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Evangelou Z, Linos K. Nevus, melanoma or something else? Mesenchymal neoplasms with melanocytic differentiation. J Cutan Pathol 2022; 49:747-759. [PMID: 35338512 DOI: 10.1111/cup.14232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/13/2022] [Accepted: 03/20/2022] [Indexed: 11/30/2022]
Abstract
The overwhelming majority of cutaneous neoplasms with melanocytic differentiation are nevi, melanomas and more rarely melanocytomas. Nevertheless, there is also a group of mesenchymal neoplasms with genuine melanocytic differentiation which can create diagnostic difficulties with significant repercussions. These can rarely present as primary or metastatic cutaneous lesions. Theones that are relevant to a dermatopathologist include malignant melanotic nerve sheath tumor, perivascular epithelioid cell neoplasm and clear cell sarcoma. This work will provide a thorough review of clinical presentation, morphologic and immunohistochemical features as well as molecular pathogenesis of these tumors. We hope to familiarize the general dermatopathology readership with a group of neoplasms of mesenchymal lineage exhibiting melanocytic differentiation and ultimately avoid diagnostic misadventures. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Zoi Evangelou
- Department of Pathology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Konstantinos Linos
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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2
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Neumann NM, LeBoit PE, Cohen JN. Superficial Angiomyxomas Frequently Demonstrate Loss of Protein Kinase A Regulatory Subunit 1 Alpha Expression: Immunohistochemical Analysis of 29 Cases and Cutaneous Myxoid Neoplasms With Histopathologic Overlap. Am J Surg Pathol 2022; 46:226-232. [PMID: 34889853 DOI: 10.1097/pas.0000000000001851] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Superficial angiomyxomas (SAMs) are benign cutaneous tumors that arise de novo and in the setting of the Carney complex (CC), an autosomal dominant disease with several cutaneous manifestations including lentigines and pigmented epithelioid melanocytomas. Although most SAM do not pose a diagnostic challenge, a subset can demonstrate histopathologic overlap with other myxoid tumors that arise in the skin and subcutis. Traditional immunohistochemical markers are of limited utility when discriminating SAM from histopathologic mimics. Since protein kinase A regulatory subunit 1 alpha (PRKAR1A) genetic alterations underlie most CC cases, we investigated whether SAM demonstrate loss of PRKAR1A protein expression by immunohistochemistry. In our series, 29 SAM, 26 myxofibrosarcoma, 5 myxoid dermatofibrosarcoma protuberans, 11 superficial acral fibromyxomas, and 18 digital mucous cysts were characterized. Of the 29 SAM examined in this study, 1 was associated with documented CC in a 5-year-old girl. SAM tended to arise in adults (mean 49.7 y; range: 5 to 87 y). Loss of PRKAR1A was seen in 55.2% of cases (16/29) and had a male predilection (87.5%, 12/16). PRKAR1A-inactivated SAM demonstrated significant nuclear enlargement (100%, 16/16 vs. 23.1%, 3/13), multinucleation (81.3%, 13/16 vs. 23.1%, 3/13), and presence of neutrophils (43.8%, 7/16 vs. 0%, 0/13). In contrast, PRKAR1A was retained in all cases of myxofibrosarcoma (100%, 26/26), myxoid dermatofibrosarcoma protuberans (100%, 5/5), superficial acral fibromyxomas (100%, 11/11), and digital mucous cyst (100%, 18/18). Taken together, PRKAR1A loss by immunohistochemistry can be used as an adjunctive assay to support the diagnosis of SAM given the high specificity of this staining pattern compared with histopathologic mimics.
