Difference between revisions of "Dermatologic neoplasms"

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==Melanoma==
==Melanoma==
{{Main|Malignant melanoma}}
{{Main|Malignant melanoma}}
===General===
*Known as the great mimicker in pathology; it may look like many things.
*Known as the great mimicker in pathology; it may look like many things.
===Microscopic===
Features:
*Classic appearance of melanoma:
**Loosely cohesive; mix of small nests of cells, single cells.
**Usu. mixed of spindle and ovoid cell morphology.
**+/-Occasional large binucleated cells.
**+/-Cytoplasm: brown pigment (melanin).
**+/-Prominent (large) red nucleoli (like in ''serous carcinoma'' of the ovary).
**Often marked nuclear pleomorphism - variation in cell size, shape & staining (like in ''serous carcinoma'' of the ovary).
**[[Nuclear pseudoinclusions]] (like in ''papillary thyroid carcinoma'').


=Less common malignant=
=Less common malignant=

Revision as of 01:50, 18 December 2013

This article deals with dermatologic neoplasms. It includes dermatologic cancer, which can be deadly. Collectively, dermatologic cancers are the most common form of cancer.

An introduction to dermatopathy is found in the dermatopathology article. Non-malignant disease is covered in the non-malignant skin disease article.

The Big Three malignant

Basal cell carcinoma

Squamous cell carcinoma of the skin

  • Abbreviated skin SCC, SCC of the skin, and SCC of skin.

General

Precursor:[1]

  • Actinic keratosis (solar keratosis).
    • Clinical: yellow-brown scaly, patches, sandpaper sensation.

Risk factors:[1]

  • Sun exposure.
  • Immune suppression (e.g. organ transplant recipients).

Notes:

  • Keratoacanthoma.
    • Some don't believe this entity exists.
      • These people sign this entity as low grade squamous cell carcinoma, keratoacanthoma type.[2]

Microscopic

High risk features - for SCC of the skin:[3]

  • Primary site is ear or lip.†
  • Clark level IV/V = reticular dermis or deeper.
  • >=2 mm thickness -- measured from granular layer (stratum granulosum) or ulcer base to deepest aspect.
  • Lymphovascular invasion.
  • Perineural invasion.
  • Poorly differentiated.

Note:

  • † The words used are "hair-bearing lip" - but there is considerable confusion about this as the AJCC manual contradicts itself.[4]

DDx:

Bowen disease

Bowen disease is squamous cell carcinoma in situ of the skin.

Histologic DDx of Bowen disease:

Images

IHC

Bowen's disease panel:

Sign-out

Invasive SCC

SKIN, SITE, BIOPSY: 
- MODERATELY-DIFFERENTIATED INVASIVE SQUAMOUS CELL CARCINOMA, SEE COMMENT. 
- NEGATIVE FOR LYMPHOVASCULAR INVASION.
- NEGATIVE FOR PERINEURAL INVASION.

COMMENT: 
The nearest margin (lateral margin) is 1 mm.  The tumour is 9 mm in maximal dimension.
SKIN LESION, SITE, EXCISION:
- INVASIVE SQUAMOUS CELL CARCINOMA, MODERATELY-DIFFERENTIATED.
-- TUMOUR GREATEST DIMENSION: ___ CM.
-- TUMOUR THICKNESS: ___ MM.
-- LATERAL MARGINS: NEGATIVE FOR IN SITU CARCINOMA AND INVASIVE CARCINOMA.
-- DEEP MARGIN: NEGATIVE FOR INVASIVE CARCINOMA.
-- NEAREST MARGIN: 1 MM, LATERAL MARGIN.
-- NEGATIVE FOR LYMPHOVASCULAR INVASION.
-- NEGATIVE FOR PERINEURAL INVASION.
- EXTENSIVE SOLAR ELASTOSIS.
SKIN, SITE, BIOPSY: 
- INVASIVE SQUAMOUS CELL CARCINOMA, SEE TUMOUR SUMMARY.

TUMOUR SUMMARY:
Histologic type: squamous cell carcinoma, type not otherwise specified.
Histologic grade: moderately differentiated.
Greatest dimension: ___ cm.
Tumour thickness: ___ mm.
Peripheral margin: negative for invasive carcinoma and in situ carcinoma.
Deep margin (invasive component): negative for invasive carcinoma.
Closest margin: deep margin, ___ mm.
Lymphovascular invasion: not identified.
Perineural invasion: not identified.

