Recurrent atypical fibroxanthoma with satellite metastasis.

Atypical fibroxanthoma (AFX) is a cutaneous neoplasm of uncertain etiology that develops on sun-exposed regions of elderly males. It is widely considered to act indolently, despite its highly malignant cytologic features. Reports of metastatic AFX are very rare, and recurrence is uncommon. We report a case of recurrent AFX exhibiting a pattern of satellite metastasis followed by evidence of regional lymph node metastasis. A 76-year-old male with prior occupational and therapeutic radiation exposure and numerous squamous cell carcinomas had AFX of the left vertex scalp limited to the dermis completely removed by micrographic surgery. Twenty months later, multiple lesions appeared at the site of previous surgery. Imaging revealed no metastases or calvarial involvement. Wide local excision showed multiple well-defined nodules involving dermis and subcutis. The primary and recurrent neoplasms were similar and composed of pleomorphic epithelioid and spindled cells with marked nuclear atypia, hyperchromasia and mitotic activity. Immunohistochemistry was positive for CD10, procollagen1 and vimentin and negative for cytokeratins AE1/AE3, cytokeratins 5/6, 34ßE12, MNF116, p63 CD31, Mart1, smooth muscle actin, desmin, S100 and CD34. Forty-eight months after removal of the primary, left intraparotid and posterior triangle lymph nodes are suspected to be involved by metastasis using clinical and positron emission tomography/ computed tomography examinations.

Ossifying plexiform tumor.

We report a rare case of ossifying plexiform tumor in a 64-year-old female. The patient had a 2-year history of gradual hardening of the right thumb pad and pain that radiated up the forearm. Physical examination showed a tender, mobile 2-cm subcutaneous nodule distending the tip of the right thumb. The biopsy specimen showed a well-delineated tumor with multiple lobules of epithelioid and spindled cells arranged in a plexiform pattern separated by fibrous bands and having foci of bone formation. The neoplastic cells had scant-to-moderate amphophilic cytoplasm with mild nuclear pleomorphism in a myxocollagenous background. No necrosis, mitoses or cytological atypicia were seen. The osteocytes present in the bone islands were bland, with occasional rimming osteoblasts. X-ray showed stippled calcification in the soft tissue of the distal thumb without involvement of the phalanx. The patient is tumor free for 1 year after complete local excision. Only three cases of ossifying plexiform tumor have been reported. All previous cases and the current case presented as subcutaneous nodules on hand digits of females, measuring 1-2 cm in greatest dimension. Ossifying plexiform tumor appears to be a benign neoplasm with no reports of progression or metastasis.

Photoletter to the editor: Diffuse cocaine-related purpura.

Diffuse purpura is an uncommon skin manifestation found in platelet and coagulation disorders, meningococcemia, vasculitides and cocaine use. Reports of cocaine-related purpura predominantly involve adulteration with the anti-helminthic, levamisole. Levamisole enhances the effects of cocaine and is known to cause vasculitis. Recently, the CDC also released an advisory of oxymorphone being used intravenously causing thrombogenic thrombocytopenic purpura (TTP). We report the case of a patient with diffuse purpura ultimately diagnosed with cocaine-related thrombogenic vasculopathy. In the current environment of adulterated cocaine usage and increased prescription narcotic abuse, it is crucial to investigate substance abuse as a cause of diffuse purpura.