Over-expression of p53 protein as an indicator of the malignant transformation in spiradenoma

Lymphangiectatic Variant of Low-Grade Malignant Eccrine Spiradenoma

Low-grade malignant eccrine spiradenoma (spiradenocarcinoma) is a rare sweat gland tumor, which usually arises from a pre-existing benign eccrine spiradenoma. This paper presents the case of a 55-year-old male who had a lesion in his right elbow for 10 years. The microscopic examination revealed a well-demarcated, multilobulated tumor in the dermis and subcutis, which presented with many blood-filled vessels and extensive hemorrhage. The tumor was composed of hyperchromatic, round to oval cells with nucleolar prominence, mild to moderate atypia, and increased mitotic index. Additionally, lymphangiectatic appearance was observed in areas with prominent stromal lymphedema. P53 and Ki-67 had high positivity. Surgical excision of the lesion was performed with adequate surgical margins, and the dissected lymph nodes in the axilla were tumor-negative. After 15 months of follow-up, there was no recurrence or distant metastasis.

Challenges in diagnosis and management of a spiradenocarcinoma: a comprehensive literature review

BACKGROUND

Spiradenocarcinoma is a rare skin adnexal neoplasm that may behave aggressively. It is often associated with a benign slow-growing spiradenoma that has undergone malignant transformation. Given the paucity of cases in the literature, there is a lack of consensus on treatment.

METHODS

The terms 'malignant spiradenoma' or 'spiradenocarcinoma' were systematically used to search the PubMed, MEDLINE and Google Scholar databases. A total of 182 cases of spiradenocarcinoma were identified as eligible for this comprehensive literature review.

RESULTS

Spiradenocarcinoma was commoner in older age and Caucasian race. In most cases, surgical excision for local disease is the mainstay of treatment. Lymph node dissection is usually reserved for those with suspected or confirmed lymph node metastases. High rates of local recurrence (20.8%), metastasis (37.4%) and mortality (19.1%) were identified, prompting some authors to suggest regular follow up including chest X-rays and liver function tests.

CONCLUSIONS

Patients with spiradenocarcinoma may benefit from a magnetic resonance imaging and fluorodeoxyglucose-positron emission tomography/computed tomography to establish the extent of disease. We recommend wide local excision as the treatment of choice to achieve surgical margins of ≥1 cm, with node resection to be determined on a case-to-case basis. Regular follow up is important given the high rate of local recurrence, metastasis and mortality. This should include an examination of the regional lymph nodes. Further research is required to refine an evidence-based approach to spiradenocarcinoma.

Low grade malignant eccrine spiradenoma of the vulva: case report, review of the literature and discussion about the role of p53 and HPV

BACKGROUND

Malignant eccrine spiradenoma is one of the rarest sweat-gland tumors. Here, we describe a rare case of low grade malignant eccrine spiradenoma located at the vulva.

CASE PRESENTATION

The vulvar lesion was described as a mass measured 3.5 cm and located in the dermis and subcutis with no attachment to the epidermis. The neoplasm was arranged in ragged sheets or solid nodules sometimes with focal necrosis. The tumor cells had hyperchromatism, pleomorphism, and prominent nucleoli with high mitotic index and KI-67 estimated at 70-80%.

CONCLUSIONS

It's only the fifth case of malignant eccrine spiradenoma localized at the vulva. This is the first time that an HPV genotyping was made in this type of lesion with no HPV found while the p16 expression was diffuse. Moreover, it's the first time that a p53 mutation is detected by sequencing in this location.

Spiradenocarcinoma: A Comprehensive Data Review

INTRODUCTION

Spiradenocarcinomas (SCs) are rare and potentially aggressive skin adnexal tumors. Optimal treatment has not yet been established. Experiences with this carcinoma are mostly presented in case reports and few case series.

OBJECTIVE

To generate to a synopsis of published data on SC with regard to diagnostic procedures, treatment, and outcome.

