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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 2744 - 12 January 2021 Posted By: Iskander H. Chaudhry

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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66M, Right cheek incisional biopsy. 6/12 history of increasing ulcerated lesion.


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tyelaine

Posted (edited)

Great resource and virtual slide is quite nice.

My first few attempts so hopefully reasonable.

Nodular pushing growth from epidermis down to the deep subcutis. Tumour cells are non-pigmented pleomorphic with eosinophilic/finely vacuolated cytoplasm, spindled and form fascicles. Mitoses is frequent. Very rare suggestion of some abortive tiny lumens in the cytoplasm. No definite necrosis. Small amount of accompanying lymphoplasmacytic infiltrate. Adjacent solar elastosis. Seems no definite in-situ lesion in the epidermis. No definite ulceration. No perivascular or perineural invasion.

Looks like a spindle cell tumour - probably need immunos to help in the diagnosis. May also be limited by biopsy specimen - may need to correlate with excision. Need to first exclude diagnoses such as angiosarcoma (spindle cell variant), may help with ERG+ (or other vascular markers). Sebaceous carcinoma, with expression for adipophillin (but seems classically less spindled?). Other differentials including amelanotic melanoma (spindle cell) (SOX10+ or other melanocytic markers), spindle cell carcinoma (may express some epithelial markers), etc. Will need to consider atypical fibroxanthoma (spindle cell variant)/pleomorphic dermal sarcoma after exclusion of other possibilities.

Interested to know the approach and views from other participants.

Edited by tyelaine

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Alex-Ventura-Leon

Posted

Malignant spindle cell neoplasm.

Very instructive description by tyelaine

My differentials are: Spindle cell SCC, AFX and Melanoma (probably in that order)

Virtual slide is so nice

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Richard Logan

Posted

Congratulations to the DermpathPRO team for introducing the innovation of digitally scanned slides to the SpotDiagnosis section.

I agree with earlier comments regarding the differential diagnosis of this mitotically active, malignant spindle cell tumour. 

It doesn't seem pleomorphic enough for a typical AFX, or sufficiently penetrating for a pleomorphic dermal sarcoma.

I would be inclined towards atypical intradermal smooth muscle tumour (leiomyosarcoma). Obviously immunohistochemistry is necessary to settle the issue.

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Victor Delgado

Posted

I did it!!! TKS @Richard Logan

My bet is for spindle SCC however agree with all the DD. 

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Eman El-Nabarawy

Posted (edited)

Favor atypical intradermal smooth muscle neoplasm...

Edited by Eman El-Nabarawy

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vincenzo

Posted

Favor Spindle Cell Melanoma

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Dr. Richard Carr

Posted

I tend to limit my panel in "malignant" spindle cell tumours (on biopsy) in severe sun-damaged skin to Pan-keratin, p63, S100, CD10 for histogenesis. I've been adding p53, p16 & Ki67 for "malignancy" if the differential is with a scar or some benign fibrohistiocytic proferation (not relevant here).

Here I see some subtle nesting of the theques and would think melanoma first.

To be controversial as long as it's excised with clear margins the diagnosis is irrelevant until it metastasises (which vast majority won't in my experience) and even then (if it's melanocytic) most melanomas on severely sun-damaged skin are BRAF mutation neg. Anecdotally we're seeing a high rate, in malignant spindle lesions on severely sun-damaged skin, of p16 null and a high rate of either null or markedly up-regulated p53 but this would require a formal study.

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Leila Ahmed

Posted

Totally agree with Dr Carr. I also add sma & desmin in my panel. 

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Iskander H. Chaudhry

Posted

Well done all - it was a spindle cell Melanoma with diffuse S100 protein staining. 

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