-
[show abstract]
[hide abstract]
ABSTRACT: INTRODUCTION The classification of malignant eccrine tumors is one of the most confusing areas of dermatopathology, with identical tumors reported in the literature under three or more designations. Furthermore, tumors with heterogeneous histologic features that defy classification are common. Some earlier reports give scant histologic details, precluding reassessment. Ductal eccrine carcinoma with intraductal squamous metaplasia is an exceedingly rare tumor that shows eccrine ductal differentiation combined with intraductal squamous metaplasia. Similar cases have been reported with the term "squamoid eccrine ductal carcinoma" (SEDC). We present an extremely rare case of ductal eccrine carcinoma with intraductal squamous metaplasia with review of the literature. PATIENT AND METHODS A 54-year-old woman presented with a 1-year lasting slowly growing nodular lesion on the right tibial region. The lesion measured 12x11 mm. Excisional biopsy was obtained. The patient has been free from recurrence or metastasis for 18 months after excision. The tumor was well circumscribed and showed an infiltrative appearance at the periphery, consistent with low-grade malignancy (Fig. 1). Histologically, the lesion was composed of numerous tubular structures, lined by one or several layers of atypical basaloid cells with focal finding of a cuticular luminal border, admixed with clear myoepithelial cells. Diffuse intraductal squamous metaplasia was present (Figs. 2 and 3). The tumor was associated with a fairly dense sclerotic stroma. The carcinoembryonic antigen (CEA) stain was performed and was strongly positive in the areas of ductal differentiation. DISCUSSION We examined all reports of SEDC published in the literature to date. In the three cases of SEDC reported by Wong et al. (1), the squamoid differentiation consisted of squamous cell carcinoma (SCC). The authors do not specify if the two components were intermingled or separated. The diagnosis should be "eccrine carcinoma mixed or associated with SCC". In the case described by Herrero et al. (2), three neoplastic components have been described. The first was composed of invasive sheets and islands of atypical keratinocytes with squamous eddies, horn cyst and the occasional presence of intercellular bridges. The description and "B" microphotograph showed the malignant nature of the squamous proliferation. The second component showed ductal differentiation. The third component was represented by "in situ SCC" within the eccrine sweat ducts or glands found at the periphery of the tumor mass. The definitive diagnosis should be "mixed SCC and eccrine carcinoma with in situ intraductal SCC". The neoplasm described by Kim et al. (3) was mostly composed of atypical keratinocytes with prominent squamous differentiation and ductal component at the periphery of the tumor. The "A" microphotograph on Figure 2 does not clearly illustrate the composition of the tumor. It is probable that the neoplasm was composed of eccrine carcinoma with a squamous component, whose benign or malignant nature cannot be established by histologic description and microphotographs. The authors do not specify if the two components were separated or intermingled. Moreover, the microphotographs are indicative of the presence of two separated components. Therefore, the diagnosis of SEDC is not convincing (4). The case described by Terushkin et al. (5) was incorrectly diagnosed as SEDC. In histologic description, the neoplasm consisted of aggregates with squamoid features connected to the overlying epidermis, but squamoid islands were not identified within the lumina. The ductal component was separated by squamoid aggregates. In our opinion, the diagnosis should be "eccrine ductal carcinoma associated with squamoid nodules". In the case presented by Chhibber et al. (6), the histologic description and illustrations are convincing for the identification of ductal eccrine carcinoma intermingled with squamous metaplasia. Kavand and Cassarino (7) describe a case of a slow-growing tumor, occurring on the great toe of a 61-year-old woman, which was unusual as it showed follicular differentiation in addition to squamoid and ductal areas. The lesional cells were positive for cytokeratins 7 and 17, CEA (which highlighted ductal structures), and p63 (favoring a primary cutaneous tumor), and showed low levels of staining with Ki-67 and p53, consistent with a low-grade tumor. These authors believe that "squamoid eccrine ductal carcinoma" may be closely related to microcystic adnexal carcinoma and similarly show differentiation along both follicular and ductal lines, likely indicating folliculosebaceous-apocrine, rather than eccrine origin or differentiation. We believe that "squamoid" or "squamous differentiation" are improper terms because they are not conclusive of the benign nature of squamous metaplasia. The significance of squamous differentiation in eccrine neoplasms has been a subject of much debate. While some authors believe that this differentiation delineates a subtype of eccrine neoplasm with a more aggressive biologic behavior, others believe that it is an incidental finding without real clinical significance, as it does not appear to have an impact on the biology of the disease (8,9). In the past, there has been some debate about the origin (eccrine or apocrine) and differentiation of certain adnexal tumors. Histochemistry and electron microscopy sometimes gave conflicting results, with features suggestive of both apocrine and eccrine differentiation reported by some authors. The recent development of various monoclonal antibodies for use with immunoperoxidase techniques has assisted marginally in the classification of the various adnexal tumors (10). McCalmont believes that optic microscopy alone is insufficient to establish eccrine lineage, save for the exclusion of other modes of differentiation. In the early exploration of adnexal lineage, electron microscopy has not permitted distinction between apocrine and eccrine cells because the ultra structural features of these cells, whether normal or neoplastic, are not unique (11). We believe that the duct formation lined by cuticular material may be considered a histologic feature suggestive of eccrine differentiation combined with other well-known characteristics of eccrine carcinoma (Fig. 3). CONCLUSION In the diagnosis of SEDC, histologic criteria should be very stringent. Squamous metaplasia should be an intraductal finding. We prefer the terminology of "eccrine ductal carcinoma with intraductal squamous metaplasia", in order to emphasize that the two components are intermingled and that the intraductal squamous metaplasia is benign. The term "squamous differentiation" and "squamoid" are generic because they are not conclusive of the benign or malignant nature of the intraductal squamous metaplasia.
