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Diagnostics Training and education, Histology

Case of the Month

A 73-year-old Caucasian male with a history of multiple non-melanoma skin cancers presented to dermatology for evaluation of a growth on the left scalp. He reported that the lesion had been present for over three years and was slowly becoming larger and more exophytic over time. More recently, the lesion had bled spontaneously and was intermittently painful to the touch. The patient was otherwise in good health and had no known history of immunosuppression.

A pink-brown verrucous plaque with filiform projections and focal hemorrhagic crust involving the left parietal scalp was observed on physical examination. The lesion measured 5.2 x 3.8 cm. Saucerization biopsy of the most inferior, exophytic portion of the lesion was performed for histopathologic analysis.

Verrucous plaque with hemorrhagic crusting on the scalp.
H&E; 1x magnification.
H&E; 15x magnification.
H&E; 20x magnification.

What is your diagnosis?

a. Unna’s (papillomatous) nevus
b. Inflammatory linear verrucous epidermal nevus (ILVEN)
c. Verrucous pseudonevoid melanoma
d. Verrucous carcinoma

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A. Branchial cleft cyst

Branchial cleft cysts usually present as neck masses. Mediastinal mass is a rare presentation; to our knowledge, only six cases have been reported to date. The official diagnosis is defined as a cyst derived from the remnants of the branchial apparatus, a precursor to many head and neck structures. This arch overgrows the second, third, and fourth branchial clefts forming the cervical sinus, which is usually lined with respiratory epithelium. A focal area of lymphoid aggregate is present in the cyst wall with adjacent pigment-laden macrophages, findings suggestive of cystic rupture. However, the additional classic finding of keratinaceous luminal debris is absent.

Cysts are usually unilocular and lined by various types of epithelium, including stratified squamous and respiratory types. Fibrosis is frequently visible, but without the thick, heavy capsule seen in metastatic cystic squamous cell carcinoma. Absence of dysplasia, pleomorphism, and increased mitoses rules out malignancy. The lack of dermal, musculoskeletal, or neuroendocrine components suggests against a diagnosis of mature cystic teratoma. Thymoma is ruled out due to the absence of thymic tissue.

Submitted by Erina McKinney, University of Kansas School of Medicine, Kansas City, Kansas, and Huiwen Bill Xie, Assistant Professor, Duke Department of Pathology, Raleigh, North Carolina, USA.

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