1
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Wan L, Park A, Khachemoune A. Syringocystadenocarcinoma papilliferum: a systematic review of clinical characteristics, reappraisal of associations, diagnostic pitfalls and management challenges. Arch Dermatol Res 2024; 316:421. [PMID: 38904691 DOI: 10.1007/s00403-024-03176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 05/21/2024] [Accepted: 06/08/2024] [Indexed: 06/22/2024]
Abstract
Syringocystadenocarcinoma papilliferum (SCACP) is a rare and aggressive malignant adnexal tumor originating from apocrine or pluripotent appendageal glands, often associated with a preceding syringocystadenoma papilliferum (SCAP) or nevus sebaceus (NS). This systematic review rigorously examines SCACP through an analysis of 78 cases documented between 1980 and 2024. The study aims to provide a comprehensive review of the clinical manifestations, diagnosis, treatment modalities, and outcomes associated with SCACP, while also reappraising its associations, particularly with NS. SCACP predominantly affects older adults, with an average age of 66.3 years and a slight male predominance, commonly presenting as ulcerated nodules or plaques on the scalp. This review highlights the aggressive nature of SCACP, evidenced by significant rates of metastasis and recurrence. Treatment is primarily surgical, with Mohs micrographic surgery offering potential benefits in terms of margin control and cosmetic outcomes. The association of SCACP with NS is critically evaluated, suggesting a complex etiopathogenesis and underscoring the importance of recognizing this association for timely diagnosis and management. Our review also briefly discusses potential pitfalls faced by clinicians in the diagnosis of SCACP. Our findings emphasize the need for standardized treatment protocols and further research into targeted therapies to improve patient outcomes in SCACP.
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Affiliation(s)
- Leo Wan
- West Virginia School of Osteopathic Medicine, Lewisburg, WV, USA
| | - Aileen Park
- University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Amor Khachemoune
- Department of Dermatology, SUNY Downstate, 450 Clarkson Ave, Brooklyn, NY, USA.
- State University of New York Downstate and Veterans Affairs Medical Center, 800 Poly Pl, Brooklyn, NY, 11209, USA.
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2
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Cornejo KM, Hutchinson L, O'Donnell P, Meng X, Tomaszewicz K, Shalin SC, Cassarino DS, Chan MP, Quinn TR, Googe PB, Nazarian RM. Molecular Profiling of Syringocystadenocarcinoma Papilliferum Reveals RAS-Activating Mutations. Arch Pathol Lab Med 2024; 148:215-222. [PMID: 37074845 DOI: 10.5858/arpa.2022-0474-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 04/20/2023]
Abstract
CONTEXT.— Syringocystadenocarcinoma papilliferum (SCACP) is a rare adnexal carcinoma and the malignant counterpart of syringocystadenoma papilliferum (SCAP), which is commonly located on the head and neck and may arise in association with a nevus sebaceus. RAS mutations have been identified in both SCAP and nevus sebaceus. OBJECTIVE.— To evaluate the clinicopathologic and molecular features of SCACPs, which have not been previously explored. DESIGN.— We obtained 11 SCACPs from 6 institutions and reviewed the clinicopathologic features. We also performed molecular profiling using next-generation sequencing. RESULTS.— The cohort comprised 6 women and 5 men with ages ranging from 29 to 96 years (mean, 73.6 years). The neoplasms occurred on the head and neck (n = 8; 73%) and extremities (n = 3; 27%). Three tumors possibly arose in a nevus sebaceus. A total of 4 cases showed at least carcinoma in situ (adenocarcinoma, n = 3; squamous cell carcinoma [SCC], n = 1), and 7 cases were invasive (SCC, n = 5; mixed adenocarcinoma + SCC, n = 2). A total of 8 of 11 cases (73%) had hot spot mutations consisting of HRAS (n = 4), KRAS (n = 1), BRAF (n = 1), TP53 (n = 4), ATM (n = 2), FLT3 (n = 1), CDKN2A (n = 1), and PTEN (n = 1). All 4 cases with HRAS mutations occurred on the head and neck, whereas the KRAS mutation occurred on the extremity. CONCLUSIONS.— RAS-activating mutations were detected in 50% of the cases, of which most (80%) involved HRAS and occurred on the head and neck, which shows overlapping features with SCAP, supporting that a subset may arise as a result of malignant transformation and likely an early oncogenic event.
