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In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 1188 - 12th January Posted By: Guest

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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The patient is a 74 year old white man with a previous biopsy performed at another facility. An excision with margin exam is taken from the left lateral lower abdomen.

Case posted by Dr Mark Hurt


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Dr. Mona Abdel-Halim

Posted

A suspected epidermal origin is perceived in images 2 and 4, if this is the case, porocarcinoma comes first. If no epidermal connection, will like to exclude metastatic adenocarcinoma.

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Guest Giovanni Falconieri

Posted

Agree, I suspect from primary in stomach

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Robledo F. Rocha

Posted

My first impression is metastatic adenocarcinoma. Nuclear pleomorphism is too high for a tumor from prostate and the lack of intracytoplasmatic mucin makes gastrointestinal origin less likely, so lung must be considered.

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Mark A. Hurt MD

Posted

Here is a critical immunostain:

[img]https://dermpathpro.com/uploads/spot_diagnosis_comment_img/Case%201188%20-%20image%2010.jpg [/img]

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Dr. Mona Abdel-Halim

Posted

So it is metastatic hepatocellular carcinoma

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Guest Jim Davie MD

Posted

Agree with metastatic carcinoma. Favor metastatic colon adenocarcinoma at first glance.

[size=4]With positive granular staining for HSA, the differential diagnosis may swing in favor of metastatic pseudoglandular hepatocellular carcinoma, although [/size][size=4]HSA (hepatocyte "specific" antigen), despite the name, is not that specific...it can deceitfully stain positive in cholangiocarcinoma, colonic [/size][size=4]adenocarcinoma and gastric adenocarcinoma. Additional stains like CK7, CK20, AFP, etc. as part of a panel can separate these differential possibilities.[/size]

[size=2]Hep Par 1 Antibody Stain for the Differential Diagnosis of Hepatocellular Carcinoma: 676 Tumors Tested Using Tissue Microarrays and Conventional Tissue Sections. [/size][i][size=2]Mod Pathol 2003;16(2):137–144[/size][/i]
[size=2] [url="http://www.nature.com/modpathol/journal/v16/n2/full/3880729a.html"]http://www.nature.co...l/3880729a.html[/url][/size][size=2] (Free Full Article link)[/size]

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Metastatic carcinoma, be it adeno- or hepatocellular.

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Mark A. Hurt MD

Posted

Thanks everyone, especially Jim, for your comments on this case. Here is my diagnosis and micro:

[b]-- METASTATIC CARCINOMA, compatible with metastatic hepatocellular carcinoma[/b]
[b]COMMENT: [/b]I don't identify this lesion involving the margins of resection, and I don't identify any intralymphatic embolization as such, but the pattern is characteristic of metastatic carcinoma, and the immunophenotype seems to support this as compatible with metastatic hepatocellular carcinoma. The lesion is about 1.7 mm from the deep margin of resection, and adipose tissue is identified deep.


MICROSCOPIC DESCRIPTION:

There is a neoplasm in the dermis that comes close to the epidermis, but it does not actually interact with the epidermis, as it is separated by a very small grenz zone. The lesion is somewhat circumscribed with a slightly tattered border. The neoplasm has a growth pattern of small nested areas, as well as some columns and strands all meshed in a slightly fibrotic stroma. The neoplasm infiltrates the adipose tissue to some degree, and intercalates around the adipocytes individually. Cytologically, these cells have fairly large epithelioid nuclei with abundant blue-gray cytoplasm, and they have some cytoplasmic molding, but not nuclear molding. There are many mitotic figures noted throughout. A few intercellular lumina are identified as well as some intracellular lumina. The lesion inserts around smooth muscle and is to a number of small nerves in the field. Immunophenotypically, the lesion is positive, strongly with CK7 and CAM 5.2, and is strongly positive with Pancytokeratin. I am not convinced of any intralymphatic embolization with a dual stain with Pancytokeratin and D2-40. There is weak staining with CK5/6, and the lesion stains negatively with CK20, p63, prostate specific antigen, PSAP, TTF-1, D2-40, estrogen receptor, progesterone receptor, gross cystic disease fluid protein 15.

An additional battery of stains was obtained to look for different organ systems. Of these, the hepatocyte specific antigen (OCH1E5) shows strong granular staining in the cytoplasm of the neoplastic cells, and is comparable to the external control, which also has granular cytoplasmic positivity. I don't see any positivity with AMACR, CDX-2, RCC, NSE, chromogranin, or synaptophysin.

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Thank Dr Hurt for such an interesting case. I agree with all the discussions above. But as for the primary origin of the tumor, per your staining results that the CK 7 is strongly postive are rarely seen In hepatocellular carcinoma which is often CK7 and CK20 negative tumor . Like Dr Davie mentioned, Hepar 1 is not specific for hepatocellular carcinoma. I think now there is a more specific marker for hepatocellular carcinoma called Glypican 3 if you want confirm it. Just don't like the strong CK7 positivity here for considering hepatocellular carcinoma as primary.

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