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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 1779 - 23 March - 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: 22 Female, excision of pigmented lesion.

Case Posted by Dr Arti Bakshi


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vincenzo polizzi

Posted

Difficult!!!

My first thought is Melanoma, balloon cell type. I think this is a primary, dermal based lesion, but xanthomatous changes like these are usually seen in metastatic cases. 

DD with a pigmented variant of JXG. Favour melanoma because in pic1/2 you can see some questionable junctional nest..and because of the nested growth pattern.

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Raul Perret

Posted

Hard case indeed, difficult to asses only by pictures. For me this is a melanocytic lesion of uncertain malignant potential, favor malignant. The balloon and multinucleated cells are actually reassuring to me and they have banal nuclear features. The problem is the relative asymmetry, crowding, heavy irregular pigmentation, isolated cells with fine dusty cytoplasmic melanin (pic7), prominent lymphocytic infiltrate between neoplastic cells and at the edges, and as Vincenzo remarked it is difficult to assure a component at the junctional level but it also caught my eyes. I dont know if there is also a mitotic figure out of focus in pic9? I would do some immunos and I think even BAP-1

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Mariantonieta Tirado

Posted

Agree difficult, however I favor benign (symmetric, sharply demarcated, in pictures no deep mitoses,didn't see in the epidermis, scatter or irregular distribution of melanocytes ). There are balloon cell changes, though you can see them in benign and malignant lesions. Some cells look spitzoid. My differentials would be combined compound nevus with a cellular blue component or atypical spitz lesion. Melanoma not outruled. Would do MelA, HMB45, p16. Sometimes we do BRAF with ALK  and certainly show it to my colleagues 

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Dr. Richard Carr

Posted

Looks like an "odd" combined or "clonal" naevus to me. The clone being slightly epithelioid/xanthoma-like. Probably carries a translocation or fusion or deletion (including BAP) etc. While admitting the difficulty of labelling and slight uncertainty I'd favour a likely benign behaviour. Watch and wait as it fully excised.

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vincenzo polizzi

Posted

May be I'm wrong, as often happens in difficult and questionable cases like this. However I'd favour a "melanoma-congruent treatment" in this case, because the growth pattern is confluent, nodule-expansive with pushing margins in deep dermis. The right half looks like a proliferative nodule in a congenital nevus, but it seems we are far away from this condition. 

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Dr. Mona Abdel-Halim

Posted

Thinking of combined nevus with balloon cell change... 

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Robledo F. Rocha

Posted

This nevus does not give me real cause for concern since it looks benign and it was entirely excised. The problem for me is how to name it! Maybe combined Wiesner nevus and blue nevus with balloon-cell change.

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Arti Bakshi

Posted

Agree a difficult one to categorise! I and Nitin both looked at this case and went for benign based on the circumscription, symmetry, lack of a worrying junctional component and scant mitoses. (there was only one convincing one pictured in image 9). The problem was the nomenclature. Massi and LeBoit's textbook mentions a polypoid exophytic variant of DPN, which often lacks the deep extension and plexiform pattern typical of usual DPN, but shows the typical cytological composition of DPN (which I thought this case had) The other d/d was ofcourse, a Combined naevus, as many of you have mentioned. The BAP1 immunostain was retained.

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Arti Bakshi

Posted

I attach the summary of my report:

''This is a rather challenging melanocytic lesion to accurately categorise. Although cells are epithelioid I do  not think the lesion belongs to the Spitz group of tumours. Instead, the cytological composition of the cells with the admixed macrophages is rather suggestive of of a deep penetrating 
naevus. Deep penetrating naevi sometimes may not show the typical deep wedge shaped architecture and can be polypoid  and superficial in nature. This would explain the apparent lack of maturation and the occasional deep mitotic figures which are well within the spectrum of this group of  lesions. An alternative would be to classify this as a  subtype of a combined naevus (common acquired and blue     
naevus). A BAPOMA was certainly a good thought but the retention of BAP1 nuclear staining excludes this  possibility. Regardless of the exact nomenclature, I do not think there are sufficient features to be worried about malignancy. The lesion is well excised.''

Many thanks to Dr Latifaj for sharing this case with me.

 

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Guillermo García

Posted

It´s possible a balloon cell blue nevus?
 

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