Mohs micrographic surgery for the treatment of hidradenocarcinoma: the Mayo Clinic experience from 1993 to 2013

A rare case of hidradenocarcinoma with anaplastic and invasive features arising from a nodulocystic hidradenoma

A 91-year-old man presented with a cutaneous left abdominal mass. The mass was longstanding (over 5 years) and slow-growing. Examination revealed a violaceous, multinodular, and exophytic non-tender mass surrounded by patchy erythema. Excisional biopsy was performed and revealed a nodular and cystic dermal proliferation of predominately basaloid cells with focal duct formation, surrounded by prominent hyalinized stroma. The superficial portion of the mass was identified as a nodulocystic hidradenoma. Along the deep aspect and in association with the benign hidradenoma, sheets of markedly atypical epithelioid cells invaded the surrounding tissue, consistent with malignant transformation. Perineural and lymphovascular invasion were seen among areas with anaplastic features. This case supports that some hidradenocarcinoma originates from benign counterparts, and as such, ample sampling is required to definitively exclude a more sinister diagnosis. Diagnostic, prognostic, histopathological, and molecular characteristics, and current knowledge limitations are briefly discussed.

Hidradenocarcinoma: A Case Series From the Scripps Clinic With a Systematic Review of the Literature

BACKGROUND

Hidradenocarcinoma (HAC) is a rare adnexal carcinoma. To the best of the authors' knowledge, there are no published systematic reviews on HAC.

OBJECTIVE

To incorporate a case series from the authors' institution and systematically integrate reported information to provide a reference tool for optimization of diagnosis and management.

METHODS

A comprehensive MEDLINE search was conducted from database inception to 2021 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This yielded 225 studies with 165 cases of HAC. References of included articles were also searched. In addition, 9 patients with HAC were identified from the authors' institution over the past 10 years.

RESULTS

The mean age of HAC presentation is 60 years with a slight male predilection (60%). The head and neck is the most commonly affected region. Over 36% of cases either presented with metastatic disease or went on to metastasize. The most common treatment type was wide local excision, followed by Mohs micrographic surgery.

CONCLUSION

Early detection with accurate histologic interpretation is prudent in all cases of HAC. Wide local excision is the current first-line treatment. However, Mohs micrographic surgery offers complete marginal analysis with evidence of reduced risk of metastasis and better outcomes compared with wide local excision. Currently, there are no National Comprehensive Cancer Network guidelines for the treatment of HAC, and consensus guidelines are limited to tumor and nodal metastasis staging provided by the American Joint Committee on Cancer, eighth edition. Thus, this case series and systematic review integrates important aspects of diagnosis, workup, and management of HAC.

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.

Low-Grade Hidradenocarcinoma of the Foot With Metastasis to a Lymph Node

ABSTRACT

Hidradenocarcinoma (HAC) is a rare adnexal tumor associated with the potential for locoregional recurrence and systemic metastasis. The clinical appearance of HAC is nonspecific, frequently presenting as a solitary firm subcutaneous nodule or plaque on the head and neck region or distal extremities. These tumors show histomorphologic heterogeneity, as they can be low and high grade. Distinguishing HAC from hidradenoma, especially the low-grade variant of HAC, can be challenging as both tumors can show histologic overlapping features. In this article, we describe a case of a 33-year-old patient presenting with a low-grade HAC of the plantar foot who was subsequently found to have lymph node metastasis.

Nodular hidradenocarcinoma of the forehead presenting as a lipoma: A case report with a review of literature

INTRODUCTION

Hidradenocarcinoma is an uncommon slow-growing malignant tumor that originates from sweat glands, it is most seen in the head and neck, and present typically as hard asymptomatic nodule. Diagnosis is confirmed by histopathology and immunohistochemistry, and wide local excision is the mainstay of the treatment. In our study, we discuss the approach and management of this rare disease, with focusing on the importance of histopathology in diagnosing such cases.

PRESENTATION OF CASE

We present a very rare case of a 58-year-old female who presented with painless slow growing forehead swelling for 2 years, with clinical feature suggestive of lipoma. The patient underwent surgical excision, and post-operative histopathological examination of the specimen was consistent with nodular hidradenocarcinoma.

DISCUSSION

Hidradenocarcinoma is a very rare malignant tumor that was first reported in 1954. This tumor was reported to be more common in males, and the incidence increases with age. The origin of hidradenocarcinoma is mostly de novo. The definitive diagnosis requires histopathological examination, and wide local excision is the mainstay of the treatment.

CONCLUSION

Hidradenocarcinoma is a very rare sweat gland malignancy, and the diagnosis can be challenging. In our study, we emphasize the importance of raising the awareness among the surgical oncology society regarding this rare tumor, and we discuss the approach and management of such an uncommon disease, with focusing on the importance of histopathology in diagnosing such cases.

