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女,46岁,左拇趾肿块,1119385

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    图15P63

 2001年发现左拇趾肿块,切除,2004年复发,再次切除,现又复发,切除肿块病检。未提供前两次病检结果。

 

 

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1 楼    发表于2011-08-28 22:07:58举报|引用
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肉眼所见:灰白灰红肿物一个,体积1.2×1.2×1.1cm,上附梭形皮肤面积1.2×0.7cm,切面灰白灰红质中。

 

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2 楼    发表于2011-08-28 22:08:39举报|引用
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免疫组化:Actin(-)、Desmin(-)、SMA(-)、S-100(-)、HMB-45(-)、Vimentin(-)、GCDFP-15(-)、CD34(-)、Ki-67(+1%)、GFAP(-)、P63(+)、CK(+)。

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3 楼    发表于2011-08-28 22:12:08举报|引用
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请讨论:

1、肌上皮肿瘤?

2、多形性腺瘤?

3、上皮-肌上皮肿瘤?

4、鳞癌?觉得没有异型性,不够癌。

5、血管球瘤?IHC不支持。

6、其它。

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4 楼    发表于2011-08-28 22:28:32举报|引用
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考虑皮肤附属器肿瘤可能,无明显异型,生长方式似恶性…?

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5 楼    发表于2011-08-28 22:36:34举报|引用
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汗腺源性,低恶

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6 楼    发表于2011-08-29 13:51:13举报|引用
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典型位置典型形态的侵袭性指趾乳头状腺癌

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7 楼    发表于2011-08-29 20:44:18举报|引用
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引用 6 楼 TK1905 在 2011-08-29 13:51:13 的发言:

典型位置典型形态的侵袭性指趾乳头状腺癌


有关于“侵袭性指趾乳头状腺癌”的相关文献吗?

谢谢!

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本帖最后由 TK1905 于 2011-08-29 23:10:26 编辑
J Cutan Pathol. 1987 Jun;14(3):129-46.

Aggressive digital papillary adenoma and adenocarcinoma. A clinicopathological study of 57 patients, with histochemical, immunopathological, and ultrastructural observations.

Abstract

Fifty-seven examples of a rare eccrine sweat gland tumor (aggressive digital papillary adenoma and adenocarcinoma) were studied by means of light microscopy, electron microscopy, and immunoperoxidase techniques. The neoplasm occurred as a single, painless mass, almost exclusively on the fingers, toes, and adjacent skin of the palms and soles. Microscopic features were distinct from those of other eccrine sweat gland tumors and often led to the diagnosis of such metastatic carcinoma as that of the breast. The characteristic histologic features included tubuloalveolar and ductal structures with areas of papillary projections protruding into cystic lumina. The stroma varied from thin, fibrous septae to areas of dense, hyalinized collagen. Forty tumors were classified as adenoma (ADPA) and 17 as adenocarcinoma (ADPAca). Histologically, ADPAca was distinguished from ADPA by its poor glandular differentiation and by necrosis, cellular atypia and pleomorphism, invasion of soft tissue and bone, and invasion of blood vessels. Eighteen (50%) patients with ADPA and 8 (47.0%) who had ADPAca developed recurrent lesions (2 months to 9 years) after surgical removal of the tumor. Seven (41.2%) patients with ADPAca developed metastases, of which 5 involved the lung. Three patients died of metastases, 5 to 20 years after surgical treatment of the primary tumor. The histologic malignant features in ADPAca are indicative of potential for distant metastasis and fatality. The recognition of aggressive digital papillary adenoma and adenocarcinoma as a distinct clinicopathological eccrine sweat gland neoplasm is important because of the potential for aggressive local growth and distant metastasis.

 

2000 Jun;24(6):775-84.

Aggressive digital papillary adenocarcinoma (aggressive digital papillary adenoma and adenocarcinoma revisited).

Source

Armed Forces Institute of Pathology, Department of Dermatopathology, Washington, DC 20306-6000, USA.

