de Feraudy, Sebastien

Elsensohn, Ashley

Hosking, Anna-Marie

Kassira, Sama

Pouldar, Delila

Smith, Janellen

English

eScholarship - University of California

UC IrvineUC Irvine Previously Published WorksTitleA green-brown plaque on the dorsal handPermalinkhttps://escholarship.org/uc/item/7wk1z2gnJournalJAAD Case Reports, 5(1)ISSN2352-5126AuthorsHosking, Anna-MariePouldar, DelilaElsensohn, Ashleyet al.Publication Date2019DOI10.1016/j.jdcr.2018.09.011Copyright InformationThis work is made available under the terms of a Creative Commons Attribution License, availalbe at https://creativecommons.org/licenses/by/4.0/ Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaIMAGES IN DERMATOLOGYA green-brown plaque on the dorsal handAnna-Marie Hosking, BS, Delila Pouldar, MD, Ashley Elsensohn, MD, MPH, Sama Kassira, MD,Janellen Smith, MD, and Sebastien de Feraudy, MD, PhDIrvine, CaliforniaFrom the Department of Dermatology, University of California,Irvine.Funding sources: None.Conflicts of interest: None disclosed.Correspondence to: Anna-Marie Hosking, BS, Department ofDermatology, University of California, Irvine, 118 Med Surge I,Irvine, CA 92697. E-mail: ahosking@uci.edu.JAAD Case Reports 2019;5:60-2.2352-5126ª 2018 by the American Academy of Dermatology, Inc. Publishedby Elsevier, Inc. This is an open access article under the CCBY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).https://doi.org/10.1016/j.jdcr.2018.09.01160JAAD CASE REPORTSVOLUME 5, NUMBER 1Hosking et al 61A 62-year-old man presented with a 1-year history of a green-colored plaque over his left dorsal hand (Fig 1).The patient denied any history of trauma, and there were no associated symptoms, including pain or pruritus.The discolored area was stable in size, and the patient denied any fever, chills, night sweats, or weight loss.Physical examination of the left dorsal hand found a green-brown plaque measuring 4 cm by 3 cm. A punchbiopsy specimen was obtained and staining was performed, including hematoxylin-eosin (Fig 2, A-C ), ironspecial stain (Fig 2, D) and CD34 (Fig 2, E ). Definitive surgery was completed after histopathologic review.Question 1: What is your diagnosis?A. Spindle cell lipomaB. Dermatofibrosarcoma protuberans (DFSP)C. Hemosiderotic fibrolipomatous tumor (HFLT)D. Spindle cell hemangiomaE. Epithelioid sarcomaAnswers:A. Spindle cell lipoma e Incorrect. Spindle celllipoma more commonly occurs on the neck, shoul-der, or back. Histopathologically, spindle cell li-poma presents as an adipocytic tumor with variableadmixture of spindle cells but, unlike HFLT, has aprominent myxoid stroma and bundles of ropycollagen and lacks abundant hemosiderin.1B. DFSP e Incorrect. DFSP presents as a slow-growing large nodule or plaque, most commonly onthe trunk or extremities. On histopathology, DFSPalso shows a CD341 spindle cell proliferation,often arranged as whorls (so-called storiformpattern), but does not exhibit prominent hemosid-erin deposition, the prominence of adipocytes, orinflammation.1C. HFLT e Correct. HFLT presents as a slow-growing faintly green plaque on the dorsal aspect ofthe distal extremities, most commonly involving theankle or foot. Histopathologically, HFLT is a nonen-capsulated fatty lesion composed of short fasciclesof CD341 spindle cells with vesicular, occasionallyhyperchromatic, nuclei and indistinct nucleoli,some multinucleated cells, disposed betweenmature adipocytes within an inflammatorybackground containing abundant hemosiderindeposition. Numerous thick-walled vessels mayalso be present.1,2D. Spindle cell hemangioma e Incorrect. A spin-dle cell hemangioma commonly presents as a sub-cutaneous mass on the distal extremities and couldaccount for the CD341 spindle cell proliferationwith abundant hemosiderin deposition, but spindlecell hemangioma also presents with large, dilatedcavernous spaces. The presence of matureadipocytes admixed with spindle cells does not fitthis type of tumor.1E. Epithelioid sarcoma e Incorrect. Althoughepithelioid sarcoma also presents as CD341, slow-growing firm subcutaneous nodules that commonlyinvolve the distal extremities (hands), prominenthemosiderin deposition, and mature adipocytes arenot present.1Question 2: Which of the following immuno-histochemistry staining profiles is character-istic of this tumor?A. CD341, desmin, smooth