Unusual localization of a pigmented basal cell carcinoma on a type V Fitzpatrick fototype patient
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P7881 Subcutaneous nodule on the dorsal hand of a 43-year-old woman: Report of a case of Merkel cell carcinoma Joyce Wang, Boston University, Boston, MA, United States; Deborah Cummins, MD, Boston University, Boston, MA, United States; Lynne Goldberg, MD, Boston University, Boston, MA, United States; Manisha Thakuria, MD, Brigham and Women’s Hospital, Boston, MA, United States Merkel cell carcinoma (MCC) is a rare but aggressive cutaneous malignancy that remains poorly understood and commonly misdiagnosed. We report an unusual case of advanced MCC in sustained remission that highlights the heterogenous nature of this malignancy and the importance of early imaging. A 43-year-old white female presented with a 1-cm skin-colored mobile nodule on the dorsal right hand that had been gradually enlarging for 5 months. It was painful but did not itch or bleed. She was not on immunosuppression and had no known immune abnormalities. Though a clinical diagnosis of epidermal inclusion cyst was suspected, pathology revealed MCC. Subsequent FDG-PET/CT revealed involvement of a right axillary node and the right epitrochlear region. The patient underwent wide local excision of the primary site, resection of the epitrochlear mass, and right axillary dissection. Pathology revealed MCC of the epitrochlear mass and 1 axillary lymph node, consistent with stage IIIb MCC. Postoperative adjuvant radiation therapy was administered to all sites. At 27 months after diagnosis of stage IIIb MCC, the patient continues to be followed in clinic and receives regular FDG-PET/CT scans. She has no evidence of recurrence. MCC most commonly presents in white immunosuppressed patients as a rapidly expanding asymptomatic dermal nodule on ultraviolet-exposed sites. Our patient was unusual in regards to her age, lack of immunosuppression, and painful, slow-growing presentation. Despite her advanced stage disease, she has been clinically and radiologically without evidence of disease for over 2 years. We suspect that early detection of metastatic disease by PET/CT, found to be more sensitive than CT, and subsequent treatment have contributed to her good outcome. Commercial support: None identified. P8325 Subtypes of skin cancers seen in ECU dermatology clinic: A 10-year review Natalie Davies, MD, Brody School of Medicine at East Carolina University, Greenville, NC, United States; Charles Phillips, MD, Brody School of Medicine at East Carolina University, Greenville, NC, United States; Jennifer Defazio, MD, Brody School of Medicine at East Carolina University, Greenville, NC, United States; Vos Paul, PhD, East Carolina University College of Allied Health, Greenville, NC, United States Skin cancer treatment and likelihood of a tumor being more aggressive depends on several variables. One variable is the subtype of skin cancer. Morpheaform basal cell carcinomas (BCC) require a more aggressive approach to management. Poorly differentiated and moderately differentiated squamous cell carcinomas (SCCs) also are more aggressive. For melanoma, the depth of invasion and other recognized pathologic characteristics, such as ulceration, predicts the aggressiveness. Some types of melanoma tend to be more aggressive at the time of diagnosis. We looked at the subtypes of skin cancer seen in East Carolina University Dermatology clinics over a 10-year period in order to define our population. Original data were collected and maintained in a log book. Skin cancer biopsy data from 2000-2010 was collected and recorded electronically. 3,233 BCCs were treated in clinic in this 10-year period. Of these, 83 (2.5%) were morpheaform, 435 (13.5%) were micronodular, and 681 (21%) were infiltrative. We also looked at how many BCCs showed multiple subtypes. Overall, we found that 21.4% had a secondary type and 2.6% had a third type. Our number of infiltrating BCCs was higher than that reported in the literature. 1,473 invasive SCCs were seen in that same 10-year period. The more aggressive forms of SCC seen in our population were 222 moderately differentiated lesions (15%) and 65 poorly differentiated lesions (4.4%) which require more aggressive therapy. 