Self Assessment Cases

Self assessment course
Aleodor Andea, MD Associate Professor of Pathology and Dermatology Director of Dermatopathology University of Alabama at Birmingham Birmingham, AL aandea@uab.edu
Cazul 1
Un pacient de 42 de ani se prezinta cu un nodul facial asimptomatic.
A. B. C. D. E. Tricofoliculom Tricoadenom Tricoblastom Tricoepiteliom Chist eruptiv cu par velos
Cazul 1
Un pacient de 42 de ani se prezinta cu un nodul facial asimptomatic.
A. B. C. D. E. Tricofoliculom Tricoadenom Tricoblastom Tricoepiteliom Chist eruptiv cu par velos
Trichofolliculoma
Clinical:
Flesh colored papules with central pore with protruding hairs Adults Face, scalp,neck
Alte optiuni
Tricoadenom Tricoepiteliom Tricoblastom
Trichoadenoma
Trichoepithelioma
Trichoblastoma
Variant of trichoepithelioma Constituted largely of follicular germinative cells
Vellus hair cyst

Multiple small (eruptive), papules on face, neck, chest, limbs, axillae young adults/ children
Eruptive vellus hair cyst
Cazul 2
Un pacient se prezinta cu un nodul de culoare rosiatica localizat la baza incheieturii miini.
A. B. C. D. Keratosa seboreica Hidroacanthom Spiradenom ecrin Porom ecrin
Cazul 2
Un pacient se prezinta cu un nodul de culoare rosiatica localizat la baza incheieturii miini.
A. B. C. D. Keratosa seboreica Hidroacanthom Spiradenom ecrin Porom ecrin
Eccrine Poroma
Clinical:
Adults solitary, sessile skin-colored to red papule / nodule skin sole or side of the foot; rare in other sites up to 3cm in diameter
Eccrine poroma
Alte optiuni
Hidroacantom Keratosa seboreica Spiradenom ecrin
Hidroacanthoma Simplex
Clinical:
skin colored to red papule or plaque trunk or extremities elderly Often confused with SK, BCC, or SCC
Hydroacanthoma simplex
Seborrheic Keratosis
Among the most common benign epidermal proliferations developing in the middle-aged and elderly.
Seborrheic Keratosis
Hyperkeratosis, papillomatosis Pseudohorn cysts
Spiradenoma
Clinical:
0.3-5.0 cm. 0.3 dermal painful nodule blue coloration young adults head, neck, upper trunk or upper extremities
spiradenoma
Cazul 3
O femeie de 67 de ani se prezinta cu o leziune pe picior de culoare rosiatica, in relief, cu scuame prezenta de citeva luni.
A. B. C. D. E. Pheohifomicoza Necrobioza lipoidica Xanthogranulom necrobiotic Cromoblastomicoza Tinea nigra
Cazul 3
O femeie de 67 de ani se prezinta cu o leziune pe picior de culoare rosiatica, in relief, cu scuame prezenta de citeva luni.
A. B. C. D. E. Pheohifomicoza Necrobioza lipoidica Xanthogranulom necrobiotic Cromoblastomicoza Tinea nigra
Chromoblastomycosis
Disease of tropics and subtropics Caused by saprophitic pigmented fungi from plants debris and soil Organisms
Fonseca pedrosoi (Phialospora pedrosoi) Phialospora compacta Phialospora verucossa Cladosporium carrionii
Verrucous nodule or plaque
Alte optiuni
Pheohifomicoza Necrobioza lipoidica Xanthogranulom necrobiotic Tinea nigra
Mycoses
Superficial fillamentous infections
Dermatophytoses
Dematiaceous fungi
Chromomycosis Phaehyphomycosis Sporotrichosis Tinea nigra
Yeast infections
Candidosis Cryptococcosis Pityriasis versicolor Pityrosporum folliculitis Blastomycosis Coccidioidomycosis Paracoccidioidomycosi Histoplasmosis
Zygomycoses Hyalohyphomycoses
Fusariosis Penicilliosis Aspergilosis
Systemic mycoses
Algal infections
Protothecosis
Phehyphomycosis
Verrucous, nodular or cystic lesions Organisms
Exophiala jeanselmei Wangiella dermatidis
Tinea nigra
Exophiala werneckii Slowly enlarging brown to black macule Palms, plantar surface Mimicks melanocytic lesions
Necrobiotic xanthogranuloma
Chronic disease Sharply demarcated nodules and plaques Violaceous to red Periorbital area
Cazul 4
O femeie de 30 de ani se prezinta cu un nodul intradermic dureros pe antebratul sting.
A. B. C. D. E. Neurofibrom Neurilemom Neurom Leiomiom Leiomiosarcom
Cazul 4
O femeie de 30 de ani se prezinta cu un nodul intradermic dureros pe antebratul sting.
A. B. C. D. E. Neurofibrom Neurilemom Neurom Leiomiom Leiomiosarcom
SCHWANNOMA (neurilemmoma)
Clinical:
single, sporadic tumors; 20-50 yrs; M=F; head, neck, limbs (i.e. usually named nerves)
SCHWANNOMA
CM
S-100
Alte optiuni
Neurofibrom Neurom Leiomiom Leiomiosarcom
PERIPHERAL NERVE SHEATH TUMORS

