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Presented by Peter Illei, M.D. and prepared by Wang (Steve) Cheung, M.D., Ph.D.
Case 5: 86 y.o. white male patient with a 1.7 cm deep dermal/subcutaneous scalp mass.
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1. Question
Week 328: Case 5
86 y.o. white male patient with a 1.7 cm deep dermal/subcutaneous scalp mass./images/10220751.jpg
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/images/10220754.jpgCorrect
Answer: Metastatic malignant melanoma
Histology: The tumor is well circumscribed and shows variably histologic appearance. There areas with large vacuolated cells with focal fine dusky brown pigment, others show spindle cells infiltrating dense collagen or solid sheets of oval epithelioid cells with round to oval nuclei that have small nucleoli. No definite squamous or glandular differentiation is seen. Immunostains are positive for melanoma markers (S-100, Hmb-45, tyrosinase and Melan-A) and negative for cytokeratin. These features are consistent with metastatic malignant melanoma.
Discussion: The differential diagnosis includes sebaceous carcinoma which lack pigment and are typically composed of mitotically active large atypical vacuolated lipid containing cells. Metastatic renal cell carcinoma can be excluded by PAS positive vacuoles and EMA staining. Clear cell squamous cell carcinoma exhibit intercellular bridges and keratin positive.
Incorrect
Answer: Metastatic malignant melanoma
Histology: The tumor is well circumscribed and shows variably histologic appearance. There areas with large vacuolated cells with focal fine dusky brown pigment, others show spindle cells infiltrating dense collagen or solid sheets of oval epithelioid cells with round to oval nuclei that have small nucleoli. No definite squamous or glandular differentiation is seen. Immunostains are positive for melanoma markers (S-100, Hmb-45, tyrosinase and Melan-A) and negative for cytokeratin. These features are consistent with metastatic malignant melanoma.
Discussion: The differential diagnosis includes sebaceous carcinoma which lack pigment and are typically composed of mitotically active large atypical vacuolated lipid containing cells. Metastatic renal cell carcinoma can be excluded by PAS positive vacuoles and EMA staining. Clear cell squamous cell carcinoma exhibit intercellular bridges and keratin positive.