RESULTS

Median patient age was 60 years and sex distribution was balanced. Tumor manifestations were evenly distributed within the sweat gland carrying skin. The most commonly reported symptom was accelerated growth of a longstanding indolent lesion, typically present for more than 2 years. Metastatic spread to the lung, bone, lymph nodes, liver, kidney, and breast has been documented. For staging computed tomography (CT) and positron emission tomography-CT are recommended, especially for detection of hematogenic metastases and lymph node involvement. Clear resection margins and tumor free regional lymph nodes reduce recurrence and carcinoma related death. Although low-grade SCs were reported over 3 times more often, high-grade carcinomas show a greater likelihood for recurrence and lethal outcome.

CONCLUSION

Suspicion of an SC should lead to performance of a magnetic resonance imaging for defining tumor extent, and a fludeoxyglucose positron emission tomography-CT for detection of metastases. Radical tumor excision and resection of tumor involved regional lymph nodes are essential for a curative approach. Histopathological evaluation should involve determination of tumor differentiation grade, because high-grade carcinomas seem to have a much more aggressive behavior. Excision of distant metastases has no therapeutic value. Follow-up needs to be carried out in short intervals with frequent imaging.

Malignant eccrine breast spiradenoma. A case report and literature review

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Eccrine spiradenomas are rare adnexal tumors of the skin. Malignant transformation of benign forms is even more unfrequent.

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We report a case of malignant breast eccrine spiradenoma diagnosed on the basis of breast cancer prevention programme.

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Imaging findings of these tumors have not been clearly demonstrated because of the rare incidence and lack of workup.

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The MRI findings of epidermal inclusion cysts and eccrine spiradenomas are different and so these findings might be used in making the differential diagnosis.

Introduction

Eccrine spiradenomas are rare adnexal tumours of the skin that originate in the sweat glands. There are only three cases, including ours, diagnosed as malignant transformation in the breast.

Presentation of case

We present a case of an asymptomatic 48 year old woman in whom the lesion was detected on the basis of breast cancer prevention programme. The metastatic study detection and the sentinel lymph node biopsy were negative so wide excision of the mass was performed with no further treatment. After 32 months of follow-up, there is no evidence of recurrent or metastatic disease in our patient.

Discussion

The lesions usually show a typical history of a long-standing unchanged cutaneous solitary nodule that becomes enlarged. The imaging findings of breast eccrine spiradenomas have not been clearly demonstrated. Diagnosis is based in histopathological findings of malignant focus.

A large list of uncommon dermatological skin malignancies and breast benign lesions can mimic malignant eccrine spiradenomas (MES); therefore, determination of inmunophenotype allows narrowing differential diagnosis. Distant metastases portend an ominous prognosis. The mainstay of treatment is surgical removal with wide excision margins. Radiation and hyperthermic chemotherapy can also be administered to prevent focal recurrence. Due to the high risk of developing metastases, close follow up of these patients for early detection of recurrence should be carried out.

Conclusion

Eccrine spiradenomas are rare adnexal tumours of the skin. Intraparenquimatous breast location is especially infrequent. Diagnosis is based on histopathological examination. MES metastasizes (40%), so a close follow up is recommended.

Morphologically low-grade spiradenocarcinoma: a clinicopathologic study of 19 cases with emphasis on outcome and MYB expression

Spiradenocarcinoma is a rare skin adnexal neoplasm with potential for aggressive behavior, classified histologically into low- and high-grade tumors. Morphologically, low-grade tumors are thought to behave more favorably. Limited information is available, however, with only 18 published cases. To study their clinical behavior, histological features, and the diagnostic value of immunohistochemistry, 19 morphologically low-grade spiradenocarcinomas were retrieved and compared with 21 spiradenomas and cylindromas. H&E-stained sections were reviewed, follow-up was obtained, and immunohistochemistry for Ki-67, p53 and, MYB was performed. The tumors were solitary, measuring 0.8-7 cm (median: 2.7 cm), with a predilection for the head and neck of elderly patients (median age: 72 years; range 53-92) without gender bias. Histologically, the tumors were multinodular and located in deep dermis and subcutis. A pre-existing spiradenoma was present in all cases. The malignant component was characterized by expansile growth with loss of the dual cell population, up to moderate cytological atypia and increased mitotic activity (median: 10/10 HPF; range 1-28). Additional findings included squamoid differentiation (n=9), necrosis (n=7), and ulceration (n=5). P53 expression was variable and no significant differences were noted in the benign compared with the malignant parts of the tumors. In contrast, in the malignant components the Ki-67 proliferative index was slightly increased, and MYB expression was lost. Follow-up (median: 67 months; range: 13-132) available for 16 patients (84%) revealed a local recurrence rate of 19% but no metastases or disease-related mortality. In this large study with long-term follow-up, we demonstrate that spiradenocarcinomas with low-grade morphology pursue an indolent course, characterized by local recurrence only. Metastases and disease-related mortality appear to be exceptional. Lack of MYB expression may be useful as an additional aid in the diagnosis of these challenging tumors.

