Clear cell eccrine carcinomas of the skin. A clinicopathologic study of nine patients

Hidradenoma of Pinna -Report of a Rare Case at a Rare Site

There are various reports of hidradenoma of cartilaginous part of external auricular canal (ear), but the documented evidence of occurrence of hidradenoma of pinna is seldom available in world literature, hence we report one such case. The patient was a 45-year female with a lump in the region of the posterior aspect of the pinna of the right ear for the past 6 months. No history of pain except for serous discharge from the lump. FNAC of the lump showed histological feature of hidradenoma. Wide surgical excision of the lump was done under local anaesthesia and sent for histopathological examination. HPE confirmed the diagnosis of Hidradenoma. She is on follow up, till date no sign of recurrence.

Pseudosquamous Adenocarcinoma of the Lung: Clinicopathologic and Immunohistochemical Study of 10 Cases

Pseudosquamous adenocarcinoma of the lung is an unusual morphologic variant of poorly differentiated non-small cell lung carcinoma that superficially resembles a squamous cell carcinoma. We have examined 10 cases of these tumors in 4 women and 6 men, aged 47 to 93 years. The tumors were all peripheral and measured from 1.5 to 5.5 cm. All cases were characterized by solid nests of large polygonal tumor cells containing atypical nuclei with abundant cytoplasm and sharp cell borders, adopting a pavement-like architecture that simulated squamous cell carcinoma. Some cases demonstrated intracytoplasmic hyaline inclusions suggestive of keratinization. The nests of tumor cells often showed central comedo-like areas of necrosis. Intercellular bridges were not seen in any of the cases. The tumors often displayed marked clearing of the cytoplasm enhancing their epidermoid appearance. In 4 cases, the solid pseudosquamous areas were seen to merge with a focal lepidic adenocarcinoma component, and in 1 case, abortive microscopic foci of acinar differentiation were also noted within the tumor. One case showed focal sarcomatoid spindle cell areas. The tumor cells were negative for p40 and CK5/6 and labeled with TTF1 or Napsin-A, confirming an adenocarcinoma phenotype. Clinical follow-up information was available in 8 patients; 6 patients died of their tumors between 6 months to 11 years after diagnosis (mean: 3.1 y). One patient died of complications related to surgery and one patient with a low-stage tumor died at 27 years from other causes. Solid pattern adenocarcinomas can be confused for squamous cell carcinoma and may require immunohistochemistry to determine their true phenotype.

Sweat Gland Carcinoma of the Head and Neck: Case Report and Literature Review

INTRODUCTION

The main aim of this article is to discuss and summarize the research advancements and the treatment methods for sweat gland carcinoma (SGC) based on 2 cases of SGC in our hospital and the related literature.

CASE REPORT

This article presents 2 patients with SGC who were treated in the China Medical University, Liaoning Provincial Key Laboratory of Oral Diseases from 2007 to 2019. We analyzed the clinical features, therapies, and prognosis of the patients and searched for related literatures.

DISCUSSION

Two patients underwent extended resection for local lesions with no adjuvant radiotherapy. Neither local recurrence nor distant metastasis was detected during follow-up. Reviewing previous literature, the treatment of SGC includes surgical resection, radiotherapy, and chemotherapy. We have not found an effective treatment. The prognosis of SGC occurred in head and neck is relatively good compared with another primary-site location, primary surgical excision with safe resection margins and neck dissection is recommended.

An Unusual Presentation of Nodular Hidradenoma

Benign adnexal neoplasms are quite a common occurrence in adults, especially in the head and neck region. They raise suspicion for malignancy if there are red flag signs like rapid increase in size, pain, ulceration or recurrence. We hereby report a case of a middle-aged gentleman who consulted our surgical OPD with right-sided neck swelling, which was initially thought to be a dermoid cyst; on further evaluation, found to be a dermal sweat gland tumour with features of nodular hidradenoma. The point that is of interest but coincidence to note is that this swelling was preceded by a minor trauma. Characterising these swellings using simple imaging and pathological investigation modalities is important to study their behavioural pattern and add the same to our existing database. This will also help the treating surgeons to keep in mind the possibility of occurrence of such histologies in soft tissue swellings when they present with uncommon clinical features, instead of brushing them aside as the common epidermal or dermoid cysts. Incidence of malignancy is almost nil in nodular hidradenoma, which when found, is attributed to poor surgical clearance; hence the prudence to operate with adequate clearance is extremely significant in preventing the transformation of a mole into a mountain.

Prognostic analysis of hidradenocarcinoma: a SEER-based observational study

BACKGROUND

Hidradenocarcinoma is a rare malignancy of sweat gland differentiation. Published literature has reported that hidradenocarcinoma has a high recurrence and metastasis rate, and the prognosis is extremely poor. However, the sample sizes included in these studies are insufficient, and therefore, the findings are doubtful.

MATERIALS AND METHODS

Clinicopathological characteristics and survival data of 289 hidradenocarcinoma patients were extracted from the SEER database (covering 18 registries, 2000-2018) released in July 2021. The distribution of clinicopathological characteristics was compared using the Pearson chi-square test. Overall survival (OS) and cancer-specific survival (CSS) were analysed using the log-rank test and univariate analysis.