85 melanomas (excluding in situ) were also diagnosed in our clinic over 10 years. There were 6 (7%) nodular melanomas and 3 (3.5%) acrolentiginous melanomas. The aggressiveness and survivability of melanoma are predicted more by the depth of invasion and other recognized pathologic characteristics, such as ulceration, but these subtypes appear to be more aggressive and are larger contributors to mortality. In conclusion, each of the 3 common skin cancers may frequently present with more aggressive histologic subtypes, and determining this aggressive potential with initial biopsy can have important clinical implications regarding management of these patients and the need for more aggressive therapy. Our clinic population had a higher incidence of BCCs with an infiltrative component compared to other reviews. We also illustrate the importance of a skilled and experienced dermatopathologist to properly report an accurate histologic pattern for optimum management of skin cancers. Commercial support: None identified. P7613 Ultrasonography for diagnosis of plantar angioleiomyoma Sachiko Sakamoto, MD, Department of Dermatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan; Akira Kawada, MD, PhD, Department of Dermatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan; Naoki Oiso, MD, PhD, Department of Dermatology, Osaka-Sayama, Japan; Tomohiko Narita, MD, PhD, Department of Dermatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan Cutaneous leiomyomas are benign tumors that arise from smooth muscle. Angioleiomyoma commonly presents as a painful solitary lesion usually in the subcutis or rarely in the deep dermis. Acral lesions are rarely affected. We reported a case of plantar angioleiomyoma with a feeder vessel showing pulsed blood flow within the mass detected by color Doppler ultrasonography and fast Fourier transform (FFT) analysis. A 65-year-old man was referred to us with an asymptomatic nodule on the right sole. The patient noticed it 1 year earlier. A physical examination revealed an asymptomatic, solitary, elevated, elastic hard nodule 22 3 16 mm in size on the right sole. Ultrasonography showed an oval-shaped, well-circumscribed, homogeneous, hypoechoic lesion with posterior acoustic enhancement. Color Doppler ultrasonography illustrated a feeder vessel showing blood flow within the mass. FFT analysis detected pulse beats. A biopsied specimen showed a well circumscribed nodular mass comprised of intersecting smooth muscle bundles and vessels. It was located from the dermis to the subcutis. High magnification revealed uniform spindle cells with eosinophilic cytoplasm and cylindrical nuclei with blunted ends. We confirmed vascular involvement with ultrasonography and diagnosed the tumor as plantar angioleiomyoma with histopathologic assessment. The patient underwent an excision of the tumor. At the initial examination, no painful sensation indicated less possibility of painful skin tumor including angioleiomyoma. We initially suspected the tumor as a plantar epidermoid cyst associated with human papillomavirus infection and performed ultrasonography for differential diagnosis. The presence of vascular structure denied a plantar epidermoid cyst and suggested a vascular-involving skin tumor with a feeder vessel. In our case, ultrasonography showed that the tumor contained sufficient hyper- vascularity even though histologic specimens gave the impression that the most spaces were composed of tumor cells derived from smooth muscles. We suspected that tumor itself shrank after excision and vessels became shrinking and slit. Commercial support: None identified. P7898 Unusual localization of a pigmented basal cell carcinoma on a type V Fitzpatrick fototype patient Juliana Budoia, MD, S~ ao Paulo, Brazil; Marcela Carvalho, MD, S~ ao Paulo, Brazil Introduction: Basal cell carcinoma (BCC) is the most common malignancy in humans, and its etiology is closely related to the exposure to ultraviolet radiation. It is more commom in elderly individuals, affects mainly the face of whites, and presents local invasive behavior; however, with low metastatic potential. Pigmented lesions are a frequent finding in higher phototypes and differential diagnosis includes nodular melanoma. Case report: A 45-year-old woman, Fitzpatrick fototype IV-V, from Piaui, reported