Abstract

In 1987 a clinicopathologic study by the Armed Forces Institute of Pathology (AFIP) of rare sweat gland tumors, termed aggressive digital papillary adenoma and adenocarcinoma, was published. Since that time, the AFIP has continued to collect these tumors for study. Based on additional follow-up data, we think the original classification of these tumors requires revision. Sixty-seven cases of aggressive digital papillary adenoma and adenocarcinoma were studied according to their clinical characteristics and histologic features. Fifty of these were originally diagnosed as adenoma and 17 as adenocarcinoma. Follow up on 45 (67%) of the patients was obtained. None of the clinical or histologic parameters studied were found to be predictive of recurrence or metastasis, indicating that the originally proposed criteria for distinguishing between benign (adenoma) and malignant (adenocarcinoma) do not predict biologic behavior. When primary tumors were treated by subsequent reexcision or amputation, only one recurred (5%), when not so treated, 11 recurred (50%) regardless of the original diagnosis (p <0.05). Metastasis occurred in six (14%) cases and in three cases led to the death of the patient. Three of these metastatic cases had met the earlier criteria for adenoma. Pulmonary metastases were observed in five cases. No effective treatment for widespread metastatic disease has yet been developed. Because histologic features with prognostic significance could not be demonstrated in this retrospective review, we propose that all aggressive digital papillary tumors be designated aggressive digital papillary adenocarcinoma.

 

 

J Am Acad Dermatol. 2009 Feb;60(2):331-9. Epub 2008 Sep 25.

Aggressive digital papillary adenocarcinoma: a report of two diseases and review of the literature.

Source

Department of Medicine, Division of Dermatology, University of Tennessee, Memphis, Tennessee, USA. jeder2880@hotmail.com

Abstract

Aggressive digital papillary adenocarcinoma (ADPAca) is a rare, underreported, and often misdiagnosed malignant tumor of the sweat glands most commonly occurring in males in their fifties to seventies. We report two cases of ADPAca with important clinical implications. A 54-year-old man presented 3 years after digit amputation for ADPAca with new blue nodules on his arm, lymphadenopathy, and a lung nodule; he was diagnosed with and treated for metastatic ADPAca. He underwent chemotherapy, but died 4 months later. A 15-year-old boy presented with an enlarging tumor on his finger occurring after a trauma 3 years earlier. The tumor was suspected to be a deep fungal infection or pyogenic granuloma; however, results of excisional biopsy revealed an ADPAca. The patient underwent amputation and sentinel lymph node examination. No signs of metastases were found, and he is alive and well. These cases highlight both the importance of high clinical suspicion of digital tumors, even in children, enabling prompt diagnosis and treatment and also emphasize the metastatic potential of the tumor and the need for aggressive treatment and close long-term follow-up.

 

 

 

Clin Exp Dermatol. 2010 Mar;35(2):113-9. Epub 2009 Oct 23.

Aggressive digital papillary adenocarcinoma: a review.

Source

Department of Dermatology, Chang Gung Memorial Hospital, Chang Gung University college of Medicine, Taoyuan, Taiwan.

Abstract

Vigorous treatment of aggressive digital papillary adenocarcinoma (ADPA), including amputation, has been recommended by most authors, but the appropriateness and effectiveness of excision as an alternative to amputation has not been systematically evaluated. To evaluate the appropriateness and effectiveness of excision as an alternative to amputation in the treatment of ADPA, we reviewed the clinical presentations, treatments and patient outcomes presented in case reports on ADPA available on Ovid MEDLINE. We also assessed the results of immunohistochemical staining for proliferation markers in one patient in order to explain the nonaggressive nature of ADPA noted in that patient. Except for the duration of lesions, there was no significant difference in clinical outcome between the excision and amputation groups. We also found that p63 may be a useful marker for distinguishing primary ADPA from metastatic adenocarcinomas. In addition, the intensity of Ki67 expression in tumour cells may be a marker of aggressive behaviour and thus be helpful in therapeutic decision-making. Wide excision with or without sentinel lymph-node biopsy is a feasible alternative to amputation. It should be considered in patients who present with a long-standing history of ADPA without evidence of underlying bone invasion or distant metastasis and with low-intensity expression of proliferation markers.

 

 

Aggressive digital papillary adenoma/ adenocarcinoma

Introduction

There is a peculiar group of rare neoplasms which tend to occur in adults on the acral parts, in particular the fingers, toes and adjacent skin of the palms and soles, as an isolated solid or solid and cystic mass. Termed aggressive digital papillary adenoma or adenocarcinoma, this lesion presents as a tumefactive nodule on a digit and invades the adjacent soft tissue, but rarely ulcerates. Since the year 2000, the approach taken by pathologists to such neoplasms has undergone a radical change, reflecting novel publications in the peer-reviewed medical literature that in turn reflect the reported experience of national reference centers that deal with patients who develop these rare neoplasms.

