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June 25, 2019 Join the Discussion at #Asceconf 2019-2020 SERIES HANDOUT June 25, 2019 Challenges and Pitfalls in Cytomorphology of Melanoma Xiaoqi Lin, MD, PhD Join the discussion at #asceconf 100 West 10th Street, Suite 605 Wilmington, DE 19801 Phone: (302) 543-6583 ext 103 | Fax: (302) 543-6597 Email: [email protected] Web site: cytopathology.org 6/20/2019 ASC Cytoeconference Challenges and Pitfalls in Cytology of Malignant Melanoma Xiaoqi Lin, MD, PhD Northwestern University Chicago, IL Dr. Lin has no relevant financial and ethical conflicts to report. 1 Educational Objectives 1. Utilize a case based approach to highlight the various cytomorphologic features of melanoma in FNA smears and touch prep of cores. 2. Discuss pitfalls and differential diagnosis of melanoma cytology. 3. Discuss updated ancillary studies for melanoma. 2 Malignant Melanoma (MM) Melanoblasts are neural crest derivatives and are notorious for causing primary cutaneous neoplasms. Accounts for 1 - 3% of all malignancies. The most common primary site is skin (foot followed by maxilla and thigh). Any organ system may be involved. Metastatic melanoma of unknown origin accounts for 2 - 6% of all melanoma cases. 3 1 6/20/2019 Sampling Methodology Fine needle aspiration (FNA): Percutaneous, EUS, transcleral and vitrectomy-assisted transvitreal. Core needle biopsy (CNB) with touch preparation (TP): Percutaneous, EBUS and EUS. Body fluids. Pap smears 4 LN Staging of MM Patients US: Is a method for the early detection of clinically nonevidential metastases. Sensitivity: 25 - 50%. Specificity: 81%. Gamma probe- guided US is a highly accurate method for correctly identifying the sentinel LN. FNA: Should be performed early, which provides a diagnosis before identification of the primary lesion in up to 20% of cases. Sensitivity: 96.3%; Specificity: 98.9%. FNACs guided by palpation has sensitivity and specificity similar to that by US/gamma probe US (98.4% vs 97.2%, 100% vs 99.8%). It is still debated if US-FNAC adds significantly to the staging and management of patients with mainly thin cutaneous melanomas. For the present, sentinel lymph node biopsy remains the most accurate method of regional lymph node staging in patients with newly diagnosed melanoma. 5 27y, M H/o melanoma in the ankle Palpable groin LN 6 2 6/20/2019 Discohesive Pattern 7 Differential Diagnosis Benign lymph node Burkitt lymphoma Metastatic undifferentiated/ poorly differentiated carcinoma Metastatic melanoma 8 Differential Diagnosis Benign Lymph Node 9 3 6/20/2019 Differential Diagnosis Burkitt Lymphoma CD20 10 Differential Diagnosis Undifferentiated/Poorly Differentiated Carcinoma FISH – BRD3-NUT 11 S100 HMB45 Melan A 12 4 6/20/2019 Loosely Cohesive Clusters 3D-Dimentional Cohesive Clusters 13 Differential Diagnosis Neuroendocrine neoplasm Poorly differentiated / undifferentiated carcinoma Malignant melanoma 14 Differential Diagnosis Neuroendocrine Neoplasm Chromogranin 15 5 6/20/2019 Differential Diagnosis Poorly Differentiated/Undifferentiated Adenocarcinoma Metastatic pancreatic adenocarcinoma to left supraclavicular lymph node 16 81y, M H/o smoking and prostate carcinoma Presents