Neuroma Palisaded encapsulated neuroma Neurofibroma Schwannoma Granular cell tumor
NEUROMA (traumatic neuroma)

Clinical:
history of injury nerve severing event a firm, painful nodule
TRAUMATIC NEUROMA
NEUROFIBROMA
Clinical:
90% are solitary, not associated with NF; diffuse & plexiform closely associated with NF-1
Neurofibroma vs. Schwannoma
NEUROFIBROMA
NEUROFIBROMA
PLEXIFORM NEUROFIBROMA
PLEXIFORM NEUROFIBROMA
Cazul 5
O femeie de 40 de ani se prezinta cu o placa dureroasa, eritematoasa si indurata in zona posterioara a gambei.
A. Eritem nodos B. Erithem indurat C. Necroza grasa diseminata (Paniculita pancreatica) D. Deficienta de alfa-1-antitripsina E. Paniculita lipomembranoasa
Cazul 5
O femeie de 40 de ani se prezinta cu o placa dureroasa, eritematoasa si indurata in zona posterioara a gambei.
A. Eritem nodos B. Erithem indurat C. Necroza grasa diseminata (Paniculita pancreatica) D. Deficienta de alfa-1-antitripsina E. Paniculita lipomembranoasa
Erythema nodosum
Septal panniculitis
Erythema Nodosum
acute painful nodules, anterior lower legs
Classification of panniculitis
Septal Lobular
Septal
Erythema Nodosum Subcutaneous morphea/scleroderma Necrobiosis Lipoidica
Lobular
Erythema Induratum Pancreatic Panniculitis Alpha 1 anti-trypsin deficiency Lupus panniculitis Subcutaneous panniculitis-like T cell Lymphoma Subcutaneous fat necrosis of the newborn & Sclerema neonatorum Lipodermatosclerosis
Alte optiuni
Erithem indurat Paniculita pancreatica Deficienta de alfa-1-antitripsina Paniculita lipomembranoasa
Alpha-1-antitrypsin deficiency
Tender nodules on trunk or extremities, Precipitated by trauma Ulceration and oily discharge.
Erythema induratum
Tender nodules on calves
Lipomembraneous Panniculitis or Membranous Lipodystrophy

Venous insufficiency: =Lipodermatosclerosis.
End result of multiple disease processes:

EN, Morphea profunda, Lupus, traumatic fat necrosis, insulin lipoatrophy, encapsulated fat necrosis, dermatomyosistis and Bechets disease.
Lipodermatosclerosis
indurated inverted champagne bottle appearance
Pancreatic panniculitis
Painful subcutaneous nodules / plaques Thighs, buttocks, lower trunk & distal extremities. Acute pancreatitis Acinic cell pancreatic carcinoma Etiology: fat digestion by of pancreatic enzymes
Cazul 6
O femeie de 31 de ani se prezinta cu un nodul polipoid de 3 cm crescut pe o leziune in placa indurata pe partea superioara a spatelui.
A. B. C. D. Neurilemom Dermatofibrom Dermatofibrosarcom protuberant Fibroxantom atipic
Cazul 6
O femeie de 31 de ani se prezinta cu un nodul polipoid de 3 cm crescut pe o leziune in placa indurata pe partea superioara a spatelui.
A. B. C. D. Neurilemom Dermatofibrom Dermatofibrosarcom protuberant Fibroxantom atipic
DFSP
Fibrohistiocytic tumor Intermediate malignant potential:
locally aggressive (11-73% local recurrence) (11 but a low rate of metastasis (1-3%) to lung. (1-
FIBROHISTIOCYTIC TUMORS
Benign
Dermatofibroma
Intermediate
Atypical fibroxanthoma Dermatofibrosaroma protuberans
Malignant
Malignant fibrous histiocytoma
Enlarging plaque, sometime with a nodule.
Alte optiuni
Neurilemom Dermatofibrom Fibroxantom atipic Histiocitom fibros malign
DERMATOFIBROMA
Clinical:
0.5 1 cm Leg puckers when pinched may be pigmented (due to melanin or hemorrhage)
Cazul 7
Un barbat de 30 de ani a remarcat aparitia recenta a unui nodul rosu-purpuriu de bratul drept. Biopsia confirma un diagnostic de:
A. B. C. D. E. Hemangiom capilar Angiokeratom Sarcom Kaposi Nev intradermic Carcinom cu celule squamouase, tip cu celule fusiforme
Cazul 7
Un barbat de 30 de ani a remarcat aparitia recenta a unui nodul rosu-purpuriu de bratul drept. Biopsia confirma un diagnostic de:
A. B. C. D. E. Hemangiom capilar Angiokeratom Sarcom Kaposi Nev intradermic Carcinom cu celule squamouase, tip cu celule fusiforme
Kaposi Sarcoma
Low-grade clonal endothelial proliferation Variants:
Classic KS:
Elderly patients Distal extremities
African KS
Likely related to chronic immunosuppression
AIDS-related/ immunosuppression:
Disseminate multi-organ disease, predilection for mucocutaneous sites, aggressive course
PAS
CD 31
CD 34
HHV8
Alte optiuni
Hemangiom capilar Angiokeratom Nev intradermic Carcinom cu celule squamouase, tip cu celule fusiforme
Lobular capillary hemangioma (Pyogenic granuloma)
Angiokeratoma
Intradermal nevus
Cazul 8
O femeie de 60 de ani se prezinta cu leziuni eritematoase dureroase pe frunte. Biopsia confirma un diagnostic de:
A. B. C. D. E. Foliculita bacteriana Zona zoster Lupus eritematos bulos Reactie la intepatura de insecta Pemfigus vulgar
Cazul 8
O femeie de 60 de ani se prezinta cu leziuni eritematoase dureroase pe frunte. Biopsia confirma un diagnostic de:
A. B. C. D. E. Foliculita bacteriana Zona zoster Lupus eritematos bulos Reactie la intepatura de insecta Pemfigus vulgar
Zona Zoster
Clinical:
epidemic, acute vesicular eruption with a febrile illness rash develops in successive stages pneumonia in immunocompromised
Alte optiuni
Foliculita bacteriana Lupus eritematos bulos Reactie la intepatura de insecta Pemfigus vulgar
Staphyloccal folliculitis
Bullous lupus
Insect bite
Insect bite
Case 9
Care este cel mai probabil diagnostic bazat pe examenul histopatologic?
A. B. C. D. E. Carcinoma bazocelular Tricoblastom Porom ecrin Carcinom cu celule Merkel Limfom cutanat cu celule B mari, difuz
Case 9
A. B. C. D. E. Carcinoma bazocelular Tricoblastom Porom ecrin Carcinom cu celule Merkel Limfom cutanat cu celule B mari, difuz
Merkel cell carcinoma

First reported by Toker in 1972 Merkel cell origin is not clearly demonstrated Neuroendocrine tumor of the skin Clinical:
Sun-exposed areas of elderly patients Nodules 2 cm average diameter
3 cm ulcerated and crusted nodule Clinical Dx: BCC, Amelanotic MM, Metastatic cancer
CK 20
Chromogranin
Synaptophysin
Alte optiuni
Carcinoma bazocelular Tricoblastom Porom ecrin Limfom cutanat cu celule B mari, difuz
Basal Cell Carcinoma

Most common cutaneous malignant tumor (70%) Head and neck areas Males Age related
Microscopic
Basaloid cells with peripheral palisading
Primary cutaneous diffuse large Bcell lymphoma, leg type

Definition: is a primary cutaneous large cell lymphoma with confluent sheets of centroblasts and immunoblasts which occurs on the legs
Willemze et al. 2005 105:3768-85
Case 10
A. B. C. D. E. Porfirie cutanata tardiva Eritem multiform Pemfigoid bulos Pemfigus vulgar Lupus eritematos bulos
Case 10
A. B. C. D. E. Porfirie cutanata tardiva Eritem multiform Pemfigoid bulos Pemfigus vulgar Lupus eritematos bulos
Porphyria cutanea tarda