the appearance of a painless nodular lesion in the right lower limb lasting 6 months, that showed progressive growth. She denied local itching and bleeding. Dermatologic examination revealed a gray nodule, measuring approximately 2.5 cm in diameter, edges well defined, slightly scaly, and with a soft consistency in the pretibial region of the right leg. At dermoscopy, pigmented network was not observed, there were grey-whitish pacthes and a reddish area on the superior side of the lesion. A punch biopsy was performed to elucidate the diagnosis. Diferential diagnosis consisted of a nodular melanoma and basal cell carcinoma. Histopathology analysis showed a malignant epithelial neoplasm, composed of infiltrative growth of anaplastic cells, containing large amounts of melanin pigment in their cytoplasm and peripheral palisading arrangement, corresponding to the diagnosis of pigmented basal cell carcinoma. We proceeded with complete excision of the tumor. The remaining material was analyzed and final diagnosis was of an infiltrating pigmentad basal cell carcinoma with surgical resection margins free of neoplastic involvement. Discussion: Pigmented BCC show histologic features similar to those of nodular BCCs, but with the addition of melanin. Color may range from a brown-black to a black-blue nodule, making it very hard to differenciate from a nodular melanoma during physical examination and dermoscopy. Ulceration of the nodule may occur as the lesion grows, such transformation was not observed in this case report even though the patient had a large nodule. Most of these tumors are located in the head and sun-exposed areas. Souza et al in a recent retrospective study of 1,042 lesions, revealed 74% of the tumors were located in the head, and that only 2% (19) were located on the lower limbs. Bariani et al revealed that 95,5% of BCCs occur in Fitzpatrick phototypes I and II and that only 2% of the tumors occur on phototype IV. Commercial support: None identified. AB140 JAM ACAD DERMATOL MAY 2014
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Transcript of Unusual localization of a pigmented basal cell carcinoma on a type V Fitzpatrick fototype patient
P7881Subcutaneous nodule on the dorsal hand of a 43-year-old woman: Reportof a case of Merkel cell carcinoma
Joyce Wang, Boston University, Boston, MA, United States; Deborah Cummins,MD, Boston University, Boston, MA, United States; Lynne Goldberg, MD, BostonUniversity, Boston, MA, United States; Manisha Thakuria, MD, Brigham andWomen’s Hospital, Boston, MA, United States
Merkel cell carcinoma (MCC) is a rare but aggressive cutaneous malignancy thatremains poorly understood and commonlymisdiagnosed.We report an unusual caseof advanced MCC in sustained remission that highlights the heterogenous nature ofthis malignancy and the importance of early imaging. A 43-year-old white femalepresented with a 1-cm skin-colored mobile nodule on the dorsal right hand that hadbeen gradually enlarging for 5 months. It was painful but did not itch or bleed. Shewas not on immunosuppression and had no known immune abnormalities. Thougha clinical diagnosis of epidermal inclusion cyst was suspected, pathology revealedMCC. Subsequent FDG-PET/CT revealed involvement of a right axillary node and theright epitrochlear region. The patient underwent wide local excision of the primarysite, resection of the epitrochlear mass, and right axillary dissection. Pathologyrevealed MCC of the epitrochlear mass and 1 axillary lymph node, consistent withstage IIIb MCC. Postoperative adjuvant radiation therapy was administered to allsites. At 27 months after diagnosis of stage IIIb MCC, the patient continues to befollowed in clinic and receives regular FDG-PET/CT scans. She has no evidence ofrecurrence. MCC most commonly presents in white immunosuppressed patients asa rapidly expanding asymptomatic dermal nodule on ultraviolet-exposed sites. Ourpatient was unusual in regards to her age, lack of immunosuppression, and painful,slow-growing presentation. Despite her advanced stage disease, she has beenclinically and radiologically without evidence of disease for over 2 years. We suspectthat early detection of metastatic disease by PET/CT, found to be more sensitive thanCT, and subsequent treatment have contributed to her good outcome.
