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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 1896 - 04 Sept - Dr Limin Yu 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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41 yo F right thigh, clinical impression: pyogenic granuloma


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vincenzo polizzi

Posted

A broad spectrum of Ddx here: low grade leiomyosarcoma, cellular neurothekeoma, fibromatosis variant of plexiform fibrohistiocytic tumor and, finally, the one I'm thinking of as the clinics-pathologically more consistent: primitive non neural granular cell tumor ( Le Boit ).

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Raul Perret

Posted

I thought of atypical granular cell tumor for immunos, neural or non-neural. I do not have experience with non neural granular cell tumor so I need to read the articles. Nevertheless, I think they are hard to differenciate from atypical cellular neurothekeoma based on the phenotype and morphology? 

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vincenzo polizzi

Posted

Yes, Raul, hard to differentiate from CNT, but I think there is a typical "granular" cytology in this particular case (fig15 and last fig), with pseudo vacuoles. Large cytoplasmic granules, surrounded by a clear halo. In Weedon's book these granules are named "pustule-ovoid bodies of Milian". 

What do you think about?

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Raul Perret

Posted

2 hours ago, vincenzo polizzi said:

Yes, Raul, hard to differentiate from CNT, but I think there is a typical "granular" cytology in this particular case (fig15 and last fig), with pseudo vacuoles. Large cytoplasmic granules, surrounded by a clear halo. In Weedon's book these granules are named "pustule-ovoid bodies of Milian". 

What do you think about?

I had the same impression as you about the granules, as a matter of fact it was one of the points that made me favour GCT. We usually see a central eosinophilic granule surrounded by the vacuole but I still think they are Milian bodies as you remark. Cellular neurothekeoma can have a granular cytoplasm too and is usually a commom differential of GCT. On the other had, I have read that Milian bodies contain Myelin so this would go against a non-neural GCT, do you agree?

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vincenzo polizzi

Posted

I have read that Milian bodies contain Myelin so this would go against a non-neural GCT, do you agree?

Yes agree...

...But the questions are many, and for now I will only support the diagnosis of primitive non neural GCT, because of the clinical presentation (pyogenic granuloma-like) and the strictly fascicular pattern, in opposite the usual nested or plexiform pattern of CNT. I would like to know if the S100 is positive...

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Primitive non neural granular cell tumor  is a great thought, fitting the clinical impression. The other thought was epithelioid cell histiocytoma; so ALK immunostain was performed and it was positive (see attached image). 

 

This case was signed out as epithelioid cell histiocytoma. The ALK rearrangement was discussed in this article https://www.ncbi.nlm.nih.gov/pubmed/25857825

ALK2.jpg

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