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Historia Clínica
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A preoperative ultrasound investigation of the abdomen in a 50-years old man (who is candidate for videolaparoscopic surgery for cholelithiasis) reveals two discrete and well demarcated retroperitoneal tumor masses located close to the aortic bifurcation and the proximal tract of right common iliac artery, the largest measuring about 5 cm at its largest diameter. Apart from mild complaints due to cholelithiasis, the patient is in apparent good health and his previous clinical history is unremarkable. A fine-needle aspiration biopsy is performed on the largest tumor mass with multiple passes. Direct smears (Figs 1 to 4) and a cell block from needle rinse (Figs. 5 and 6) are prepared. Immunostaining of cell block paraffin sections for CK8,18(cam5.2), CK(AE1-AE3), S100 protein, Placental Alkaline Phosphatase (PlAP), CDX2 and CD10 give negative results.
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Un’indagine ecografica addominale condotta in un uomo di 50 anni in previsione di un’intervento di colecistectomia videolaparoscopica per colelitiasi consente di evidenziare due masse pelviche ben demarcate e separate fra loro in corrispondenza della biforcazione aortica e del tratto prossimale dell’arteria iliaca comune di destra, la maggiore di circa 5 cm di diametro. Il paziente gode di apparente buona salute fatta eccezione per la lieve sintomatologia connessa alla colelitiasi e non esiste alcun precedente anamnestico di rilievo. Si esegue prelievo bioptico aspirativo con ago sottile sulla massa maggiore con preparazione di strisci diretti (Figg. da 1 a 4) e citoincluso da lavaggio ago (Figg. 5 e 6). Colorazioni immunoistochimiche per CK8,18(cam5.2), CK(AE1-AE3), proteina S100, Fosfatasi alcalina placentare (PlAP), CDX2 e CD10 sulle sezioni in paraffina allestite dal citoincluso hanno esito negativo.
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Comentarios
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El 10/7/2005 22:42, Manuel Medina dijo:
Metástasis de tumor germinal no seminomatoso.
El 11/7/2005 8:04, Maurizio Ferretti dijo:
L'ipotesi diagnostica di metastasi da disgerminoma mi sembra la più probabile, dato che la negatività delle citocheratine fa escludere un carcinoma e quella per S-100 il melanoma. Mi piacerebbe comunque conoscere i risultati di vimentina e HMB-45, come anche i livelli sierici di AFP e beta-HCG. Un saluto a tutti. Maurizio Ferretti
El 11/7/2005 12:13, Túlio Souza dijo:
. Um diagnóstico geral para esse caso é de uma neoplasia maligna de células redondas. Para complementação do painel de imunohistoquimica, acho que está faltando alfa feto proteína, Vimentina, Beta-HCG e marcadores para linfoma . Acho que linfoma e sarcoma são dois bons diagnósticos diferenciais. The general diagnostic for this case is a malignant round small cell tumor. The immunohistochemistry study needs to be completed with alpha-fetoprotein, Vimentin, Beta-HCG and lymphoid markers. In my point of view, lymphoma and sarcoma would be good differentials diagnostics. Túlio Souza Hospital Aliança Salvador - Bahia - Brasil .
El 11/7/2005 13:11, Gregor Stransky dijo:
Plasmocytoma
El 11/7/2005 16:02, Romualdo Correia Lins Filho dijo:
Caro Dr. Giorgio As imagens parecem mostrar pequenos agregados frouxos e irregulares de células neoplásicas com citoplasma escasso a moderadamente abundante, algumas vezes exibindo vacúolos. Os limites celulares parecem ser nítidos. Alguns núcleos exibem bordos aplanados (squared-off). Os nucléolos são proeminentes e exibem formatos irregulares, alguns lembrando as letras "Y"e "H". De permeio há núcleos redondos pequenos que parecem corresponder a linfócitos. Apesar da negatividade para PLAP acredito que o diagnóstico mais provável seja o de seminoma clássico metastático (a presença de dois nódulos retroperitoneais favorece o diagnóstico de metástase) e sugeriria o exame clínico e ultrassonográfico dos testículos. Abraços Romualdo
El 11/7/2005 22:38, Ricardo Drut dijo:
La disposición no-cohesiva de las células parece favorecer el dg de Linfoma de células grandes, aunque no se reconoce la célula característica ("hallmark" cell). El panel a realizar a continuación debiera incluir CD30, CD20, CD3 (ó CD45RO) y ALK. Para evitar sorpresas y a pesar de la negastividad de la Fosfatasa alcalina placentaria, agregaría CD117 y OCT3/4, como marcadores de tumor germinal seminomatoso (además de un cuidadoso estudio clínico e imagenológico de los testículos.
El 12/7/2005 9:28, Bayardo Flores dijo:
De este enigmático caso sabemos más lo que no es que lo que puede ser. Si los datos de IHQ son confiables y estoy seguro que lo son, nos eliminan el seminoma (PLAP), el carcinoma sea de orígen renal,intestinal u otro(CKs, CD10,CDX2) el melanoma (S-100), pero quedan aún algunos tumores gonadales que podrían ser compatibles con estos resultados y faltan otros marcadores que posiblemente se investigaron: vimentina, hormonas esteroides, alfa 1 inhibina, CD117, alfa feto proteinas séricas, etc. y ante otras posibilidades diagnósticas ya citadas al menos CD45, SMA y desmina. En espera de la solución al enigma que seguramente nos senseñará mucho, los saludo.