RESULTS

The primary site of hidradenocarcinoma in 121 patients was located in the head and neck, accounting for 41.9%, and the others were located in the trunk and limbs. For hidradenocarcinoma, the mean OS and CSS were 164 months and 165.9 months, respectively; the 10-year OS rate and CSS rate were 60.2% and 90.5%, respectively. Survival analysis showed that the primary site, sex, age, race, histologic grade, stage, and surgery are not associated with hidradenocarcinoma patients' OS or CSS. For head and neck hidradenocarcinoma or trunk and limbs hidradenocarcinoma, sex, age, race, histologic grade, AJCC stage, and primary site surgery are still not related to prognosis. Tumour size is correlated with patients' OS rather than CSS.

CONCLUSIONS

Hidradenocarcinoma is a malignant tumour with a good prognosis, which is different from previous views. Tumour size is inversely proportional to patients' overall survival time affecting the OS and CSS of patients. Improving health awareness, initial histological examination and timely surgery are the keys to improving the prognosis.

Malignant Nodular Hidradenoma of the Left Knee: A Malignant Mystery With an Overview of Literature

Malignant nodular hidradenoma is a rare eccrine sweat gland neoplasm characterized by recurrence, metastasis, and a locally aggressive course. In our case report, a 74-year-old man presented with a seemingly benign swelling which was persistent for the last 30 years, which was excised at an outside institute. Since the patient presented to the hospital during the peak of the pandemic, considering the age of the patient, the pandemic situation, the logistics of radiotherapy during such a situation, preserving the knee joint function in view of close proximity of the tumour to the joint, it was decided to keep the patient on follow up and continue expectant management. After a follow-up period of 24 months, no locoregional recurrence or metastasis has been observed. The patient is on annual follow-up with clinical examination and PET-CECT imaging.

Rapidly Enlarging Hidradenoma of the Eyelid

Hidradenoma is a rare benign neoplasm, with few cases reported to involve the eyelid. When affecting the eyelid, hidradenomas may mimic other benign or malignant lesions. Rarely, a benign hidradenoma may transform into a malignant hidradenoma and metastasize. The authors present a case of a benign hidradenoma arising from the eyelid, presenting with rapid growth, ulceration, and bleeding, suggestive of a malignant lesion.

Giant metastasizing malignant hidradenoma in a child

An 8-year-old girl presented with a scalp swelling. The swelling was recurrent, reappearing everytime after local excision. She underwent surgery and the histopathologic diagnosis was malignant hidradenoma. This very rare and aggressive tumor is known to occur in elderly population and is histopathologically distinct from its commonly occuring benign counterpart. Malignant hidradenoma is resistant to chemotherapy and radiotherapy. We empahsize that being cognizant of the possibility of this rare tumor would assist in timely action in the form of wide resection, with possible reduction in morbidity and mortality.

Clear cell proliferations of the skin

Clear cell proliferations of the skin consist of a diverse group of lesions characterized by the presence of cells with abundant clear cytoplasm. They may arise from primary, metastatic, or non-neoplastic origins, with their distinctive cytoplasmic clearing attributable to causes ranging from artifact to accumulation of materials such as glycogen, mucin, or lipids. Despite the heterogeneity of these lesions, their distinguishing characteristics may be subtle, especially at high power. As such, histologic diagnosis can be challenging, and proper consideration relies on an understanding of the scope of possible origins, etiologies, and key immunohistochemical staining patterns of the various entities. This review categorizes cutaneous clear cell neoplasms by histogenesis, and offers differential diagnostic strategies to aid in their clinicopathologic evaluation.

Whole exome sequencing of a patient with metastatic hidradenocarcinoma and review of the literature

Hidradenocarcinoma is a rare malignancy of the sweat glands with only a few cases reported in literature. The management of these tumors is based on the extent of disease with local disease managed with surgical resection. These can tumors carry a high potential of lymphatic and vascular spread and local and distant metastases are not uncommon. Given the rarity of the tumor and lack of genetic and clinical data about these tumors, there is no consensus on the proper management of metastatic disease. Here in we report the first case of metastatic hidradenocarcinoma with detailed molecular profiling including whole exome sequencing. We identified mutations in multiple genes including two that are potentially targetable: PTCH1 and TCF7L1. Further work is necessary to not only confirm the presence of these mutations but also to confirm the clinical significance.

Malignant eccrine hidradenoma

Hidradenomas are adenomatous tumors of sweat gland origin that are usually benign and can occur in any cutaneous skin surface. When malignant, the tumors have high recurrence rates and are often fatal. Because of their infrequency and clinical ambiguity, hidradenomas are often misdiagnosed as other soft-tissue masses. Radiation and chemotherapy have not shown to be of benefit; therefore, wide aggressive excision and lymphadenectomy are currently the treatments of choice. We present the case of a patient with a malignant hidradenoma presenting in her medial heel. After excisional biopsy identified the tumor, the patient was successfully treated with wide excision and delayed closure via vacuum-assisted closure.

