Search

Primary cutaneous sweat gland carcinomas (SGCs) are rare tumors that commonly involve axillae, have a high local recurrence rate, and rarely show sarcomatoid transformation. A 68-year-old man presented with rapid enlargement of a previously stable, asymptomatic pea-sized nodule in the left axilla. Initial excision (with positive surgical margins) at another institution showed characteristic histologic features of a high-grade osteosarcoma and molecular analysis using a 92-gene real-time quantitative reverse transcription-polymerase chain reaction assay confirmed a diagnosis of osteosarcoma with 96% certainty. Notably, the molecular assay demonstrated consistently high relative expression of pannexin 3 (PANX3), a gene involved in normal osteoblast differentiation which, when highly expressed, strongly predicts osteosarcoma per the assay's algorithm. However, on further histologic review, the tumor also contained focal cystic areas, nests, and ducts composed of malignant epithelial cells reminiscent of SGC; these areas directly transitioned into the osteosarcomatous component and were strongly positive for pancytokeratin, CK7, and p63. Within 2 weeks, the lesion recurred and grew rapidly, prompting complete resection, histologic sections of which showed high-grade osteosarcoma without residual epithelial elements. This is the fifth report, to our knowledge, of osteosarcomatous transformation in a SGC, and the only report to date including molecular data. This case demonstrates that osteosarcoma arising from a SGC has a similar molecular profile to de novo primary osteosarcoma of bone. It also emphasizes the importance of histopathologic findings as the established diagnostic gold standard and the need to interpret molecular results within the clinical context.

Malignant melanomas are known to express vimentin, among other intermediate filaments. Though anomalous keratin expression by malignant melanoma has been reported, its frequency is not well-established and this phenomenon is not well-known. We have seen in consultation a number of malignant melanomas with anomalous expression of keratin, other intermediate filaments, or synaptophysin, and therefore studied a large group of primary and metastatic melanomas to determine the frequency of these events. About 73 cases of malignant melanoma (22 primaries and 51 metastases) from 71 patients (51 male, 20 female; mean 59 years, range 17-87 years) were retrieved from our archives. Prior diagnoses were confirmed by re-review of hematoxylin and eosin sections and relevant (e.g., S100 protein, HMB45, Melan-A, and tyrosinase) immunohistochemical studies. Available sections were immunostained for keratin (OSCAR and AE1/AE3 antibodies), desmin, neurofilament protein, glial fibrillary acidic protein, synaptophysin, and chromogranin A. Not all cases could be tested for all markers. Cases were predominantly epithelioid (48/73, 66%) or spindle cell/desmoplastic (25/73, 34%). S100 protein, Melan-A, HMB45, and tyrosinase were positive in 60/65 (92%), 34/64 (53%), 30/60 (50%), 25/48 (52%) of cases, respectively. All five S100-protein-negative cases expressed at least one of the other melanocytic markers: Melan-A (two of four, 50%), HMB45 (two of three, 67%), and tyrosinase (one of two, 50%). All cases expressed at least one melanocytic marker. Cases were positive for keratin (OSCAR, 17/61, 28%; AE1/AE3, 16/40, 40%), desmin (11/47, 24%), neurofilament protein (5/31, 16%), glial fibrillary acidic protein (3/32, 9%), and synaptophysin (10/34, 29%), typically only in a minority of cells. Chromogranin was negative (0/32, 0%). Altogether 9/73 cases (12%) showed expression of >1 intermediate filament. All S100-protein-negative melanomas showed anomalous intermediate filament expression (keratin--one case, desmin--three cases, neurofilament protein--one case). Anomalous intermediate filament or synaptophysin expression was more common in epithelioid (intermediate filament, 27/48, 56%; synaptophysin, 7/22, 32%) as compared with spindle cell/desmoplastic (intermediate filament, 8/25, 32%; synaptophysin, 3/12, 25%) melanomas. Overall, 48% (35/73) of cases showed anomalous expression of at least one intermediate filament. Anomalous expression of all intermediate filaments and synaptophysin was found in significant subsets of malignant melanoma, representing potentially serious diagnostic pitfalls. While the inclusion of consultation cases may inflate the frequency of these findings in this series, similar findings were also seen in institutional cases. Malignant melanoma showing anomalous intermediate filament and synaptophysin expression may easily be mistaken for carcinomas, rhabdomyosarcomas, and neuroendocrine tumors. Awareness of this phenomenon, careful histopathological evaluation, and an appropriate melanocytic immunohistochemical panel should facilitate the diagnosis of malignant melanoma with unusual immunophenotypes.