Bowen's disease

SKIN LESION, RIGHT EAR, BIOPSY:
- SQUAMOUS CELL CARCINOMA IN SITU (BOWEN'S DISEASE), INCOMPLETELY EXCISED.

COMMENT:
Complete excision of the lesion is recommended.
SKIN LESION, CHEST, EXCISIONAL BIOPSY:
- SQUAMOUS CELL CARCINOMA IN SITU (BOWEN'S DISEASE), COMPLETELY EXCISED.
- SOLAR ELASTOSIS, MILD.
Micro

The sections show hair bearing skin. The squamous epithelium has full thickness changes including an increased nuclear-cytoplasmic ratio, loss of polarity, and nuclear hyperchromasia. Mitoses are seen in the upper third of the epithelium. Nucleoli are not apparent. No atypical cells are seen in the dermis. Parakeratosis overlies the abnormal keratinocytes. Solar elastosis is present. No melanocytic nests are identified.

Melanoma

  • Known as the great mimicker in pathology; it may look like many things.

Less common malignant

Dermatofibrosarcoma protuberans

  • Abbreviated DFSP.

Cutaneous B-cell lymphoma

  • Abbreviated CBCL.

General

  • CBCL is less common than cutaneous T-cell lymphoma (CTCL).[8]

Microscopic

Features:

  • Dermal lymphoid infiltrate.
  • "Grenz zone" - space between the epidermis and the dermal infiltrate - key feature.

IHC

  • B cell and T cell markers.

Cutaneous T-cell lymphoma

  • Abbreviated CTCL.

General

  • Mycosis fungoides - is a subtype (???).
  • CTCL is more common than cutaneous B-cell lymphoma (CBCL).[9][10]

Stages - like Kaposi sarcoma:

  • Patch.
  • Plaque.
  • Nodular.

Microscopic

  • Atypical lymphocytes:
    • Have folded "cerebriform" nuclei; Sezary-Lutzner cells.[11]
  • Grouping:
    • Nests in the epidermis - known as "Pautrier microabscesses".
    • Single lymphocytes in epidermis - without accompanying edema.
    • Short linear arrays of lymphocytes along the basal layer of the epidermis; "epidermotropism".[11]

DDx:

Images

www:

IHC

Key stain:

Other stains:

  • CD3 +ve.
  • CD8 -ve.
  • CD20 -ve (to r/o significant B cell population).
  • CD30 -ve.
  • CD5 +ve.
  • CD7 -ve (often lost first in T cell lymphomas).
  • Ki-67 high.
  • CD56 -ve.

Merkel cell carcinoma

Eccrine carcinoma

General

  • Arises from the proximal sweat duct.

Microscopic

Features:

  • Pleomorphic nuclei with nucleoli.
  • Duct-like structures - key feature.
  • Extends from dermis into epidermis (follows path of a benign sweat duct).

Notes:

Kaposi sarcoma

See Kaposi sarcoma.

Sebaceous carcinoma

Microcystic adnexal carcinoma

Trichilemmal carcinoma

General

  • Super rare.
  • Not well-described.

Microscopic

Features:[13]

  • Clear (glycogen-rich) cytoplasm in center of lesion.
  • Peripheral palisading at edge of lesion - root sheath differentiation (hair follicle).
  • Contiguous with hair follicle or assoc. with trichilemmoma.

DDx:

Lymphomatoid papulosis

General

  • Rare.
  • Benign behaviour.

Microscopic

Features:

  • Dermal lymphocytosis.
    • No epidermal lymphocytes.
  • Focal nuclear atypia.

DDx:

IHC

Rare malignant

Basosquamous carcinoma

Should not be confused with basaloid squamous cell carcinoma (AKA squamous cell carcinoma, basaloid variant).

General

Microscopic

Features:

Note:

  • Busam notes that there is disagreement about what defines this tumour;[18] however, he goes on the describe it as a collision tumour.[17]

DDx:

Intermediate

Atypical fibroxanthoma

  • Abbreviated AFX.

