Whitney A. High, MD, JD, MEng

Transcription

1 ADS Dermatopathology Meeting 2014 Selected Adnexal Tumors Whitney A. High, MD, JD, MEng Associate Professor, Dermatology & Pathology Director of Dermatopathology (Dermatology) University of Colorado School of Medicine August 2014 Perth, Australia

2 29 year old woman, left cheek

3 High Power H&E Examination

4 What ways exist to distinguish trichoepithelioma from BCC? The following has been proffered as useful in distinguishing TE/dTE from BCC: Stain BCC Trichoepithelioma Bcl-2 Uniform & diffuse Peripheral only CK20 Negative Scattered MCs CD34 Negative Supporting stroma PHLDA1 Negative Positive Also consider AR, CD10 (both + in TE), ST-1 (+ in BCC).

5 Ideas that seem great in theory

6 Bcl-2 and CK20

7 Immunostains CD 34

8 Stains To: Establish General Badness

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13 P53 and Ki67 May Be of Utility in Adnexal Proliferations

14 Spiradenocarcinoma/Malignant Hidradenoma?

15 46 year-old woman Left arm r/o cyst 12.5x

16 50x Internal Control

17 200x Hypercellularity Innumerable atypical mitoses Spontaneous necrosis

18 Internal Control Hypercellularity Innumerable atypical mitoses Spontaneous necrosis

19 Immunohistochemistry Ki-67 P53

20 Comparative measures? Pilomatrical carcinoma is a somewhat subjective diagnosis David Weedon Pilomatrical carcinoma with KNOWN mets, the Ki67 index was ~50% Study of pilomatrical carcinoma versus pilomatricoma, only the carcinomas P53 (+)

21 Scalp Lesion

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25 Tubular Apocrine Adenoma Rare sweat gland tumor First reported in 1972 Often occurs upon the scalp May occur with a syringocystadenoma papilliferum or within a nevus sebaceus Chiefly apocrine, but some are reported to have an eccrine derivation Tubulopapillary hidradenoma

26 Kim MS, et al. A Case of TAA with SCAP that Developed in a Nevus Sebaceus. Ann Dermatol. 2010; 22:

27 Other Considerations Mixed tumor of the skin Hidradenoma papilliferum

28 Another thing to be careful of Panel of p63, CK5, CK14, CK17, and mammaglobin: 100% sensitivity 91% specificity

29 Histology

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33 Ki67

34 p53

35 Papillary Eccrine Adenoma Rare sweat gland tumor First reported in 1977 (Rulon & Helwig) In the initial series the lesion occurred on the distal extremities of black women >80% remain on acral skin (even today) There is a relationship/equivalence to tubular apocrine adenoma elsewhere

36 Other diagnostic considerations How different is it from: aggressive forms, digital papillary adenocarcinoma???? Some have proposed recently (2014): papillary adenocarcinoma in situ Digital papillary adenocarcinoma also on the digits of blacks generally more cellular, more atypical often with multi-layering often with mitotic figures

37 Am J Surg Pathol, December cases all involved finger or toe nodular solid/cystic pattern mitotic figures and atypia variable but often with infiltrative qualities metastatic disease in 6 (usually lung)

38 Digital Papillary Adenocarcinoma

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43 Sebaceous Carcinoma Sebceous glands - normal part of skin Sebaceous carcinoma Ocular - most common form Extraocular - more rare occurrence Ocular form may be a lethal malignancy may masquerade as benign conditions error or delay in diagnosis is common significant mortality rate with metastasis

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45 Ocular Sebaceous Carcinoma Classic teaching seb CA was more common in elderly, women, and Asians 2009 study of 1349 cases showed: more common in elderly slightly more common in men no difference in ethnicity Confused with chalazion etc. Reported mortality may be 6% overall Dasgupta et al. Cancer 2009

46 Extraocular Sebaceous Gland Carcinoma

47 Sebaceous Carcinoma Clear cells reminiscent of the normal sebaceous glands, but disorganized

48 Clear cells with foamy cytoplasm Large atypical mitosis

49 More basaloid qualities Sebaceous differentiation Pleomorphic and crowded nuclei Mitosis

50 Troubles with IHC in Sebaceous Carcinoma Worst when you really need it to work Other candidate stains: EMA CK7 BerEp4 CAM 5.2 BRST-1 Androgen Receptor

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52 Sebaceous Carcinoma Re-excision

53 CK7

54 EMA

55 Adipophilin (the new thing) Ostler et al. Mod Pathol. 2010

56 Immunostains to Screen for Muir Torre MLH-1 MSH-2 MSH-6 Screening for sebaceous adenoma & sebaceoma as well.

57 MLH-1 (8/24) - most common loss to occur in isolation PPV 88% MSH-2 (11/24) often co-incidental loss with MSH-6 PPV 55% MSH-6 (15/24) about 1/3 isolated loss PPV 67% PMS is less importance in the cutaneous lesions

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60 N=50 consecutive patients ( ) 18% overall rate of nodal disease Recommend consideration of SLN and/or close nodal surveillance >10 mm

61 Basaloid Induction

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63 Classic Induction over DF

64 Fibrotic and cellular ( busy ) dermis above subcutis

65 Fibrohistiocytic cells intercalated between collagen bundles

66 Entrapping of collagen ( donut sign )

67 More Extreme Example

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71 Induction over FCM

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76 Other things with mucin

77 86 year old man R axilla Punch biopsy r/o cyst

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79 More Classic Case

80 Basaloid epithelial islands suspended in pools of mucin

81 Basaloid epithelial islands suspended in pools of mucin

82 Atypical mitosis Mucin

83 Ductal recapitulation Cells have some pleomorphism & prominent nucleoli

84 Infiltrative growth beneath skeletal muscle of orbit