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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 1694 - 24 November - Dr Arti Bakshi 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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Clinical History: 73/M, pigmented lesion on foot. Incisional biopsy.

Case Posted by Dr Arti Bakshi

Edited by Admin_Dermpath


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Admin_Dermpath

Posted

An artful case from Dr Arti Bakshi on this 2016 Thanksgiving Day

 

Geoff Cross - DermpathPRO Projects

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Victor Delgado

Posted

Early melanoma in situ, there is a special clue here... those dendritic projections emerging from melanocytes aswell as diffuse melanic pigment.

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Dr. Mona Abdel-Halim

Posted

Yes, worrisome. Will do Melan A to verify melanoma in situ. 

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Robledo F. Rocha

Posted

A hard case! I favor acral melanoma in situ mainly due to patient’s age, since microscopic findings are too subtle.

Yes, I can see some asymmetric confluence of basilar dendritic melanocytes with nuclei that are enlarged and hyperchromatic. Slight ascent of melanocytes into the lower malpighian layer can also be seen. Anyway, these microscopic findings are almost imperceptible and may also be found in acral benign melanocytic lesions.

I’d love to know if the lesion is located on a weight-bearing area of the foot.

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Arti Bakshi

Posted

@Robledo...just checked the clinical records...the lesion is on the plantar surface of 5th metatarsal.

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Raul Perret

Posted

I had a similar feeling as Robledo concerning this lesion. I would add that on the description it is remarked as an incisional biopsy, too subtle for me to go for melanoma. I would express the presence of some worrisome features as remarked above and suggest complete excision for better caracterization

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Dr. Richard Carr

Posted

Wise comments from colleagues above. I guess it will be clinically dramatic though! Age, clinical and dermoscopy is very useful at acral sites (often better than histopathology in lesions like this).  We've discussed previously that the distribution of melanin can be useful if you manage to cut the biopsy perpendicular to the skin markings. Probably acral lentiginous melanoma pending CPC as above.

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Arti Bakshi

Posted

Have asked Geoff to post an image of MelanA. 

I would also like to take this opportunity to congratulate my colleague and friend, Nitin Khirwadkar, a regular contributor on dermpathpro, for successfully clearing the exam for Royal College diploma in dermatopathology! Well done! Great to have a colleague who shares the same enthusiasm and passion for dermpath!

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Nitin Khirwadkar

Posted

Favour acral in-situ melanoma, on this incisional biopsy. Would be interesting to know what the excision showed. 

 

Thanks for for the kind words Arti. Thank you Raul, Mona and Vincenzo. I am hugely grateful to Dermpathpro and all the contributors . This website has a huge contribution to my success at the exam. I have learnt immensely from all the cases and the comments that have been put forth. So thank you to Dermpathpro and all of you. Special thanks to Arti who has been hugely instrumental in me chasing dermpath and has been a big help in preparation towards the exam. I would also like to thank Richard Carr for expert guidance and teaching in person ( during my many attachments at Warwick to go through the largest slide collection in the U.K.) or via Dermpathpro. His enthusiasm to teach dermpath is exceptional.

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Arti Bakshi

Posted

This was indeed a difficult case. Cant say what the correct diagnosis is... as in melanocytic lesions, it is really only an opinion. But was glad to see that everyone was worried about the lesion!!(as was I and my other colleagues in the dept). We favoured an acral lentiginous melanoma in situ. Clinically this a worrying lesion (dont know the dermsocopic findings) and following CPC, a decision was made to excise the lesion. This was done at another centre so dont know what the final excision showed.

A useful tip (from Massi and Leboit texbook on melanocytic lesions) is that benign acral naevi start showing nesting once the lesion exceeds 4-5mm in size. So if you have a lesion >5mm with a predominant lentiginous pattern (particularly in an elderly pt) , always be concerned for acral melanoma in situ. This stage can last for years and often the cytological atypia is subtle. In this case, the rather continuous lentiginous proliferation on melanA was also helpful.

  

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Arti Bakshi

Posted

Dr Carr mentioned in a recent EQA meeting ( where he runs a melanoma slide club), that often pathologists may disagree on the exact terminology of the lesion, but may be more unified in their recommendation for further management. I think this case illustrates that point very well, as some hesitated to call this lesion a melanoma straight out, but all agreed that the lesion needs to be removed! 

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