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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 1492- 14 March 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 50 year old white man with an excision with margin exam if malignant of a fluid filled mass taken from the right posterior scalp.

Case posted by Dr Mark Hurt


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vincenzo polizzi

Posted

Clear cell Hyadradenoma with goblet cell metaplasia 

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Raul Perret

Posted

I think there is loss of circumscription with areas of infiltrative pattern and deep extension. I dont see clear pleomorphism in these pictures neither mitosis but i would be very cautious with this lesion. I think it fits better with low grade hidradenocarcinoma or at least atypical like it is proposed by some authors: http://www.ncbi.nlm.nih.gov/pubmed/?term=Atypical+and+malignant+hidradenomas%3A+a+histological

Would perform ki67 and/or phh3. These tumors can be extremely unpredictable, I once saw a case that looked like a completely benign hidradenoma with only a small focus of loss of circumscription that thankfully was sent with a lymph node that the surgeon found suspicious during surgery. It turned out that the lymph node was metastatic so a dx of low grade hidradenocarcinoma was rendered.

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Dr. Mona Abdel-Halim

Posted

As Raul said, although not frankly pleomorphic and mitotic, one should deal with it in caution to avoid missing a hidradenocarcinoma

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vincenzo polizzi

Posted

Yes. The fig2 shows what looks like an infiltrative growth pattern but the other ones show a well circumscribed cystic lesion. Inside the cyst there is a perivascular extensive hyanilinization that could explain the infiltrative appearance. The Hydroadenocarcinoma is rare and usually starts ex Novo not by a malignant trasformation.

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vincenzo polizzi

Posted

But i agree with the Raul's sug in these cases.

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Mark A. Hurt MD

Posted

Thanks, everyone, for your comments.

 

My diagnosis was:

 

SKIN, LEFT POSTERIOR SCALP , EXCISION :

-- ACROSPIROMA (CLEAR CELL HIDRADENOMA; APOCRINE HIDRADENOMA),

INVOLVING MARGINS OF RESECTION FOCALLY

 

This lesion from the left posterior scalp is characterized by a multi-loculated, partly solid and partly cystic neoplasm composed of mainly clear cells with some solid pink cell staining zones as well as areas of goblet cells.  The cells are relatively monomorphous despite their somewhat varied cytoplasmic qualities.  The nuclei are mostly small and uniform, and the islands and papillations are enmeshed within a hyalinized stroma for the most part.  A few areas connect to the surface but most of the lesion is dermal.  Some margin involvement is noted in this lesion, so I don't think it has been completely excised.  On block A5, immunostains were applied for immunophenotyping, they show that there is PAS positive diastase labile material within the clear cells.  Mucicarmine shows that the goblet cells show strong staining. They also stain with PAS.  The lesion throughout is positive with CK7, Cam5.2, EMA, CEA, CK10 but negative with S100 protein, actin, desmin, CK20, renal cell carcinoma antibody, hepatocyte antibody, CDX2, PSA, PSAP, and TTF-1.

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