Skin adnexal carcinoma of the head and neck: a retrospective study in a tertiary referral center

Periocular Microcystic Adnexal Carcinoma: A Case Report and a Major Review

PURPOSE

To describe a patient with periocular microcystic adnexal carcinoma (MAC) and to review the clinical presentation, systemic work-up, histopathologic features, and outcome of all previously reported periocular MAC.

METHODS

A major literature review. PubMed/MEDLINE and Google Scholar databases were searched for all well-documented cases of periocular MAC.

RESULTS

The final analysis yielded 93 patients with MAC, 48 (52%) females, 39 (42%) males, and 6 with sex not specified (6%) with an average age of 56 years (range 3 days-95 years). Most tumors were localized to the eyebrow (26/93, 28%) and lower eyelid (20/93, 22%). Of patients with known information, MAC most commonly presented as a nodule (37/68, 54%) or plaque (20/68, 29%) with poorly-defined margins (20/51, 39%) and distortion of eyelid margin (13/51, 25%). Orbital involvement at any point of the disease course was seen in 20 of 93 (22%) patients. An accurate histopathologic diagnosis on initial biopsy was made in 25 of 70 (36%) cases. Initial management included surgical excision (47/93, 51%), Mohs micrographic surgery (17/93, 18%), and excision with frozen section control of margins (8/93, 9%). Aggressive or recurrent MAC was managed with multimodal therapies, including adjuvant radiation (10/34, 29%). The average follow-up after the last treatment was 3 years (median 2, range 0.2-20 years). In total, 33 of 86 (38%) tumors recurred, and 6 of 87 (7%) metastasized. Disease-related mortality occurred in 3 of 79 (4%) of patients.

CONCLUSIONS

Periocular MAC is frequently misdiagnosed on initial biopsy and has a tendency for recurrence and locally aggressive behavior, highlighting the importance of accurate timely diagnosis, and appropriate management.

Microcystic adnexal carcinoma of the scalp treated with surgical resection along with chemoradiation: A case report and review of the literature

Microcystic adnexal carcinoma (MAC) is an infiltrative rare cutaneous neoplasm for which there are no consensus management guidelines because of the paucity of evidence-based practice; hence, the utility of their management is based only on previously published case reports. We report a case of a scalp lesion that was successfully treated using a combination of surgical resection, chemotherapy, and radiotherapy.

Porocarcinoma: a rare cause of lateral cervical tumor

Porocarcinoma is a rare tumor of the eccrine sweat glands that usually disseminates to the regional lymph nodes, but it can also develop distant metastasis. Case presentation: We report the case of a 67 year-old female patient who underwent wide surgical resection of a left cervical cutaneous tumor in a primary care center, for which the histology exam of the specimen was mixed basal cell and squamous cell carcinoma. She was referred to our hospital's oncology clinic and histologic re-evaluation changed the diagnosis to eccrine porocarcinoma (EPC). Computer-tomography (CT) revealed cervical lymphadenopathies for which the patient underwent 4 cycles of chemotherapy, without regression. She subsequently underwent a left upper anterior jugular lymphadenectomy (group IIa) with all nodes being negative and, three months later, she developed a unique adenopathy under the parotid gland that was excised and confirmed to be metastatic. Postoperative external radiotherapy was administered with a good outcome on CT scan. Nine months after her last surgery, the patient did not show any sign of recurrence or distant metastasis. Conclusion: EPC is a challenge, both diagnostically and therapeutically. In the absence of consensus regarding the indications and extent of lymphadenectomy and adjuvant therapy, patients with EPC should be referred to an experienced multidisciplinary team in a tertiary center.

Sebaceous carcinoma: evidence-based clinical practice guidelines

Sebaceous carcinoma usually occurs in adults older than 60 years, on the eyelid, head and neck, and trunk. In this Review, we present clinical care recommendations for sebaceous carcinoma, which were developed as a result of an expert panel evaluation of the findings of a systematic review. Key conclusions were drawn and recommendations made for diagnosis, first-line treatment, radiotherapy, and post-treatment care. For diagnosis, we concluded that deep biopsy is often required; furthermore, differential diagnoses that mimic the condition can be excluded with special histological stains. For treatment, the recommended first-line therapy is surgical removal, followed by margin assessment of the peripheral and deep tissue edges; conjunctival mapping biopsies can facilitate surgical planning. Radiotherapy can be considered for cases with nerve or lymph node involvement, and as the primary treatment in patients who are ineligible for surgery. Post-treatment clinical examination should occur every 6 months for at least 3 years. No specific systemic therapies for advanced disease can be recommended, but targeted therapies and immunotherapies are being developed.

Evidence-Based Clinical Practice Guidelines for Microcystic Adnexal Carcinoma: Informed by a Systematic Review

IMPORTANCE

Microcystic adnexal carcinoma (MAC) occurs primarily in older adults of white race/ethnicity on sun-exposed skin of the head and neck. There are no formal guiding principles based on expert review of the evidence to assist clinicians in providing the highest-quality care for patients.

OBJECTIVE

To develop recommendations for the care of adults with MAC.

EVIDENCE REVIEW

A systematic review of the literature (1990 to June 2018) was performed using MEDLINE, Embase, Web of Science, and the Cochrane Library. The keywords searched were microcystic adnexal carcinoma, sclerosing sweat gland carcinoma, sclerosing sweat duct carcinoma, syringomatous carcinoma, malignant syringoma, sweat gland carcinoma with syringomatous features, locally aggressive adnexal carcinoma, and combined adnexal tumor. A multidisciplinary expert committee critically evaluated the literature to create recommendations for clinical practice. Statistical analysis was used to estimate optimal surgical margins.

FINDINGS

In total, 55 studies met our inclusion criteria. The mean age of 1968 patients across the studies was 61.8 years; 54.1% were women. Recommendations were generated for diagnosis, treatment, and follow-up of MAC. There are 5 key findings of the expert committee based on the available evidence: (1) A suspect skin lesion requires a deep biopsy that includes subcutis. (2) MAC confined to the skin is best treated by surgery that examines the surrounding and deep edges of the tissue removed (Mohs micrographic surgery or complete circumferential peripheral and deep margin assessment). (3) Radiotherapy can be considered as an adjuvant for MAC at high risk for recurrence, surgically unresectable tumors, or patients who cannot have surgery for medical reasons. (4) Patients should be seen by a physician familiar with MAC every 6 to 12 months for the first 5 years after treatment. Patient education on photoprotection, periodic skin self-examination, postoperative healing, and the possible normal changes in local sensation (eg, initial hyperalgesia) should be considered. (5) There is limited evidence to guide the treatment of metastasis in MAC due to its rarity. Limitations of our findings are that the medical literature on MAC comprises only retrospective reviews and descriptions of individual patients and there are no controlled studies to guide management.

CONCLUSIONS AND RELEVANCE

The presented clinical practice guidelines provide an outline for the diagnosis and management of MAC. Future efforts using multi-institutional registries may improve our understanding of the natural history of the disease in patients with lymph node or nerve involvement, the role of radiotherapy, and the treatment of metastatic MAC with drug therapy.