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Affiliation(s)
- Kristine M Cornejo
- From the Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts (Cornejo, Nazarian)
| | - Lloyd Hutchinson
- Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts (Hutchinson, O'Donnell, Meng, Tomaszewicz)
| | - Patrick O'Donnell
- Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts (Hutchinson, O'Donnell, Meng, Tomaszewicz)
| | - Xiuling Meng
- Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts (Hutchinson, O'Donnell, Meng, Tomaszewicz)
| | - Keith Tomaszewicz
- Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts (Hutchinson, O'Donnell, Meng, Tomaszewicz)
| | - Sara C Shalin
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas (Shalin)
| | - David S Cassarino
- Southern California Permanente Medical Group, Sunset Medical Center, Department of Pathology, Los Angeles, California (Cassarino)
| | - May P Chan
- Department of Pathology, University of Michigan Health System, Ann Arbor, Michigan (Chan)
| | - Timothy R Quinn
- Massachusetts General Physicians Organization Dermatopathology Associates, Newton, Massachusetts (Quinn)
| | - Paul B Googe
- the Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina (Googe)
| | - Rosalynn M Nazarian
- From the Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts (Cornejo, Nazarian)
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3
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Gorji L, Hamilton M, Reyes NM, O’Neill EM, Floyd ZR, Elrod MA, Archer AL. Syringocystadenoma papilliferum: case series and review of the literature. J Surg Case Rep 2023; 2023:rjad263. [PMID: 37215626 PMCID: PMC10198642 DOI: 10.1093/jscr/rjad263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
Syringocystadenoma papilliferum (SCAP) is a rare, hamartomatous tumor of the apocrine glands, which typically manifests in the head and neck region. We present a case of 60-year-old male with a several-year history of the lesion located on the abdominal wall and a second case of a 58-year-old male with a history of a slow-growing lesion located on the tragus. Despite varying presentations and locations, both patients were identified to have SCAP on pathological evaluation. Appropriate treatments of SCAP range from CO2 laser treatment to surgical excision; we recommend surgical excision due to the risk of malignant transformation.
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Affiliation(s)
- Leva Gorji
- Correspondence address: Kettering Health Dayton, Department of Surgery, 405 W Grand Ave, Dayton, OH 45405, USA. E-mail:
| | - Matthew Hamilton
- Kettering Health - Datyon, Department of Surgery, Dayton, OH 45405, USA
| | - Nicole M Reyes
- Kettering Health - Datyon, Department of Surgery, Dayton, OH 45405, USA
| | - Erin M O’Neill
- Kettering Health - Datyon, Department of Surgery, Dayton, OH 45405, USA
| | - Zachary R Floyd
- Kettering Health - Datyon, Department of Surgery, Dayton, OH 45405, USA
| | - Michael A Elrod
- Kettering Health - Datyon, Department of Surgery, Dayton, OH 45405, USA
| | - Andrew L Archer
- Kettering Health - Datyon, Department of Surgery, Dayton, OH 45405, USA
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4
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Nevus Sebaceous of the Scalp With Stepwise Progression Into Invasive Syringocystadenocarcinoma Papilliferum. Am J Dermatopathol 2021; 43:965-969. [PMID: 34797792 DOI: 10.1097/dad.0000000000002049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Syringocystadenocarcinoma papilliferum (SCACP), the malignant counterpart of syringocystadenoma papilliferum (SCAP), is an extremely rare malignant adnexal neoplasm. It is described by the World Health Organization as a malignant transformation of SCAP occurring in middle-aged to elderly individuals with a predilection for the head and neck. SCACP seems to arise from a long-standing syringocystadenoma probably on a background of nevus sebaceous (NS) through a multistep progression. A 75-year-old man was referred to our department with a long-standing NS with a recent newly developing nodule on his scalp. The tumor was excised. On histology, the overall architecture of the tumor still resembled an unusual SCAP within NS but simultaneously showed transition to syringocystadenocarcinoma papilliferum in situ and invasive SCACP as recognizable by the presence of areas of nuclear atypia, increased proliferative activity, and infiltrative growth. In summary, we report an extremely rare case of an invasive SCACP of the scalp that demonstrates histological evidence for all transitive steps in the hypothetical multistep progression from NS to invasive SCACP in one single lesion. The implications of these findings are discussed in the light of the relevant literature.
