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Case Number : Case 2156 - 13 September 2018 Posted By: Raul Perret

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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15 year old patient with a lesion on the scalp.


User Feedback


I favour Angiomatoid fibrohistiocytic tumor over aneurysmal

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Looks like a deep seated spindle and maybe epithelioid lesion. Kind of atypical cytologically although not really high-grade. I have the feeling it is infiltrative into the subcutaneous tissue. There is perineural invasion in Fig 3. So looks like a lesion that probably have at least potential of local recurrence.

The last 2 pictures show a sprinkling of lymphocytes in the lesion. So definitely would like to rule out a fibrohistiocytic lesion. Follicular dendritic cell tumor can show similar histologic findings. So will definitely need IHC (and probably molecular studies now that we know Dr. Perret a little bit better). CK, S-100, CD21, CD23, CD31, CD34 for a start.

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dermpath1

Posted

Extracrainial fasciitis.No need for further work up.

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Anil Patki

Posted

Seems to arise from nerve sheath.  Is it a peripheral malignant nerve sheath tumour? 

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vincenzo

Posted

What about a Spindle Cell Juvenile Xanthogranuloma? Unusual subcutaneous localization, but there are histiocytic foamy cells in fig 3. And intermingled inflammatory cells fit well.

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John Zhang

Posted

To me also looks like a fibrohistiocytic lesion, would run keratin, S100, CD1a, GMS and CD68.

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vincenzo

Posted

This nodular ( cranial ) fasciitis is, morphologically, very odd for me, but pathology is as fascinating as unpredictable.

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Raul Perret

Posted

Thank you all for the great comments. This was a case of nodular fasciitis confirmed by the presence of a USP6 rearrangement by FISH. Nodular fasciitis can show a spectrum of morphological aspects and I find the "cellular pattern" seen in this case to be the hardest to catch. In this case the immunophenotype was helpful, there was expression of smooth muscle actin without expression of desmin and h-caldesmon (classic myofibroblastic phenotype). Morphologically, the presence of a chronic inflammatory component and interstitial haemorrhage were also nice clues. 
Finally, it is important to remark that most cases (>95%) of NF are supposed to harbour USP6-MYH9 translocations that can be reliably demonstrated by molecular biology or FISH (USP6 is the consensus gene). Please keep in mind that the sensitivity of FISH may vary between labs  (in our experience it tends to be lower than 95%). 
Hope you liked the case and Please Anh call me Raul, reserve the Dr. X to senior (old) pathologists like Richard Carr :P
 

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Dr. Richard Carr

Posted

He's young, handsome and a gentleman and now it seems a comedian!  I hate him. Grrr.

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