Volume 5, Issue 4, Pages (April 2019)

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Volume 5, Issue 4, Pages 375-378 (April 2019) The metastatic dissemination of a squamous cell carcinoma arising from an epidermal cyst and subsequent failure to respond to programmed death 1 inhibition Melissa A. Lumish, MD, Mark A. Anderson, MD, Patrick S. Rush, DO, Florian J. Fintelmann, MD, Lyn Duncan, MD, Ryan J. Sullivan, MD, Meghan J. Mooradian, MD JAAD Case Reports Volume 5, Issue 4, Pages 375-378 (April 2019) DOI: 10.1016/j.jdcr.2019.01.032 Copyright © 2019 American Academy of Dermatology, Inc. Terms and Conditions

Fig 1 Preoperative photographs of the 5- × 5- × 4-cm mass at the anteromedial aspect of the left knee. JAAD Case Reports 2019 5, 375-378DOI: (10.1016/j.jdcr.2019.01.032) Copyright © 2019 American Academy of Dermatology, Inc. Terms and Conditions

Fig 2 Sagittal MRI (T2-weighted with fat saturation) through the left knee; blue arrow indicates the cystic lesion with an irregular, enhancing mural nodule along its anterior wall (arrow). JAAD Case Reports 2019 5, 375-378DOI: (10.1016/j.jdcr.2019.01.032) Copyright © 2019 American Academy of Dermatology, Inc. Terms and Conditions

Fig 3 Pathologic findings of completely resected left knee mass. A, Low-power image of adjoining sections of a dermal and subcutaneous epidermal inclusion cyst. The cyst wall is composed of nonneoplastic keratinizing squamous epithelium with a granulomatous inflammatory response to cyst wall rupture laterally and a large central nodule of basaloid epithelial proliferation with areas of necrosis. B, Medium-power image is demarcated by the hash-box in A, showing the cyst wall transition from well-differentiated squamous-lined cyst with orderly keratinocyte maturation (left) to an area of high-grade malignant transformation (right). A and B, Hematoxylin-eosin stain; original magnifications: A, ×12.5; B, ×100. JAAD Case Reports 2019 5, 375-378DOI: (10.1016/j.jdcr.2019.01.032) Copyright © 2019 American Academy of Dermatology, Inc. Terms and Conditions

Fig 4 CT scan of the chest with contrast pretreatment. Blue arrow shows original rounded metastatic lesion. Postimmunotherapy CT imaging after 4 cycles of pembrolizumab. Red arrows show new pulmonary metastases. JAAD Case Reports 2019 5, 375-378DOI: (10.1016/j.jdcr.2019.01.032) Copyright © 2019 American Academy of Dermatology, Inc. Terms and Conditions