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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 1805 - 28 April - Dr Richard A Carr Posted By: Guest

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Clinical History: Skin lesion on buttock. Excised after 8 courses of antiotics. Case c/o of Dr Manuel Diaz Sotres.

Case Posted by Dr Richard A Carr


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vincenzo polizzi

Posted

SCC, verrucous/cuniculatum type.

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Arash Daryakar

Posted

I think of verrucous carcinoma.

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Vishal Gupta

Posted

Keratoacanthoma vs well-differentiated SCC.

It does have the glassy enlarged keratinocytes, the architecture and eosinophils in the dermis to favour KA over SCC.

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Dr. Richard Carr

Posted

I have posted an additional comment to my case from 2 weeks ago. Case 1795 14th April (I am happier with a diagnosis of subungual exostosis).

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Mariantonieta Tirado

Posted

KA, second verrucous. Because of the glassy appearance and neutrophils I favor KA; though it doesn't show the typical cup architecture filled with keratin. 

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Dr. Richard Carr

Posted

I think this is a very challenging case but I favoured a well differentiated (follicular) squamous cell carcinoma. The architecture is somewhat difficult due to the nature of the specimen but the lesion lacks the central crater and the individual lobules are rather rounded and pushing rather than the more infiltrative pattern of a proliferative KA with prominent elastic and collagen entrapment (typical of KA) lacking in this lesion. A more established or maturing KA should have more evidence of regression, lichenoid perilesional inflammation and fibrosis, than we see here. I did ponder if there was background hidradenitis supurativa (some slightly comedonal follicles in the background) and given the young age. I also wondered if the lesion could be induced by HPV. I am awaiting follow-up. Prognosis should be excellent as the lesion is well differentiated and has almost entirely pushing borders.

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Raul Perret

Posted

On 4/29/2017 at 16:34, Dr. Richard Carr said:

I think this is a very challenging case but I favoured a well differentiated (follicular) squamous cell carcinoma. The architecture is somewhat difficult due to the nature of the specimen but the lesion lacks the central crater and the individual lobules are rather rounded and pushing rather than the more infiltrative pattern of a proliferative KA with prominent elastic and collagen entrapment (typical of KA) lacking in this lesion. A more established or maturing KA should have more evidence of regression, lichenoid perilesional inflammation and fibrosis, than we see here. I did ponder if there was background hidradenitis supurativa (some slightly comedonal follicles in the background) and given the young age. I also wondered if the lesion could be induced by HPV. I am awaiting follow-up. Prognosis should be excellent as the lesion is well differentiated and has almost entirely pushing borders.

Did you perform p16 and p53 Richard?

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Dr. Richard Carr

Posted

I don't think so. I did not make a note of having done so in my report. They tend to be less helpful in well differentiated lesions in my experience showing wild type staining or only slight up-regulation. I have not systematically studied lesions such as this though.

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Dr. Richard Carr

Posted

Follow-up now kindly received. The patient underwent a re-excision at one of our larger cancer centres in the UK and was reported as residual well differentiated squamous cell carcinoma, completely excised. Nothing mentioned about hidradenitis suppurativa.

I have to say I have re-commented on case 1282 (22nd May 2015) that I now favour that lesion also be a well differentiated SCC with some KA-like features (ano-genital lesion with background lichen sclerosus). Currently I will be very wary about making a diagnosis of KA on anogenital skin as I believe well differentiated skin cancers at this location can closely mimic the cytomorphology (abundant glassy pink cytoplasm) making distinction near impossible on small or partial specimens let alone complete excisions. Counter-intuitively proliferative KA in general look altogether more worrying (poorly differentiated at the periphery) lesions than these rather bland pushing tumours that are KA-like.

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