Case Number : Case 1799 - 20 April - Dr Arti Bakshi Posted By: Guest

As usual a beautiful case from Dr Arti Bakshi.

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I thought of acantholytic SCC for immunohistochemical confirmation. There is actinic keratosis on the overlying epithelium and abnormal abrupt keratinization. In picture 3 I have doubts on whether we see a neoplastic emboli, also the cells have clearer cytoplasm in this foci. I would perform p63, keratins, CEA and PAS just to discard the presence of mucin and get some clinical information in case there is suspicion for metastatic disease.

I agree with acantholytic SCC. I think there is epidermal connection (picture 3) and the cells seem to show keratinization. I would also add IHC (panel of keratins) and levels

I think its acantholytic SCC. I wouldlike to see p63....

Acantholytic SCC

First thought: Acantholitic SCC.

agree... acantholytic SCC

Agree with acantholytic squamous cell carcinoma.

A question to the panel: comparing tumors with similar greatest dimension, thickness, anatomic level, margins status, and pathologic staging, in your experience, does the acantholytic type carry a worst prognosis than the conventional type? I feel data from literature are contradictory.

For me too: acantholytic SCC

Yes, acantholytic SCC. p63 was diffusely positive.

A very valid comment from Robledo regarding the prognosis of this group of tumours. I agree the literature is not conclusive and although this has been included as a high risk group, there do not appear to be large studies/series supporting this. In routine practice, I find  this to be a particular problem when dealing with small diameter, relatively well to moderately differentiated (and often fairly superficial) lesions which show focal areas of acantholysis. The guidelines do not indicate how extensive the acantholysis should be to categorsie a lesion as an 'acantholytic' and hence a 'high risk' subtype. It does seem an overcall to label these lesions as high risk. Would be good to hear other people's experiences.....

An article on acantholytic SCC in J Cutaneous Pathol is the topic for the first Dermpath Journal club on Twitter. Some of Arti's questions are raised in this article.

Acantholytic invasive squamous cell carcinoma: tumour diameter, invasion depth, grade of differentiation, surgical margins, perineural invasion, recurrence and death rate. J Cutan Pathol 2017: 44: 320-327 

J H Pyne, E Myint et al

I'm a strong advocate of the type of invasive border. If cohesive and pushing - virtually no risk (many follicular SCC are for practical purposes in situ lesions). If an acantholytic SCC invades the dermis it will by definition be pretty infiltrative and poorly differentiated. Difficult to tell in this biopsy how much invasion there is, could be the tip of the ice-berg. But beware the pseudocircumscript poorly differentiated SCC running through the collagen and elastic unimpeded (these I exclude from "pushing" borders). The ENT bods have been using this system for sometime and it was reported as useful on SCC's of the ear.

Thank you all for your kind comments on my query. I was not aware about Dr. Pyne's article, so I gonna read it right now.