Blisters develop in sun-exposed areas Dorsum of the hands
Alte optiuni
Eritem multiform Pemfigoid bulos Pemfigus vulgar Lupus eritematos bulos
Bullous Pemphigoid
Most common subepidermal blistering disease. Abdomen, groin, flexor surface of arms and legs Elderly
Case 11
Cel mai probabil diagnostic bazat exclusiv pe examenul histopatologic este:
A. Scleromixedem B. Fasciita nodulara C. Morfea profunda D. Fibroxantom atipic E. Histiocitom fibros malign
Case 11
A. Scleromixedem B. Fasciita nodulara C. Morfea profunda D. Fibroxantom atipic E. Histiocitom fibros malign
Nodular Fasciitis
Upper extremities, trunk Rapid growth Easily confused with a sarcoma
Alte optiuni
Scleromixedem Morfea profunda Fibroxantom atipic Histiocitom fibros malign
Scleromyxedema
M-protein Paraproteinemia (85%): IgG Onset: Middle aged adults
Scleromyxedema
Papules, plaques & infiltrative lesions Face; Neck upper Arms, legs.
Deep morphea
Case 12
A. B. C. D. Lichen plan Lichen striat Lichen nitidus Lichen planopilar
Case 12
Lichen Planus
Papules Pruritic Poligonal Purple Flexor surface or wrists, trunk, thighs, genitalia
Band-like infiltrate Epidermal acanthosis Compact Hyperkeratosis Wedge-shaped hypergranulosis
Saw-tooth rete
Vacuolar-interface changes = liquefactive degeneration
Subepidermal clefting Caspary-Joseph Space
Dyskeratotic cells = Civatte bodies Melanophages
Colloid bodies
Direct immunofluorescence
Fibrin IgM
Case 13
Case 13
Lichen Striatus
Unknown etiology Linear papular eruption along one side of body, usually the length of an extremity
Lichenoid infiltrate on 3-4 dermal papillae Less dense than in LP Acanthosis Spongiosis with exocytosis of lymphocytes Hyperorthokeratosis and focal parakeratosis
Vacuolar interface changes Dyskeratotic cells at all levels Spongiosis with exocytosis of lymphocytes
Alte optiuni
Lichen nitidus Lichen planopilar
Lichen Nitidus
Multiple small flesh colored papules 1-2 mm Upper extremities, chest, abdomen, genitalia Children and young adults
Claw-like rete (ball and claw) Lichenoid infiltrate Thinned epidermis with dyskeratosis and vacuolar changes
Granulomatous infiltrate
Perieccrine infiltrate
Lichen Planopilaris
A common cause of scarring alopecia Keratotic follicular lesions and erythema at margins
Case 14
Cel mai probabil diagnostic bazat exclusiv pe examenul histopatologis este:
A. B. C. D. Lupus eritematos cronic cutanat (discoid) Lichen plan Keratoza lichenoida Eritem multiform
Case 14
A. B. C. D. Lupus eritematos cronic cutanat (discoid) Lichen plan Keratoza lichenoida Eritem multiform
Erythema multiforme
Pleomorphic eruption Individual lesions: papule -> vesicle>target Herpes, drugs, mycoplasma Minor/ major forms (Stevens-Johnson)
Erythema multiforme/Stevens-Johnson
Alte optiuni
Lichen plan Lupus eritematos cronic cutanat (discoid) Keratoza lichenoida
Lichen Planus-Like Keratosis

Solitary, 3-10 mm Scaly, violaceous or pink Arms and chest Middle age and elderly women DDX: BCC, SCCIS
Case 15
Cel mai probabil diagnostic histologic este:
A. B. C. D. E. Psoriasis Lichen simplex cronicus Lichen sclerotic si atrofic Morfea Fasciita eosinofilica
Case 15
Cel mai probabil diagnostic histologic este:
A. B. C. D. E. Psoriasis Lichen simplex cronicus Lichen sclerotic si atrofic Morfea Fasciita eosinofilica
Alte optiuni
Psoriasis Lichen simplex cronicus Morfea Fasciita eosinofilica
Lichen simplex chronicus

Scaly thickened plaques develop in response to persistent rubbing Predilection for:
Nape of neck Ulnar border of forearms Wrists Pretibial region Dorsa of feet Perianal and genital region
Eosinophilic Fasciitis (Shulmans Syndrome)

Sudden onset 50% occur after strenuous activity. Symmetric induration of skin of limbs > trunk Characteristic orange-peel appearance. Spares hands. Peripheral eosinophilia. Malaise, weakness, fever and weight loss
OrangeOrange-peel appearance
Layering effect of hyalinized sclerotic collagen alternating with trapped fat and inflammatory cells.
Case 16
A. B. C. D. Dermatita spongiotica Psoriasis Pitiriasis rubra pilaris Micoza fungoida
Case 16
Psoriasis
Well-circumscribed erythematous patches with a silvery scale Extensor surfaces of the extremities, sacral region, scalp, nails
Cazul 17
Cazul 17
Mycosis fungoides
Small to medium sized T lymphocytes with cerebriform nuclei Older adults Indolent clinical course
Patch Plaque Tumor
Pautrier microabscesses
CD 3 +
CD 4 +
CD 8 -
CD 7 -
Alte optiuni
Dermatita spongiotica Psoriasis Pitiriasis rubra pilaris
Spongiotic dermatitis
Allergic contact dermatitis Dyshidrotic eczema Nummular dermatitis Atopic dermatitis Seborrheic dermatitis Phototoxic dermatitis Pityriasis rosea Stasis dermatitis
Almost identical histology
Pityriasis rubra pilaris