Histopathology

The entity termed ‘aggressive digital papillary eccrine adenoma and adenocarcinoma’ first appeared in the English language medical literature in 1984.183 Papillary eccrine neoplasms in other anatomic locations were recognized prior to their identification in digits and other acral parts.184, 185, 186, 187 The papillary digital eccrine adenomas and adenocarcinomas typically manifest features of eccrine differentiation by virtue of showing intracytoplasmic lumina and common luminal margins (Figures 15 and 16). The neoplasm is divergent morphologically from the typical eccrine spiradenoma or eccrine acrospiroma and other allied benign eccrine adnexal neoplasms by virtue of showing a papillary or micropapillary architecture cognate to that of in-situ papillary carcinomas of ductal structures of the human breast.186, 188, 189, 190, 191, 192, 193, 194, 195, 196 In particular, these neoplasms tend to manifest areas of micropapillary projections protruding into cystically dilated luminal spaces; these micropapillary structures lack fibrovascular cores. The micropapillae comprise tufts of banal or variably atypical low columnar epithelium, sometimes showing apocrine differentiation. This constellation of findings is reminiscent of the intraductal papillomas, atypical papillomas and papillary carcinomas seen in breast ducts. Such areas may merge to form complex sheets of cells associated with stromal invasion. A subset of digital papillary eccrine neoplasms is capable of provoking distant metastatic spread with significant patient morbidity and mortality. Predicting which of these digital eccrine neoplasms belong to the subset having a metastatic potential is extremely difficult. The so-called low-grade ‘aggressive digital papillary adenoma’ is distinguished from the ‘high-grade adenocarcinoma’ by virtue of the latter showing greater pleomorphism, mitoses and necrosis. Notwithstanding the foregoing, criteria distinguishing benign from malignant eccrine neoplasms have been elusive in the literature. Currently, all such digital eccrine papillary neoplasms are lumped together and are held to have a metastatic potential, albeit the said potential is apparently greater in the more floridly atypical and mitotically active forms. Thus, the term ‘aggressive digital papillary adenoma’ favored in an earlier era seems soon to be abandoned. Earlier textbooks in the discipline,197 and some subspecialty textbooks of skin adnexal neoplasia,151 distinguish papillary eccrine adenoma of acral parts from malignant papillary eccrine tumors. In earlier works, most such neoplasms were held to represent adenomas151 lacking the capacity to generate distant metastases and/or mortality. However, even prior to 1990, it was recognized that ‘at least 40% of recurrent lesions have regional lymph node and/or pulmonary metastases’.151 The challenge of differentiating benign from malignant variants of these tumors is further clouded by the recognized capacity of histologically banal eccrine neoplasms to transform into cancers.198 The concept of progressive transformation of benign to malignant proliferations of epithelial and other cell types has long been recognized in other tissues in humans and in animals. It is thus possible, indeed even likely, that some cases of otherwise indolent digital papillary eccrine adenoma undergo malignant transformation as well.

 

Long Course Article

Modern Pathology (2006) 19, S93–S126. doi:10.1038/modpathol.3800511

Malignant adnexal neoplasms

A Neil Crowson1, Cynthia M Magro2 and Martin C Mihm3

Aggressive digital papillary adenoma/ adenocarcinoma

Introduction

There is a peculiar group of rare neoplasms which tend to occur in adults on the acral parts, in particular the fingers, toes and adjacent skin of the palms and soles, as an isolated solid or solid and cystic mass. Termed aggressive digital papillary adenoma or adenocarcinoma, this lesion presents as a tumefactive nodule on a digit and invades the adjacent soft tissue, but rarely ulcerates. Since the year 2000, the approach taken by pathologists to such neoplasms has undergone a radical change, reflecting novel publications in the peer-reviewed medical literature that in turn reflect the reported experience of national reference centers that deal with patients who develop these rare neoplasms.