Acta dermatovenerologica Croatica : ADC. 12/2012; 20(4):272-83.
-
[show abstract]
[hide abstract]
ABSTRACT: INTRODUCTION Hypertrophic lichen planus shows prominent hyperplasia and overlying orthokeratosis of the epidermis. To date, 50 cases of squamous cell carcinoma (SCC) have been reported as neoplastic transformation of hypertrophic lichen planus. We report a case of pseudoepitheliomatous hyperplasia (PEH) simultaneously found in hypertrophic lichen planus lesions simulating SCC, with special reference to the value of immunohistochemistry in differential diagnosis. CASE REPORT A 73-year-old woman presented with multiple erosive lesions of the oral cavity. Biopsy showed a subepithelial chronic inflammatory infiltrate that did not permit to establish the etiopathogenetic nature. Clinical examination showed multiple hyperkeratotic nodules of 14-month duration located especially on both heels and toes (Fig. 1). Biopsies of the two lesions showed typical features of hypertrophic lichen planus in continuity with an adjacent area of PEH (Fig. 2). Shave biopsy of the smallest hyperkeratotic nodule was diagnosed as well-differentiated SCC (Fig. 2). Histology of the latter nodule revealed benign irregular hyperplasia of the epidermis with gross acanthosis, downward proliferation with moderate dyskeratosis and horn cyst formation (Fig. 2). These features are typical of PEH. Shave biopsy of the smallest hyperkeratotic nodule was diagnosed as well-differentiated SCC. Excisional biopsy of another nodule showed benign irregular hyperplasia of the epidermis with gross acanthosis, downward proliferation with moderate dyskeratosis and horn cyst formation. These features were typical of PEH. In both specimens, squamous proliferation showed diffuse nuclear p53 expression. Nuclear staining was stronger in the basal cells. E-cadherin showed uniform membranous staining in epithelial growths of both specimens. Ki-67 expression was observed prevalently in the basal layer (Fig. 3). In both specimens, there were a decreased number of CD1a-positive cells, compared to the normal adjacent epidermis. Review of the first biopsy, considering further clinical findings, suggested a diagnosis of PEH rather than squamous cell carcinoma. After two years, the patient is free from recurrence. DISCUSSION PEH is a histopathologic reaction pattern rather than a disease sui generis. It is characterized by irregular hyperplasia of the epidermis, which also involves follicular infundibula and acrosyringia. This proliferation may be encountered in a number of clinically heterogeneous diseases. PEH may be misinterpreted as SCC especially in cases in which the primary process localized in the dermis is not readily apparent or the biopsy is superficial and does not include sufficient portion of the dermis. If epidermal hyperplasia is severe, it may mimic SCC on shave biopsy (1). Numerous reported SCCs arising in hypertrophic lichen planus may not be accepted as such because the hypertrophic lichen planus-squamous cell carcinoma sequence is not sufficiently histologically illustrated (2-5). Since PEH may simulate SCC, accurate criteria should be used on differential diagnosis. In our case, the infiltrative pattern was alarming and a precise diagnosis problematic. Immunohistochemistry has been used on diagnostic differentiation between PEH and SCC. Lee et al. (6) examined p53 expression in 6 PEH and 45 SCC cases. p53 expression was observed in all 6 cases of PEH and in 75.5% of SCC. The staining pattern of PEH was generally less intense and extensive compared to SCC. On diagnostic differentiation between PEH and SCC, the interpretation of p53 expression is not clear-cut. The expression of p53 protein is an indicator of immaturity and proliferative capacity of the cell rather than a marker of neoplasia or malignancy. Well-differentiated SCC and PEH stained similarly to proliferating cell nuclear antigen (7). E-cadherin has been reported to be lost in SCC but to be preserved in PEH (8). PEH has a decreased number of Langerhans cells compared to the normal epidermis (9,10). As SCC also has a decreased numbers of CD1a positive cells, this stain is not useful in differentiating these two entities. CONCLUSIONS We believe that the presence of multiple lesions, follow-up and proliferation from follicular infundibula are valuable criteria indicating PEH rather than SCC. Distinguishing PEH and SCC may be challenging for pathologists, especially in small and limited biopsies because excisional biopsies are the best diagnostic procedure. Immunohistochemistry is not useful in differentiating these two entities.