Apocrine-eccrine carcinomas: molecular and immunohistochemical analyses

Apocrine-eccrine carcinomas are rare and associated with poor prognosis. Currently there is no uniform treatment guideline. Chemotherapeutic drugs that selectively target cancer-promoting pathways may complement conventional therapeutic approaches. However, studies on genetic alterations and EGFR and Her2 status of apocrine-eccrine carcinomas are few in number. In addition, hormonal studies have not been comprehensive and performed only on certain subsets of apocrine-eccrine carcinomas. To investigate whether apocrine-eccrine carcinomas express hormonal receptors or possess activation of oncogenic pathways that can be targeted by available chemotherapeutic agent we performed immunohistochemistry for AR, PR, ER, EGFR, and HER2 expression; fluorescence in situ hybridization (FISH) for EGFR and ERBB2 gene amplification; and molecular analyses for recurrent mutations in 15 cancer genes including AKT-1, EGFR, PIK3CA, and TP53 on 54 cases of apocrine-eccrine carcinomas. They include 10 apocrine carcinomas, 7 eccrine carcinomas, 9 aggressive digital papillary adenocarcinomas, 10 hidradenocarcinomas, 11 porocarcinomas, 1 adenoid cystic carcinoma, 4 malignant chondroid syringomas, 1 malignant spiradenoma, and 1 malignant cylindroma. AR, ER, PR, EGFR and HER2 expression was seen in 36% (19/53), 27% (14/51), 16% (8/51), 85% (44/52) and 12% (6/52), respectively. Polysomy or trisomy of EGFR was detected by FISH in 30% (14/46). Mutations of AKT-1, PIK3CA, and TP53 were detected in 1, 3, and 7 cases, respectively (11/47, 23%). Additional investigation regarding the potential treatment of rare cases of apocrine-eccrine carcinomas with PI3K/Akt/mTOR pathway inhibitors, currently in clinical testing, may be of clinical interest.

Role of immunohistochemistry in diagnosing tumors of cutaneous appendages

In recent years, there has been significant progress in immunohistochemistry as an ancillary tool in diagnostic dermatopathology. In most instances, the histologic diagnosis can be rendered with the routine histologic sections; however, immunohistochemistry can help to narrow the differential in diagnosing neoplasms of cutaneous appendages in some settings including adnexal versus epidermal origin, benign versus malignant adnexal neoplasms, and primary adnexal carcinoma versus cutaneous metastases as outlined in this review.

Clear cell variant of squamous cell carcinoma originating in the esophagus: report of a case with immunohistochemical and oncogenetic analyses

The cutaneous clear cell squamous cell carcinoma (SCC) is a rare tumor thought to be associated with hair follicle or skin appendage differentiation. We report herein a rare variant case of a clear cell SCC originating in the esophagus. A 70-year-old Japanese man was found to have a tumor in the esophagus. The excised neoplasm showed dominance of clear cell over conventional SCC components; the two components in an apparent continuum. The clear cells, regular in size with a moderate nuclear/cytoplasmic ratio and relatively hyperchromatic and centrally located nuclei, were compactly arranged in sheets. Glycogen deposition was apparent on PAS staining with or without diastase digestion and under the electron microscope. The clear cell SCC components were positive for cytokeratin (CK)7, CK8, CK18 and CK19, but were negative for CK5/6 or CK14. Reciprocal staining patterns of CKs were apparent in conventional SCC components. The present case and cutaneous clear cell SCC counterparts share some histopathologic characteristics whereas CKs expression differs between the two. Overexpression of p53 protein, without evidence of any mutation, and reduced p16(INK4a) were noted in both clear cell and conventional SCC components. No mutations of Kras, BRAF or β-catenin genes were found in both tumor components.

A potential role for targeted therapy in a subset of metastasizing adnexal carcinomas

Metastasizing adnexal carcinomas are rare; thus, currently there is no uniform treatment guideline. Chemotherapeutic drugs that selectively target cancer-promoting pathways may complement conventional therapeutic approaches. We performed immunohistochemistry (epidermal growth factor receptor (EGFR), HER2, and CD117), EGFR and ERBB2 fluorescence in situ hybridization (FISH), and multiplexed SNaPshot® genotyping (testing for recurrent mutations in 15 cancer genes including BRAF, EGFR, KRAS, PIK3CA, and TP53) on primary tumors and corresponding metastases of 14 metastasizing adnexal carcinomas (three apocrine, six eccrine, two hidradenocarcinomas, two porocarcinomas, and one aggressive digital papillary adenocarcinoma). Metastasis to regional lymph node was most common, followed by skin and then lungs. Follow-up was available in 12 patients (5 months to 8 years) with 1 died of widespread metastases. Although EGFR overexpression was a prevalent feature in this cohort, seen in 7/11 (64%) primary tumors and 10/14 (71%) metastases; FISH for EGFR gene amplification was negative in 9 tested primary tumors and 12 metastases. FISH of the one primary tumor and three metastases with 2+ HER2 overexpression revealed a low level of ERBB2 gene amplification in one apocrine carcinoma and corresponding metastasis. CD117 expression was seen only in rare cases. PIK3CA (2/12, 17%) and TP53 (3/12, 25%) mutations were detected in two (one hidradenocarcinoma, one porocarcinoma) and three (one eccrine, one hidradenocarcinoma, and one aggressive digital papillary adenocarcinoma) cases, respectively. The role of EGFR inhibitor therapy in metastasizing adnexal carcinomas with protein overexpression remains unclear. Targeted therapy including PI3K pathway inhibitors might be a potential treatment for rare cases of adnexal carcinomas with metastases.

