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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 2392 - 30 August 2019 Posted By: Dr. Richard Carr

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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M70. Non-healing lesion right cheek a few months. Bleeds & scabs. Slightly palpable ?BCC, ?Bowen’s

Edited by Admin_Dermpath


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There´s a high p53 positivity associated with positive p16 cells in a squamoproliferative tumor. I think this is a Seborrheic keratosis evolving into a squamous cell carcinoma in situ.

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Diego Luis Diaz

Posted

Hello Richard, because of the coexpression of p16 and p53, could be porocarcinoma. Regards from Patagonia, Argentina

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Dr. Richard Carr

Posted

thanks Diego. This is a good case!!! Nice to hear from Patagonia.

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I don't know what this is. It seems a malignant "inverted follicular keratosis"...so why not some type of Follicular SCC?

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Dr. Richard Carr

Posted

Hm! Seems like the site is suffering from poor responses. 

The last stain indicates this is melanoma. The lesion is invasive within the papillary dermis. I've been using EVG to determine patterns of invasion in Bowenoid SCC, Follicular SCC and KA. I've been using p16, p53 and Ki67 to also study these three tumours. I thought on H&E (not a great quality stain to be honest) this was a bowenoid SCC +/- superficial invasion. In all of the bowenoid SCC I've studied there has been either a diffuse strong or null p53 or a diffuse strong or null p16. This case flumoxed me as the staining was "odd", p53 wild and p16 mainly cytoplasmic certainly not diffuse positive or null. I somehow remembered a case of melanoma I'd called SCC in the past. As soon as I'd considered melanoma in the DDx I felt embarassed I'd not throught of it earlier. However I've since shared the case by powerpoint with quite a few very experienced dermatopathologists and none mentioned melanoma in their DDx. Most felt rather embarassed they did not consider melanoma but actually some traps are triggered and best shared with colleagues to help them avoid making the same "mistake". 

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Meenakshi Batrani

Posted

17 hours ago, Dr. Richard Carr said:

Hm! Seems like the site is suffering from poor responses. 

The last stain indicates this is melanoma. The lesion is invasive within the papillary dermis. I've been using EVG to determine patterns of invasion in Bowenoid SCC, Follicular SCC and KA. I've been using p16, p53 and Ki67 to also study these three tumours. I thought on H&E (not a great quality stain to be honest) this was a bowenoid SCC +/- superficial invasion. In all of the bowenoid SCC I've studied there has been either a diffuse strong or null p53 or a diffuse strong or null p16. This case flumoxed me as the staining was "odd", p53 wild and p16 mainly cytoplasmic certainly not diffuse positive or null. I somehow remembered a case of melanoma I'd called SCC in the past. As soon as I'd considered melanoma in the DDx I felt embarassed I'd not throught of it earlier. However I've since shared the case by powerpoint with quite a few very experienced dermatopathologists and none mentioned melanoma in their DDx. Most felt rather embarassed they did not consider melanoma but actually some traps are triggered and best shared with colleagues to help them avoid making the same "mistake". 

Thanks!! This is a great case to learn.

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Dr. Richard Carr

Posted

Thanks Meenakshi. Please do keep contributing, it is appreciated.

Regards

Richard

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Diego Luis Diaz

Posted (edited)

Richard could we see the full panel? Thanks for sharing this hard case, always learning 

Edited by Diego Luis Diaz

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Diego Luis Diaz

Posted

I really dont want to do a mistake if I  have a case like this, big hug from Patagonia

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Dr. Richard Carr

Posted

S100 was diffusely positive. AE1/AE3 showed scattered cells around the majority of "nests" indicating most of the lesion was in situ. Hopefully low risk for metastasis. I'll ask for extra images to be posted.

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For some reason I didn't see your comments, Richard, but I care about telling you this is a great educational case and I have learned a lot thanks to this. Thanks Richard!!! 

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msofopoulos

Posted

Can i ask you Richard what motivated you to do p16 and p53? I thought it was Bowenoid SCC. I wouldnt have done any immuno.

Thanks for a great case!

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DR NADINE BURKE

Posted

had one like this this week, felt awful it took me so long - thought it would be bowenoid a.k with invasion.also thought of some sebaceous carcinoma- on the eyelid, dermatologist felt it was bcc/scc.

when berep4 and ema came back negative- looked again then did Mel A...diffuse positive.

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