—  SPECIALTY CONFERENCE HANDOUT  — Dermatopathology Tuesday, March 23, 2010, 7:30 PM Salon 2 Clinical histories are printed below. Click on the case numbers for text and references of each case. Click on each slide thumbnail image for an enlarged view Issues in the Evaluation of Melanocytic Lesions Moderator: STEVEN R. TAHAN Beth Israel Deaconess Medical Center, Boston, MA Disclosure: In accordance with ACCME guidelines regarding disclosure, the USCAP policy requires that faculty members who have a significant financial or other relationship with a commercial company, entity, or service (which will be discussed in this Symposium) must disclose this to attendees. The Academy also requires that speakers disclose any products that are not labeled for the use under discussion. The speakers listed below have indicated they have nothing to disclose. Panelists: MARTIN C. MIHM, Harvard Medical School, Massachusetts General Hospital, Boston, MA GEORGE F. MURPHY, Harvard Medical School, Brigham and Women's Hospital, Boston, MA STEVEN R. TAHAN, Harvard Medical School and Beth Israel Deaconess Medical School, Boston, MA ROY KING, Knoxville Dermatopathology Laboratory, Knoxville, TN Clinical histories are displayed below. For the fastest viewing of virtual slides, click: under each thumbnail image below. You must have Aperio ImageScope installed on your PC. If you do not already have Aperio ImageScope, Windows users with administrator privileges may download and install a free version in order to view USCAP Virtual Slides. Click the icon on the right to get your free copy:   Or, click on slide thumbnail images to view each slide in a Web-based slide viewer, which is somewhat slower. If you have any difficulties viewing these slides, email or call George Clay at +1.724.449.1137. Case 1 - Click here for Text and References Submitted by: Roy King - Knoxville Dermatopathology Laboratory, Knoxville, TN Clinical Summary: 63 Year old male presented to his dermatologist with a pigmented lesion on his right posterior shoulder. The patient was unaware of the duration of the lesion and has a history of multiple benign moles removed from his back. His wife noticed this lesion and is not sure if this was a site of previous biopsy. Pathological/Microscopic Findings and any Immunohistochemical or Other Studies: Additional biopsy demonstrates a broad atypical melanocytic proliferation spanning the entire dermoepidermal junction (Figure A). In one half of the biopsy there is a markedly atypical confluent proliferation of melanocytes with associated epidermal hyperplasia and no evidence of dermal scar (Figure B). In the opposite half of the biopsy, there is effacement of the retiform epidermis with proliferation of an atypical compound melanocytic proliferation with associated dermal fibrosis and lymphocytic infiltrate (Figure C and D). Case 1 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 1 - Figure A Case 1 - Figure B Case 1 - Figure C Case 1 - Figure D Figure 1. Histologic patterns of recurrent nevus phenomenon. In the histologic patterns types 1and 2, there is effacement of the retiform epidermis with junctional (a) and compound melanocytic hyperplasia (b), respectively. Dermal scar accompanies both biopsies. This is in contrast to types 3 and 4, where there is retiform epidermal hyperplasia, associated with junctional (c) and compound melanocytic hyperplasia (d), and dermal scar. Case 1 - Figure 1A Case 1 - Figure 1B Case 1 - Figure 1C Case 1 - Figure 1D Figure 2. (a) In 20 cases, prominent pagetoid upward migration of melanocytes was present. This may be confused with melanoma in situ, if taken out of context. (b) Cytologically, the dominant melanocyte present had an epithelioid configuration with round nucleus and even chromatin pattern. The dermal melanocytes retained the morphology of the junctional component, and transition to types B and C melanocytes was not evident (b). Case 1 - Figure 2A Case 1 - Figure 2B Figure 3. (a and b). In those cases with a retiform epidermis and accompanying atypical features, such as confluent growth pattern, pagetoid spread, and cytologic atypia, there was histologic overlap with primary melanoma (a and b). Case 1 - Figure 3A Case 1 - Figure 3B Figure 4. Histologic overlap of recurrent nevus and melanoma with regression. Recurrent nevus (a-c) and melanoma with regression (d-f). In partial biopsies, there may be considerable overlap between these two