Histopathology

The entity termed ‘aggressive digital papillary eccrine adenoma and adenocarcinoma’ first appeared in the English language medical literature in 1984.183 Papillary eccrine neoplasms in other anatomic locations were recognized prior to their identification in digits and other acral parts.184, 185, 186, 187 The papillary digital eccrine adenomas and adenocarcinomas typically manifest features of eccrine differentiation by virtue of showing intracytoplasmic lumina and common luminal margins (Figures 15 and 16). The neoplasm is divergent morphologically from the typical eccrine spiradenoma or eccrine acrospiroma and other allied benign eccrine adnexal neoplasms by virtue of showing a papillary or micropapillary architecture cognate to that of in-situ papillary carcinomas of ductal structures of the human breast.186, 188, 189, 190, 191, 192, 193, 194, 195, 196 In particular, these neoplasms tend to manifest areas of micropapillary projections protruding into cystically dilated luminal spaces; these micropapillary structures lack fibrovascular cores. The micropapillae comprise tufts of banal or variably atypical low columnar epithelium, sometimes showing apocrine differentiation. This constellation of findings is reminiscent of the intraductal papillomas, atypical papillomas and papillary carcinomas seen in breast ducts. Such areas may merge to form complex sheets of cells associated with stromal invasion. A subset of digital papillary eccrine neoplasms is capable of provoking distant metastatic spread with significant patient morbidity and mortality. Predicting which of these digital eccrine neoplasms belong to the subset having a metastatic potential is extremely difficult. The so-called low-grade ‘aggressive digital papillary adenoma’ is distinguished from the ‘high-grade adenocarcinoma’ by virtue of the latter showing greater pleomorphism, mitoses and necrosis. Notwithstanding the foregoing, criteria distinguishing benign from malignant eccrine neoplasms have been elusive in the literature. Currently, all such digital eccrine papillary neoplasms are lumped together and are held to have a metastatic potential, albeit the said potential is apparently greater in the more floridly atypical and mitotically active forms. Thus, the term ‘aggressive digital papillary adenoma’ favored in an earlier era seems soon to be abandoned. Earlier textbooks in the discipline,197 and some subspecialty textbooks of skin adnexal neoplasia,151 distinguish papillary eccrine adenoma of acral parts from malignant papillary eccrine tumors. In earlier works, most such neoplasms were held to represent adenomas151 lacking the capacity to generate distant metastases and/or mortality. However, even prior to 1990, it was recognized that ‘at least 40% of recurrent lesions have regional lymph node and/or pulmonary metastases’.151 The challenge of differentiating benign from malignant variants of these tumors is further clouded by the recognized capacity of histologically banal eccrine neoplasms to transform into cancers.198 The concept of progressive transformation of benign to malignant proliferations of epithelial and other cell types has long been recognized in other tissues in humans and in animals. It is thus possible, indeed even likely, that some cases of otherwise indolent digital papillary eccrine adenoma undergo malignant transformation as well.

Figure 15.
Figure 15 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Eccrine digital papillary adenocarcinoma. The low-power morphology of digital papillary eccrine carcinoma (a) is cognate to that of ductal carcinoma in situ of the breast. Within nests of neoplastic columnar epithelia are areas of confluent necrosis (b).

Full figure and legend (570K)

Figure 16.
Figure 16 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Eccrine digital papillary adenocarcinoma. The neoplastic columnar epithelia form papillary tufts and buds projecting into the dilated lumina of pre-existing eccrine structures. Due to the degree of cytologic atypia, a tumor with this architectural pattern in the breast would be considered an intermediate-grade cribriform/papillary carcinoma despite the abundant intraluminal necrosis.

Full figure and legend (209K)

It is now recognized that histologic criteria do not reliably distinguish benign (adenoma) from malignant (adenocarcinoma) in acral digital papillary eccrine adnexal neoplasms.199 Duke's paper specifically addresses and refutes the work of Kao et al,200 who felt that criteria existed to distinguish aggressive digital papillary adenoma from aggressive digital papillary adenocarcinoma histologically. In the hands of Kao et al, poor gland differentiation, necrosis, cytologic atypia, mitotic rates and invasion of soft tissue, bone or blood vessels were features that distinguished adenocarcinoma from adenoma. Despite the foregoing, the concept of papillary eccrine adenoma has persisted into the common era.201, 202, 203