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Sheldon JD, Buckley K, Ulman C, Chung CG. Anogenital syringocystadenocarcinoma papilliferum in situ or anaplastic extramammary Paget disease? A unifying concept and review of the literature. J Cutan Pathol 2021; 48:1075-1079. [PMID: 33893742 DOI: 10.1111/cup.14029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 11/28/2022]
Abstract
Extramammary Paget disease (EMPD) is a rare cutaneous malignancy that typically involves the genital skin and can be primary or associated with an underlying internal malignancy. The typical histopathological appearance of EMPD consists of single or small aggregates of cells with abundant pale cytoplasm and large pleomorphic nuclei, known as Paget cells, scattered throughout the epidermis. We report a case of anogenital EMPD occurring in a 53-year-old man with unusual histopathologic findings of marked epidermal acanthosis, acantholysis, intraepidermal glandular differentiation, and prominent plasma cell-rich fibrovascular cores. These features were entirely confined to the epidermis and adnexa with no evidence of dermal invasion or underlying systemic disease. We review and summarize the literature for atypical features noted in EMPD and summarize similar findings previously described under a variety of descriptions including anaplastic EMPD, anogenital syringocystadenocarcinoma papilliferum in situ (SCACPIS), SCACPIS-like changes in EMPD, and EMPD mimicking acantholytic squamous cell carcinoma in situ. We propose that these features represent a single entity and be considered under a unifying diagnosis to facilitate recognition of this entity.
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Affiliation(s)
- Jesse D Sheldon
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Catherine Ulman
- Division of Dermatology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Catherine G Chung
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Division of Dermatology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Altunel E, Perepletchikov A, Kozyreva O. Metastatic Syringocystadenocarcinoma Papilliferum: A Case Report, Tumor Genomic Profiling, and Literature Review. Case Rep Oncol Med 2020; 2020:9056209. [PMID: 32850165 PMCID: PMC7436348 DOI: 10.1155/2020/9056209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 07/06/2020] [Accepted: 07/30/2020] [Indexed: 11/18/2022] Open
Abstract
Syringocystadenocarcinoma papilliferum (SCACP) is an extremely rare cutaneous neoplasm of the apocrine or eccrine sweat glands. Solid and cystic glandular structures with cribriform and tubular architecture along with CK5/6, pankeratin and p63 immuno-profile set apart SCACP from other cutaneous malignancies. Wide local excision (WLE) has been the mainstay treatment for localized SCACP; however, no standard treatment has yet been established for unresectable or metastatic disease. Herein, we report a 74-year-old male with SCACP, who initially presented with a painful nodule on the upper back and later developed metastatic disease. He was treated with carboplatin and paclitaxel with concurrent intensity-modulated radiation therapy (IMRT), which resulted in disease stabilization for 12 months. Next generation sequencing (NGS) revealed a total of 18 genomic alterations associated with potential benefit from targeted therapeutics. PD-L1 expression was identified in 70% of tumor cells. These findings suggest that the opportunity of targeted therapeutics and immunotherapy exist as for metastatic SCACP. Reporting molecular profile of the rare tumors with no established standard treatment options should be encouraged.