Clinicopathological and genomic copy number variation analysis in nodular hidradenoma and hidradenocarcinoma with focus on prognostically important features

Nodular hidradenoma is a cutaneous adnexal tumor of sweat gland origin, characterized by its diverse but overlapping histomorphologic features with other skin tumors. In addition, distinction of benign hidradenoma and its malignant counterpart hidradenocarcinoma can be challenging, especially in prognostic prediction. We retrospectively reviewed pathological features of 29 cases, including benign nodular hidradenoma (n = 17) and hidradenocarcinoma (n = 12), with clinical follow-up ranging from 18 to 216 months. Genomic copy number variation (CNV) was studied in selected cases (n = 18) by single nucleotide polymorphism microarray. None of the benign hidradenomas (0/17) or low-grade hidradenocarcinomas (0/6) had recurrence or metastasis after complete excision, whereas all 6 high-grade hidradenocarcinomas (6/6) showed locally destructive disease, recurrence, or local metastases. In benign hidradenomas, CNV abnormality was absent in all clear cell hidradenomas (0/5) but was detected in a considerable portion of poroid hidradenoma (3/5), with number of abnormalities ranging 2, 4, and 9. In malignant cases, regardless of morphological classification, both low-grade hidradenocarcinomas demonstrated limited CNV abnormalities in 2 areas (2/2), whereas all high-grade hidradenocarcinomas contained 8 or more CNV abnormalities (6/6). No disease-associated death was recorded in the cohort except one case was lost to follow-up after the development of metastatic disease. Overall, the findings support that genomic CNV abnormalities may serve as a sensitive but less specific tool in detecting malignancy in these tumors, and potentially have a role in predicting clinical behavior particularly in the tumors of nonporoid morphology.

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.

Mohs micrographic surgery: a review of indications, technique, outcomes, and considerations

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.

Surgical management and lymph-node biopsy of rare malignant cutaneous adnexal carcinomas: a population-based analysis of 7591 patients

OBJECTIVE

To analyze the prognosis of cutaneous adnexal malignancies, survival relative to surgical management, and utility of lymph-node biopsy.

DESIGN

Population-based study of the SEER-18 database from 1975 to 2016.

PARTICIPANTS

7591 patients with sweat gland carcinoma, hidradenocarcinoma, spiradenocarcinoma, sclerosing sweat duct tumor/microcystic adnexal tumor (SSDT/MAC), porocarcinoma, eccrine adenocarcinoma, and sebaceous carcinoma RESULTS: Five-year OS ranged from 68.0 to 82.6%, while 5-year DSS ranged from 94.6 to 99.0%. The majority of patients were treated with narrow (42.4%) or wide local excision (16.9%). DSS at 5 years showed that patients with stage IV had significantly poorer survival (50.3%) than I, II, or III (99.3%, 97.8%, and 89.0% respectively). 5-year OS was significantly higher for narrow excision (excision with < 1 cm margin, 78.5%) than observation (65.0%), excisional biopsy (66.8%), or wide local excision (WLE, 73.2%). Lymph-node biopsy was performed in a minority of cases (8.1%) and patients showed no significant difference in survival based on nodal status. The sensitivity and specificity of lymph-node biopsy for all malignancies were 46% and 80%, respectively. The PPV and NPV for that group were 0.46 and 0.80, respectively. Invasion of deep extradermal structures was a poor predictor of nodal positivity.

CONCLUSIONS

These malignancies have excellent DSS. Narrow excisions demonstrate better 5-year DSS and OS compared with WLE. Lymph-node biopsy is a poor predictor of survival in advanced stage disease and utility is limited.

An Unusual Case of Lower Extremity Clear Cell Hidradenocarcinoma

Hidradenocarcinoma (HC) is a rare malignant sweat gland tumor with metastatic potential primarily located in the head, neck, and trunk. We present an unusual case of a large lower extremity Clear Cell HC managed with surgical resection and adjuvant locoregional radiation after excluding lymph node involvement.

Malignant Transformation of Nodular Hidradenoma in the Lower Leg

Nodular hidradenoma (NH) is a benign adnexal tumor that arises from either eccrine or apocrine sweat glands. NH can originate from any cutaneous site, but the most common sites are the head and anterior surface of the trunk, with very rare cases in the extremities. Long-standing NH has been reported to undergo malignant transformation to malignant NH (MNH); however, its occurrence in the lower leg is extremely rare with only one other case reported to date. In this report, we present a rare case of MNH occurring in the lower leg which was resected with the intent to make a diagnosis. At the final follow-up after 11 months, no local recurrence or metastasis has been observed.

Conservative thickness layers in Mohs micrographic surgery

BACKGROUND

Mohs micrographic surgery (MMS) is used to treat cutaneous malignancies in locations to maximize tissue sparing. The authors' aim is to demonstrate the utility of conservative thickness layers (CTL) in MMS and review patient and tumor characteristics and the potential anatomic locations where this technique may be most useful.

