PMC3919844_01
Clinical (A) and close up (B) images of a pale nodule on the forearm of a 61-year-old man with skin of Fitzpatrick photo-type 2. There are foci of eccentric pigmentation at the periphery. Three hairs, similar to surrounding hairs, are seen to be emerging from the nodule. [Copyright:  2014 Maher et al.]
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On examination the patient was noted to have skin of Fitzpatrick photo-type 2 and in addition to eight suspected BCCs, a lesion was noticed on the left forearm (Figure 1), which was firm and nodular to palpation.
Polarized dermatoscopy image of the lesion shown in Figure 1. There is a structureless white area with a rim of structureless brown containing focal reticular lines. A focal pattern of dot vessels coincides with a focal pattern of polarizing-specific perpendicular white lines (black arrow). There is another separate focal pattern of dot vessels (red arrow). Elsewhere at the periphery of the structureless white area there are a several linear (curved) vessels. [Copyright:  2014 Maher et al.]
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A polarized dermatoscopy image (Figure 2) taken with a DermLite DL3 dermatoscope (3Gen, LLC) coupled to a Canon EOS 450D camera showed a lesion 7 mm in maximum diameter.
Non-polarized dermatoscopy image of the lesion shown in Figure 2. No white lines are seen in this image. [Copyright:  2014 Maher et al.]
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A non-polarized dermatoscopic image (Figure 3) (DermLite DL3/Canon EOS 450D) showed the same features as the polarized image with the exception that the focus of perpendicular white lines was no longer visible and these white lines could therefore be described as polarizing-specific white lines, also known as chrysalis structures.
Low power dermatopathologic overview of the lesion shown in Figures 1-3 with a dominant nodular component comprised exclusively of markedly distended epithelioid melanocytes showing pseudo-xanthomatous cytoplasmic balloon cell morphology. On the right side of the image (black-boxed area) there is a separate invasive component of non-balloon cell malignant melanocytes. The black-boxed area is shown at higher power in Figure 5 and the red-boxed area in Figure 6. [Copyright:  2014 Maher et al.]
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Histopathology (Figures 4-7) showed an atypical melanocytic lesion with an architecturally disorganized intraepidermal component composed of both nested and single atypical melanocytes with some areas of intraepidermal pagetoid spread (Figures 5 and 6). Adjacent to this (Figure 5, left side and Figure 6) there was a relatively large nodule of melanocytes, displaying nuclear atypia, including mitotic figures and balloon cell morphology, penetrating to the deep dermis (Figures 4 and 7).
Medium high power view of the black-boxed area in Figure 4. Atypical melanocytes are confluent at the dermoepidermal junction, and on the right side of the image they are seen as a nested proliferation in the deep papillary dermis including nests in proximity to an eccrine duct. On the left side of the image a separate population of atypical melanocytes with distended balloon cell morphology is apparent. Melanin pigment can be seen at the dermoepidermal junction. [Copyright:  2014 Maher et al.]
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Histopathology (Figures 4-7) showed an atypical melanocytic lesion with an architecturally disorganized intraepidermal component composed of both nested and single atypical melanocytes with some areas of intraepidermal pagetoid spread (Figures 5 and 6). In one area, non-maturing atypical melanocytes arranged in variably sized nests and cords extended to the base of the papillary dermis (Figure 5, center). Adjacent to this (Figure 5, left side and Figure 6) there was a relatively large nodule of melanocytes, displaying nuclear atypia, including mitotic figures and balloon cell morphology, penetrating to the deep dermis (Figures 4 and 7).
Medium high power view of the red-boxed area in Figure 4. The melanocytic proliferation at the dermoepidermal junction is only focally confluent and pagetoid spread is sparse and partial-thickness only. There is abundant melanin at the basal layer. Large balloon cells are closely packed in the reticular dermis with an absence of intervening stroma in this part of the lesion. [Copyright:  2014 Maher et al.]
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Histopathology (Figures 4-7) showed an atypical melanocytic lesion with an architecturally disorganized intraepidermal component composed of both nested and single atypical melanocytes with some areas of intraepidermal pagetoid spread (Figures 5 and 6). Adjacent to this (Figure 5, left side and Figure 6) there was a relatively large nodule of melanocytes, displaying nuclear atypia, including mitotic figures and balloon cell morphology, penetrating to the deep dermis (Figures 4 and 7).
High power view of distended, vacuolated balloon cells in the base of the nodule shown in Figure 4. Arrows point to a cell in mitosis. [Copyright:  2014 Maher et al.]
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Histopathology (Figures 4-7) showed an atypical melanocytic lesion with an architecturally disorganized intraepidermal component composed of both nested and single atypical melanocytes with some areas of intraepidermal pagetoid spread (Figures 5 and 6). Adjacent to this (Figure 5, left side and Figure 6) there was a relatively large nodule of melanocytes, displaying nuclear atypia, including mitotic figures and balloon cell morphology, penetrating to the deep dermis (Figures 4 and 7).