Slide seminar. Asist. Prof. Jože Pižem, MD, PhD Institute of Pathology Medical Faculty, University of Ljubljana

Transcription

1 Slide seminar Asist. Prof. Jože Pižem, MD, PhD Institute of Pathology Medical Faculty, University of Ljubljana

2 Case 5 A 57-year-old man with a dermal/subcutaneous lesion on the scalp, which was interpreted clinically as an atheroma Gross inspection of the excision specimen: Unremarkable skin surface An 11-milimmeter large lesion in the dermis and subcutis

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9 Diagnosis?

10 CKMNF116 CKAE1/AE3

11 EMA

12 SMA

13 S100

14 p63 p63

15 calponin

16 GFAP

17 Diagnosis Malignant mixed tumour of the skin (Pleomorphic carcinoma, probably myoepithelial, in a pre-existent mixed tumour)

18 Malignant mixed tumour of the skin = pre-existent mixed tumour + malignant component: Apocrine adenocarcinoma Myoepithelial carcinoma Carcinoma, NOS Sarcomatoid (metaplastic) carcinoma Kazakov DV, 2012

19 Carcinoma ex pleomorphic adenoma Salivary glands In situ Intracapsular Microinvasive (< 5mm) Invasive Salivary duct Adenocarcinoma, NOS Adenosquamous Undifferentiated Sarcomatoid Adenoid cystic Mucoepidermoid Myoepithelial

20 Prognosis Limited information May metastasize Prognostic factors?

21 Female, 82 years Left foot 2.5 cm tumour

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27 p63

28 Diagnosis Apocrine adenocarcinoma in mixed tumour

29 Focal bizarre multinucleated cells or mild pleomorphism Focal irregular margin No or low mitotic activity Atypia predominantly involves myoepithelial cells Benign course

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31 Adnexal carcinomas arising in preexistent benign tumours Spiradenocarcinoma Hidradenocarcinoma Porocarcinoma Malignant mixed tumour Apocrine carcinoma Syringocystadenocarcinoma papilliferum

32 Porocarcinoma F, 95, forehead

33 Take home messages Consider malignant alteration of a pre-existent benign adnexal tumour in any case of an unusual carcinoma of the skin Finding a pre-existent benign adnexal tumour is the best clue for a primary skin carcinoma P63 positivity in a skin adenocarcinoma favours a primary skin carcinoma

34 Case 6 A 70-year-old woman with a skin lesion on the scalp, clinically interpreted as an inflammed epithelioma

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44 Diagnosis?

45 CK 7

46 CK7

47 CK5/6

48 S100

49 Diagnosis Breast metaplastic carcinoma with chondroid differentiation (matrix-producing carcinoma) metastatic to the skin

50 Clinical data and follow-up May 2008: Invasive ductal carcinoma with prominent hyaline and chondroid stroma, grade 3, triple negative, 1/14 LN, treated with chemo and radiotherapy November 2011: excision of the scalp lesion 2012: Lung and brain metastases

51 Primary Metastatic

52 Metaplastic carcinoma with chondroid differentiation Variant of metaplastic carcinoma Poorly differentiated carcinoma with direct production of chondorid matrix Triple negative Usually zonation with matrix production in the centre Metastatic lesions: The same pattern as primary ones More prominent chondroid differentiation CK5/6+ (90%), S100+, p63+ (90%)

53 Metaplastic carcinoma with chondroid differentiation Differential diagnosis Mucinous carcinoma Pleomorphic adenoma Myoepithelioma/carcinoma Metaplastic carcinoma Sarcoma Other tumours with myxoid differentiation

54 Cutaneous mucinous carcinoma

55 Mixed tumour

56 Myoepithelial carcinoma S100+, CK+

57 Pleomorphic sarcoma (atypical fibroxanthoma) Pleomorfni Sa M, 79, Face

58 Basal cell carcinoma

59 Skin metastases Relatively infrequent site compared to visceral organs 5% of carcinoma patients Carcinoma of breast, lung, colon, kidney, SCC The site reflects the site of primary tumours All malignant tumours tend to metastasize to the scalp (renal cell carcinoma, breast carcinoma, colon carcinoma)

60 METASTATIC CARCINOMA VS. PRIMARY (ADNEXAL)

61 Metastasis vs. primary Complete history Experience with the wide range of histological features of tumours Morphology Immunohistochemistry

62 Metastasis vs. Primary Morphology Primary Metastatic Pre-existent in situ lesion Nodular, multinodular Pre-existent benign tumour Centered in the deep dermis, subcutis Connection with the epidermis Central necrosis Lymphovascular invasion Particular morphology (dirty necrosis, clear cells,..)

63 Metastases to the skin Misleading features Conection with the epidermis/epidermotropism

64 Metastases to the skin Misleading features Tumour-to-tumour metastasis

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66 Take home messages Do not disregard basic morphologic clues Relevant clinical information is crucial Metastases can be epidermothropic Metastatic carcinomas can be S100-positive The scalp is a frequent location of metastases to the skin