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Friable Nodule on the Back

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A 78-year-old woman presented with a large friable, sharply demarcated nodule of 3 months’ duration on the left side of the back. The lesion occasionally bled but was otherwise asymptomatic. There was no perilesional paresthesia. The patient’s medical history included hypertension, depression, chronic obstructive pulmonary disease, breast cancer, osteoporosis, and aortic valve disease.

What’s the diagnosis?

a. dermatofibrosarcoma protuberans

b. Kaposi sarcoma

c. malignant fibrous histiocytoma

d. spindle cell malignant melanoma with perineural invasion

e. squamous cell carcinoma

Many studies report the increased incidence of local recurrence after excision for spindle cell melanoma as compared to non–spindle cell melanoma,16-18 which is likely related to perineural invasion as in our patient.

Spindle cell melanoma is a rare tumor that is often amelanotic and difficult to diagnose clinically. Routine hematoxylin and eosin staining shows a dermal spindle cell tumor. Immunohistochemical study is of great aid in defining the tumor. The clinician and pathologist must work together to correctly diagnose and treat this lesion.

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