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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 1565 - 24 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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M70. 12/12 persistent crusted nodule with rolled edge, ?BCC, ?follicular SCC

Dr Richard Carr


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Raul Perret

Posted

Even if the time of evolution is partly against it and I think this is a lesion with borderline features (between keratoacanthoma and FSCC). I would favour a FSCC. By the way, what do you guys think of the last picture perineural infiltration or not? during training I was taught that if the nerve is not completely surrounded it must not be considered perineural infiltration. 

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vincenzo polizzi

Posted

I think the perineural infiltration doesn't rule out KA, in this histological context and it may be a true pn infiltration.  The pathological features are all in keeping with KA for how much i can see: elastic material entrapped, horizontally oriented dermal fibrosis so typical of regressing KA, linear and circumscribed arrangement of the deep margin, symmetry and differentiated squamous appearance of the lesion. So I favour Keratoacanthoma ( on very delayed regression ).

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Raul Perret

Posted

I understand your point and I think this lesion has many features that suggest more a KA than FSCC (not the elastic fibers to my understanding as they should be in the mature areas of the neoplastic epithelium to suggest KA). I tend to favour more FSCC because of the follicular-centered areas that are seen in picture 2 (and this lesion to me doesnt look like en plaque KA). On the other hand the abrupt maturation of the nests, absence of spontaneous acantholysis, intraepidermal mucin, fibrosis, keratin granulomas, central burnout area all favour KA. I imagine Im a bit mulish with these lesions but If im not 100% sure is a KA my dx will favour FSCC.

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Nitin Khirwadkar

Posted

Would favour a regressing keratoacanthoma. It can take upto several weeks/months to regress. Perineurial infiltration can be seen with a KA. The picture does look like perineurial infiltration. Thought of an eccrine duct in proximity to a nerve, but the bilayer is lacking.

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vincenzo polizzi

Posted

Yes, i like the Raul's observations, and agree with "I tend to favour more FSCC because of the follicular-centered areas that are seen in picture 2 (and this lesion to me doesnt look like en plaque KA).",  but there is something that wins in favour of KA: the progressive enlargement almost blowup of keratinocytes toward the centre of the nests! I can be wrong of course, but i have learned in this job that an overcall can have seriously consequences as an undercall.

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Dr. Mona Abdel-Halim

Posted

KA, fig 8 shows elastic fibre entrapment.

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Dr. Richard Carr

Posted

I reported this as keratoacanthoma centrifugum marginatum with perineural invasion just beyond the tumour borders. These lesions show central resolution but persistence at the advancing border and can growth to very large size.  There is lovely typical elastic entrapment including within maturing and mature squamous epithelium (the rounded greyish areas in image 4 and 6 are elastic within mature epithelium and are quite typical).  This particular lesion was fully excised with clear margins.

 

A wrong diagnosis can result in rather excessive surgery.  Erlotinib has been reported to be effective in one patient who had a partial scalpectomy for locally recurrent KCM that recurred repeatedly following surgical attempts at removal. Bulj et al BJD 2010:163;633-637

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