General

Clinical:

  • Rapid growth.
  • Elderly.
  • Good prognosis.[24]

Microscopic

Features:[25]

  • Dermal lesion - key point.
  • Marked nuclear atypia.
  • Mitoses.
  • Mulitnucleated cells.
  • Foamy cytoplasm - key feature.

DDx:

Notes:

  • No Grenz zone. (???)

Image:

IHC

Features:[25]

  • S100 -ve (done to r/o melanoma).
  • 34betaE12 -ve.
  • p63 -ve (done to exclude SCC)
    • Scant staining not considered +ve.
  • Desmin -ve (done to r/o leiomyosarcoma).

Sign out

Incompletely excised

SKIN LESION, MID BACK, SHAVE BIOPSY:
- ATYPICAL SPINDLE CELL NEOPLASM, SEE MICRO AND COMMENT.

COMMENT:
The diagnosis of atypical fibroxanthoma (AFX) is favoured.  The main differential
diagnosis is pleomorphic undifferentiated sarcoma.

The extent of the lesion cannot be determined, as it is present at the deep margin.

This lesion should be re-excised, as it could represent an aggressive malignancy.

Benign

Syringoma

General

  • Benign sweat duct tumour.
  • Eccrine differentiation.
  • Usually close to lower eyelid.[27]

Microscopic

Features:[28]

  • Proliferation of benign ducts with lined by a bilayer (as in normal sweat ducts) with abnormal architecture:
    • Tadpole like appearing ducts.

DDx:

Images:

Chondroid syringoma

  • Used to be called mixed tumour of skin.[31]

General

  • Mixed apocrine & eccrine tumour of skin, usually in the head & neck[31], especially nose and cheek.[32]
  • May be in major and minor salivary glands.[32]

Microscopic

Features:

  • Mix tumour with:[31]
    1. Epithelial component:
      • Nests of cells with:
        • Moderate dull eosinophilic cytoplasm.
        • Round/ovoid nuclei with nucleoli.
    2. Mesenchymal component - key feature:

Images:

Dermal cylindroma

General

May be familial:[34]

  • Familial cylindromatosis (autosomal dominant).
  • Brook–Spiegler syndrome.

Gross

  • Classically scalp - usually head and neck or face.

Microscopic

Features:[34]

  • Nests of cells that fit together like a jigsaw puzzle - the borders of the nests are opposed and undulate.
    1. Basaloid cells with scant cytoplasm and dark nuclei palisade around the edge of the nests.
    2. Larger cells with moderate eosinophilic cytoplasm and lighter staining nuclei are at the centre of the nests.
  • Cells nests surrounded by a band of hyaline (i.e. glassy, eosinophilic, acellular) material ~ 2X thickness of a basilar cell - key feature.
    • This is basement membrane.

DDx:

Images

www:

Stains

  • PAS +ve (basement membrane).[34]

Keratoacanthoma

Sebaceous adenoma

General

Notes:

Microscopic

Features:

  • Abnormal sebaceous glands (pale fluffy cytoplasm):
    • Increased basal epithelium.
    • Multiple dilated glands - opening to the surface.

Images

www:

Trichilemmoma

  • May be spelled tricholemmoma.

General

  • Benign neoplasm with features of the pilosebaceous follicular epithelium.[37]
  • Associated with nevus sebaceous.[38]
  • Muliple trichilemmomas associated with Cowden syndrome.[39]

Microscopic

Features:[39]

  • Superficial dermal lesion contiguous with the epidermis:
    • Core of lesion:
      • Cuboidal cells with round nuclei, eosinophilic-clear cytoplasm.
    • Periphery of lesion:
      • Surrounded by hyaline band.
      • Peripheral palisading.

DDx:

Images:

Eccrine poroma

General

  • Benign tumour arising from the distal sweat duct.
  • Erythematous - gross.

Microscopic

Features:[42]

  • Broad sheets of basaloid cells - attached to the epidermis - containing ductal structures - key feature.
  • Biphasic stroma:
    1. Edematous stroma.
    2. Sclerotic stroma.
  • Moderate nuclear pleomorphism.
  • +/-Occasional mitoses.

Notes:

  • Area above gland appears crusted.

