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RESIDENT
CASE
STUDIES
September 11,
2003: Case 4 Table
of Contents | List
of Diagnoses | Case 1 | Case 2 |
Case
3 | Case 4
A 61 year-old male presents with shortness
of breath (SOB), cough, hemoptysis, weight loss and a left upper lobe mass
on CXR and a palpable 3 cm left scalene node. A FNA of the scalene lymph
node was performed.
Discussion by Zach Ellis, MD
Melanoma is a malignancy derived from
melanocytes most commonly originating in the skin and frequently
metastasizing to the lungs. Rarely it may arise in a bronchus.
Incidence: 3%
of all malignancies
Gross Appearance:
Usually an irregular, pigmented skin lesion.
Microscopic
Appearance:
- The fine needle aspiration reveals a
highly cellular, dicohesive specimen
- There are large binuclate and
multinucleate cell with abundant cytoplasm and cytoplasmic vacuoles
- The nuclei are granular with prominant
nucleoli and some cells display the "double mirror image
nuclei" pattern
- Nuclei with pseudoinclusions are
apparent
- Melanin pigment is not seen in this case
and is found in only 1/3 to 2/3 of cases and even then may only be
seen in a few cells
- Melanoma can have many cell patterns
- This case is an example of the giant
cell pattern
- The most common pattern is epthelioid
followed by spindle cell
- Others include clear cell, small cell,
signet ring, plasmacytoid and granular cell.
Diagnostic Criteria
- Discohesive, highly cellular
- Double mirror image nuclei ( Bug eyed
DMIN)
- Abundant, vacuolated cytoplasm
- Nuclear pseudoinclusions
- Melanin pigment
Immunostains:
Differential Diagnosis:
- Giant cell carcinoma
- Renal cell carcinoma
- Lymphoma
- Pleomorphic sarcoma
- Pheochromocytoma
References:
- Demay, RM. (1996). The Art and Science of Cytopathology. Chicago, IL: American Society for Clinical Pathology Press.
- Stephen S Sternberg et al. (Eds): Diagnostic surgical pathology, Volume 1, 3rd edition. Lippincott William & Wilkins.
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