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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 1556 - 13 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 48-year-old woman with a biopsy of a scalp mass. This was a consult case with the following history: "The clinical impression is basal cell carcinoma, I do not know if there was a previous biopsy. As you can see by my provisional report, I am confused by the growth pattern of this lesion and am considering proliferating trichilemmal tumor and squamous cell carcinoma."
Dr Mark Hurt


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I agree with dermal duct tumour, as the cells look poroid, on the condition that ducts are demonstrated by immunohistochemistry. 

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Nitin Khirwadkar

Posted

Agree. Can't see ducts on H&E, but very poroid looking cells.

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Arti Bakshi

Posted

I think better categorised as a poroid hidradenoma, in view of lack of connection to surface and absence of obvious ductal differentiation.

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Dr. Richard Carr

Posted

I find this lesion very odd. No ducts although agree poroid-like.  I see foci of subtle bowenoid dysplasia (including individual cell necrosis and atypical mitotic figures) developing into confluent parakeratosis. Profile is reminiscent of pilar sheath acanthoma. Could it be bowenoid changes within pilar sheath acanthoma? On second thoughts a low-grade hidradenocarcinoma is also a possibility.

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Raul Perret

Posted

To be honest my first impression was that of a neoplasm with predominant follicular differentiation. We have small cells poroid like with abrupt keratinization and calcification, individual apoptosis, some mitotic figures. There are some pictures where the cells look with a bit more cytoplasm and clearer. I actually thought that the suggestion  of the referring pathologist was quite good I think this is a lesion in the spectrum of proliferating trichilemmal tumor.

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vincenzo polizzi

Posted

I think there isn't any follicular differentiation, but a very ductal/poroid differentiation! May be i'm wrong but in Fig5/6/7/8 i see a ductal-cystic differentiation and the cells are too poroid...

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Raul Perret

Posted

I think there isn't any follicular differentiation, but a very ductal/poroid differentiation! May be i'm wrong but in Fig5/6/7/8 i see a ductal-cystic differentiation and the cells are too poroid...

Look at the last picture, the cells look ORS like, there is individual cell apoptosis, and on the left side of the picture there is abrupt keratinization and there are some granular layer like vestiges (variable size keratohyaline granules). I dont know it really looks like the neoplasm has follicular differentiation to my eyes

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Mark A. Hurt MD

Posted

I have sympathy with all of your comments.  Here was my diagnosis:

 

SKIN, SCALP , BIOPSY :

-- POROMA (ACROSPIROMA), NOT IDENTIFIED IN THE MARGIN OF RESECTION IN

THESE SECTIONS

COMMENT:  I don't think that this is a squamous cell carcinoma.  The monomorphic quality of the cells in the lesion is highly characteristic of poroid neoplasms. The nomenclature for these can be confusing, but in general I use the term poroma when poroid neoplasms connect to the surface, and acrospiroma when they don't, although this is not a uniform designation of lesions like this.  The fact that there is some variability of nuclear size and shape is not unusual in a lesion of this nature. Furthermore, necrosis en masse is often expected in them, and it is not a sign of malignancy.  Additionally, some mitotic figures are expected in them and should not be taken as a sign of malignancy, in my experience and with most of the literature that I read about lesions like this.  The immunostaining pattern is at least consistent with a poroma.  The presence of a small number of ducts I believe is useful in clenching the diagnosis, but this particular lesion has a paucity of ducts as opposed to many examples that I have seen.  This particular lesion lacks the classical hyalinized stroma that is usually highly characteristic of poromas.  As the lesion does not touch any margins that I can see, I think that there has been definitive treatment of it. 

 

Regarding the question of proliferating tricholemmal tumor, those lesions tend to cornify internally as opposed to having necrosis en masse. Squamous cell carcinomas generally have more variability of nuclei than the monomorphic qualities of the lesion in this specimen.

 

 

 

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