Small follicular papules with a central plug Perifollicular erythema Islands of sparing Palmoplantar keratoderma
Cazul 18
A. Psoriasis B. Pitiriasis rubra pilar C. Dermatita spongiotica D. Scabie E. Micoza fungoida
Cazul 18
A. Psoriasis B. Pitiriasis rubra pilar C. Dermatita spongiotica D. Scabie E. Micoza fungoida
Cazul 19
Alegeti cel mai probabil diagnostic din optiunile de mai jos, bazat pe examenul histopatologic.
A. B. C. D. E. Pemfigoid bulos Pustuloz exantematic acut generalizat Pemfigus vulgar Boala IgA lineara Pseudoporfirie
Cazul 19
Alegeti cel mai probabil diagnostic din optiunile de mai jos, bazat pe examenul histopatologic.
A. B. C. D. E. Pemfigoid bulos Pustuloz exantematic acut generalizat Pemfigus vulgar Boala IgA liniara Pseudoporfirie
Linear IgA Bullous Dermatosis

Chronic Bullous Disease of Childhood:
Large, tense bullae arising during the 1st decade Predilection for perioral and genital regions Usually benign course
Adult linear IgA Bullous Dermatosis

Varied presentations, sometimes annular with lesions usually involving trunk and limbs Common association with drug Rx (vancomycin)
Chronic Bullous Dermatosis of Childhood
IgA
Subepidermal Blisters
Cell Poor: Poor:
EB, EBA, PCT
Cell Rich:
Lymphocytes: EM, Fixed drug Neutrophils: DH, Linear IgA, Bullous SLE IgA, Eosinophils: BP, HG, IP, arthropod, drug Eosinophils: Mast Cells: Bullous Mastocytosis
Alte optiuni
Pemfigoid bulos Pustuloz exantematic acut generalizat Pemfigus vulgar Pseudoporfirie
Acute generalized exanthematous pustulosis

Sterile, miliary pustules on an erythematous background Fever, blood leukocytosis Occurs within hours after ingestion of drugs
DDX of subcorneal pustules

Bullous impetigo Staphylococcal scalded skin Pemphigus foliaceus IgA Pemphigus Acute generalized exanthematous pustulosis Pustular psoriasis Subcorneal pustular dermatosis
Cazul 20
Alegeti cel mai probabil diagnostic bazat pe examenul histopatologic din optiunile de mai jos.
A. B. C. D. E. Pemphigoid bulos Lupus eritematos bulos Pemfigus vulgar Boala Hailey-Hailey Pseudoporfirie
Cazul 20
A. B. C. D. E. Pemphigoid bulos Lupus eritematos bulos Pemfigus vulgar Boala Hailey-Hailey Pseudoporfirie
Pemphigus vulgaris
80% of pemphigus cases Oral blisters then cutaneous lesions Flacid blisters on normal base Trunk, groin, axillae, scalp, face, presure points
Pemphigus Vulgaris
Ab directed against desmoglein 3 About half of patients also have Ab to desmoglein 1
DIF
IgG in the intercellular regions of the epidermis, lesional and perilesional
Suprabasilar Blisters
Pemphigus Vulgaris Paraneoplastic Pemphigus Acantholytic dyskeratosis
Hailey-Hailey Disease Dariers Disease Grovers Disease
Alte optiuni
A. B. C. D. Pemphigoid bulos Lupus eritematos bulos Boala Hailey-Hailey Pseudoporfirie
Hailey-Hailey disease
Familial benign chronic pemphigus Genodermatosis, AD Onset in teens ATP2C1 (calcium pump)
Hailey Hailey Disease

Axillary skin showing erythematous eroded and crusted lesions
Partial acantholyis (dilapidated brick wall) Acantholytic cells No follicular involvement
Cazul 21
A. B. C. D. E. Granulom anular Necrobioza lipoidica Nodul reumatic Infectie cu micobacteria Sarcoidoza
Cazul 21
Sarcoid- Clinical Features

Blacks > Whites Women > Men Cutaneous lesions in <25% of patients with systemic disease If confined to skin, runs an indolent course
Asteroid body
Cazul 22
Cazul 22
Granuloma Annulare
Papules Annular or arciform plaques. Commonly on extremities.
Cazul 23
Alegeti cel mai probabil diagnostic din optiunile de mai jos, bazat pe examenul histopatologic:
Cazul 23
Rheumatoid Nodules
Subcutaneous nodules, usually in the vicinity of joints. Can persist for years
Alte optiuni
Granulom anular Necrobioza lipoidica Infectie cu micobacteria Sarcoidoza
Necrobiosis Lipoidica
Predilection for legs (shins), usually bilateral. Red papules, enlarging to become plaques which develop atrophic, depressed centers
Mycobacterial infection
Less discrete than sarcoidal granulomas with tendency toward confluence More giant cells and often accompanied by a rim of lymphocytes and plasma cells Caseous necrosis sometimes
Cazul 24
Cel mai probabil diagnostic in acest caz este:
A. Vasculita leucocitoclazica B. Angiodermita purpurica si pigmentara C. Purpura actinica D. Coagulare intravasculara diseminata
Cazul 24
A. Vasculita leucocitoclazica B. Angiodermita purpurica si pigmentara C. Purpura actinica D. Coagulare intravasculara diseminata
Leukocytoclastic vasculitis
Most common vasculitis Not a disease but a manifestation of circulating IC caused by an underlying disorder
Causes of allergic vascultitis

