in situ hybridization examination. This indicated a loss in the MYB gene, instrumental in the pathogenesis of many melanomas. Thus the original lesion was in fact melanoma even though it had strong mimicry for a melanocytic nevus.

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Dr. Mona Abdel-Halim

Posted

Interesting case that highlights the value of genetic studies in problematic melanocytic lesions...

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Dr. Richard Carr

Posted

I think we will find all clonal naevi are separated from their background lesion by an additional mutation / translocation etc. Not sure this proves a fully capable malignant melanoma though. I suspect this lesion will be of low risk (all be it uncertain potential).

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