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Interactive Case Study - July 2025

86-year-old male with a painful growing plaque on the scalp
Laura K. Archibald, MD 
Carlos Iwamoto, MD 
Daniel R. Knabel, MD 
 
 
An 86-year-old man presented with a painful growing plaque on his right parietal scalp. The lesion was present for about 6 months. A deep biopsy was performed.
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Figure 1: Clinical Image
Figure 1: Clinical Image
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Knowing that the S100, pancytokeratin, CD34, and desmin stains are negative, what is the best diagnosis?
Atypical fibroxanthoma (AFX)
Dermatofibrosarcoma protuberans (DFSP)
Pleomorphic dermal sarcoma (PDS)
Pleomorphic fibroma
Undifferentiated pleomorphic sarcoma (UPS)
Which of the following is currently considered to be the gold standard treatment for pleomorphic dermal sarcoma (PDS)?
Chemotherapy and radiation
Radiation alone
Surgical excision
Surgical excision with adjuvant radiation to the primary site
Surgical excision with sentinel lymph node biopsy
How do the estimated rates of local recurrence and metastasis compare between PDS and AFX?
PDS and AFX have similar rates of local recurrence and metastasis
PDS has higher rates of local recurrence than AFX, but the risk of metastasis is similar for PDS and AFX
PDS has similar rates of local recurrence as AFX, but the risk of metastasis is higher in PDS than AFX
PDS has higher rates of both local recurrence and metastasis compared to AFX
PDS has lower rates of local recurrence and metastasis compared to AFX
  1. Brenn T. Soft Tissue Special Issue: Cutaneous Pleomorphic Spindle Cell Tumors. Head Neck Pathol 2020 Mar;14(1):109-120.

  2. Miller K, Goodlad JR, Brenn T. Pleomorphic dermal sarcoma: adverse histologic features predict aggressive behavior and allow distinction from atypical fibroxanthoma. Am J Surg Pathol 2012 Sep;36(9):1317-26

  3. Soleymani T, Aasi SZ, Novoa R, et al. Atypical Fibroxanthoma and Pleomorphic Dermal Sarcoma: Updates on Classification and Management. Dermatol Clin 2019 Jul;37(3):253-259.

  4. Kutzner HH, Kamino H, Reddy VB, et al. Fibrous and Fibrohistiocytic Proliferations of the Skin and Tendons. In: Bolognia JL, Schaffer JV, Cerroni L, editors. Dermatology, Fourth Edition. Elsevier 2018. p.  2072-2082.

  5. Elston DM, Ko CJ, Ferringer T. Fibrous tumors. In: Elston DM, Ferringer T, editors. Dermatopathology, Third Edition. Elsevier 2019. p. 373.

  6. Soleymani T, Hollmig ST. Conception and Management of a Poorly Understood Spectrum of Dermatologic Neoplasms: Atypical Fibroxanthoma, Pleomorphic Dermal Sarcoma, and Undifferentiated Pleomorphic Sarcoma. Curr Treat Options Oncol 2017 Aug;18(8):50.

  7. Cohen PR. Cutaneous undifferentiated pleomorphic sarcoma is pleomorphic dermal sarcoma. Dermatol Online J 2020 May;26(5):16.

  8. Brenn T. Pleomorphic dermal neoplasms: a review. Adv Anat Pathol 2014 Mar;21(2):108-30.

  9. Ríos-Viñuela E, Serra-Guillén C, Llombart B, et al. Pleomorphic dermal sarcoma: a retrospective study of 16 cases in a dermato-oncology centre and a review of the literature. Eur J Dermatol 2020 Oct;30(5):545-553.

 

Acknowledgements

 

Author Profiles

Laura K. Archibald, MD

University of Minnesota Department of Dermatology

Laura Archibald, MD is the Micrographic Surgery and Dermatologic Oncology Fellow at the University of Minnesota for the 2023-2024 academic year. She received her undergraduate training at the University of Michigan then her medical degree at Case Western Reserve University School of Medicine. She graduated from dermatology residency at the University of Minnesota in June 2023.

 

Carlos Iwamoto, MD

Minneapolis VA Medical Center

Carlos Iwamoto, MD, is an anatomic and clinical pathologist and Director of the Immunohistochemistry Lab at the Minneapolis VA Health Care System in Minneapolis, MN. He completed his medical degree at University of San Marcos in Lima, Peru. He did his pathology (AP/CP) residency at the University of Illinois in Chicago, Surgical Pathology fellowship at the University of Minnesota in Minneapolis, MN and Oncologic Pathology fellowship at Memorial Sloan-Kettering Cancer Center in New York, NY. He is also an Adjunct Assistant Professor at the university of MN Department of Lab Medicine and Pathology.

 

Daniel R. Knabel, MD

Medical College of Wisconsin

Daniel Knabel, MD is currently a board-certified dermatologist, dermatopathologist, and Mohs micrographic surgeon at the Medical College of Wisconsin. He received his medical degree from the Medical College of Wisconsin. He completed dermatology residency and dermatopathology fellowship at the Cleveland Clinic. He then completed Micrographic Surgery and Dermatologic Oncology fellowship at the University of Minnesota.

 

 

 

 

 

 

 

Question:

 

 

 

 
 

86-year-old male with a painful growing plaque on the scalp

Category

Tumors > Fibrous/Mesenchymal

Description

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