Persistent, Friable Nodule of the Scalp

Thomas Stasko, MD

Disclosures

April 26, 2002

Clinical Presentation

An 87-year-old white man.

The patient had a history of resection of a malignant tumor from his scalp approximately 8 months prior to this presentation. The area had been repaired with full-thickness skin graft. However, the patient and his wife noted that the graft had failed and the area was allowed to heal by second intention. They reported that the site never completely healed, and a nonepithelialized area remained, which was painful and continued to bleed.

There was a friable 2.5 cm x 1.5 cm bright-red plaque of granulation tissue surrounded by a 3.0 cm x 2.0 cm nonfluctuant area of induration on the parietal scalp. There was also a 1.3-cm pearly papule adjacent and anterolateral to the indurated area. The patient had no palpable adenopathy except for a mobile, soft, approximately 1-cm left occipital node. The patient underwent a wide local excision with a modified radical neck dissection on the left.

(courtesy of Dr. Stasko)

There was a diffuse proliferation of atypical melanocytes in the lower and mid-epidermis. The atypical melanocytes focally extended into pilosebaceous units. There was a dermal infiltrate of moderately pleomorphic spindle-shaped cells embedded in a dense collagenous stroma. The spindle-shaped cells were arranged in fascicles present throughout the dermis with scattered mitotic figures. There was striking neurovascular infiltration by the atypical melanocytes. The tumor extended to 16 mm in thickness. Immunostaining for S-100 and vimentin was positive, while staining for HMB-45 and keratins was negative. One lymph node showed similar tumor with extracapsular spread.

(courtesy of Dr. Stasko)

What is your diagnosis?

  1. Squamous cell carcinoma

  2. Basal cell carcinoma

  3. Merkel cell carcinoma

  4. Desmoplastic melanoma

View the correct answer.

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