1. Steven A. Gustafson, D.O. and Michael C. Awasum M.D.

2. Steven A. Gustafson, D.O., Associate professor of Preclinical sciences Collage of Osteopathic Medicine 1. Michael C. Awasum M.D., Assistant Professor of Pathology, Ponce Health Sciences University 2. Michael C. Awasum M.D., Attending Pathologist at Southern Pathology Services, Ponce, Puerto Rico 2. William Carey University 1 Southern Pathology 2

3. 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”.

4. 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.

5. 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.

6. 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.

7. H and E Low power

8. H and E intermediate power

9. H and E intermediate power 40X

10. H and E intermediate power 60X

12. ALK Negative

13. 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

14. 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

15. 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.

16. 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.

17. 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.