Infection: bacteria, mycobacteria, viral Drugs: phenacetin, sulfonamies, penicilin, iodides Chemicals: insecticides Associated diseases:
SLE, other CTD Lymphoma, carcinoma RA Sjogren sd HS purpura Cryoglobulinemia
Alte optiuni
Angiodermita purpurica si pigmentara Purpura actinica Coagulare intravasculara diseminata
Pigmented purpuric dermatosis

Group of purpuric diseases Variable pigmentation Lower extremities Young adults
Solar purpura
DIC/purpura fulminans
Fibrin, platelets or mixed thrombi in the capillaries and venules
Cazul 25
Un pacient de 80 de ani se prezinta cu un nodul verucos pe fata si o biopsie este efectuata. Care este pasul urmator in tratament?
A. Revine pentru control din 6 in 6 luni. B. Programat pentru excizie cu margini largi de siguranta (1-2 cm) C. Programat pentru excizie conservative a leziunii D. Revine pentru control din 3 in 3 luni
Cazul 25
Un pacient de 80 de ani se prezinta cu un nodul verucos pe fata si o biopsie este efectuata. Care este pasul urmator in tratament?
A. Revine pentru control din 6 in 6 luni. B. Programat pentru excizie cu margini largi de siguranta (1-2 cm) C. Programat pentru excizie conservative a leziunii D. Revine pentru control din 3 in 3 luni
Nevoid melanoma
Variant of melanoma that is easily mistaken for a common nevus
Nevoid melanoma
Definition from McKee: A melanoma that a pathologist diagnosed as nevus and wished that she/he had not Borderline histology but not borderline prognosis!
Nevoid melanoma
Wide age range No gender predilection Two types
Verrucous Dome shaped
Clinical:
Verrucous resemble a verruca or SK, if pigmented a warty nevus Dome shaped -more non-specific
Histology confusing features

Dome shaped or verrucous Small size Symmetric of slightly asymmetric Circumscribed Limited intraepidermal component Pseudomaturation
Histology -clues
Confluent or sheetlike growth pattern
Histology -clues
Multiple mitotic figures Mitoses at the base of the lesion Atypical mitoses Cytologic atypia
Histologic features
NEVI
Small Symmetric Well-circumscribed No No Nested Present Absent Absent Absent Size Symmetry Circumscription Confluent growth at DEJ Pagetoid spread Dermal pattern Maturation Cytologic atypia Mitoses in dermis Atypical mitoses
MELANOMA
Large Asymmetric Poorly-circumscribed Present Prominent Sheetlike Absent Severe Present Present
Histologic features
NEVI
Small Symmetric Well-circumscribed No No Nested Present Absent Absent Absent Size Symmetry Circumscription Confluent growth at DEJ Pagetoid spread Dermal pattern Maturation Cytologic atypia Mitoses in dermis Atypical mitoses
NEVOID MELANOMA
Small Symmetric Well-circumscribed No No Sheetlike Present Mild Present Present
Cazul 26
Aceasta leziune este negativa pentru coloratiile imunohistochimice S100, keratina, p63 si desmina si pozitiva pentru CD10. Care este diagnosicul cel mai probabil?
A. Melanom desmoplastic B. Leiomiosarcom C. Carcinom squamocelular cu celule fuziforme D. Fibroxantom atipic E. Histiocitom fibros malign
Cazul 26
Aceasta leziune este negativa pentru coloratiile imunohistochimice S100, keratina, p63 si desmina si pozitiva pentru CD10. Care este diagnosicul cel mai probabil?
A. Melanom desmoplastic B. Leiomiosarcom C. Carcinom squamocelular cu celule fuziforme D. Fibroxantom atipic E. Histiocitom fibros malign
ATYPICAL FIBROXANTHOMA
Def: identical to pleomorphic malignant fibrous histiocytoma (i.e. undifferentiated pleomorphic sarcoma) Clinical: nodule on sun-exposed head/neck sun-
Leziuni dermice pleomorfice cu celule fusiforme

Histiocitom fibros malign Fibroxantom atipic Carcinom squamocelular cu celule fuziforme Melanom desmoplastic Leiomiosarcom
Maligant fibrous histiocytoma