The use of immunohistochemistry in the diagnosis of metastatic clear cell renal cell carcinoma: a review of PAX-8, PAX-2, hKIM-1, RCCma, and CD10

The diagnosis of metastatic clear cell renal cell carcinoma may be difficult in some cases, particularly in the small image-guided biopsies that are becoming more common. As targeted therapies for renal cell carcinoma are now standard treatment, the recognition and diagnosis of renal cell carcinoma has become even more critical. Many adjunctive immunohistochemical markers of renal epithelial lineage such as CD10 and RCCma have been proposed as aids in the diagnosis of metastatic renal cell carcinoma, but low specificities often limit their utility. More recently described markers (PAX-2, PAX-8, human kidney injury molecule-1, hepatocyte nuclear factor-1-β, and carbonic anhydrase-IX) offer the potential for greater sensitivity and specificity in this diagnostic setting; however, knowledge of their expected staining in other neoplasms and tissues is critical for appropriate use. In this review, we discuss the most widely used immunohistochemical markers of renal lineage with an emphasis on their sensitivity and specificity for metastatic clear cell renal cell carcinoma. Subsequently, we present a variety of organ-specific differential diagnostic scenarios in which metastatic clear cell renal cell carcinoma might be considered and we propose immunopanels for use in each situation.

A case of clear cell eccrine porocarcinoma

Eccrine porocarcinoma (EP) is a rare malignant tumor arising from the intraepidermal eccrine duct. The tumor cells frequently contain glycogen, but prominent clear cell changes in EP are rarely reported. A 78-year-old woman presented with a slightly pruritic, erythematous, verrucous plaque on her left thigh. Histopathological examination revealed intraepidermal tumor cell nests composed of small basaloid cells and duct-like structures lined by periodic acid-Schiff (PAS)-positive cuticles. Besides the typical findings of EP, clear cell changes were predominantly observed in the tumor cell aggregations. Herein we report a case of the clear cell variant of EP rarely reported in previous literature.

Giant clear cell hidradenoma of the knee

Hidradenomas, also referred to as nodular hidradenomas or clear cell hidradenomas (CCH), are benign cutaneous eccrine tumors usually 2-3 cm in dimension. Hidradenomas are relatively common; however, giant forms are rare. We report a case of an 8.0 x 6.0 x 3.0 cm clear cell hidradenoma of the left knee in a 43-year-old man. The tumor was mobile, located above the patellar tendon and was without bony involvement on imaging studies. Grossly, the resected tumor was unencapsulated and tan, with a solid and cystic cut surface showing papillary excrescences on the cyst wall. Microscopically, the tumor cells showed an infiltrative growth pattern at the periphery, however, the tumor cytology was bland and no necrosis or mitoses were identified. The overlying dermis contained hemosiderin pigment deposition and infiltration with eosinophils. Immunohistochemically, tumor cells were positive for cytokeratin, CAM5.2, p53, carcino-embryonic antigen (CEA) and epithelial membrane antigen (EMA), and negative for CD10 and Ki-67. The cytological features of hidradenomas can present diagnostic challenges, as other 'clear cell' tumors such as metastatic renal cell carcinoma should be considered. Immunohistochemical studies and differential diagnoses are discussed.

Cutaneous hidradenocarcinoma: a clinicopathological, immunohistochemical, and molecular biologic study of 14 cases, including Her2/neu gene expression/amplification, TP53 gene mutation analysis, and t(11;19) translocation

We present a series of 14 cases of cutaneous hidradenocarcinomas. The patients included 6 women and 8 men ranging in age at diagnosis from 34 to 93 years. All but 1 patient presented with a solitary nodule. There was no predilection site. One patient presented with multiple lesions representing metastatic nodules. Of 12 patients with available follow-up, 2 died of disease, whereas the remaining 10 patients were alive but 3 of them experienced a local recurrence in the course of the disease. Grossly, the tumors ranged in size from 1.2 to 6 cm. Microscopically, of the 14 primary tumors, 9 showed low-grade cytomorphology, whereas the remaining 5 neoplasms were high-grade lesions. The residuum of a hidradenoma was present in 5 of the 14 primaries. The mitotic rate was highly variable, ranging from 2 to 64 mitoses per 10 high-power field. The cellular composition of the tumors varied slightly, with clear cells, epidermoid cells, and transitional forms being present in each case. In 1 case, there was metaplastic transformation into sarcomatoid carcinoma. Glandular differentiation varied from case to case and appeared most commonly as simple round glands or as cells with intracytoplasmic lumens. Necrosis en masse was detected in 8 specimens. One specimen represented a reexcision and was unusual as it showed a well-demarcated intradermal proliferation of relatively bland clear cells accompanied by an overlying intraepidermal growth of clear cells resembling hidradenoacanthoma simplex. Despite the bland appearance, the tumor metastasized to a lymph node. Immunohistochemically, 5 of the 8 specimens studied for Her2/neu expression were negative, whereas 3 specimens from 2 cases yielded score +2, but all the 3 specimens with score 2+ subsequently proved negative for Her2/neu gene amplification by fluorescence in situ hybridization. Of 10 primaries studied, 4 tumors showed positive p53 immunoreaction in more than 25% of the cells comprising the malignant portion of the lesions, in 2 cases, a minority of the neoplastic cells (10%-20%) demonstrated nuclear staining, whereas the remaining 4 cases were negative. Of 9 specimens of hidradenocarcinoma studied for TP53 mutations, 2 harbored mutations, whereas the remaining 7 specimens showed the wild-type sequence. Of 11 specimens studied for translocation t(11;19), 2 cases harbored the translocation. It is concluded that cutaneous hidradenocarcinomas show some microscopic heterogeneity and comprise both low- and high-grade lesions that cytologically are similar to their benign counterpart, the hidradenoma. Within the spectrum of low-grade lesions, there seem to exist tumors almost indistinguishable from hidradenomas but still being capable of regional or distant metastasis. Similar to hidradenomas, hidradenocarcinomas show a t(11;19) translocation, but it is a significantly rarer event. Even rarer is the amplification of the Her2/neu gene. Of note is the relatively low frequency of TP53 mutations despite a high rate of p53 protein expression at the immunohistochemical level.