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Affiliation(s)
| | - Philip E LeBoit
- Departments of Pathology
- Dermatology
- Helen K. Diller Cancer Center, University of California, San Francisco, CA
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3
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Huang RSP, Tse JY, Harries L, Graf RP, Lin DI, Murugesan K, Hiemenz MC, Parimi V, Janovitz T, Decker B, Severson E, Levy MA, Ramkissoon SH, Elvin JA, Ross JS, Williams EA. OUP accepted manuscript. Oncologist 2022; 27:655-662. [PMID: 35552752 PMCID: PMC9355815 DOI: 10.1093/oncolo/oyac090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/23/2022] [Indexed: 11/14/2022] Open
Abstract
Background Materials and Methods Results Conclusions
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Affiliation(s)
- Richard S P Huang
- Corresponding author: Richard S.P. Huang, MD, 7010 Kit Creek Road, Morrisville, NC 27560, USA. Tel: +1 919 748 5944;
| | - Julie Y Tse
- Foundation Medicine, Inc., Cambridge, MA, USA
| | | | - Ryon P Graf
- Foundation Medicine, Inc., Cambridge, MA, USA
| | | | | | | | | | | | | | | | - Mia A Levy
- Foundation Medicine, Inc., Cambridge, MA, USA
- Rush University Medical Center, Chicago, IL, USA
| | - Shakti H Ramkissoon
- Foundation Medicine, Inc., Cambridge, MA, USA
- Wake Forest Comprehensive Cancer Center, and Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Jeffrey S Ross
- Foundation Medicine, Inc., Cambridge, MA, USA
- Department of Pathology, State University of New York (SUNY) Upstate Medical University, Syracuse, NY, USA
| | - Erik A Williams
- Foundation Medicine, Inc., Cambridge, MA, USA
- Department of Pathology, Department of Dermatology, UCSF Dermatopathology Service, University of California San Francisco, San Francisco, CA, USA
- Department of Pathology and Laboratory Medicine, University of Miami, Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospitals, Miami, FL, USA
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Pigmented Epithelioid Melanocytomas and Their Mimics; Focus on Their Novel Molecular Findings. BIOLOGY 2021; 10:biology10121290. [PMID: 34943205 PMCID: PMC8698474 DOI: 10.3390/biology10121290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/16/2022]
Abstract
Simple Summary Pigmented epithelioid melanocytoma (PEM) is a rare entity with a controversial biological behavior. Some of these tumors behave in an indolent manners while others can locally spread. Herein, we review the clinical presentations, the pathological features as well as the genomic signatures associated with this rare entity. We also report an example of a challenging case of PEM that we encountered and show how usage of novel molecular diagnostic techniques focusing helps addressing this diagnostic conundrum. Abstract Pigmented epithelioid melanocytoma (PEM) is a unique tumor with significantly pigmented appearance and indolent behavior; however, it can demonstrate cytological atypia and metastasize to local lymph nodes. Clinical and histomorphological overlap between PEM and its lower or higher-grade mimics can make it difficult to distinguish in certain cases. Genomic, transcriptomic and epigenetic data indicate that PEMs are molecularly distinct entities from other melanocytic neoplasms and melanomas. In addition, methylation studies are emerging as a tool that can be useful in difficult cases. In this review, we focus on the clinical, histopathologic and recent insights in the molecular features of pigmented epithelioid melanocytic melanocytomas and their mimics. We also present a challenging case that was resolved using methylation analysis providing a proof of concept for using epigenetic studies for similar challenging cases.
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5
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Ferrara G, Argenziano G. The WHO 2018 Classification of Cutaneous Melanocytic Neoplasms: Suggestions From Routine Practice. Front Oncol 2021; 11:675296. [PMID: 34277420 PMCID: PMC8283700 DOI: 10.3389/fonc.2021.675296] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/31/2021] [Indexed: 12/13/2022] Open
Abstract
The "multidimensional" World Health Organization (WHO) classification 2018 of melanocytic tumors encompasses nine melanoma pathways (seven of which for cutaneous melanoma) according to a progression model in which morphologically intermediate melanocytic tumors are cosidered as simulators and/or precursors to melanoma. These "intermediates" can be subclassified into: i) a "classical" subgroup (superficial/thin compound: dysplastic nevus), which is placed within the morphologic and molecular progression spectrum of classical (Clark's and McGovern's) melanoma subtypes (superficial spreading and, possibly, nodular); and ii) a "non-classical" subgroup (thick compound/dermal: "melanocytomas") whose genetic pathways diverge from classical melanoma subtypes. Such a progression model is aimed at giving a conceptual framework for a histopathological classification; however, routine clinicopathological practice strongly suggests that most melanomas arise de novo and that the vast majority of nevi are clinically stable or even involuting over time. Clinicopathological correlation can help identify some severely atypical but benign tumors (e.g.: sclerosing nevus with pseudomelanomatous features) as well as some deceptively bland melanomas (e.g.: lentiginous melanoma; nested melanoma), thereby addressing some ambiguous cases to a correct clinical management. The recently available adjuvant therapy regimens for melanoma raise the problem of a careful distinction between severely atypical (high grade) melanocytoma and "classical" melanoma: conventional morphology can guide an algorithmic approach based on an antibody panel (anti-mutated BRAF, BAP1, PRAME, ALK, TRKA, MET, HRAS-WT, ROS; beta catenin; R1alpha; p16; HMB45; Ki67), a first-line molecular study (identification of hot spot mutations of BRAF and NRAS) and an advanced molecular study (sequencing of NF1, KIT, BRAF, MAP2K1, GNAQ, GNA11, PLCB4, CYSLTR2, HRAS; fusions studies of BRAF, RET, MAP3K8, PRKCA); as a final step, next-generation sequencing can identify melanocytic tumors with rare genetic signatures and melanocytic tumors with a high tumor mutation burden which should be definitely ascribed to the category of classical melanoma with the respective therapeutic options.