AB140
cial support: None identified.
CommerP8325Subtypes of skin cancers seen in ECU dermatology clinic: A 10-year review
Natalie Davies, MD, Brody School of Medicine at East Carolina University,Greenville, NC, United States; Charles Phillips, MD, Brody School of Medicine atEast Carolina University, Greenville, NC, United States; Jennifer Defazio, MD,Brody School of Medicine at East Carolina University, Greenville, NC, UnitedStates; Vos Paul, PhD, East Carolina University College of Allied Health,Greenville, NC, United States
Skin cancer treatment and likelihood of a tumor being more aggressive depends onseveral variables. One variable is the subtype of skin cancer. Morpheaform basal cellcarcinomas (BCC) require a more aggressive approach to management. Poorlydifferentiated and moderately differentiated squamous cell carcinomas (SCCs) alsoare more aggressive. For melanoma, the depth of invasion and other recognizedpathologic characteristics, such as ulceration, predicts the aggressiveness. Sometypes of melanoma tend to be more aggressive at the time of diagnosis. We looked atthe subtypes of skin cancer seen in East Carolina University Dermatology clinicsover a 10-year period in order to define our population. Original data were collectedand maintained in a log book. Skin cancer biopsy data from 2000-2010 was collectedand recorded electronically. 3,233 BCCs were treated in clinic in this 10-year period.Of these, 83 (2.5%) were morpheaform, 435 (13.5%) were micronodular, and 681(21%) were infiltrative. We also looked at how many BCCs showed multiplesubtypes. Overall, we found that 21.4% had a secondary type and 2.6% had a thirdtype. Our number of infiltrating BCCswas higher than that reported in the literature.1,473 invasive SCCs were seen in that same 10-year period. The more aggressiveforms of SCC seen in our population were 222 moderately differentiated lesions(15%) and 65 poorly differentiated lesions (4.4%) which require more aggressivetherapy. 85 melanomas (excluding in situ) were also diagnosed in our clinic over 10years. There were 6 (7%) nodular melanomas and 3 (3.5%) acrolentiginousmelanomas. The aggressiveness and survivability of melanoma are predicted moreby the depth of invasion and other recognized pathologic characteristics, such asulceration, but these subtypes appear to be more aggressive and are largercontributors to mortality. In conclusion, each of the 3 common skin cancers mayfrequently present with more aggressive histologic subtypes, and determining thisaggressive potential with initial biopsy can have important clinical implicationsregarding management of these patients and the need for more aggressive therapy.Our clinic population had a higher incidence of BCCswith an infiltrative componentcompared to other reviews. We also illustrate the importance of a skilled andexperienced dermatopathologist to properly report an accurate histologic patternfor optimum management of skin cancers.
cial support: None identified.
