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CASES FROM ACKERMAN ACADEMY
Year : 2015  |  Volume : 6  |  Issue : 4  |  Page : 284-285  

A solitary auricular polyp


1 Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
2 Ackerman Academy of Dermatopathology, New York, USA

Date of Web Publication8-Jul-2015

Correspondence Address:
Michael J McFall
142 North Clark Drive, Apartment 3, West Hollywood, CA 90048
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.160276

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How to cite this article:
McFall MJ, Griffin JR, Elston DM. A solitary auricular polyp. Indian Dermatol Online J 2015;6:284-5

How to cite this URL:
McFall MJ, Griffin JR, Elston DM. A solitary auricular polyp. Indian Dermatol Online J [serial online] 2015 [cited 2020 Apr 6];6:284-5. Available from: http://www.idoj.in/text.asp?2015/6/4/284/160276

A 73-year-old man presented to his dermatologist with a 1 cm, polypoid, left auricular lesion of 1-year duration. His past medical history was significant for prostatic adenocarcinoma.

A biopsy was obtained, and immunohistochemical staining for Melan-A was performed [Figure 1] and [Figure 2].
Figure 1: (a) Dilated vascular spaces associated with atypical epithelioid cells (H and E, ×20), (b) Nested atypical epithelioid cells within vascular lumen (H and E, ×100)

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Figure 2: (a) Epithelioid cells with moderate cytoplasm, visible nucleoli, and focal mitosis (H and E, ×600), (b) Diffuse cytoplasmic staining of the population of interest with Melan-A (red chromogen) (×100)

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The most likely diagnosis is:

  • Congenital pattern nevus with pseudovascular spaces
  • Epithelioid angiosarcoma
  • Glomangioma
  • Metastatic melanoma associated with an angiokeratoma
  • Lobular capillary hemangioma (pyogenic granuloma).

   Answer Top


Metastatic melanoma associated with an angiokeratoma


   Discussion Top


The histological sections demonstrated dilated and focally thrombosed vascular spaces within the superficial dermis. The overlying epidermis showed focal atrophy, but was otherwise unremarkable. Adjacent to and within the vascular lumens, atypical epithelioid cells arranged in nests and sheets were noted, without definitive maturation or dispersion [Figure 1]a and b]. Furthermore, conspicuous nucleoli and rare mitoses were appreciated in the epithelioid cell proliferation [Figure 2]a]. Immunohistochemical stains for S-100 and Melan-A [Figure 2]b] highlighted the tumor.

Albeit rare, published case reports and small series have described the co-occurrence of cutaneous melanoma and other neoplasms (epithelial, mesenchymal, and hematopoietic). Concomitant melanoma and malignant (basal cell carcinoma [BCC], squamous cell carcinoma, chronic lymphocytic leukemia, leiomyosarcoma, Paget's disease, atypical fibroxanthoma, and Merkel cell carcinoma) [1],[2],[3],[4],[5],[6],[7] as well as benign tumors (seborrheic keratosis) [8] have been documented with BCC reported most often. To further clarify the confusing terminology used to describe these unique lesions, several authors have proposed a standardized nomenclature with four general subcategories including: combination, collision, biphenotypic, and colonization tumors.[9],[10],[11],[12] However, due in large part to the relative paucity of cases, the biology and therefore clinical relevance of these lesions is not well-understood.

In the current case, given the clinical history of a solitary lesion, the possibility of a primary melanoma was considered. However, the absence of an in-situ lesion, focal sheet-like growth with poor maturation in a predominantly intravascular location, and relatively monomorphic atypical cytology of the nevoid/epithelioid population suggest a metastasis. As the distinction between primary cutaneous and metastatic melanoma has significant prognostic and therapeutic implications, criteria incorporating both architectural and cytologic features have been proposed in an attempt to elucidate this quandary. [13] The presence of an intraepidermal (in-situ) and/or benign nevic component, relative absence of lymphovascular invasion, polymorphous cytology, and fewer mitoses favor a primary lesion. In contrast, a dermal and/or subcutaneous infiltrate, extensive lymphovascular invasion, monomorphous population, and numerous mitoses favor a metastasis. Ultimately, however, the correlation of clinical and radiologic findings, as was suggested in our case, is critical in arriving at an accurate diagnosis.



 
   References Top

1.
Belisle A, Gautier MS, Ghozali F, Plantier F, Wechsler J. A collision tumor involving Basal cell carcinoma and lentigo maligna melanoma. Am J Dermatopathol 2005;27:319-21.  Back to cited text no. 1
    
2.
Ahlgrimm-Siess V, Hofmann-Wellenhof R, Zalaudek I, Cerroni L, Kerl H. Collision of malignant melanoma (lentigo maligna type) with squamous cell carcinoma in solar-damaged skin of the face. Dermatol Surg 2007;33:122-4.  Back to cited text no. 2
    
3.
Cahill RA, McGreal G, Neary P, Redmond HP. Synchronous high-risk melanoma and lymphoid neoplasia. Melanoma Res 2001;11:517-22.  Back to cited text no. 3
    
4.
Ul-Mulk J, Rasmussen H, Breiting L, Siim E. A case of collision tumor or transdifferentiation between malignant melanoma and leiomyosarcoma. Indian J Pathol Microbiol 2012;55:538-9.  Back to cited text no. 4
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5.
Hill SJ, Berkowitz R, Granter SR, Hirsch MS. Pagetoid lesions of the vulva: A collision between malignant melanoma and extramammary Paget disease. Int J Gynecol Pathol 2008;27:292-6.  Back to cited text no. 5
    
6.
Wilsher MJ. Collision tumour: A typical fibroxanthoma and invasive melanoma. Pathology 2009;41:699-701.  Back to cited text no. 6
[PUBMED]    
7.
Forman SB, Vidmar DA, Ferringer TC. Collision tumor composed of Merkel cell carcinoma and lentigo maligna melanoma. J Cutan Pathol 2008;35:203-6.  Back to cited text no. 7
    
8.
Defazio J, Zalaudek I, Busam KJ, Cota C, Marghoob A. Association between melanocytic neoplasms and seborrheic keratosis: More than a coincidental collision? Dermatol Pract Concept 2012;2:202a09.  Back to cited text no. 8
    
9.
Rodriguez J, Nonaka D, Kuhn E, Reichel M, Rosai J. Combined high-grade basal cell carcinoma and malignant melanoma of the skin ("malignant basomelanocytic tumor"): Report of two cases and review of the literature. Am J Dermatopathol 2005;27:314-8.  Back to cited text no. 9
    
10.
King R, Lyons J, Meyers AL, Googe PB, Page RN, Gupta VK. Primary invasive melanoma and basal cell carcinoma (collision tumor) with blue nevus-like cutaneous metastases. J Cutan Pathol 2007;34:629-33.  Back to cited text no. 10
    
11.
Pool SE, Manieei F, Clark WH Jr, Harrist TJ. Dermal squamo-melanocytic tumor: A unique biphenotypic neoplasm of uncertain biological potential. Hum Pathol 1999;30:525-9.  Back to cited text no. 11
    
12.
Satter EK, Metcalf J, Lountzis N, Elston DM. Tumors composed of malignant epithelial and melanocytic populations: A case series and review of the literature. J Cutan Pathol 2009;36:211-9.  Back to cited text no. 12
    
13.
Barnhill RL, Piepkorn M, Busam KJ. Pathology of Melanocytic Nevi and Malignant Melanoma. 2 nd ed. New York: Springer; 2004.  Back to cited text no. 13
    


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  [Figure 1], [Figure 2]



 

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