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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 2661 - 17 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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83M, left leg.


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Gabriel Tabosa

Posted

The images remind me of Kaposi Sarcoma. HHV8 IHC stains would be useful.

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Epithelioid atypical cells and intradermal dissecans pattern of growth, push for ANGIOSARCOMA.  

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Richard Logan

Posted

I agree with the suggestion of angiosarcoma.  What is the explanation of the hyaline material filling the dermal papillae and surrounding the superficial dilated vessels?  Is it amyloid or something else?  The superficial vessels have slightly pleomorphic endothelial nuclei so I guess these must also be part of the main pathology.

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Krishnakumar subramanian

Posted

I also agree with angiosarcoma. IHC can help us

since it is on the leg was there any lymphedema for a long duration

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Meenakshi Batrani

Posted

I would keep differential of both KS and angioarcoma. 

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Saleem Taibjee

Posted

Hi

You made this look easy. I thought it was quite a challenging recent case of angiosarcoma, certainly on this biopsy. By the way, immunohistochemistry for HHV8 was negative, and the clinical appearance was typical for angiosarcoma. The patient did have some evidence of pre-existing venous stasis but no established lymphoedema, and hence lacked any of the usual risk factors for angiosarcoma.

I showed the slide blind of the clinical information to one of our junior doctors within our department, and it was interesting to see how the eye is immediately drawn to the clefted spaces in the superficial dermis, and therefore possible to miss the more subtle atypical dissecting pathology at the deeper aspect.

This illustrates a potential pitfall in superficial biopsies, that some malignant vascular neoplasms such as angiosarcoma and Kaposi sarcoma can show lymphangioma-like changes superficially which can lead to a potential misdiagnosis if one is not aware of this. Of course, this is perhaps not so surprising since both angiosarcoma and Kaposi sarcoma may derive from lymphatic endothelium, as supported by expression of lymphatic markers such as D2-40.

Here are a couple of relevant references.

Postmastectomy low-grade angiosarcoma. An unusual case clinically resembling a lymphangioma circumscriptum https://pubmed.ncbi.nlm.nih.gov/3232756/

Lymphangioma-like variant of Kaposi’s sarcoma https://pubmed.ncbi.nlm.nih.gov/9056649/

Fortunately in this particular case the clinician was querying angiosarcoma, and had submitted a couple of other biopsies which were more obviously angiosarcoma. See images below.

05865_20.0xe.jpg

05865_40.0x.jpg

05865_5.0x.jpg

05865_40.0x.jpg

05865_40.0xc.jpg

 

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Richard Logan

Posted

What's the pink stuff in the dermal papillae Saleem?  Is it basement membrane thickening?

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Admin_Dermpath

Posted

Please see below the comment from Dr. Saleem Taibjee;

Hi Richard. I’m not 100% sure about the nature of the pink material. But I think it is hyalinised collagen. On reflection, I think we can sometimes see it in other vascular lesions (e.g. pyogenic granuloma, etc).

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Saleem Taibjee

Posted

Hi Richard. I’m not 100% sure about the nature of the pink material. But I think it is hyalinised collagen. On reflection, I think we can sometimes see it in other vascular lesions (e.g. pyogenic granuloma, etc).

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