with hilar and mediastinal lymphadenopathy Biopsy a 2.4cm left paratracheal node 17 Pseudopapillary Pattern 18 6 6/20/2019 Differential Diagnosis Metastatic solitary pseudopapillary tumor Metastatic melanoma 19 Differential Diagnosis Solitary Pseudopapillary Tumor -catenin 20 S100 HMB45 Melan A 21 7 6/20/2019 65y, M H/o colonic adenocarcinoma and melanoma Presents with a rib lesion 22 Plasmacytoid Cells with Binucleation / Multinucleation and Granular Cytoplasm 23 Intranuclear Cytoplasmic Invaginations 24 8 6/20/2019 Differential Diagnosis Neuroendocrine neoplasm Multiple myeloma / plasmacytoma Melanoma 25 Differential Diagnosis Multiple myeloma / plasmacytoma Kappa Lambda 26 Melan A 27 9 6/20/2019 57y, M H/o melanoma at R mid back (excision showed melanoma in situ and scar), and marginal cell lymphoma 3 cm PET avid R axillary LN 28 Spindle Cells 29 Differential Diagnosis Sarcoma, including malignant peripheral nerve sheath tumor Metastatic sarcomatoid carcinoma Metastatic melanoma 30 10 6/20/2019 Differential Diagnosis Sarcoma, Including MPNST 31 Spindle Melanoma vs. MPNST Markedly pleomorphic spindle cells forming cohesive fascicles or whorls intermingled, with individual cell apoptosis, necrosis and myxoid stroma. Spindle melanoma: Scattered epithelioid tumor cells. IHC: Positive for SOX10, vimentin and S-100 (Diffuse vs. focal). Negative for pan-CK. Melanoma tends to lose expression of HMB45 and Melan A. EM: Melanoma - Intracytoplasmic melanosomes and cisternae of rough endoplasmic reticulum with intracisternal parallel tubules 32 Differential Diagnosis Sarcomatoid Carcinoma HCC Lung RCC Thyroid AE1/AE3 Vimentin Vimentin AE1/AE3 HepPar-1 TTF1 CA IX PAX8 33 11 6/20/2019 SOX10 Desmin 34 MDM2 35 44y, F Presented as heel ulcerated lesion and enlarged inguinal LNs 36 12 6/20/2019 Lymphoma-Like Cells 37 Differential Diagnosis Undifferentiated carcinoma Lymphoma PNET / Ewing’s sarcoma Melanoma 38 Differential Diagnosis Diffuse Large Cell Lymphoma Positive for B cell markers (IHC, flow cytometry, ISH) 39 13 6/20/2019 Differential Diagnosis PNET / Ewing’s Sarcoma CD99 40 HMB45 Melan A CD3 CD20 41 67y, M H/o melanoma and prostatic adenocarcinoma, 3+3 and 3+4 Sample a 2 cm RLL nodule. 42 14 6/20/2019 Epithelioid / Spindle Cells with Pigment, Pigmented Macrophages, Necrosis 43 Differential Diagnosis Anthracotic pigment Hemosiderin pigment Melanin pigment Other sites Lipofuscin pigment Tattoo pigment 44 Differential Diagnosis Anthracotic Pigment 77y, M, with a history of melanoma; now with lung and kidney masses; sampling a 1.5 cm lung mass that was hot on PET; clinical suspicion is for metastatic disease. Reactive type II pneumocytes and macrophages 45 15 6/20/2019 Differential Diagnosis Hemosiderin Pigment 46 Differential Diagnosis Lipofuscin Pigment Thyroid Liver 47 Differential Diagnosis Tattoo SOX10 33y, F, h/o multiple melanomas, undergoing axillary LN bx. <1 cm. Pt. obtained a tattoo in the area of sample 8 years ago. 48 16 6/20/2019 S100 Melan A HMB45 PSA TTF1 49 64y, F Biopsy a thigh lesion 50 Cells with Cytoplasmic Vacuolation 51 17 6/20/2019 Melan A HMB45 52 41y, M Back lesion 2.5 cm L axillary LN 53 Ballooning Cells 54 18 6/20/2019 Differential Diagnosis Macrophages