In the June 2011 edition of CAP Today, then-College of American Pathologists (CAP) President Stephen N. Bauer, MD, authored an article titled ‘‘50 Ways to Leave the Basement.’’ In addition to challenging pathologists and laboratory professionals to redefine pathology for our clinical colleagues, patients, and the public, the article provided specific examples of how to do so. One particular line stands out: ‘‘To secure our place in the evolving landscape, we must become aggressive intellectual and economic capitalists.’’ Aggressive, one might say, is too strong or that it connotes adversarial undertones, but aggressive we must become, as we calmly and confidently guide a detailed, well-informed dialogue highlighting our critical role in patient care. We are physicians after all, having been educated alongside colleagues who went on to become internists, neurosurgeons, and radiologists to name a few. However, legislators, clinicians, and patients are often unclear on the role of pathology as a specialty and our ability to direct cost-effective, quality care by merging diagnostic skills with guidance on ancillary testing and patient management. Similarly, as pathologists, we are often unaware of the potential effect we can and should have on the changing face of medicine. We can accomplish our collective goals and take an active stand in the evolution of health care by focusing on 3 primary objectives—that is, to educate, to motivate, and to cultivate. This article will focus on applying those objectives within the arena of health care policy.

Objectives: To define indices of completeness and accuracy of clinical information in the skin biopsy requisition form (RF) and correlate them with health care delivery outcomes and pathology service utilization. Methods: RFs in our pathology information system were reviewed and assessed for the presence of 10 clinical elements considered critical for dermatopathologic diagnosis. Accuracy was determined by reviewing corresponding clinical notes. Results: In total, 249 RFs were reviewed. In inflammatory dermatoses, provision of a clinical impression, provision of more than two elements, and achieving more than 75% accuracy were associated with improved outcomes and decreased utilization. For all nonlymphoproliferative cases, higher quality clinical information was associated with decreased turnaround time (P

Background. Malignant melanoma of the nail apparatus is exceedingly rare. Increasingly, genetic studies have been employed to aid in distinguishing between malignant melanoma and benign melanocytic nevi. Methods. Archived nail apparatus melanomas were analyzed by fluorescence in situ hybridization (FISH) using probes targeting the genes at 6p25 (RREB1), 11q13 (CCND1), 8q24.1 (MYC), 6q23 (MYB), 9p21 (CDKN2A) and the centromeres of chromosomes 8 (D8Z2) and 6 (D6Z1). The results were correlated with clinical and demographic information. Results. Mean patient age was 57.8 years (range 23-92 years). In all, 5 of 7 (71%) cases involved the upper extremity digits. RREB1 gain was seen in all cases. CCND1 gain was seen in 6 of 7 (86%) cases, 3 of which were amplified. MYB loss and MYC gain were both seen in 5 of 7 (71%) cases. Homozygous loss of CDKN2A was not observed in any case. Two of 7 (28.6%) patients had lymph node metastasis and died of widely metastatic disease. These 2 patients harbored the most genetic aberrations: gains of RREB1, CCND1, and MYC, and MYB loss. Both benign melanocytic nevi controls showed normal FISH results. Conclusions. RREB1 and CCND1 gains are common in nail apparatus melanoma as in most melanomas, and an increased number of genetic aberrations may be associated with a poorer prognosis, though the limited number of cases precludes definitive correlation. FISH appears to be a useful adjunct in the diagnosis of nail apparatus melanomas and improves diagnostic confidence even in the setting of unambiguous histomorphology.

