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
29 year old woman, left cheek
High Power H&E Examination
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).
Ideas that seem great in theory
Bcl-2 and CK20
Immunostains CD 34
Stains To: Establish General Badness
P53 and Ki67 May Be of Utility in Adnexal Proliferations
Spiradenocarcinoma/Malignant Hidradenoma?
46 year-old woman Left arm r/o cyst 12.5x
50x Internal Control
200x Hypercellularity Innumerable atypical mitoses Spontaneous necrosis
Internal Control Hypercellularity Innumerable atypical mitoses Spontaneous necrosis
Immunohistochemistry Ki-67 P53
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 (+)
Scalp Lesion
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
Kim MS, et al. A Case of TAA with SCAP that Developed in a Nevus Sebaceus. Ann Dermatol. 2010; 22:319-22.
Other Considerations Mixed tumor of the skin Hidradenoma papilliferum
Another thing to be careful of Panel of p63, CK5, CK14, CK17, and mammaglobin: 100% sensitivity 91% specificity
Histology
Ki67
p53
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
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
Am J Surg Pathol, December 2012 31 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)
Digital Papillary Adenocarcinoma
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
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
Extraocular Sebaceous Gland Carcinoma
Sebaceous Carcinoma Clear cells reminiscent of the normal sebaceous glands, but disorganized
Clear cells with foamy cytoplasm Large atypical mitosis
More basaloid qualities Sebaceous differentiation Pleomorphic and crowded nuclei Mitosis
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
Sebaceous Carcinoma Re-excision
CK7
EMA
Adipophilin (the new thing) Ostler et al. Mod Pathol. 2010
Immunostains to Screen for Muir Torre MLH-1 MSH-2 MSH-6 Screening for sebaceous adenoma & sebaceoma as well.
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
N=50 consecutive patients (1999-2010) 18% overall rate of nodal disease Recommend consideration of SLN and/or close nodal surveillance >10 mm
Basaloid Induction
Classic Induction over DF
Fibrotic and cellular ( busy ) dermis above subcutis
Fibrohistiocytic cells intercalated between collagen bundles
Entrapping of collagen ( donut sign )
More Extreme Example
Induction over FCM
Other things with mucin
86 year old man R axilla Punch biopsy r/o cyst
More Classic Case
Basaloid epithelial islands suspended in pools of mucin
Basaloid epithelial islands suspended in pools of mucin
Atypical mitosis Mucin
Ductal recapitulation Cells have some pleomorphism & prominent nucleoli
Infiltrative growth beneath skeletal muscle of orbit