Acta dermatovenerologica Croatica : ADC. 06/2012; 20(2):112-4.
-
[show abstract]
[hide abstract]
ABSTRACT: The first case of cutaneous clear cell perivascular epithelioid cell tumor (PEComa) with negative HMB-45 marker is presented. The tumor was a nodule 3x2 cm in size, located on the right foot in a 60-year-old man. The lesion consisted of large irregularly shaped cells with clear cytoplasm, negative for S-100 protein, HMB-45, Melan-A, pancytokeratin, epithelial membrane antigen and CAM5.2. Multifocal positivity for desmin, microphthalmia transcription factor and tyrosinase was found. The diagnosis of cutaneous PEComa of clear cell type was made. Clear cell change is a very unusual finding in PEComa and may pose problems in diagnostic differentiation from other clear cell cutaneous lesions that may be excluded with immunohistochemistry. In our case, the HMB-45 negativity may be explained by extensive clear cell change. Additional studies are necessary to accept the clear cell cutaneous HMB-45 negative PEComa as a new variant of perivascular epithelioid cell tumor.
Acta dermatovenerologica Croatica : ADC. 04/2012; 20(1):27-9.
-
Indian Journal of Pathology and Microbiology 04/2012; 55(2):265-6. · 0.68 Impact Factor
-
Dermatologic Surgery 12/2011; 37(12):1819-20. · 1.80 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Although a trichilemmal cyst is a relatively common benign cutaneous condition and ossification has been observed within many cutaneous lesions to our knowledge, the association between ossification and trichilemmal cyst has not been previously reported. We describe for the first time the case of a trichilemmal cyst with marked osseous metaplasia arising on the scalp of a 46 year-old woman. Microscopically the lesion showed the typical features of a trichilemmal cyst with the finding of intra-extraluminal foci of calcification and the exceptional feature of mature bone formation. No areas of mature cartilage were observed near the focus of ossification. The cutaneous bone may have been directly formed from osteogenic stromal elements without a cartilaginous precursor (membranous or mesenchymal ossification). The dystrophic calcification might also contribute to the bone-forming process.
The American Journal of dermatopathology 12/2011; 33(8):867-8. · 1.30 Impact Factor
-
The American Journal of dermatopathology 11/2011; 34(2):227-8. · 1.30 Impact Factor
-
Orthopedics 11/2011; 34(11):836-7; author reply 837. · 2.66 Impact Factor
-
Journal of Clinical Oncology 09/2011; 29(29):3943-4. · 18.37 Impact Factor
-
Urologia Internationalis 06/2011; 87(1):125-6. · 0.99 Impact Factor
-
The American Journal of dermatopathology 06/2011; 33(6):634-6. · 1.30 Impact Factor
-
World Journal of Urology 05/2011; · 2.41 Impact Factor
-
Renal Failure 01/2011; 33(8):844-5. · 0.82 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Abdominal-pelvic actinomycosis is often mistaken for other conditions, presenting a preoperative diagnostic challenge. In a 46-year-old female, computed tomography showed an abdominal-pelvic retroperitoneal mass extending from the lower pole of the right kidney to the lower pelvis. The patient had a 3-year history of intrauterine device. The mass appeared to involve the ascending colon, cecum, distal ileum, right Fallopian tube and ovary, and ureter anteriorly and the psoas muscle posteriorly. The resection of retroperitoneal mass, distal ileum appendicectomy, right hemicolectomy, and right salpingo-oophorectomy was performed. The postoperative period was uneventful. Penicillin therapy was given for six months without any complication. The retroperitoneal mass measured 4.5 × 3.5 × 3 cm, surrounded adjacent organs and histologically showed inflammatory granulomatous tissue, agglomeration of filaments, and sulfur granules of Actinomyces, with positive reaction with periodic acid Schiff. Right tubo-ovarian abscess was present. Abdominalpelvic actinomycosis should always be considered in patients with a pelvic mass especially in ones using intrauterine device.
Infectious Diseases in Obstetrics and Gynecology 01/2011; 2011:747059.
-
Medical Molecular Morphology 12/2010; 43(4):253; author reply 254. · 1.39 Impact Factor
-
Diseases of the Colon & Rectum 11/2010; 53(11):1576; author reply 1576. · 3.13 Impact Factor
-
Indian Journal of Pathology and Microbiology 54(1):208-9. · 0.68 Impact Factor