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Affiliation(s)
- Gerardo Ferrara
- Anatomic Pathology Unit, Macerata General Hospital, Macerata, Italy
| | - Giuseppe Argenziano
- Department of Dermatology, 'Luigi Vanvitelli' University School of Medicine, Naples, Italy
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Saggini A. Feasibility of a Tumor Progression Model in PRKAR1A-inactivated Melanomas. Am J Surg Pathol 2021; 45:868-869. [PMID: 33949345 DOI: 10.1097/pas.0000000000001648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Andrea Saggini
- Center for Dermatopathology Freiburg im Breisgau, Germany
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7
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Benton S, Zhao J, Asadbeigi S, Kim D, Zhang B, Gerami P. Pigmented Epithelioid Melanocytoma: Morphology and Molecular Drivers. Surg Pathol Clin 2021; 14:285-292. [PMID: 34023106 DOI: 10.1016/j.path.2021.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pigmented epithelioid melanocytoma (PEM) was originally described based on keen morphologic analysis identifying a group of melanocytic tumors sharing heavily pigmented epithelioid melanocytes. It is defined as heavily pigmented epithelioid, spindled, and dendritic melanocytes with characteristic vesicular nuclei, prominent nucleoli, and melanophages. PEM often involves regional lymph nodes. Recent advances in molecular analysis have allowed for subclassification of PEM into more specific subsets of melanocytic tumors. The most common subsets include PRKCA fusions, which result in pure PEMs with sheets of monomorphic epithelioid melanocytes, and PEMs with combined pattern and mutations in both PRKAR1A and BRAF.
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Affiliation(s)
- Sarah Benton
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Jeffrey Zhao
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Sepideh Asadbeigi
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Daniel Kim
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Bin Zhang
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA
| | - Pedram Gerami
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA; Robert H. Lurie Cancer Center, Feinberg School of Medicine, Northwestern University, 676 North St Clair Street, Suite 1765, Chicago, IL 60611, USA.
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Genomic and Clinicopathologic Characteristics of PRKAR1A-inactivated Melanomas: Toward Genetic Distinctions of Animal-type Melanoma/Pigment Synthesizing Melanoma. Am J Surg Pathol 2020; 44:805-816. [PMID: 32118628 DOI: 10.1097/pas.0000000000001458] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Melanocytic tumors with inactivation of protein kinase A regulatory subunit-α (PRKAR1A) have large oval nuclei and intense pigmentation. Historically, these tumors have been categorized under various names, including epithelioid blue nevus, pigmented epithelioid melanocytoma (PEM) and animal-type melanoma. Although a subset of PEM harbor BRAF activating mutations and biallelic inactivation of PRKAR1A, there are only a few reports of melanomas, or of tumors with genomic alterations beyond those of PEMs. Herein, we describe the clinicopathologic and genetic features of 8 melanomas and tumors that lack PRKAR1α expression by immunohistochemistry but do not fit with conventional PRKAR1A-inactivated melanocytomas. These tumors tended to affect younger patients than conventional melanomas (median age=38 y) and presented as dark brown/black papules and nodules. Histopathologically, they demonstrated nodularity, sometimes in a background of conventional melanoma, and large vesicular nuclei with prominent nucleoli. With the exception of 1 case, the mitotic index was not significantly elevated. Immunohistochemically, all cases showed loss of PRKAR1α and of p16 expression. Seven tumors underwent massively parallel short read (next-generation) sequencing of a panel of 480 cancer-associated genes. Five tumors demonstrated truncating mutations of PRKAR1A and the 2 in which such mutations were not identified demonstrated loss of heterozygosity of the PRKAR1A locus. Four of the tumors harbored BRAF V600E mutations, and 1 harbored a FAM39B-BRAF gene fusion. Another harbored a GNA11 activating mutation. A MAP kinase activating mutation was not identified in the remaining case. Four tumors displayed TERT promoter mutations and chromosomal copy number changes supporting the diagnosis of melanoma. Two cases without these alterations and were classified as "high-grade PRKAR1A-inactivated melanocytomas". The 1 case with widespread metastases demonstrated mutations in TP53 and RB1. Overall, we provide the first genetic characterization of PRKAR1A-inactivated melanomas, discuss the differential diagnosis of heavily pigmented epithelioid melanocytic neoplasms, and propose a new nomenclature for such tumors.