Aceasi histologie cu fibroxantomul atipic Tumora este centrata in tesutul subcutanat sau muschi Prognosticul este foarte diferit:
AFX -100% supravietuire la 5 ani MFH - ~20% supravietuire la 5 ani
Spindle cell SCC
Keratin (CK 903)
Desmoplastic melanoma
Predilection for elderly males Sun-damaged areas 4% of invasive melanomas Infiltrated plaque or amelanotic nevus Often unsuspected clinically
Spindle cells dispersed into a dense stroma
Nodular lymphoid infiltrates Associated MIS lentigo maligna type (only about half of cases) Carlson J. Cancer
1995: 76:478-94
Oval to fusiform nuclei
Perineural invasion
Deep infiltration into dermis and subcutis Mitoses (sometimes scant)
Variable pleomorphism
S100
Mart-1
HMB45
Leiomyosarcoma
Cutaneous leiomyosarcoma Deep leiomyosarcoma Prognosis depends on location
Dermal: benign Deeper: more aggressive
Desmin
Cazul 27
A. B. C. D. E. Cicatrice Cicatrice hipertrofica Dermatofibrom Morfea Keloid
Cazul 27
A. B. C. D. E. Cicatrice Cicatrice hipertrofica Dermatofibrom Morfea Keloid
Morphea
trunk or extremities ivory plaque with violaceous border.
Linear Scleroderma:

Frontalparietal involvement called Coup de Sabre
Systemic Scleroderma
Multi-system disorder affecting the subcutaneous tissue, internal organs and walls of blood vessels.
Scleroderma/morphea Histololgy Early
Scleroderma/morphea Histology Late
Alte optiuni
Cicatrice Cicatrice hipertrofica Keloid Dermatofibrom
Hypertrophic Scars and Keloids

Exuberant wound healing that either
remains within the boundaries of original wound = hypetrophic scar extends outside the site of injury = keloid.
More common in blacks
Scar
Cazul 28
A. Lupus eritematos bulos B. Lupus eritematos cronic cutanat (discoid) C. Lupus eritematos cutanat subacut D. Lupus eritematos tumid E. Dermatomiozita
Cazul 28
A. Lupus eritematos bulos B. Lupus eritematos cronic cutanat (discoid) C. Lupus eritematos cutanat subacut D. Lupus eritematos tumid E. Dermatomiozita
Discoid lupus erythematosus

Female preponderance Sharply demarcated, erythematous scaly patches Follicular plugging Face, neck, scalp, eyelids, lips, oral mucosa, hands Atrophy and scaling
Lupus Erythematosus Histology

Vacuolar interface dermatitis Superficial and deep perivascular and periadnexal dermatitis Increased dermal mucin
Direct immunofluorescence
IgG, IgM, IgA, C3, fibrin 50%-90% positivity in involved skin Less positivity on the chest
Alte optiuni
Lupus eritematos bulos Lupus eritematos cutanat subacut Lupus eritematos tumid Dermatomiozita
Subacute cutaneous lupus erythematosus

Annular or papulosquamous lesions Photosensitive areas: face, neck, upper trunk, extensor surface of arms Non-scarring lesions May be associated with drug ingestion
In annular form histo differs only in degree from DLE

More basal vacuolar changes More Chivatte bodies More epidermal atrophy More superficial dermal edema More superficial dermal mucin Less hyperkeratosis Less follicular plugging Less basement membrane thickening Less dense dermal infiltrate, sometimes confined to upper dermis
Papulosquamous form: identical with DLE
DIF
DIF from lesional skin positive in 60% Band is not as thick an in DLE IgG dust like particles described in the cytoplasm of basal cells
Tumid lupus
Only dermal changes
Dermatomyositis
Polymyositis Skin involvement
Violaceous, erythematous, scaly Face, shoulders, extensor surface of the forearms and thighs Poikiloderma Pruritus Heliotrope rash Gottrons papules
10-20% with underlying malignancy
Histology
Mild vacuolar-interface dermatitis Rare apoptotic cells Sparse dermal infiltrate, often superficial Abundant dermal mucin
DIF
Usually negative C5b is positive perivascular
Connective tissue disease