Management

Management of the aggressive digital papillary adenoma and adenocarcinoma remains a controversial issue, with some authors advising digital amputation.180 In addition to high local recurrence, some 50% of tumors manifest distant metastases, typically to lungs and lymph nodes. As with acral melanomas, amputation at or above the nearest joint is one recommended strategy for local control.180, 181, 182 In part because of the rarity of these tumors, modern surgical approaches such as sentinel lymphadenectomy that are commonplace for melanomas are reportable as isolated cases when applied to the digital papillary eccrine tumors.204, 205 Currently, the use of aggressive local surgical extirpation is generally advised for any digital papillary eccrine neoplasm as the ‘originally proposed criteria for distinguishing benign (adenoma) and malignant (adenocarcinoma) do not necessarily predict biological behaviour’.205

Differential Diagnosis

Differential diagnostic considerations include the microcystic adnexal carcinoma, hidradenoma papilliferum, syringocystadenoma papilliferum and the nipple adenoma. Microcystic adnexal carcinoma shows thin vertically and haphazardly oriented columns of variably atypical epithelia surmounted by keratinizing microcysts with a granular cell lining internally. It therefore lacks the architectural organization of the papillary eccrine and apocrine neoplasms and also does not show apocrine differentiation. Stromal desmoplasia is frequent in the microcystic adnexal carcinoma and is not seen in the digital papillary neoplasms of benign character. In contrast, the digital papillary adenocarcinomas of increasing dedifferentiation show irregularly shaped and sized nests associated with pronounced stromal fibroplasia, in concert with abundant endolumenal necrosis, overt nuclear anaplasia and mitotic activity. These large tubulopapillary structures are thus strikingly different and simultaneously more cytologically atypical than the microcystic adnexal carcinoma, and should be easily distinguished even at scanning magnification. As mentioned above, they have more in common morphologically with in-situ ductal breast carcinoma than with the indolent or low-grade eccrine neoplasms. Hidradenoma papilliferum typically seen in areas of high apocrine gland concentration, such as the vulva, perineum and the axillae, exhibits large structures with a rounded peripheral contour containing papillary proliferations of apocrine epithelium lacking cytologic atypia, necrosis or mitotic activity. The syringocystadenoma typically opens to the epidermal surface, as seen in the setting of an underlying nevus sebaceus, and manifests banal apocrine epithelium admixed with cuboidal cells covering fibrovascular stromal cores which are rich in plasma cells. The nipple adenoma may also open to the epidermal surface to form the so-called ‘erosive adenoma’, and is morphologically similar to syringocystadenoma papilliferum. Furthermore, the hidradenoma papilliferum is confined, in the great majority of cases, to women. As mentioned above, the distinction of a benign eccrine papillary neoplasm from one with a metastatic potential is extremely difficult and, in the view of some authorities, impossible.

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9 楼    发表于2011-08-30 09:14:19举报|引用
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看了图结合兔疫组化考虑汗腺来源的粘液表皮样癌请查找粘液型上皮

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10 楼    发表于2011-08-31 22:03:22举报|引用
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谢谢TK1905 提供文献资料!

本例形态有点像肌上皮,而文献中的图有点像腺样,此例补做CK8/18(+)、Calponin(-)。

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11 楼    发表于2011-08-31 22:05:45举报|引用
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想听听大家的观点,报告如下可否?谢谢!

(左拇趾背侧)HE形态结合免疫组化,较支持侵袭性指趾端乳头状汗腺癌,请临床结合病史及第 一、二次病检结果综合考虑,必要时到上级医院请软组织病理专家会诊;
免疫组化:肿瘤细胞Actin(-)、Desmin(-)、SMA(-)、S-100(-)、HMB-45(-)、 Vimentin(-)、GCDFP-15(-)、CD34(-)、Ki-67(+1%)、GFAP(-)、P63(+)、 CK(+)、CK8/18(+)、Calponin(-)。
注:因本病罕见,网上经与专家讨论,依据病史及发病部位,考虑以上诊断,查阅相关文献,提示该病易局部复发(约30%),可见远处转移(约14%),常转移至肺,偶有死亡的病例报道。

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12 楼    发表于2011-09-01 01:03:34举报|引用
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侵袭性指趾乳头状腺癌要考虑。

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13 楼    发表于2011-09-01 21:02:20举报|引用
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不懂

 

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