Steven A. Gustafson, D.O. and

Michael C. Awasum M.D.

• Steven A. Gustafson, D.O., Associate professor of Preclinical sciences Collage of Osteopathic Medicine1.

• Michael C. Awasum M.D., Assistant Professor of Pathology, Ponce Health Sciences University2.

• Michael C. Awasum M.D., Attending Pathologist at Southern Pathology Services, Ponce, Puerto Rico2.

William Carey University 1

Southern Pathology 2

Clinical History

• Facial tumor with satellite lesions in a 63 year old male with a history of Basal cell carcinoma.

• Pre-Operative diagnosis “Basal cell carcinoma”.

• Post-operative diagnosis “Basal cell carcinoma”.

Gross specimen

• Scalp tumor, a 8.0 x 4.5 x 0.7 unoriented ellipse of skin with subcutaneous fatty tissue. The epidermal surface shows a 4.5 x 3.0 elevated ulcerated lesion that involves the subcutaneous fatty tissue on serial sectioning.

• Additional satellite lesions consisting of multiple fragments of skin measuring 1.0 x 0.2 x 0.2 cm.

• Immunohistochemical stains were preformed with the following markers: CD3, CD4, CD30, CD45RO, BCL2, Ki57, LCA, MUM-1, CD10, CD20, CD21, CD23, CD25, CD56, CD79A, CK7, CK19, CK20, AE1, AE3, ALK, BCL-6, FOXP1, TIA, TTF1, S-100, P40, GATA-3, NKX3-1, Melan A, D2-40, PAX8, Granzyme.

Immunohistochemical stains performed with the following markers were positive for:CD3, CD4 (strong and focal), CD30, CD45RO, BCL2, Ki67 (60%), LCA, MUM1.

The remaining immunohistochemical stains were negative, notable: ALK, granzyme, and TIA.

H and E Low power

H and E intermediate power

H and E intermediate power 40X

H and E intermediate power 60X

H and E intermediate power 60X

ALK Negative

Take home message

• Anaplastic large cell lymphoma is a distinct category defined by strong expression of CD30.

• Three types have been defined:– Primary systemic ALCL, (ALK+)– Primary systemic ALCL, (ALK-)– Primary cutaneous ALCL

Take home message• Within the primary systemic type several

sub types have been defined:– Giant cell-rich type– Small cell type– Lymphohistiocytic type– Hodgkin-like

• Rare sub forms, sarcomatoid, neutrophil rich, eosinophil rich, signet ring

Take home message

• ALCL has morphologic and clinical features witch overlap with several other hematolymphoid neoplasms most commonly diffuse large B-cell lymphoma, classical Hodgkin disease.

• Primary cutaneous ALCL, overlaps with lymphomatoid papulosis.

Take home message

• It is important to utilize cytogenetic and immunohistochemical markers to sort out these neoplasms some have a poor prognosis, while others are more favorable.

• Thanks to Southern Pathology’s Adalberto Mendoza M.D., Attending Pathologist at Southern Pathology Services, Ponce, Puerto Rico for the initial diagnosis.

• Sothern Pathology, 234-A Sabanet Industrial Park Ponce PR 00716

• William Carey University Collage of Osteopathic Medicine, Hattiesburg, Mississippi 39401.