Case 1 - Click here for Text and References
Submitted by: Lyn McDivitt M. Duncan
Clinical Summary:
A 48 year old man presented with nausea/ vomiting, fatigue, and 50 pound weight loss in 4 months. Four months prior he was seen at an OSH for nausea, vomiting and jaundice. ERCP and CT revealed enlargement of the pancreatic head with peripancreatic, celiac and retroperitoneal lymphadenopathy and dilatation of the common bile duct (CBD). FNA of peripancreatic lymph nodes and cytobrush from the CBD were non-diagnostic. A biliary stent was placed to relieve obstructive jaundice. Results of exploratory laparotomy with pancreatic biopsy, retroperitoneal lymph node biopsy and FNA of the common bile duct led to a diagnosis of autoimmune pancreatitis. The lymphadenopathy and symptoms did not respond to treatment with prednisone.
He was referred to MGH with 50 pound weight loss in 4 months, increased nausea and vomiting, fatigue, fever to 103, and erythematous changes to the exploratory laparotomy abdominal incision.
Dermatology was consulted for expanding erythema at the surgical site. The patient first noticed pain and tenderness and small erythematous papules around the surgical site two weeks prior. The erythema slowly expanded and the central area near excision site became exquisitely painful to touch. No significant discharge was identified at the wound site.
A skin biopsy of the abdomen was performed.
A diffuse proliferation of tumor cells occupies the dermis with overlying epidermal hyperplasia and serum imbued scale crust.
The tumor cells are separated from the epidermis by a grenz zone of uninvolved dermis.
There is marked nuclear anaplasia with large nuclei, multiple eosinophilic macronucleoli, amphophilic to eosinophilic cytoplasm and numerous mitoses.
Some of the tumor cells display cytoplasmic vacuoles
The tumor is intimately associated with the vasculature and adnexae
Case 2 - Click here for Text and References
Submitted by: David E. Elder
Clinical Summary:
A lesion on the parietal scalp of a 28-year-old female. Reason for consultation. In a few areas, the lesion shows features which suggest to me that it may represent a cellular blue nevus. However, I am concerned about the possibility that it may represent a malignant blue nevus or malignant melanoma.
Low magnification of a bulky tumor located in the dermis and subcutis. There are at least two major components visible at scanning magnification, one more superficial and pigmented, the other more deeply located, forming a mass.
Low magnification of a bulky tumor located in the dermis and subcutis. There are at least two major components visible at scanning magnification, one more superficial and pigmented, the other more deeply located, forming a mass.
The superficial component itself has at least two major components. At the periphery, there are small spindle cells placed in the reticular dermis collagen fiber bundles. Toward the center, there is a more densely cellular pigmented population with a "mixed-biphasic" pattern.
There is a more sparsely cellular population at the periphery comprised of spindle cells, which have the characteristics of a banal blue nevus, albeit with scant pigmentation.
There is a more sparsely cellular population at the periphery comprised of spindle cells, which have the characteristics of a banal blue nevus, albeit with scant pigmentation.
The more central portion of the tumor is more heavily pigmented and demonstrates a "mixed-biphasic" pattern of a cellular blue nevus.
There is also a fascicular pattern comprised of heavily pigmented spindle cells.
The more deeply situated tumor is comprised of relatively large epithelioid cells with a somewhat "rhabdoid" phenotype, showing no evidence of maturation. Mitotic figures were readily detected with a maximal mitotic rate of approximately 2 per square millimeter.
The more deeply situated tumor is comprised of relatively large epithelioid cells with a somewhat "rhabdoid" phenotype, showing no evidence of maturation. Mitotic figures were readily detected with a maximal mitotic rate of approximately 2 per square millimeter.
The more deeply situated tumor is comprised of relatively large epithelioid cells with a somewhat "rhabdoid" phenotype, showing no evidence of maturation. Mitotic figures were readily detected with a maximal mitotic rate of approximately 2 per square millimeter.
Case 3 - Click here for Text and References
Submitted by: Bruce R. Smoller
Clinical Summary:
51 y.o. female with a history of NSHD presented with a 2.0 cm erythematous plaque on the back of her right hand. The lesion was tender and centrally crusted. The patient had no systemic symptoms. The clinical impression was foreign body reaction vs. keratoacanthoma vs. follicular abscess.
Case 4 - Click here for Text and References
Submitted by: Janis M . Taube
Clinical Summary:
59 year-old woman with erythematous plaques involving the nose x 3 years, not responding to laser treatments. Patient has a "15 year history of rosacea, rule out rhynophyma, syphilis, other infectious process (TB, histoplasmosis), NK T cell lymphoma".
Pertinent Laboratory Data:
PCR assay for TCRgamma demonstrates a clone. Special stains for PAS, FITE, and Warthin-Starry fail to reveal microorganisms.
HE high
HE low