Atypical and malignant hidradenomas: a histological and immunohistochemical study

The histological features of atypical hidradenoma are worrisome for increased risk of recurrence and possible malignant potential; however, earlier studies with immunohistochemistry or patient follow-up have not been reported. In addition, immunohistochemical analysis of hidradenocarcinoma exists in the literature mainly as case reports and as a single series of six cases. We compare the histological features and Ki-67, phosphorylated histone H3, epidermal growth factor receptor, and Her2/neu expression profiles of 15 atypical and 15 malignant hidradenomas with those of benign hidradenoma and metastasizing adnexal carcinomas. Infiltrative growth pattern, deep extension, necrosis, nuclear pleomorphism, and > or =4 mitoses per 10 high-power fields are specific features of hidradenocarcinomas. Significant difference in mean Ki-67% was observed between benign and malignant hidradenomas (P<0.001), benign and metastasizing adnexal carcinomas (0.002), atypical and malignant hidradenomas (P<0.001), and between atypical hidradenomas and metastasizing adnexal carcinomas (0.002). Significant difference in mean phosphorylated histone H3% was observed between benign and malignant hidradenomas (P<0.001), benign and metastasizing adnexal carcinomas (0.003), atypical and malignant hidradenomas (P<0.001), and between atypical hidradenomas and metastasizing adnexal carcinomas (P<0.001). Mean epidermal growth factor receptor total score was significantly different in benign and atypical hidradenoma when compared with that in metastasizing adnexal carcinoma (P=0.014 and 0.019, respectively). Equivocal or 2+ Her2/neu positivity was observed in one hidradenocarcinoma and in two metastasizing adnexal carcinomas. Receiver operating characteristic curve analysis for Ki-67 and phosphorylated histone H3% positivity reveals statistically significant criterion values of >11.425 and >0.7, respectively, for distinguishing malignant hidradenomas from atypical hidradenomas. Despite the presence of some worrisome histological features, the significantly different immunoprofile from the malignant counterpart suggests that atypical hidradenomas are likely to recur but are unlikely to metastasize. A tumor with Ki-67>11% and/or phosphorylated histone H3>0.7% would likely be a malignant rather than an atypical hidradenoma. The infrequent Her2/neu overexpression in hidradenocarcinoma suggests its limited therapeutic role.

Malignant nodular hidradenoma of the skin: report of seven cases

BACKGROUND

Malignant nodular hidradenoma (MNH) is an infrequent, highly malignant, primary skin tumour derived from eccrine sweat glands. Most tumours occur in elderly individuals. MNH has very poor prognosis, high recurrence and a high rate of metastases. The best method of treatment is still unclear: radical surgical excision is widely used, and selective lymph node dissection is also suggested. The value of the adjuvant radiotherapy and chemotherapy has not been confirmed.

PATIENTS AND TREATMENT

Seven MNH patients (4 men, 3 women, age 60-87 years) were treated between 1991 and 2007 in the Dermatology Unit of San Donato Hospital of Arezzo and in the Section of Dermatology of University of Siena, Italy. Tumours varied from 0.8 to 4.4 cm in size. All patients underwent local excision; five also had lymph node dissection. One patient underwent adjuvant radiotherapy, and three received chemotherapy.

RESULTS

Six of seven patients died, with survival varying from 15 to 45 months. Distant metastases occurred in two patients. Survival time was inversely proportional to the size of the tumour.

CONCLUSIONS

MNH is an aggressive tumour and should be diagnosed and excised as early as possible. Histological parameters are paramount, but correct diagnosis also calls for attention to clinical presentation and any history of recurrence or recent enlargement of long-standing lesions. In our experience, radiotherapy and chemotherapy do not seem to prolong survival.

Adnexal clear cell carcinoma with comedonecrosis: clinicopathologic analysis of 12 cases

CONTEXT

Cutaneous clear cell tumors can pose a diagnostic challenge even to the experienced dermatopathologist; this is partly because of limitations of existing diagnostic categories.

OBJECTIVE

To describe a previously unrecognized, distinctive cutaneous adnexal carcinoma capable of an aggressive clinical course.

DESIGN

Clinicopathologic analysis of a series of 12 cases.

RESULTS

The patients were older individuals (median age, 71 years) with equal gender frequency. The lesions showed wide anatomic distribution with predilection for the head and neck area, especially the scalp. The lesions presented as rapidly growing, erythematous to flesh-colored, solitary papules/nodules that were capable of quickly reaching a size of several centimeters. Histologically, adnexal clear cell carcinoma with comedonecrosis was characterized by dermal proliferation of nests of epithelial cells showing distinctive zonal arrangement. The periphery of the tumor nests was formed by squamoid cells merging with centrally located clear cell areas containing foci of comedonecrosis. The lesions often showed multilobular or trabecular growth pattern and infiltrating border. Nuclear pleomorphism was variable; mitotic count ranged from 2 to 32/mm2 (median, 8/mm2). No ductal, cuticular, or apocrine differentiation was seen. All cases showed expression of epithelial membrane antigen and cytokeratin 17 in clear cells, with focal carcinoembryonic antigen expression in some cases. Follow-up (average, 37 months) revealed local recurrence (4 cases) and regional and distant metastases (2 cases).