Spiradenocarcinoma, cylindrocarcinoma and spiradenocylindrocarcinoma: a clinicopathological study of nine cases

AIMS

To elucidate diagnostic criteria for spiradenocarcinoma, cylindrocarcinoma and spiradenocylindrocarcinoma, and to emphasize correlations between clinical behaviour and variable morphological patterns.

METHODS AND RESULTS

We investigated the clinicopathological and immunophenotypic features of nine cases. There were five men and four women, with ages ranging from 58 years to 82 years. The tumour size varied from 10 mm to 50 mm. The head and neck were most commonly involved. Three cases of spiradenocarcinoma and three cases of cylindrocarcinoma showed a salivary gland-type basal cell adenocarcinoma-like pattern, low-grade (BCAC-LG) and/or high grade (BCAC-HG). The remaining three cases of spiradenocarcinoma showed adenocarcinoma in situ, with invasive adenocarcinoma being seen in one of these cases. PAS staining revealed loss of the PAS-positive hyaline sheath in malignant zones of cylindrocarcinoma. p53 staining was variably positive in the malignant components of all cases. Follow-up was available for all patients, ranging from 5 months to 107 months. Two patients died of disease, one experienced recurrence, and one died of an unrelated cause.

CONCLUSIONS

Patients with BCAC-LG have a better prognosis. BCAC-HG is more likely to be found in cylindrocarcinoma, and its clinical behaviour seems to be more aggressive. Close follow-up for early detection of recurrence and metastases is strongly recommended.

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.

Pilomatrix carcinomas contain mutations in CTNNB1, the gene encoding beta-catenin

Mutations in beta-catenin are present in benign pilomatrixomas. beta-catenin is a downstream effector in the WNT-signalling pathway, acting as a signal for differentiation and proliferation. Mutations in CTNNB1, the gene encoding beta-catenin, are present in a wide variety of benign and malignant neoplasms. We examined beta-catenin in a series of pilomatrix carcinomas (15 cases) by using immunohistochemistry and DNA sequencing of exon 3 from CTNNB1, and compared these to a series of benign pilomatrixomas (13 cases). All 11 pilomatrix carcinomas available for examination showed nuclear localization of beta-catenin and mutations in exon 3 similar to those demonstrated in benign pilomatrixomas. Two of 11 pilomatrix carcinomas showed significant nuclear accumulation of p53, whereas this was absent in all 13 benign pilomatrixomas. Expression of nuclear cyclin D1 was similar in both benign pilomatrixomas and pilomatrix carcinomas. Clinical follow-up from the 15 malignant cases reported in this study and by others indicates that wide excision offers superior control of local recurrence, compared to simple excision. Immunohistochemical and molecular analysis of beta-catenin reveals that both pilomatrix carcinomas and benign pilomatrixomas harbour mutations in beta-catenin. This implies a common initial pathogenesis and is compatible with the proposition that pilomatrix carcinomas may at least on occasion arise from their benign counterparts.

Loss of heterozygosity at cylindromatosis gene locus, CYLD, in sporadic skin adnexal tumours

AIM

The gene for familial cylindromatosis (CYLD) has been localised to chromosome 16q, and has recently been cloned. Loss of heterozygosity (LOH) at 16q has also been demonstrated in sporadic cylindromas. The aim of this study was to investigate whether CYLD plays a role in the development of other skin appendage tumours.

METHODS

A total of 55 cases of skin adnexal tumours, comprising 12 different types, and a control group of 14 squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs) were studied. Three microsatellites (D16S407 (16p), D16S304 (16q), and D16S308 (16q)) were analysed for LOH after microdissection from paraffin wax embedded sections using laser capture microdissection.