METHODS

We performed a retrospective chart review of patients with tumors treated with CTL in MMS of 339 tumors, recording patient demographics, tumor characteristics, MMS stages for clearance, repairs, complications, and follow-up.

RESULTS

A total of 339 tumors were treated with CTL. The most common site was the leg (28.6%), with 77.4% of these being female. The next most common sites were nose (24.5%), scalp (13.9%), and back (11.5%). Most tumors were cleared with one layer (269), but some required two layers (42), three layers (11), and four layers (1). A total of 264 tumors were left to granulate, while 75 of the nasal tumors had immediate dermabrasion.

CONCLUSION

In the properly selected patient and anatomic location, CTL taken as the first stage in MMS can be an effective and time-saving technique, leaving wounds in optimal condition for granulation with a low complication rate. Tissue sparing may allow for more reconstructive options.

Adnexal Carcinomas Treated With Mohs Micrographic Surgery: A Comprehensive Review

BACKGROUND

Adnexal carcinomas (ACs) are rare cutaneous malignancies of sweat gland or pilosebaceous origin. Optimal treatment and metastatic potential of AC are poorly defined. Mohs micrographic surgery (MMS) has been increasingly used to treat AC.

OBJECTIVE

To review selected primary cutaneous AC and their treatment outcomes with MMS.

MATERIALS AND METHODS

Literature review using PubMed search for articles related to primary cutaneous ACs.

RESULTS

Sebaceous carcinoma treated with MMS recurred and metastasized in 6.4% and 3.7%, respectively. Primary cutaneous mucinous carcinoma treated with MMS recurred and metastasized in 9.6% and 6.4%, respectively. After MMS, 4.7% of microcystic AC recurred with no reported metastases. After MMS, recurrences and metastases of trichilemmal carcinoma or hidradenocarcinoma have not been reported. Two (4.2%) regional lymph node metastases but no distant metastases or local recurrences have been reported in eccrine porocarcinoma. Squamoid eccrine duct tumor, pilomatrix carcinoma, and spiradenocarcinoma treated with MMS are also reviewed.

CONCLUSION

The rarity of ACs and the lack of comparative data on treatment makes conclusive recommendations on treatment difficult. Recent large case series and reviews suggest MMS is a useful and possibly superior treatment for AC and should be considered if primary cutaneous disease is suspected.

Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist

The incidence and diagnosis of cutaneous malignancies are steadily rising. In addition, with the aging population and increasing use of organ transplant and immunosuppressive medications, subsets of patients are now more susceptible to skin cancer. Mohs micrographic surgery (MMS) has become the standard of care for the treatment of high-risk nonmelanoma skin cancers and is increasingly used to treat melanoma. Mohs micrographic surgery has the highest cure rates, spares the maximal amount of normal tissue, and is cost-effective for the treatment of cutaneous malignancies. As in other medical fields, appropriate use criteria were developed for MMS and have become an evolving guideline for determining which patients and tumors are appropriate for referral to MMS. Patients with cutaneous malignancies often require multidisciplinary care. With the changing landscape of medicine and the rapidly increasing incidence of skin cancer, primary care providers and specialists who do not commonly manage cutaneous malignancies will need to have an understanding of MMS and its role in patient care. This review better familiarizes the medical community with the practice of MMS, its utilization and capabilities, differences from wide excision and vertical section pathology, and cost-effectiveness, and it guides practitioners in the process of appropriately evaluating and determining when patients with skin cancer might be appropriate candidates for MMS.

Treatment of Porocarcinoma With Mohs Micrographic Surgery: The Mayo Clinic Experience

BACKGROUND

Eccrine porocarcinoma (EPC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment.

OBJECTIVE

This study reviews the clinical characteristics and outcomes of patients with EPC treated with Mohs micrographic surgery (MMS).

MATERIALS AND METHODS

The authors performed a retrospective chart review of patients with EPC treated by MMS at the Mayo Clinic from 1995 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality.

RESULTS

A total of 9 patients underwent MMS for EPC in 19 years. The average age was 64.2 years, with 6 males and 3 females. All patients were Caucasian. The head and lower extremity were the most common locations (44% each), with 1 on the forearm. Of the 9 tumors, 8 were located on the right side of the body. The mean preoperative tumor size and postoperative defect were 2.9 and 7.8 cm, respectively, when 2 outliers were excluded. An average of 1.3 MMS stages was required for clearance. The mean postoperative follow-up was 3.3 years (range: 1-60 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality.

CONCLUSION

Mohs micrographic surgery seems to be a useful treatment modality for EPC. This is one of the largest single-center series of EPC treated with MMS.