Case of the (undefined time period) #3

[yaah]

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Derm case for the skin lovers:

67 year old man with a "Plaque on the forearm" and no history of anything else.

Overview of shave bx:

 

[yaah]

 

[yaah]

Higher

 

[yaah]

Do you have a dx?

A ddx?

 

[beary]

Whoa, I have no idea what that is but it's very very pretty.

 

[Thaitanium]

I wouldnt say it's pretty. It looks really sexyyyyyyyyyy.

 

[djmd]

I wouldnt say it's pretty. It looks really sexyyyyyyyyyy.

Okaaaaay then... thats freaky...

Kind of like the high powers above... the close you get the scarier those cells get...

talk about variation in size...

 

[torero]

A skin case from yaah?
Got to be metastatic prostate cancer.

 

[yaah]

A skin case from yaah?
Got to be metastatic prostate cancer.

I'm on derm this month.

But your thought is a good one since this case looks exactly like Gleason 4 prostate cancer.

Further history though: Pt has no history of prostate cancer and no physical exam findings to suggest it, and his serum PSA is about 1.5.

 

[Mindy]

Met renal cell?

ddx some sort of primary cutanenous adnexal tumor with clear cell and cribiform features...

i.e. beats me. Though if you didn't rule out a renal primary, I'd be suspicious of your dx.

Mindy

 

[Matte Kudesai]

Met renal cell?

ddx some sort of primary cutanenous adnexal tumor with clear cell and cribiform features...

i.e. beats me. Though if you didn't rule out a renal primary, I'd be suspicious of your dx.

Mindy

This really does look like a metastatic RCC...... its pretty vascular and has clear cell features . RCC does have a propensity toward metastasizing to the skin. It can appear as plaques as well.
Nice Papers
Urology, Volume 63, issue 6 (June, 2004), p. 1021-1026

J Cutan Pathol. 2004 Jul;31(6):419-30

 

[dmdmd]

Acc???

 

[LADoc00]

DDX: metastatic carcinoma with ductal differentiation, eccrine ductal carcinoma, type of porocarcinoma.

follow this link and learn:
www.markwickmd.com/documents/wick_adnexal_tumors2.ppt

 

[SLUsagar]

great case, great pics.

hmm...tough one.

agree, ddx includes:
adenexal tumors, namely (nodular) clear cell hidradenoma
met saliv gland tumors, namely mucoep or acinic cell ca
met RCC


that's it for now, hopefully i'll think of more.

 

[yaah]

Funny, because I mentioned RCC to the attending and she was like, "eh, no." And then I convinced myself it didn't really look like it. But that one picture does look like RCC, including the koilocyte like cells. Staining pattern didn't really fit though. Dermpath people thought it was probably not an adnexal tumor, also based on immunostaining as well as morphology. At the edge of the tumor (not shown in the images) it looked like it was in a lymphatic.

Will post a stain tomorrow if I remember!

 

[Mindy]

It is a great case... thanks for posting, and looking forward to your consensus!

Mindy

 

[yaah]

So, it's unlikely to be an adnexal tumor because p63 and K903 are negative. CK7 and 20 were mostly negative, there was some patchy staining in one of them, can't remember which.

PSA (Pros. AP was similar but less strong)

Our dx was metastatic adenocarcinoma. We favor prostate based on morphology and immunoprofile. Because of the patient's lack of suspicion for prostate cancer (apart from being 67) we can't say for sure that it is though, although it is certainly consistent with it and prostate certainly needs to be ruled out.

I keep trying to find out what other tumors can stain for PSA - the literature doesn't help that much (IMHO). Some adnexal and breast tumors can, but usually it is not this strong (per reports).

 

[l&usibari]

I keep trying to find out what other tumors can stain for PSA - the literature doesn't help that much (IMHO). Some adnexal and breast tumors can, but usually it is not this strong (per reports).

I found out recently about another tumor that stains for PSA...someplace in the head and neck region, but I can't remember where. Perhaps salivary gland? Parotid?

Btw, I'm really not seeing the RCC in those pics. I don't get it.

Also, how did you get such fine quality photos? I'm really impressed.

 

[yaah]

I found out recently about another tumor that stains for PSA...someplace in the head and neck region, but I can't remember where. Perhaps salivary gland? Parotid?

Btw, I'm really not seeing the RCC in those pics. I don't get it.

Also, how did you get such fine quality photos? I'm really impressed.

RCC can look like almost anything at times, overall this tumor doesn't look that much like it but there are areas that make one think of it.

As far as taking pictures, we have a couple of decent cameras, basically you just have to get the lighting and the contrast right, sometimes it works better than others.

 

[dmdmd]

RCC can look like almost anything at times, overall this tumor doesn't look that much like it but there are areas that make one think of it.

As far as taking pictures, we have a couple of decent cameras, basically you just have to get the lighting and the contrast right, sometimes it works better than others.

Did you tweak the pictures with Photoshop software?

 

[Blue Fish]

Is AMACR helpful in this case?

 

[l&usibari]

Yes, salivary gland neoplasms may express PSA. I found a couple papers. Here's one:
Prostate marker immunoreactivity in salivary gland neoplasms. A rare pitfall in immunohistochemistry.Am J Surg Pathol. 1993 Apr;17(4):410-4.

 

[yaah]

Is AMACR helpful in this case?

AMACR is not really helpful for anything except small acinar proliferations in the prostate (i.e. cancer vs not cancer). It can be used to stain nephrogenic adenomas but normally that is a cautionary thing (i.e., just because a small acinar proliferation stains for AMACR doesn't mean it's prostate). AMACR stains lots of things including colon adenomas and many kidney tumors, among others.

Yes, salivary gland neoplasms may express PSA. I found a couple papers. Here's one:
Prostate marker immunoreactivity in salivary gland neoplasms. A rare pitfall in immunohistochemistry.Am J Surg Pathol. 1993 Apr;17(4):410-4.

Problem is though that PSA immunostain formulation is not consistent over the years (from what I can gather), so many early studies used different types of preparations. In general though it is good to be aware that salivary gland and occasionally breast can stain for PSA. Don't know if they will also stain for PsAP though.