Case Number : 82 Posted By: Guest

Phillip McKee - Overseas Consultations (Arizona, USA) Wrote:

The final diagnosis is Trichilemmal Carcinoma. Elsewhere mitotic figures and basement membrane thickening are present. Naturally, off a single image you are often left with a differential diagnosis so those who did not get it don't worry. Have a lovely weekend and see you next week.

Submitted on 01/10/2010 21:02
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Juan Carlos Garcés - Hospital Oncológico /Hospital Luis Vernaza (Guayaquil, Ecuador) Wrote:

I love this place.. I am learning a lot every day.. Thanks Prof. Mckee for the opportunity.. Thans Dr. Carr for your educative comments. Have a good weekend!!

Submitted on 01/10/2010 20:38
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Jonathan Shelton - UK () Wrote:

A difficult case - clear cells with palisading and necrosis - mild atypia - for me the necrosis would not be acceptable so I would go for tricholemmal carcinoma.

Submitted on 01/10/2010 17:57
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Donald Gates - Florida (USA) Wrote:

Hello, just dreaming about the weekend and the clear cells with necrosis looks like a hidradenocarcinoma (if not connected to epidermis) or a clear cell porocarcinoma

Submitted on 01/10/2010 17:09
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Carlos - (Spain) Wrote:

Dear All, I love coming on this site as the discussion is wonderful and very educational. I have just finished dreaming about the weekend and would like to suggest trichilemmal carcinoma.

Submitted on 01/10/2010 17:05
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Phillip McKee - Overseas consultations (Arizona) Wrote:

Dear All, thank you for your comments; again a special thanks to Richard for his insightful analysis of the case. The atypia is significant in this case!! and if you are thinking adnexal you are in the right ball park. All to be revealed later.

Submitted on 01/10/2010 16:54
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Marcela Saeb Lima - Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán" (Mexico City) Wrote:

Talking for my self, I can not be assertive in most of the cases because I do not have the whole histopathological and clinical settings. For this case I would support Dr Juan Carlos Garces, whom by the way, is usually correct in the diagnoses.

Submitted on 01/10/2010 16:37
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Eman El-Nabarawy - Cairo University (Egypt) Wrote:

I have been thinking, reading, searchin all the day verifying the 2 DD trichilemmal carcinoma and hidradenocarcinoma, finding both good ideas. I will favor trichilemmal carcinoma, as after the valuble comment of Dr Carr, at last found the follicular clue in this photo and at the same time cant find any intracytoplasmic lumina which is an important feature of hidradenocarcinoma. Vey difficult case.

Submitted on 01/10/2010 16:28
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Richard A. Carr - Warwick (UK) Wrote:

Well my attempt to create more discussion perhaps has back-fired as the posts today are dissappointingly few. Perhaps it is just a busy friday for everyone dreaming of the weekend. I really hope it is not because people don't like a challenge. This case based on one high power field is a great challenge. Phillip usually tries to help us as much as possible with a diagnosis. Is necrosis diagnostic of malignancy. The answer is no of course. This field for me lacks "significant" "bowenoid" cytological atypia so I personally would be very wary about making a diagnosis of malignancy based on this field. I think by Dr Martinez-Luna and Dr Carces are on the right track suggesting a tricholemmal tumour. In the left of the field with have the characteristic reversed polarity (nucle orientated away from the basal layer)of the pale cells and a quite distinct basement membrane typical of the outer root sheath differentiation we are seeing. The suggestion of hidradenoma/hidradenocarcinoma is a good one and keratinisation is certainly seen in these tumours as well (quite often the ducts in these tumours are lined by a keratinising cuticular lining and this may show parakeratosis. That said I favour this tumours as a tricholemmoma (much more common) or a tricholemmal carcinoma. Interestingly there are very few reports to truely infiltrative tricholemmal carcinomas in the literature and they are said to be similar in behaviour to nodular BCC. If you want to confirm a tricholemmoma (usually a clinically non-descript lesion on the central face, but assoc. with Cowden's when multiple - an important cancer syn.) do a CD34 (they are always strongly positive in between 10% to 50% of the characteristically bulbous epithelium. Watch or for the desmomplastic variant in superficial shaves that is frequently mis-diagnosed as an invasive squamous cell carcinoma (based on "some atypia"). Incidentally these lesions are usually pale rather than clear and we have seen a number of basaloid variants very closely mimicking BCC. Having said all this I am probably totally wrong but at least I had a go!! Regards to all. Richard.

Submitted on 01/10/2010 16:09
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Lushen Pillay - Wits Dermatology, South Africa (South Africa) Wrote:

I see some atypia, but can't be sure of a definitive diagnosis. Eagerly awaiting it :-)

Submitted on 01/10/2010 14:31
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Juan Carlos Garcés - Hospital Oncológico / Hospital Luis Vernaza (Guayaquil Ecuador) Wrote:

Sorry Dr. Carr.... Sometimes I it is very diffult to make a correct diagnosis with only one high power field.. So I put my firt impresion...An epithelial neoplasma with squamoid cells, some of them clear, with well defined membranes, queratinization and necrosis.. probably malingnant because of the necrosis.. probably Tricholemal carcinoma.

Submitted on 01/10/2010 14:29
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Mona Abdel-Halim - Dermatology Department, Faculty of Medicine, Cairo University (Egypt) Wrote:

What I percieved here is a solid neoplasm with area of necrosis. The nuclei look very variable in their outlines (iregular nuclear membranes) but they don't appear to me that much hyperchromatic. No mitoses is seen. I studied the cellular features. I think that some cells are rounded, others are polygonal and very few are fusiform. The cell membranes are distinct. The cytoplasm of some of the cells is clear but the majority have esinophilic cytoplasm. I am not sure about an intracytoplasmic lumen formation in the right part of the field (I might be wrong and will be glad if Dr Carr gave us a comment about this). I am thinking of hidradenocarcinoma especially that I have read about a deceptively bland appearance in some cases. Nice case. Looking forward to a detailed educational comment from Dr Carr as we have got used to!!

Submitted on 01/10/2010 08:28
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Eman El-Nabarawy - Cairo University (Egypt) Wrote:

On this site, I really appreciate the descriptive comments of Dr Carr and Dr Carlos. I learn from them a lot.Thanks.Agree with Dr Carr.

Submitted on 01/10/2010 07:27
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Richard Carr - Warwick (UK) Wrote:

Dear Colleagues - I hope we are not in future to base all diagnoses of malignancy on "some atypia"! Please can we have some objective criteria?

Submitted on 01/10/2010 06:59
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Juan Carlos Garcés - Hospital Oncológico / Hospital Luis Vernaza (Guayaquil, Ecuador) Wrote:

Good evening.. agree with Eduwiges.. Tricholemal carcinoma

Submitted on 01/10/2010 05:01
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Eduwiges Martínez-Luna - Hospital Gea González (trainee) (Mexico City) Wrote:

I can see a folicular diferenciation with clear cell, but there some atypia, I think tricolemal carcinoma ?

Submitted on 01/10/2010 03:07
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