DDx:

Images:

Nodular hidradenoma

General

  • Benign adnexal tumour.[44]

Typical locations:[43]

  • Scalp.
  • Face.
  • Trunk, anterior.

Microscopic

Features:[44]

  • Well-circumscribed dermal lesions with:
    • Back-to-back nests with a whorled appearance.
    • Spaces between cells.
    • Nuclei ovoid and centrally placed in the cell.
      • No nucleolus.
    • Cystic spaces with degenerated cells.

DDx:

Images

IHC

Features:[44]

  • CAM5.2 +ve.
  • AE1/AE3 +ve.
  • EMA +ve.
  • S100 -ve.
  • Desmin -ve.

Trichoblastoma

Trichofolliculoma

General

  • Benign.

Microscopic

Features:[45]

  • Irregular hair follicle (basilar nest of cells with an acellular hair shaft) with:
    • Smaller satellites (follicles) consisting of well-circumscribed basilar cells.

Note:

  • Lack artificial clefting between the (basilar) nests and stroma (seen in BCC).
  • Surrounding stroma does not have a basophilic tingle (seen in BCC).

DDx:

Images

www:

Apocrine carcinoma of the skin

General

  • Rare.[46]
  • Usually very good prognosis.[46]

Microscopic

Features:[46]

  • Nests.
  • Apocrine snouts - "decapitation secretion"

DDx:

Images

Stains

Features:[46]

  • PAS +ve.
  • PASD +ve.

IHC

  • GCDFP-15 (gross cystic disease fluid protein-15) +ve.[46]

Dermatomyofibroma

Should not be confused with dermatofibroma.
  • Abbreviated DMF.

General

  • Uncommon.

Microscopic

Features:[47]

  • Poorly formed fasicles parallel to the skin surface, usu. restricted to the superficial dermis.
  • Moderate cellular density - less cellular than DFSP.
  • Eosinophilic cytoplasm.

DDx:

Images:

IHC

Features:[47]

  • CD10 +ve.
  • Vimentin +ve.

Others:[47]

  • CD34 -ve.
  • Factor XIIIa -ve.
  • S-100 -ve.

Papillary eccrine adenoma

  • Abbreviated PEA.

General

  • Uncommon.
  • Benign.[48]

Treatment:

Gross

  • Central location.

Note:

  • The digital papillary adenoma is considered malignant; the AFIP says these are best classified as adenocarcinomas, i.e. digital papillary adenocarcinoma.[50]

Microscopic

Features:[51][52]

  • Well-circumscribed lesions consisting of multiple cystic spaces lined by a bilayered epithelium with:
    • Papillary projections into the lumen.
    • Amorphous eosinophilic material in the cystic spaces.
    • Surrounded by a fibrous stroma.[53]

Note:

  • May appear to have more than two cell layers.

DDx:

Image:

IHC

Outer layer of epithelium:[53]

  • SMA-alpha +ve.
  • Keratin 14 +ve.

Inner layer of epithelium:[53]

  • Keratin 8 +ve.

Other stains:[52]

  • Vimentin +ve.
  • CEA +ve.
  • EMA +ve.
  • S-100 +ve.

Sign out

SKIN LESION, LEFT PARIETAL SCALP, BIOPSY:
- PAPILLARY ECCRINE ADENOMA.

Micro

The sections show a well-circumscribed multi-locular superficial dermal lesion with a bilayered epithelium and intracystic papillary projections. The cystic spaces contain amorphous eosinophilic material. The cystic component is surrounded by a dense fibrous stroma with a mixed inflammatory infiltrate, consisting primary of plasma cells and lymphocytes.

There is no significant nuclear atypia and no mitotic activity is appreciated. The overlying epidermis matures appropriately. A granular layer is present.

See also

References

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  2. RS. 17 May 2010.
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  4. Buethe, D.; Warner, C.; Miedler, J.; Cockerell, CJ. (2011). "Focus Issue on Squamous Cell Carcinoma: Practical Concerns Regarding the 7th Edition AJCC Staging Guidelines.". J Skin Cancer 2011: 156391. doi:10.1155/2011/156391. PMC 2990020. PMID 21151529. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990020/.
  5. RS. May 2010.
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