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Case Number : Case 2379 - 8 August 2019 Posted By: Arti Bakshi

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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37 year old male – right axillary lymph node biopsy.Previous history of partial nephrectomy (left kidney) for clear cell renal cell carcinoma. Also history of benign adnexal tumour excised from axilla, 3 years back.

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Krishnakumar subramanian

Posted

IHC data on CAIX and CK 7 needed with a history of Clear cell RCC

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IgorSC

Posted

At first glance, it seems obviously a metastatic clear cell renal cell carcinoma. The clinical history and the histological pictures are pretty suggestive of RCC metastasis. But there is a history of a benign adnexial tumor in the axilla 3 years ago. Looking closer, we do not see the classical vasculature of RCC. There are reports of a rare nodal clear cell hidradenoma wich could be primary nodal or secondary to a "benign" metastasis. IHQ with PAX-8, RCC, p63 and keratin 5/6 could help in this differentiation.

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Meenakshi Batrani

Posted

4 hours ago, IgorSC said:

At first glance, it seems obviously a metastatic clear cell renal cell carcinoma. The clinical history and the histological pictures are pretty suggestive of RCC metastasis. But there is a history of a benign adnexial tumor in the axilla 3 years ago. Looking closer, we do not see the classical vasculature of RCC. There are reports of a rare nodal clear cell hidradenoma wich could be primary nodal or secondary to a "benign" metastasis. IHQ with PAX-8, RCC, p63 and keratin 5/6 could help in this differentiation.

Agree. Lymph node involvement by clear cell nodular hidradenoma is known. In last image, there appears to be a cystic/duct like structure with apocrine type lining. IHC needed to differentiate from RCC. 

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vincenzo

Posted

Agree with above.  There aren’t erythrocytes between clear cell nests and there is an obvious apocrine cystic change in last fig.  Thinking of a Low grade hydradenocarcinoma.  

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Yes, this is a hidradenoma showing 'benign' metastasis to lymph node. Its not a RCC for the reasons well highlighted by Igor. Immunohistochemistry confirmed a different profile for the 2 tumours.

On review, the previous skin excision of hidradenoma had been incomplete. There were no histological features of malignancy either in the first excision or in the tumour nodules within the LN.

Rare cases of  lymphatic spread of histologically benign hidradenomas  have been described. The malignant potential of this group of tumours remains uncertain, although the vast majority have an excellent prognosis. (see ref below)

This case is a few years old now and the patient has not had any further spread of disease

 

 
Am J Surg Pathol. 2012 Dec;36(12):1835-40. doi: 10.1097/PAS.0b013e3182699363.

Clear cell nodular hidradenoma involving the lymphatic system: a tumor of uncertain malignant potential or a novel example of "metastasizing" benign tumor?

Abstract

Exceedingly rare cases of neoplasms with clear-cut histopathologic features of benignity can show locoregional or even distant spread. Such cases can become putative examples of "benign metastasis" when a completely favorable clinical outcome is documented after an adequately long follow-up. We report 8 cases of morphologically benign clear cell nodular hidradenoma (CCNH) with lymphatic involvement. In 5 cases the cutaneous tumor showed small foci of intravascular deposits of neoplastic cells; in 2 cases the cutaneous tumor presented with a synchronous tumor in a regional node; in 1 case a nodal location CCNH was found with no evidence of any primary in the skin. All the cases were treated with conservative surgery and none of them showed disease progression during a follow-up period ranging from 2 to 11 years. These data suggest that in the absence of other histopathologic features of malignancy, lymphatic spread in CCNH can still carry an excellent prognosis and can be therefore considered as an example of "benign metastasis." As the latter concept can be set forth only after an uneventful long-term follow-up, in routine practice, cases of morphologically benign CCNH with lymphatic involvement are best labeled "atypical CCNH," or "CCNH-like tumor of uncertain malignant potential."

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