Granular cell tumor Melanoma 55 Differential Diagnosis Macrophages 56 Differential Diagnosis Granular Cell Tumor S100 Positive for SOX10; Negative for HMB45 and Melan A. 57 19 6/20/2019 S100 Melan A HMB45 CD68 58 44y, F Presented as heel ulcerated lesion Enlarged inguinal LNs 59 Small Cells 60 20 6/20/2019 Melanoma with Osteoclast-Like Giant Cells May mean a more aggressive behavior. Immunophenotype: +ve for CD68, MiTF, p16; -ve for S100, HMB45, Melan-A, SOX10, Ki67, CD163, BRAF. Melanoma with Cartilaginous Differentiation Melanoma with Rhabdoid Features Enlarged, eccentrically placed nuclei with prominent nucleoli. Moderate amount of cytoplasm possessing round, globular inclusions. IHC: +ve for S-100, HMB-45 and vimentin. Desmoplastic Melanoma Less cellular. Less often exhibited intranuclear cytoplasmic invaginations. Less mitotic figures. 61 Melanoma in Body Fluid More epithelioid feature. Intranuclear cytoplasmic invaginations: 21.9%, less. Melanin pigment: 25.0%. 62 Metastatic Melanoma in Pleural Fluid 63 21 6/20/2019 Metastatic Melanoma in Peritoneal Fluid 64 Metastatic Melanoma in CSF 65 S100 HMB45 Melan A 66 22 6/20/2019 Uveal Melanoma Spindle cells: 98% (63% mixed and 35% spindle only). Only epithelioid cells: 2%. Melanin granules were observed in 80% of samples. Iris melanoma has bland features compared with ciliary and choroidal melanoma. 67 68 SOX10 S100 Melan A 69 23 6/20/2019 Pap Smear 70 Excision of Malignant Melanoma 71 Classic Cytologic Features of Melanoma Discohesive cellular pattern (94%) (loosely cohesive pattern) Plasmacytoid morphology (78 - 88%) and spindle cells (88%) Intranuclear pseudoinclusions (63 – 100%) Macronucleoli / prominent nucleoli Binucleation (94 – 100%)/ multinucleation (44%) Cytoplasmic melanin pigments (44 – 77%), pigmented melanophages (88%) Cytoplasmic vacuolation (83 – 88%) 72 24 6/20/2019 Less Common or Significant Cytologic Features of MM Pseudopapillary pattern (19%) Pure spindle cell dominant (6%) Lymphoma-Like (6%) Balloon cells Necrosis (56%) 73 Ancillary Studies IHC Molecular studies Cell blocks Cores Direct-smear / cytospin / liquid-based slides 74 Immunohistochemistry of MM Immunomarkers Positivity SOX10 100% S100 87 - 95% Melan A/MART-1 88% HMB45 81% MiTF 83 – 90% KBA.62 75% COX-2 100% CD117 46% Pan-CK Negative Desmin Negative CD45 Negative Glypican-2 Negative 75 25 6/20/2019 Expression of SOX10 in Neurogenic Neoplasms Neoplasms SOX10 Neoplasms SOX10 Benign PNST 100% Nerve sheath myxoma 100% Cellular blue nevus 100% Neuroblastoma 62% Clear cell sarcoma 95% Neurofibroma 100% Granular cell tumor, S100+ 100% Neurothekeoma 0% Granular cell tumor, S100- 0% Olfactory neuroblastoma 71% MPNST 22% Paraganglioma 75% Melanoma, metastatic 95% Perineurioma 0% Melanoma, desmoplastic 96% Schwannoma, soft tissue 99% Melanoma, sinonasal 88% Schwannoma, GI-tract 100% Miettnen M, et al. Am J Surg Pathol. 2015 39:826-35. 76 Expression of SOX10 in Soft Tissue Neoplasms Neoplasm SOX10 Ossifying fibromyxoid tumor 4.3% Rhabdomyosarcoma, alveolar 7.4% Neoplasms negative for SOX10: Alveolar soft part sarcoma, angiosarcoma, benign fibrous histiocytoma, chondrosarcoma, dermatofibrosarcoma
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