CONCLUSIONS

Adnexal clear cell carcinoma with comedonecrosis appears to be a distinctive adnexal neoplasm that has to be distinguished from more indolent squamous cell and tricholemmal carcinomas.

Clear cell hidradenoma of the ankle

Clear cell hidradenoma is a relatively common, benign eccrine neoplasm with rare presentations in the foot and ankle. Variable clinical and histopathologic characteristics of the tumor warrant careful consideration over primary and recurrent malignancy, particularly eccrine carcinoma. The first known case of primary benign clear cell hidradenoma of the ankle is presented with imaging studies, surgical management, and clinicopathologic correlation, distinguishing the neoplasm from its malignant counterparts.

[Malignant nodular hidradenoma and multiple nodular hidradenomas in a hypogonadic patient]

BACKGROUND

We report a case of multiple benign nodular hidradenomas associated with malignant nodular hidradenoma in a hypogonadic patient.

CASE-REPORT

A 49 year-old man presented 11 benign nodular hidradenomas in the pectoral region. A malignant nodular hidradenoma had recently appeared in this region some distance from the pre-existing benign modular hidradenomas. This patient had peripheral hypogonadism associated with congenital bilateral cryptorchidia responsible for gynecomastia due to "relative hyperestrogenism". Large numbers of estrogen receptors were demonstrated in each of the benign nodular hidradenomas. The malignant nodular hidradenoma mass was unavailable and screening for these receptors was not possible.

DISCUSSION

Cases of multiple nodular hidradenoma are extremely rare: we have seen only two. To the best of our knowledge, there have been no reports to date of combined malignant nodular hidradenoma and multiple benign nodular hidradenoma. However, there is histological evidence of transition forms. The coexistence of endocrine anomalies associated with this type of tumour has never been reported. However, the presence of estrogen receptors has occasionally been demonstrated in benign nodular hidradenomas. Our patient's endocrine disease may have played a role in the presentation of multiple hidradenomas, but this cannot be demonstrated.

Nodular hidradenocarcinoma over the parotid gland: A pathologic presentation

BACKGROUND

Nodular hidradenocarcinoma (NHAC), an eccrine carcinoma, has been reported in the dermatology and pathology literature, but few references have been made in the otolaryngology literature even though the head and neck is a common site of occurrence.

METHODS

A case report of a 37-year-old Hispanic man with a right-sided neck mass diagnosed preoperatively as a parotid mass by imaging and fine-needle aspiration is presented. After presentation at our multidisciplinary tumor board, excision of the mass was undertaken.

RESULTS

Final pathology revealed a NHAC, which is presented in our report.

CONCLUSION

NHAC is an aggressive malignant tumor that is often misdiagnosed preoperatively and that must be treated with aggressive multimodality therapy for increased survival.

Sweat-gland tumours: a clinical review of cases in one centre over 20 years

AIMS

Sweat-gland tumours (SGTs) are uncommon, but malignant varieties are very rare. We have added our data on 30 new cases seen at the Royal Marsden NHS Foundation Trust to the published literature, particularly concentrating on clinical issues. We include a literature review.

MATERIALS AND METHODS

The Royal Marsden NHS Foundation Trust database was searched for cases of SGT from 1972. Data were collected on all cases, including patient demographics and tumour characteristics, treatment and outcome.

RESULTS

Thirty cases were confirmed histologically to be SGTs. Fourteen were malignant, 15 benign and the degree of malignancy in one was histologically indistinguishable. Mean age was 55 years (64 for malignant, 47 for benign tumours). The 15 patients with benign tumours were almost all treated with complete excision. Those with local relapse underwent successful re-excision. Their 5-year disease-free survival was 78% and cause-specific survival was 100%. Twelve of the 14 malignant tumours had localised disease at diagnosis, one had nodal disease and one had metastatic tumour nodules. All except one were treated with wide local excision. The patient with nodal involvement also had a lymph-node dissection. Two received adjuvant radiotherapy to the tumour bed. One received a melphalan limb perfusion. Eight of the 14 had no relapse. Six had locoregional relapse, and four of these also developed distant metastases. Visceral disease was always fatal. Radiotherapy and chemotherapy at relapse were unsuccessful. Five-year disease-free survival was 45%, and cause-specific survival was 57%.

CONCLUSION

These rare tumours should be treated initially with complete wide local excision. In malignant tumours, lymph-node involvement is a poor prognostic sign. Wide local excision remains the primary treatment. Adjuvant radiotherapy may be useful in high-risk cases.

Malignant adnexal neoplasms

Malignant cutaneous adnexal neoplasms are one of the most challenging areas of dermatopathology. Tumors of the pilosebaceous apparatus can occur as single-lineage neoplasms or may manifest as complex proliferations with multilineal differentiation patterns including not only the germinative component of the hair bulb, the inner or outer root sheath epithelium and the sebaceous gland and duct, but also the sweat duct components that relate to the apocrine secretory apparatus which empties into the follicle near the follicular bulge. Eccrine and apocrine neoplasms present a bewildering array of morphologies, which often defy precise classification. The purpose of this review is to discuss in detail the malignant neoplasms of the cutaneous adnexae and their benign and prognostically indeterminate mimics.