CommerJ AM ACAD DERMATOL
P7613Ultrasonography for diagnosis of plantar angioleiomyoma
Sachiko Sakamoto, MD, Department of Dermatology, Kinki University Faculty ofMedicine, Osaka-Sayama, Japan; Akira Kawada, MD, PhD, Department ofDermatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan; NaokiOiso, MD, PhD, Department of Dermatology, Osaka-Sayama, Japan; TomohikoNarita, MD, PhD, Department of Dermatology, Kinki University Faculty ofMedicine, Osaka-Sayama, Japan
Cutaneous leiomyomas are benign tumors that arise from smooth muscle.Angioleiomyoma commonly presents as a painful solitary lesion usually in thesubcutis or rarely in the deep dermis. Acral lesions are rarely affected. We reported acase of plantar angioleiomyoma with a feeder vessel showing pulsed blood flowwithin the mass detected by color Doppler ultrasonography and fast Fouriertransform (FFT) analysis. A 65-year-old manwas referred to uswith an asymptomaticnodule on the right sole. The patient noticed it 1 year earlier. A physical examinationrevealed an asymptomatic, solitary, elevated, elastic hard nodule 223 16 mm in sizeon the right sole. Ultrasonography showed an oval-shaped, well-circumscribed,homogeneous, hypoechoic lesion with posterior acoustic enhancement. ColorDoppler ultrasonography illustrated a feeder vessel showing blood flow within themass. FFT analysis detected pulse beats. A biopsied specimen showed a wellcircumscribed nodular mass comprised of intersecting smooth muscle bundles andvessels. It was located from the dermis to the subcutis. High magnification revealeduniform spindle cells with eosinophilic cytoplasm and cylindrical nuclei withblunted ends. We confirmed vascular involvement with ultrasonography anddiagnosed the tumor as plantar angioleiomyoma with histopathologic assessment.The patient underwent an excision of the tumor. At the initial examination, nopainful sensation indicated less possibility of painful skin tumor includingangioleiomyoma. We initially suspected the tumor as a plantar epidermoid cystassociated with human papillomavirus infection and performed ultrasonography fordifferential diagnosis. The presence of vascular structure denied a plantarepidermoid cyst and suggested a vascular-involving skin tumor with a feeder vessel.In our case, ultrasonography showed that the tumor contained sufficient hyper-vascularity even though histologic specimens gave the impression that the mostspaces were composed of tumor cells derived from smooth muscles. We suspectedthat tumor itself shrank after excision and vessels became shrinking and slit.
cial support: None identified.
CommerP7898Unusual localization of a pigmented basal cell carcinoma on a type VFitzpatrick fototype patient
Juliana Budoia, MD, S~ao Paulo, Brazil; Marcela Carvalho, MD, S~ao Paulo, Brazil
Introduction: Basal cell carcinoma (BCC) is the most common malignancy inhumans, and its etiology is closely related to the exposure to ultraviolet radiation. Itis more commom in elderly individuals, affects mainly the face of whites, andpresents local invasive behavior; however, with lowmetastatic potential. Pigmentedlesions are a frequent finding in higher phototypes and differential diagnosisincludes nodular melanoma.
Case report: A 45-year-old woman, Fitzpatrick fototype IV-V, from Piaui, reported theappearance of a painless nodular lesion in the right lower limb lasting 6months, thatshowed progressive growth. She denied local itching and bleeding. Dermatologicexamination revealed a gray nodule, measuring approximately 2.5 cm in diameter,edges well defined, slightly scaly, and with a soft consistency in the pretibial regionof the right leg. At dermoscopy, pigmented network was not observed, there weregrey-whitish pacthes and a reddish area on the superior side of the lesion. A punchbiopsy was performed to elucidate the diagnosis. Diferential diagnosis consisted of anodular melanoma and basal cell carcinoma. Histopathology analysis showed amalignant epithelial neoplasm, composed of infiltrative growth of anaplastic cells,containing large amounts of melanin pigment in their cytoplasm and peripheralpalisading arrangement, corresponding to the diagnosis of pigmented basal cellcarcinoma. We proceeded with complete excision of the tumor. The remainingmaterial was analyzed and final diagnosis was of an infiltrating pigmentad basal cellcarcinoma with surgical resection margins free of neoplastic involvement.
Discussion: Pigmented BCC show histologic features similar to those of nodularBCCs, but with the addition of melanin. Color may range from a brown-black to ablack-blue nodule, making it very hard to differenciate from a nodular melanomaduring physical examination and dermoscopy. Ulceration of the nodule may occur asthe lesion grows, such transformation was not observed in this case report eventhough the patient had a large nodule. Most of these tumors are located in the headand sun-exposed areas. Souza et al in a recent retrospective study of 1,042 lesions,revealed 74% of the tumors were located in the head, and that only 2% (19) werelocated on the lower limbs. Bariani et al revealed that 95,5% of BCCs occur inFitzpatrick phototypes I and II and that only 2% of the tumors occur on phototype IV.
cial support: None identified.
CommerMAY 2014