El 12/7/2005 23:20, Manuel Torres Nájera dijo:
Tambien pienso que se trate de un plasmocitoma, claro que la inmuno más otros datos clínicos nos indiquen otra cosa, pero así de lejitos y sin mucho compromiso es un plasmocitoma. Manuel Torres Monterrey, México
El 14/7/2005 7:13, Julián José Ahijado González dijo:
Me parece un PLASMOCITOMA. Un saludo a tod@s
El 14/7/2005 16:29, David Cubero dijo:
Por la tendencia a la cohesión, pienso se trate de un tumor epitelial, a veces parece existir cierta disposición glandular, un tumor germinal es una posibilidad, otra sería la próstata o el tejido cromafin como posible histogénesis, hay que ver o mas tejido o más inmuno. Saludos David
El 14/7/2005 20:48, Giorgio Gherardi dijo:
Dear friends, After examining the FNA sample and the results of immunohistochemical investigations (no additional paraffin sections were available from the cell block material for further immunostains) we asked for further clinical investigation. The titers of serum AFP, beta-HCG and several other tumor markers were within normal values. There was no serum monoclonal gammopathy. The urologist excluded any testicular or paratesticular mass based also on ultrasound examination. CT-scan confirmed the presence of the two masses which were interpreted as metastatic lymph nodes and excluded any other tumor masses in the abdomen, thorax and brain. Positron emission tomography (P.E.T.) scanning demonstrated an accumulation of the radioactive tracer only in the pelvic area. The patient was totally asymptomatic and in apparent good health. Any suggestions? The case is less enigmatic than it would seem. Un caro saluto a tutti
El 14/7/2005 21:45, emilio mayayo dijo:
Estoy desorientado. ¿y si fueran histiocitos? una malakoplaquia? Es por dar otra opinión y animar. Saludos/saluti a tutti. Emilio
El 14/7/2005 22:46, Manuel Medina dijo:
Hola. El paciente tiene 50 años, y, en principio toda una vida por delante. Todos hemos estados de acuerdo en que es una neoplasia. Pienso que es razonable quitar al menos uno de los nódulos para estudio histológico, y tirar con la histología. Calculo que eso es lo que vais a hacer. En todo caso, por prudencia, el día antes le repetiría la ecografía testicular. Pensar en un tumor testicular quemado no sería un disparate. Saludos, M Medina
El 15/7/2005 11:51, Bayardo Flores dijo:
Con las últimas informaciones de laboaratorio se eliminaron otras posibilidades, por lo que como dice Emilio Mayayo para animar la discusión propongo una Enfermedad de Castleman, probablemente a células plasmáticas. Ciao a tutti e buone ferie!!
El 17/7/2005 2:01, Hernan Molina Kirsch dijo:
En realidad las figuras 1, 2, 5 y 6 muestran agregados epiteliodes que pueden fácilmente interpretarse como metástasis de un carcinoma. Con la ayuda de la inmuno se puede reinterpretar lo presente como: macrófagos con restos celulares intracitoplasmaticos, agregados de células histiociticas (¿o serán dendríticas?), células plasmáticas, linfocitos pequeños y maduros e inmunoblastos. ¿ Me pregunto si no se trata de una linfadenitis? Figures 1, 2, 5 and 6 showed epitheliod cell agregates easely confused with metastatic carcinoma cells. Taken into account the immuno there are macrophages, histiocytes (dendritic cells?), plasma cells, small mature lymphocytes and immunoblast. I wonder if it is a lymphadenitis?
El 17/7/2005 8:49, Juan María LOIZAGA dijo:
Ya que no es una metástasis de carcinoma, ni un tumor germinal ni parece un linfoma,según los datos aportados, pienso en un tumor retroperitoneal del tipo del RABDFOMIOSARCOMA.
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Comentario del Autor
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The immunohistochemical profile and the morphologic data of FNA biopsy did not provide conclusive data and the patient underwent an excisional surgical biopsy of the two lymph nodes for diagnostic purposes. On histology, both lymph nodes appeared to be subtotally replaced by a diffusely necrotic, solid and structureless proliferation of polygonal or elongated medium sized epithelioid cells that recapitulated the picture of the aspirate (Fig. 7). In areas, the presence of larger epithelioid cells with macronucleoli, nuclear cytoplasmic inclusions and eosinophylic to clear cytoplasm strongly suggested the diagnosis of metastatic melanoma (Fig. 8). Immunostaining of cells, as seen in Figs. 9 and 10, showed a negative reaction for S100P (Clone 15E2E2, tested in different dilutions 1:300 to 1:100) and a positive reaction for HMB-45 (dilution 1:100) and MELAN-A (Clone MART-1, dilution 1:40). S100P positivity was seen in very limited areas and in few elements (Fig. 11). Fontana-Masson argentaffin method disclosed melanin granules in sparse cells throughout the tumor (Fig. 12). The markers tested on the FNA sample were tested again with similar results. In addition, immunostaining for smooth muscle actin and desmin was negative. The positivity for HMB-45 and MART-1 strongly supported the diagnosis of metastatic melanoma and the interest of this case lies in the fact that the tumor had a minimal or negligible expression of S100P. Zubovits et al 1 studied the immunohistochemistry of melanoma metastases to lymph nodes in 126 cases and found that although the S100P expression was seen in 98% of their series, in 44% of S100P-positive cases the percentage of immunoreactive cells was less than 50%. Thus, there is an inherent variability of tissue expression of S100P and the chance of observing a S100P negativity in tissue specimens from limited sampling of metastatic melanoma can be relevant. S100P is the most sensitive marker for melanoma but it cannot be used alone especially in the context of needle biopsy samples: if HMB-45 and/or MART-1 had been tested in conjunction to S100P in our case we would have been able to correctly identify the lesion. To date, the site of the primary tumor in the current case is unknown but the clinical investigation is still in progress.
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