Penile Clear Cell Carcinoma

We present a series of 5 penile clear cell carcinomas, which arose in middle-aged men at the inner side of the foreskin. They were large, exophytic, partly ulcerated, and widely invasive tumors with sharp demarcation to the surrounding normal skin/mucosa. Histologically, they were composed of large clear cells with intracytoplasmic PAS/d-PAS-positive material and showed extensive lymphatic and blood vessel invasion. Strong staining with antibodies to Muc-1, EMA, and CEA was typical. All carcinomas harbored HPV16 DNA, although only one carcinoma revealed HPV-related cytologic cell changes. All 5 patients had extensive, partly cystic inguinal lymph node metastases with a striking clear cell differentiation and focal dense sclerotic basement membrane material, either at or within several months after initial diagnosis. Two patients are alive without disease after 7 and 10 years. One patient died after 9 months of widespread disease and 2 patients are presently alive at 7 and 17 months follow-up with widespread lymphatic and hematogenous metastases despite adjuvant chemo- and radiation therapy. In contrast to squamous cell carcinoma, penile clear cell carcinomas show extensive blood and lymph vessel invasion and early metastases to regional lymph nodes. Clear cell carcinomas represent a distinct group of penile cancers that may have a different clinical behavior than usual penile squamous cell carcinomas.

Nodular Hidradenocarcinoma on the Scalp of a Young Woman: Case Report and Review of Literature

BACKGROUND

Nodular hidradenocarcinoma was first reported as clear-cell eccrine carcinoma by Keasby and Hadley in 1954 (Cancer 1954;7:934-52) and rare malignant tumor. Several synonyms and related terms for nodular hidradenocarcinoma have appeared in the literature.

OBJECTIVE

They have potential for uncontrollable local recurrence, tend to metastasize, and often cause death. Most cases have been reported in the pathology literature with limited clinical information.

METHODS

We report a 27-year-old woman with nodular hidradenocarcinoma on the scalp.

RESULT

The management of rare cases is not well defined. In our case, she was only treated with a wide local excision, and no recurrence was observed 2 years after excision.

CONCLUSION

Most authors have concluded that early wide surgical excision of the tumor is the treatment of choice. The efficiency of adjuvant therapy generally has not established.

Clear cell atypical fibroxanthoma:a clinicopathologic study

INTRODUCTION

The atypical fibroxanthoma (AFX) is considered by most authorities to represent a superficial or minimally invasive variant of malignant fibrous histiocytoma that most often presents as a solitary nodule on the sun-exposed skin of the elderly. Among the rarest variants is the clear cell AFX, a lesion which raises consideration to a differential diagnosis encompassing a variety of neoplastic and non-neoplastic clear cell proliferations.

METHODS

We describe three cases of a distinctive cutaneous neoplasm arising in the sun-exposed skin of elderly patients. In all cases, formalin-fixed, paraffin-embedded tissue was available for analysis. The histology in concert with the immunophenotype was held to be diagnostic of the clear cell variant of AFX.

RESULTS

All tumors comprised sheets of large cells with foamy cytoplasms and hyperchromatic, polyploid nuclei manifesting frequent and atypical mitoses. The critical cells in our cases expressed CD68 but none of CD3, CD20, CD34, S-100 protein, muscle-specific actin, factor XIIIa, Melan-A, carcinoembryonic antigen, or cytokeratin.

CONCLUSION

Although typical examples of AFX provoke diagnostic consideration of spindle cell cancers of the skin (most often spindle cell melanoma, spindle cell squamous cell carcinoma, and leiomyosarcoma), the clear cell variant raises other differential diagnostic considerations instead. These include balloon cell melanoma, sebaceous carcinoma, pleomorphic liposarcoma, chordoma, parachordoma, tricholemmal carcinoma and clear cell squamous cell carcinoma. A diagnosis of AFX is one of exclusion; one must employ immunohistochemical markers to rule out the aforementioned differential diagnostic considerations. By reporting the fifth, sixth and seventh cases of clear cell AFX, we hope to alert dermatopathologists to this distinctive and unusual neoplasm, recognition of which is essential to avoid under- or over-diagnosis and inappropriate therapy.

Recurrent polymorphous sweat gland carcinoma of the skin

Polymorphous sweat gland carcinoma is an unusual, recently described variant of low-grade malignant adnexal neoplasm of the skin characterized by a prolonged clinical course and predilection for the extremities. We describe a case of recurrent polymorphous sweat gland carcinoma in a 56-year-old man who presented with multiple large skin nodules distributed along the flexor surface of his left arm. The lesions were treated by surgical excision; multiple local recurrences, as well as the development of new lesions, were observed over a period of 5 years. No distant metastases have been observed so far. The clinical differential diagnosis and management of these unusual lesions are discussed.

Carcinomas of sweat glands: report of 60 cases

CONTEXT

Several aspects of sweat gland carcinomas (incidence, classification, diagnosis, and behavior) have not been definitively clarified and need to be studied further.

OBJECTIVE

The clinicopathologic findings of a large series of sweat gland carcinomas, collected during a period of 15 years, are presented.

METHODS

Sixty sweat gland carcinomas (41 porocarcinomas, 3 syringomatous carcinomas, 8 ductal carcinomas, 5 adenoid cystic carcinomas, and 3 mucinous carcinomas) were analyzed histologically and immunohistochemically.