CD30-positive cutaneous lymphoproliferative disorders, a group of T-cell neoplasms, including lymphomatoid papulosis (LyP) and cutaneous anaplastic large cell lymphoma, require careful clinicopathologic correlation for diagnosis. An association between LyP and the development of a second hematolymphoid malignancy has been established in the literature. LyP has also been reported with systemic amyloidosis, but no such reports have documented coexisting cutaneous amyloid deposition with LyP to our knowledge. A 66-year-old woman with cutaneous amyloidosis, secondary to multiple myeloma, in remission, presented with erythematous and dark-brown papules involving the right arm, scalp, and torso. Punch biopsy of the arm showed a dermal infiltrate of intermediate-sized lymphocytes, some of which displayed a plasmacytoid morphology and prominent nodular subepidermal amyloid deposition. Punch biopsy of the scalp similarly showed a nonepidermotropic dense dermal infiltrate of intermediate-sized plasmacytoid lymphocytes and multifocal amyloid deposition. Both infiltrates were immunophenotypically CD30-positive, anaplastic lymphoma kinase-negative T-cell lymphoproliferative processes. Subsequent studies showed no systemic involvement, and clinical correlation suggested a final diagnosis of LyP. We present this case of LyP, which histologically mimics a B-cell proliferation with a plasmacytoid morphology arising in association with cutaneous amyloidosis to highlight the importance of clinicopathologic correlation, a thorough battery of immunohistochemical studies, and consideration for a second hematologic malignancy arising in the setting of LyP.

Esophagitis dissecans superficialis (EDS) is a desquamative disorder of the esophagus, but there is a paucity of the literature regarding this condition. We examined our institution’s experience to further characterize clinical outcomes, and endoscopic and histopathologic features. Endoscopy and pathology databases were retrospectively reviewed from 2000 to 2013 at Mayo Clinic Rochester to identify potential cases of EDS. Medical records and endoscopic images were reviewed to identify cases, and original pathologic specimens were also reviewed. Clinical, endoscopic, and histologic characteristics of EDS were defined. Forty-one subjects were identified with a median age at diagnosis of 65.0 years (IQR 52.8–76.1) and a female preponderance (63.4 %). Many patients were taking a psychoactive agent (73.1 %) or acid-suppressive therapy (58.5 %) preceding the index endoscopy. Strips of sloughed membranes had a predilection for the distal and/or middle esophagus and resolved in 85.7 % of subjects at endoscopic follow-up. Parakeratosis and intraepithelial splitting were histologic features seen in all patients, while splitting of the connective tissue and intraepithelial bullae were seen in 46.2 and 11.1 %, respectively. There were no disease-related complications at a median follow-up of 10.4 months (IQR 1.2–17.2). EDS is likely under-recognized. A distinct endoscopic feature of EDS is “sloughing” strips of mucosa with parakeratosis and intraepithelial splitting being sine qua non histologic findings. The use of psychoactive agents (particularly a SSRI or SNRI) was prevalent at endoscopic diagnosis, although the clinical relevance of this is uncertain. EDS appears to be a benign, incidental finding without complications.

Kayexalate (sodium polystyrene sulfonate), a cation exchange resin often used to treat hyperkalemia, is known to produce gastrointestinal complications in a minority of patients. These complications range from mild gastrointestinal bleeding to perforation with acute abdomen. The typical histopathologic findings include mucosal ulceration, necrosis, and the presence of polygonal basophilic refractile crystals with a “fish scale” appearance. We present a unique case of Kayexalate crystals embedded in a perihepatic inflammatory pseudotumor, developing adjacent to a colostomy site in a 62-year-old woman following Kayexalate treatment. Microscopically, the lesion demonstrated a myofibroblastic proliferation rich in histiocytes and inflammation (lymphocytes, plasma cells, and eosinophils) as well as the presence of scattered typical Kayexalate crystals. This is the first report of extraintestinal Kayexalate identification in association with an inflammatory pseudotumor.