Case Number : Case 1705 - 9 December - Dr Richard A Carr Posted By: Guest

Dr Richard A Carr has got you a 'difficult' case to round of your week.

Cheers, Geoff Cross - DermpathPRO Projects

am thinking on the lines of a vasoformative lesion and given the history of a 'mass' would consider kaposi's, angiosarcoma. Immunos...

Very difficult!!

Got an impression of patch stage KS (especially from image 7 and from the extensive extravasated erythrocytes) but the clinical setting is weird??

The  4th image shows lymphoid infiltrate dissecting in between the collagen bundles with some cells showing indian filing., the cells do not look that atypical though!

So I am between two lines: weird presenttaion of KS (may be in an HIV patient) vs. a lymphoproliferative/leukemic infiltration..

I wish other images are yet to be presented or immunos!!!

I had the exactly same impression as Mona, we have good markers for assistance so would perform IHC. Just with this images I think the infiltrate looks rather polymorph for KS and image 4 really looks like the kind of infiltration I have seen in leukemia/some lymphomas.

Me too am between two lines, but sincerely no impression of KS. My lines are: 

1) lymphoplasmacytic proliferation with systemic amyloidosis ( amyloidosis of the tongue could fit well on swallow pain ).

2) a weird systemic scleromyxedema starting as localized skin neck mass.

Agree with amyloidoma or systemic amyloidosis presenting as neck mass.

This is an old case from my slide collection that a recent visitor brought to me because they could not really fathom the proffered diagnosis.  Yes it is very difficult and the visitor was quite surprised that on low power I raised the possibility of angiosarcoma based on some very important clues.  Severe solar elastosis with evident red cell extravasation and a slightly busy look to the dermis and subcutis.  I said we have to do vascular markers (although I agree the history was totally misleading that was the information submitted with the biopsy). The diagnosis is angiosarcoma (well done Urmila), endothelial markers highlighted the dissecting vessels that we can see in some of the images (also containing lymphocytes). I subsequently found the patient had had another biopsy 6 months earlier from a forehead lesion and angiosarcoma had not been considered clinically or histologically but retrospective endothelial markers confirmed it also showed angiosarcoma.  As I said on Hafeez's case angiosarcoma can be a perilous diagnosis but we must always think of it in severely sun-damaged skin with red cell extravasation and haemosiderin deposition.

Just saw this case, along with the diagnosis. Yes, a sneaky angiosarcoma. 

Well done Urmila. This was a very difficult case. And I have learnt something important from it. 

Thanks for sharing Dr Carr.. nice case :-)

Thanks for sharing such interesting cases Richard and the dermpathpro team of specialists. Being a generalist, am learning so much from all you expert dermatopathologists through this exceptional website.