DLE SCLE Tumid lupus Dermatomyositis
Follicular plugging Basement membrane thickening Superficial and deep dermal infiltrate Dermal mucin
Prominent epidermal changes No follicular plugging No basement membrane thickening Sparse dermal infiltrate, confined to upper dermis
No epidermal changes Superficial and deep dermal infiltrate Prominent dermal mucin
Very subtle epidermal changes Very sparse dermal infiltrate Prominent dermal mucin
Cazul 29
Un pacient de 8 de ani se prezinta cu un nodul pe fata si o biopsie este efectuata. Care este pasul urmator in tratament?
A. Informeaza pacientul si parintii despre natura benigna a acestei leziuni si programeaza pacientul la controala regulate. B. Programeaza pentru excizie cu margini largi de siguranta. C. Trimite specimenul pentru teste de "fluorescence in situ hybridization" pentru a stabili natura maligna sau benigna a tumorii. D. Trimite specimenul pentru teste de "comparative genomic hybridization" pentru a stabili natura maligna sau benigna a tumorii.
Cazul 29
Un pacient de 8 de ani se prezinta cu un nodul pe fata si o biopsie este efectuata. Care este pasul urmator in tratament?
A. Informeaza pacientul si parintii despre natura benigna a acestei leziuni si programeaza pacientul la controala regulate. B. Programeaza pentru excizie cu margini largi de siguranta. C. Trimite specimenul pentru teste de "fluorescence in situ hybridization" pentru a stabili natura maligna sau benigna a tumorii. D. Trimite specimenul pentru teste de "comparative genomic hybridization" pentru a stabili natura maligna sau benigna a tumorii.
Spitzs Nevus
Red colored papule, usually < 1 cm in diameter Children or young adults Common on lower extremities, but can occur at almost any body site
Spitzs nevus
Spitzs Nevus (micro)

Symmetry Spindled or epithelioid cells Maturation with increasing depth of dermal component May have some pagetoid spread of solitary melanocytes (extensive in pagetoid Spitz)
Spitzs Nevus (micro 2)

Circumscribed nests which separate from adjacent keratinocytes (clefting) Multinucleate cells Little pleomorphism No deep atypical mitoses Dermal edema/telangiectasia
Cazul 30
A. Angioleiomiom B. Leiomiosarcom C. Carcinom squamocelular D. Dermatofibrom E. Leiomiom pilar
Cazul 30
A. Angioleiomiom B. Leiomiosarcom C. Carcinom squamocelular D. Dermatofibrom E. Leiomiom pilar
PILAR LEIOMYOMA
Erector pili muscle Multiple lesions Familial syndrome associated with renal carcinoma and uterine leiomyomas
Alte optiuni
Angioleiomiom Leiomiosarcom Carcinom squamocelular Dermatofibrom
ANGIOLEIOMYOMAS
Clinical:
painful subQ tumors Women 40 60 yrs Lower leg
New York, NY, US
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Self Assessment Cases

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Self assessment course

Vellus hair cyst

Eruptive vellus hair cyst

Verrucous nodule or plaque

PERIPHERAL NERVE SHEATH TUMORS

NEUROMA (traumatic neuroma)

Neurofibroma vs. Schwannoma

Lipomembraneous Panniculitis or Membranous Lipodystrophy

End result of multiple disease processes:

indurated inverted champagne bottle appearance

Enlarging plaque, sometime with a nodule.

Lobular capillary hemangioma (Pyogenic granuloma)

Merkel cell carcinoma

Basal Cell Carcinoma

Primary cutaneous diffuse large Bcell lymphoma, leg type

Willemze et al. 2005 105:3768-85

Porphyria cutanea tarda

Band-like infiltrate Epidermal acanthosis Compact Hyperkeratosis Wedge-shaped hypergranulosis

Vacuolar-interface changes = liquefactive degeneration

Subepidermal clefting Caspary-Joseph Space

Dyskeratotic cells = Civatte bodies Melanophages

Lichen Planus-Like Keratosis

Lichen simplex chronicus

Eosinophilic Fasciitis (Shulmans Syndrome)

Almost identical histology

Pityriasis rubra pilaris

Linear IgA Bullous Dermatosis

Adult linear IgA Bullous Dermatosis

Chronic Bullous Dermatosis of Childhood

Acute generalized exanthematous pustulosis

DDX of subcorneal pustules

Hailey Hailey Disease

Partial acantholyis (dilapidated brick wall) Acantholytic cells No follicular involvement

Sarcoid- Clinical Features

Causes of allergic vascultitis

Pigmented purpuric dermatosis

Histology confusing features

Confluent or sheetlike growth pattern

Leziuni dermice pleomorfice cu celule fusiforme

Maligant fibrous histiocytoma

Spindle cell SCC

Keratin (CK 903)

Spindle cells dispersed into a dense stroma

Oval to fusiform nuclei

Deep infiltration into dermis and subcutis Mitoses (sometimes scant)

Frontalparietal involvement called Coup de Sabre

Scleroderma/morphea Histololgy Early

Scleroderma/morphea Histology Late

Hypertrophic Scars and Keloids

More common in blacks

Discoid lupus erythematosus

Lupus Erythematosus Histology

Subacute cutaneous lupus erythematosus

In annular form histo differs only in degree from DLE

Papulosquamous form: identical with DLE

10-20% with underlying malignancy

Connective tissue disease

Spitzs Nevus (micro)

Spitzs Nevus (micro 2)

New York, NY, US

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