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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 1497- 21 March 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 an 80 year old white man with a shave biopsy of a nonhealing bleeding lesion that gets crusted, present for three months, taken from the mid upper forehead.

Case posted by Dr Mark Hurt


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Raul Perret

Posted

Due to clinical information and morphology I would consider atypical fibroxanthoma, it bothers me that there is no grenz zone though. Of course a wide panel of immunos should be performed first (CK, P63 or P40, S-100, melanocytic markers, desmin, CD31, CD10). Picture 5 shows some basal membrane thickening I was wondering the cause...

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vincenzo polizzi

Posted

Pleomorphic tumor, sarcomatoid pattern, with perinuclear cytoplasmic clearing, Golgi-like, reminiscent of ALCL, sarcomatous type. Obviously it needs IHC.

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vincenzo polizzi

Posted

I may be wrong but i see several cells with abundant cytoplasm, horseshoe (“hallmark”) nucleus or wreath-like or multiple nuclei, perinuclear eosinophilic region...so i favor Anaplastic Large Cell Lymphoma.

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Dr. Mona Abdel-Halim

Posted

I thought based on morphology of ALCL, but complete IHC work up should be done

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Nitin Khirwadkar

Posted

Poorly differentiated tumour, requiring a good panel of IHC. My differentials, pleomorphic dermal sarcoma/AFX, angiosarcoma, pseudovascular SCC, melanoma (unlikely), LMS.

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Mark A. Hurt MD

Posted

My diagnosis was:

 

-- SUPERFICIAL PLEOMORPHIC SARCOMA ("ATYPICAL" FIBROXANTHOMA)

COMMENT: This lesion appears to be a fairly superficial lesion, but it does extend to the base of the biopsy; thus, I suggest excising it completely as a precaution, if appropriate clinically.

 

This specimen consists of a relatively diffuse lesion occupying almost the entire dermis. The lesion abuts the epidermis in some areas, and it consists of large, pleomorphic epithelioid cells, some of them multi-nucleated, and many of them with very large nuclei intermixed with lymphocytes and some plasma cells.  Although the lesion abuts the epidermis, I don't see a clear-cut merging with it, such as one might see in a squamous cell carcinoma.  A few areas have fascicle-like patterns.  A few swirls of entrapped squamous epithelium are noted, but I don't think that those are part of the lesion.  The lesion extends to the base of this biopsy.

 

Immunophenotypically, the lesion is negative with p40, negative with Melan A, negative with SOX-10, diffusely positive with CD31 (but mostly positive in the vessels).  Some of the individual cells are outlined by CD31.  CD34, however, stains only the vessels in the lesion and not the lesional cells.  This is also true with ERG.  It is also true with D2-40.  Pancytokeratin is negative in the lesion, except for muscle that traverses the lesion.  CK5/6 is negative in the lesion. CD10 shows diffuse positivity throughout.  Smooth muscle actin has a weak signal and stains mainly the vasculature. Desmin and Calponin are both negative in the lesion.  CD68 shows some positivity in these epithelioid cells, about 80% of them.  The elastic stain shows mostly elastic loss in the lesion.  The reticulin stain seems to outline vessels primarily, but does not have a diffuse or uniform staining quality.

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