RESULTS

Porocarcinomas were composed of eosinophilic and clear atypical cells arranged in solid-cystic lobular masses. These tumors were divided into 2 subgroups: horizontal porocarcinomas, showing a prominent intraepidermal component, and nodular porocarcinomas, which demonstrated predominant nodular growth. Syringomatous carcinomas presented keratinizing and nonkeratinizing cysts, dilated tubules (sometimes with a "tadpole" appearance), small neoplastic ducts, solid islands, and cellular cords. Ductal carcinomas were characterized by a prominent formation of tubules, solid islands, and cellular cords. Adenoid cystic carcinomas presented a characteristic pattern, showing basaloid monomorphous cells with moderately atypical nuclei, arranged in cribriform or solid islands and in tubular structures. Mucinous carcinomas were composed of moderately atypical cells with eosinophilic vacuolated cytoplasm, forming solid and cystic islands floating in large mucin pools. Immunohistochemically, cytokeratin was found in neoplastic cells in all cases, carcinoembryonic antigen was detected in 73% of cases, and actin-positive (myoepithelial) cells were not found.

CONCLUSIONS

Although numerous studies have been published in recent years, the histologic features, histogenesis, and classification of sweat gland carcinomas still remain controversial and need to be clarified by further studies.

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

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.

Cutaneous Metastatic Lung Cancer: Literature Review and Report of a Tumor on the Nose from a Large Cell Undifferentiated Carcinoma

Cutaneous metastatic disease is a prognostically important diagnosis. We report the case of a 64-year-old man who had an uncommon histologic type of lung cancer—a large cell undifferentiated carcinoma, which was metastatic to the skin of the nose. The relative frequency of cutaneous metastasis is similar to that of primary cancers. Cutaneous disease as the first sign of metastasis is most often seen in cancer of the lung. However, its appearance as a large tumor on the nose, which was observed in this case, is unusual.

Clear cell syringoid carcinoma: an ultrastructural and immunohistochemical study

Syringoid carcinoma (syringoid "eccrine" carcinoma or eccrine epithelioma) is a rare cutaneous tumor with some controversy regarding its correct definition. It may also be difficult to differentiate from its benign counterpart (syringoma), other adnexal carcinomas, and cutaneous metastasis from adenocarcinomas. We present a case of a syringoid carcinoma of the clear cell variant complemented with an immunohistochemical and ultrastructural study, the latter revealing cytoplasmic accumulation of glycogen and presence of intercellular and intracellular lumina in clear tumor cells, as well as diverse hallmarks of malignancy (i.e., perineural invasion, tumor necrosis, and deep invasion). Clear tumor cells showed cytoplasmic and membranous immunoreactivity to epithelial membrane antigen, carcinoembryonic antigen, keratins, and S-100. Our ultrastructural and immunohistochemical results support the ductal differentiation of the glycogen-filled clear cell tumor population.

[Lung neoplasms revealing a rare cutaneous tumor: eccrine porocarcinoma]

INTRODUCTION

Eccrine sweat gland carcinoma, which belongs to the eccrine sweat gland carcinoma family, is a rare malignancy of the skin with a potential aggressive growth and metastatic spread.

EXEGESIS

We report here a case of malignant eccrine poroma arising on the upper leg, with widespread pulmonary metastases.

CONCLUSION

A brief synopsis of the pathological and clinical aspects of eccrine sweat gland carcinoma is presented with the currently available therapies.

Signet-ring squamous cell carcinoma: a case report

A-50-year-old Hispanic man presented to the dermatology clinic with a 0.6-cm eroded, erythematous, scaly plaque on the left side of his neck. On shave biopsy, the lesion was composed of intra-epidermal and invasive dermal cells characterized by a signet-ring appearance. One area suggestive of typical squamous cell carcinoma prompted the inclusion of that entity in the differential diagnosis. Mucicarmine stains were negative, while the extra-vacuolar cytoplasm focally reacted with periodic acid-Schiff staining, the positive reaction for which was abolished by diastase, consistent with glycogen. Malignant cells expressed keratins by reacting to antibodies, Mak6, AE1/AE3, Ker 903, and CAM5.2. Additionally, weak reactivity occurred with antibodies to CEA and EMA. Tumor cells did not express S-100, HM-B45, Leu M1, or actin. By ultrastructural examination, the large vacuoles corresponded to markedly dilated endoplasmic reticulum. A diagnosis of signet-ring squamous cell carcinoma, a rare form of cutaneous squamous cell carcinoma which has been described in only one case report in the last 10 years, was made. Immunohistochemical staining provided information useful in differentiating this lesion from other clear cell and signet-ring cell tumors which involve the skin.

Microcystic adnexal carcinoma with extensive sebaceous differentiation

We report two cases of microcystic adnexal carcinoma showing extensive sebaceous differentiation. Multiple cellular nests and strands within a moderately sclerotic stroma involving the full thickness of the dermis were observed. Clusters of basaloid cells with extensive sebaceous differentiation were present. Foci of sebaceous ductal differentiation were observed in the more superficial areas. Neither strikingly atypical cells nor mitotic figures were present. Perineural invasion was present in the deep areas of both tumors. Clinically, the lesions were solitary whitish-pink papules with a central dell on the faces of 2 men (aged 78 and 73 years old). We propose a relationship between these tumors and other cytologically bland but locally aggressive adnexal carcinomas. Sebaceous differentiation itself in a poorly circumscribed neoplasm does not indicate conventional extraocular sebaceous carcinoma. We propose a simple classification of locally aggressive adnexal carcinomas that takes into account the full range of adnexal differentiation that can occur in such lesions.