RESULTS

In keeping with previous data, a proportion of cylindromas exhibited LOH at markers on 16q, but not at 16p. The skin adnexal tumours showing a similar pattern included apocrine hydrocystomas, eccrine spiradenomas, and sebaceous adenoma. One case of syringoma showed LOH at 16q, and a further case at 16p, but not 16q. One case of eccrine hydrocystoma showed loss at 16p, but not 16q. The remaining tumours were either negative or non-informative. All tumours in the control group were either negative or non-informative, except for a single case of BCC showing LOH at 16q.

CONCLUSION

CYLD may be involved in the development of skin adnexal tumours other than cylindromas.

p53 expression in two cases of spiradenocarcinomas

p53 protein is a nuclear 53-kDa phosphoprotein that acts as a suppressor protein. There are several studies on the expression of p53 in skin tumors, but few deal with adnexal malignant tumors because of their rarity. We performed immunohistochemistry for the detection of p53 and Ki-67 in two cases of malignant spiradenomas and six cases of spiradenomas retrieved from our files. In our cases, p53 was expressed only in the malignant areas of the lesions, whereas the benign areas of the spiradenocarcinomas and all the spiradenomas were negative (nuclear positivity <10%). These results seem to support the idea that p53 is implicated in the malignant transformation of adnexal tumors.

p53 mutations in sweat gland carcinomas

Sweat gland carcinomas are rare skin tumours and little is known about their etiology and molecular basis. In this study, we analyzed p53 mutations in 16 sweat gland carcinomas with different histologic types, including 2 spiradenocarcinomas, 1 composed adnexal carcinoma, 5 porocarcinomas, 2 eccrine hidradenocarcinomas, 2 syringocystadenocarcinomas, 1 sclerosing sweat gland carcinoma, 1 adenoid cystic carcinoma, 1 cylindrocarcinoma and 1 apocrine adenocarcinoma. Single-stranded conformation polymorphism (SSCP) analyses followed by direct DNA sequencing revealed that 5 carcinomas (31%) contained a p53 mutation, 4 of which were G:C-->A:T transition mutations and 1 of which was a deletion. Three G:C-->A:T mutations were located at dipyrimidine sequences on the antisense strand (2 spiradenocarcinomas, 1 eccrine hidradenocarcinoma), suggesting that UV light may play a role in the development of sweat gland carcinomas. In 2 spiradenocarcinomas, p53 mutations were present in the carcinoma but not in the adenoma portions, suggesting that p53 mutations may be associated with malignant progression in these rare adnexal tumours.

Malignant eccrine spiradenoma with carcinomatous and sarcomatous elements

A case of a 60 year old man with malignant eccrine spiradenoma involving the perineum is described. Areas of typical eccrine spiradenoma were admixed with carcinomatous and sarcomatous elements. Immunohistochemical and ultrastructural analysis revealed no evidence of epithelial differentiation in the sarcomatous areas. The tumour qualified for the designation carcinosarcoma arising in eccrine spiradenoma. The clinical course was aggressive with rapid development of nodal and pulmonary metastases.

Beta 2 microglobulin haemodialysis related amyloidosis: distinctive gross features of gastrointestinal involvement

Two cases of beta 2 microglobulin amyloidosis following long term haemodialysis found during necropsy are reported. The patients were 59 and 65 year old Japanese men, respectively. In both cases, systemic distribution of beta 2 microglobulin amyloid deposits was observed. The gastrointestinal tract including the stomach, small intestine, and colon showed the distinctive gross feature of rippled appearance, which was characterised by serosal wrinkles along the muscle layer arrangement. These areas were confirmed to contain deposits of beta 2 microglobulin in the muscularis propria. Although the outline of the muscle layers was preserved, most muscle fibres, encircled by the amyloid deposits, were atrophic or had disappeared microscopically. In neither case could a definite diagnosis of amyloidosis be made while the patient was alive. Interestingly, the oesophagus presented less involvement compared to the remainder of the gastrointestinal tract. In comparison with the AA or AL type of amyloidosis, beta 2 microglobulin haemodialysis related amyloidosis showed a rippled appearance of the serosal rather than mucosal changes, which may explain the difficulty in diagnosing amyloid deposits using biopsies of the gastrointestinal tract.