muscle actin(SMA)1, keratin, S1001B. CD341, desmin, SMA1, keratin, S100C. CD341, desmin, SMA, keratin, S100D. CD34, desmin, SMA, keratin1, S1001E. CD34, desmin1, SMA, keratin1, S1001Answers:A. CD341, desmin, SMA1, keratin, S1001 eIncorrect. The S100 stain is used to differentiatemelanocytic from nonmelanocytic lesions. Mostmelanomas are S1001, whereas, HFLT is S100.3B. CD341, desmin SMA1, keratin, S100 eIncorrect. SMA is a marker for myofibroblasts andmuscle cells. It is positive in smooth muscle tumors,glomus tumors, and some atypical fibroxanthomasbut is negative in HFLT. This staining pattern is seenwith pleomorphic hyalinizing angiectatic tumor(PHAT), which is thought to be a later stage ofHFLT.1,4C. CD341, desmin SMA, keratin, S100 eCorrect. HFLT is positive for CD34, an endothelialmarker that is also positive in vascular tumors,DFSP, epithelioid sarcoma, spindle cell lipoma,neurofibroma, and others. HFLT is negative fordesmin, SMA, keratin, and S100 protein.3,5D. CD34, desmin, SMA, keratin1, S1001 eIncorrect. Keratin is found in epithelial cells. It ispositive in epithelial tumors and some adnexaltumors as well as epithelioid sarcoma, which isJAAD CASE REPORTSJANUARY 201962 Hosking et alCD341 and keratin1 (AE1/AE3), but keratin isnegative in HFLT.3E. CD34, desmin1, SMA, keratin1, S1001 eIncorrect. Desmin is found in muscle cells (skeletaland smooth muscle) and positive in leiomyomasand leiomyosarcomas but is negative in HFLT.3Question 3: This type of tumor shares anidentical chromosomal translocation withwhich of the following?A. Malignant fibrous histiocytoma (MFH)B. Myxoinflammatory fibroblastic sarcoma (MIFS)C. LeiomyosarcomaD. Myxoid liposarcomaE. Atypical fibroxanthomaAnswers:A. MFH e Incorrect. MFH is a soft-tissue sarcomathat frequently occurs in deep soft tissues of theextremities with a high risk of metastasis, but MFHdoes not share an identical chromosomal transloca-tion with HFLT.1B. MIFS e Correct. MIFS and HFLT share anidentical chromosomal translocation t(1;10)(p22;q24) in a subset of tumors with the fusiongene TGFBR3-MGEA5. Further, some HFLT tumorscan progress to a so-called hybrid hemosideroticfibrolipomatous tumor- myxoinflammatory fibro-blastic sarcoma that is similar to, but distinct from,classic MIFS. PHAT also shares the same identicalchromosomal translocation in a subset of patients.6C. Leiomyosarcoma e Incorrect. Leiomyosarcomais a superficial malignant smooth muscle tumor thatdoes not share an identical chromosomal transloca-tion with HFLT.1D. Myxoid liposarcoma e Incorrect. Myxoid lip-osarcoma is a type of liposarcoma that often presentsas an asymptomatic nodule. This tumor is associatedwith a t(12;16)(q13;p11) translocation resulting ina FUS/DDIT3 fusion protein ([90% of cases).1E. Atypical fibroxanthoma e Incorrect. Atypicalfibroxanthoma is a superficial variant of MFH thattypically occurs in elderly patients. Atypical fibrox-anthoma does not share an identical chromosomaltranslocation with HFLT.1Abbreviations:DFSP: dermatofibrosarcoma protuberansHFLT: hemosiderotic fibrolipomatous tumorMFH: malignant fibrous histiocytomaMIFS: Myxoinflammatory fibroblastic sarcomaPHAT: pleomorphic hyalinizing angiectatic tumorSMA: smooth muscle actinREFERENCES1. Lindberg MR. Diagnostic Pathology: Soft Tissue Tumors. ElsevierHealth Sciences; 20152. Moretti VM, Brooks JSJ, Ogilvie CM. Case report: hemosideroticfibrohistiocytic lipomatous lesion: a clinicopathologic charac-terization. Clin Orthop Relat Res. 2010;468(10):2808-2813.3. Ferringer T. Immunohistochemistry in dermatopathology. ArchPathol Lab Med. 2015;139:23.4. Kao Y, Ranucci V, Zhang L, et al. Recurrent BRAF generearrangements in myxoinflammatory fibroblastic sarcomas,but not hemosiderotic fibrolipomatous tumors. Am J SurgPathol. 2017;41(11):1456-1465.5. Wilk M, Zelger BG, Zelger B. Hemosiderotic fibrolipomatoustumor. Am J Dermatopathol. 2016;38(9):714-716.6. Boland JM, Folpe AL. Hemosiderotic Fibrolipomatous tumor,pleomorphic hyalinizing angiectatic tumor, and myxoinflam-matory fibroblastic sarcoma: related or not? Adv Anat Pathol.2017;24(5):268-277.

A green-brown plaque on the dorsal hand

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A green-brown plaque on the dorsal hand.

A green-brown plaque on the dorsal hand.

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