lesions. This was especially true for cases of MM with late regression with loss of tumor, effacement of the retiform epidermis, and fibrosis. Case 1 - Figure 4 Case 2 - Click here for Text and References Submitted by: Steven R. Tahan - Harvard Medical School and Beth Israel Deaconess Medical School, Boston, MA Clinical History: This nevus was shaved from the neck of a 35 year old woman who was 29 weeks pregnant for indication of increasing size. Case 2 - Figure 1 Low power view showing bosselated surface of nevus removed at 29 weeks of pregnancy. Case 2 - Figure 2 Higher power of superficial micronodules. Case 2 - Figure 3 Superficial micronodules showing small clusters of large epithelioid cells within expanded surface bosselation. Case 2 - Figure 4 Superficial micronodules Case 2 - Figure 5 Superficial micronodules Case 2 - Figure 6 Superficial micronodules comprised of rounded clusters of 3-20 large epithelioid melanocytes with prominent nucleoli, abundant pale eosinophilic cytoplasm, and occasional fine melanosomes. Case 2 - Figure 7 Mitoses within superficial micronodules Case 2 - Figure 8 Mitoses within superficial micronodules Case 2 - Figure 9 MIB-1 immunostain for Ki-67 shows positive cells, predominantly in superficial micronodules. Case 2 - Figure 10 HMB45 immunostain reacts with cells in superficial micronodules and mid-dermis Case 2 - Figure 11 Nevoid melanoma showing deceptively small cell size, but monotonous. Case 2 - Figure 12 Nevoid melanoma with large dermal nests. Case 2 - Figure 13 Congenital nevus with large proliferative nodule (lower portion of lesion), courtesy of Dr. Xaiwei Xu of UPenn, with permission. Case 3 - Click here for Text and References Submitted by: Martin C. Mihm - Harvard Medical School, Massachusetts General Hospital, Boston, MA Clinical Summary: At age 8 this boy developed a mole on the posterior scalp. His parents thought that it was the result of a "bug bite." the lesion gradually became raised and intermittently bled. By age 13 it was large and ulcerated. The parents had been treating it with a variety of herbal medicines and other remedies. He began to wear a hat to cover the area. The lesion became so large that it bled almost daily. Finally, after much taunting by other children and after much bleeding he sought medical advice. A biopsy was taken. Case 3 - Figure 1 A nodule of tumor is clearly seen in the dermis adjacent to the ulcerated area. Note the absence of an intraepidermal component, a change consistent with a nodular melanoma or a metastasis. Case 3 - Figure 2 The tumor is composed of numerous spindle cells in fascicles. Case 3 - Figure 3 The tumor is composed of closely packed spindle cells, the nuclei of which are large. The nuclear to cytoplasmic ratios of the tumor cells is very large so that the cells are tightly apposed. Mitotic figures are visible as well as focal melanization of the cytoplasm. Rare melanophages are also present. Case 3 - Figure 4 The tumor is composed of closely packed spindle cells, the nuclei of which are large. The nuclear to cytoplasmic ratios of the tumor cells is very large so that the cells are tightly apposed. Mitotic figures are visible as well as focal melanization of the cytoplasm. Rare melanophages are also present. Case 3 - Figure 5 The tumor is composed of closely packed spindle cells, the nuclei of which are large. The nuclear to cytoplasmic ratios of the tumor cells is very large so that the cells are tightly apposed. Mitotic figures are visible as well as focal melanization of the cytoplasm. Rare melanophages are also present. Case 4 - Click here for Text and References Submitted by: George F. Murphy - Harvard Medical School, Brigham and Women's Hospital, Boston, MA Clinical Summary: A 59-year-old man presented with a 4mm brown papule on the left calf. Shave biopsy was performed and is represented in images 1-7. Fourteen months later, left inguinal adenopathy was noted and a lymph node dissection was performed (representative image of node - images 8-10 [s100 stain=image 10]). Case 4 - Figure 1 Case 4 - Figure 2 Case 4 - Figure 3 Case 4 - Figure 4 Case 4 - Figure 5 Case 4 - Figure 6 Case 4 - Figure 7 Case 4 - Figure 8 Case 4 - Figure 9 Case 4 - Figure 10 Handouts for all Specialty Conferences will be accessible via the "Educational Materials" section on the homepage the morning after each respective conference. Printed copies of the handout will not be available at the meeting.