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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 2651 - 03 September 2020 Posted By: Saleem Taibjee

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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81M, Excision nodular lesion scalp.


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It could be atypical fibroxanthoma clear cell variant, but needs IHC to rule out more common differential Dx 

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At a glance: balloon cell melanoma.

Growth pattern, nested type, ---> Ballon Cell Melanoma; but cytological details ( nuclear indentation by cytoplasmic vacuoles ) ---> histiocytic/lipomatous/sebaceous tumor, for example AFX, balloon cell type, but also Clear Cell Renal Cell Carcinoma.It needs CPC and IHC.

 

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Alex-Ventura-Leon

Posted

Quote

At a glance: balloon cell melanoma.

Growth pattern, nested type, ---> Ballon Cell Melanoma; but cytological details ( nuclear indentation by cytoplasmic vacuoles ) ---> histiocytic/lipomatous/sebaceous tumor, for example AFX, balloon cell type, but also Clear Cell Renal Cell Carcinoma.It needs CPC and IHC.

Totally agree. I recall a case with similar features here: https://dermpathpro.com/spot-diagnosis-1/free-spot-diagnosis-december-2014/september-2017/case-1899-07-sept-dr-richard-carr-r1956/

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Krishnakumar subramanian

Posted

Clear Cell Atypical Fibroxanthoma DD  Balloon cell melanoma

IHC and CPC is needed

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Alex-Ventura-Leon

Posted

AFX Clear/Ballon cell variant (after seen the IHCs)

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Saleem Taibjee

Posted

Yes, this is a clear cell variant of AFX. The cytology is quite beautiful. I included the p53 above just to highlight that I have found p53 very helpful over the years in AFX / pleomorphic dermal sarcoma, not only in diagnosis but in determining margins (especially in re-excision specimen in distinguishing between scar). Most cases are mutated in my experience, mostly upregulated, but this was an example of a null. 

It is really quite amazing how similar the morphology is to Richard's previous case of balloon cell melanoma which was quoted above, and shows how dependent we are upon immunohistochemistry.

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Alex-Ventura-Leon

Posted

Very interesting case Dr Saleem.

Just for the record the case cited above was actually a Metastasic Renal Cell Carcinoma

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