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Williams EA, Shah N, Danziger N, Montesion M, Sokol ES, Pavlick DC, Miller VA, Ross JS, Elvin JA, Tse JY. Clinical, histopathologic, and molecular profiles of PRKAR1A-inactivated melanocytic neoplasms. J Am Acad Dermatol 2020; 84:1069-1071. [PMID: 32682887 DOI: 10.1016/j.jaad.2020.07.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 05/22/2020] [Accepted: 07/08/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Erik A Williams
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Foundation Medicine, Inc, Cambridge, Massachusetts.
| | - Nikunj Shah
- Foundation Medicine, Inc, Cambridge, Massachusetts
| | | | | | | | | | | | - Jeffrey S Ross
- Foundation Medicine, Inc, Cambridge, Massachusetts; Department of Pathology, State University of New York Upstate Medical University, Syracuse, New York
| | | | - Julie Y Tse
- Foundation Medicine, Inc, Cambridge, Massachusetts; Department of Pathology and Laboratory Medicine, Tufts University School of Medicine, Boston, Massachusetts
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Abstract
Melanotic schwannoma is a pigmented tumor of peripheral nerve differentiation. Primary cutaneous presentations are extremely rare, as the bulk of melanotic schwannomas tend to develop in paraspinal and axial sites. Tumors arise sporadically and in the setting of the Carney complex. Alterations in the gene encoding protein kinase A regulatory subunit-α (PRKAR1A) underlie most patients with the Carney complex and mediate melanotic schwannoma tumorigenesis. Melanotic schwannomas from noncutaneous sites can locally recur and metastasize widely, leading to a recent proposal to change the nomenclature to "malignant melanotic schwannian tumor." However, the clinicopathologic features of primary cutaneous melanotic schwannomas are relatively unexplored. We present a case of a nodule arising on the vulva of a 34-year-old woman. Microscopically, a dermal-based, heavily pigmented proliferation of plump spindled and epithelioid cells arrayed in nodules and fascicles was seen. Lesional cells stained positively for S100, Melan-A, and BAP1 but were negative for Prkar1α. Next-generation sequencing of a panel of 480 cancer-associated genes revealed that the tumor harbored a PRKAR1A p.S299fs truncating mutation and copy neutral loss of heterozygosity of chromosome 17q, the locus at which PRKAR1A resides. Importantly, no other genetic abnormalities or chromosomal copy number changes were identified. On the basis of combined histopathologic, immunohistochemical, and genetic features, a diagnosis of melanotic schwannoma was rendered. Overall, we present the first clinicopathologic description of a vulvar melanotic schwannoma, review the literature concerning cutaneous presentations of melanotic schwannoma, and propose that melanotic schwannian tumors native to skin may behave more indolently than their noncutaneous counterparts.
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Motaparthi K, George EV, Guo R. Distant metastasis due to heavily pigmented epithelioid melanoma with underlying
BRAF
V600E,
NOTCH1
,
ERBB3
, and
PTEN
mutations. J Cutan Pathol 2019; 46:613-618. [DOI: 10.1111/cup.13485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Kiran Motaparthi
- Department of DermatologyUniversity of Florida College of Medicine Gainesville Florida
| | - Eva V. George
- Department of DermatologyUniversity of Florida College of Medicine Gainesville Florida
| | - Ruifeng Guo
- Department of Laboratory Medicine and PathologyMayo Medical School Rochester Minnesota
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