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Affiliation(s)
- Erdem Altunel
- Department of Medicine, Saint Elizabeth's Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Division of Medical Oncology, Dana Farber Cancer Institute at Saint Elizabeth's Medical Center, Boston, Massachusetts, USA
| | - Aleksandr Perepletchikov
- Department of Pathology, Saint Elizabeth's Medical Center, Boston, Massachusetts, USA
- Department of Pathology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Olga Kozyreva
- Department of Medicine, Saint Elizabeth's Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Division of Medical Oncology, Dana Farber Cancer Institute at Saint Elizabeth's Medical Center, Boston, Massachusetts, USA
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7
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Lee KG, Choi W, Lim JS, Hahn HJ, Myung KB, Cheong SH. Syringocystadenocarcinoma Papilliferum: A Case Report and Review of the Literature. Ann Dermatol 2019; 31:559-562. [PMID: 33911649 PMCID: PMC7992554 DOI: 10.5021/ad.2019.31.5.559] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/30/2018] [Accepted: 08/27/2018] [Indexed: 11/08/2022] Open
Abstract
Syringocystadenocarcinoma papilliferum (SCACP) is a rare malignant adnexal neoplasm, which is considered as a malignant counterpart of syringocystadenoma papilliferum (SCAP). Clinically, SCACP appears as a nodule, inflammatory plaque, or tumor. The lesion is usually covered with crusts, which are formed by secretion of the apocrine epithelial cells. Histologically, SCACP resembles SCAP, with cystic papillomatous invaginations connected to the skin surface by funnel-shaped structures lined by infundibular epithelium. The stroma of the tumor consists of a dense inflammatory infiltrate of plasma cells and lymphocytes. SCACP differs from SCAP in terms of the architectural and cytological features of the tumor cells, and is characterized by higher nuclear cytoplasmic ratio, nuclear irregularity, coarse chromatin, and increased mitotic activity. However, the immunohistochemical findings of SCACP vary. Since only 49 cases of SCACP have been reported in the English literature, the clinical and histologic characteristics of SCACP have not been fully established. Further studies on the diagnostic criteria for SCACP are warranted. Here, we report a rare case of SCACP and present a review of other relevant literature.
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Affiliation(s)
- Kyoung Geun Lee
- Department of Dermatology, College of Medicine, Konyang University, Daejeon, Korea
| | - Won Choi
- Department of Dermatology, College of Medicine, Konyang University, Daejeon, Korea
| | - Joon Soo Lim
- Department of Dermatology, College of Medicine, Konyang University, Daejeon, Korea
| | - Hyung Jin Hahn
- Department of Dermatology, College of Medicine, Konyang University, Daejeon, Korea
| | - Ki Bum Myung
- Department of Dermatology, College of Medicine, Konyang University, Daejeon, Korea
| | - Seung Hyun Cheong
- Department of Dermatology, College of Medicine, Konyang University, Daejeon, Korea
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8
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Syringocystadenocarcinoma Papilliferum: Case Report and Review of the Literature. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2017.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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9
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Syringocystadenocarcinoma Papilliferum: Case Report and Review of the Literature. ACTAS DERMO-SIFILIOGRAFICAS 2017; 109:366-369. [PMID: 29074144 DOI: 10.1016/j.ad.2017.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 03/18/2017] [Accepted: 03/21/2017] [Indexed: 11/23/2022] Open
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10
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Zhang Y, Kong YY, Cai X, Shen XX, Kong JC. Syringocystadenocarcinoma papilliferum: Clinicopathologic analysis of 10 cases. J Cutan Pathol 2017; 44:538-543. [PMID: 28337777 DOI: 10.1111/cup.12934] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/10/2017] [Accepted: 03/21/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Syringocystadenocarcinoma papilliferum (SCACP) is an exceedingly rare cutaneous adnexal neoplasm. We aimed to investigate the clinicopathologic and immunophenotypic features of SCACP, and to discuss the prognosis of this rare entity. METHOD We retrospectively collected clinical, pathological and follow-up data of 10 cases with SCACP. RESULTS There were 8 males and 2 females, with ages ranging from 26 to 74 years. The chest was most frequently involved. Histologically, 1 case only showed SCACP in situ, 9 cases presented with variable invasive components of adenocarcinoma and/or squamous cell carcinoma in addition to areas of in situ. Apocrine differentiation with decapitation was evident in 4 cases and mucinous metaplasia was noted in 1 case. P63 was positive in invasive squamous cell carcinoma, while CK7 was variably positive in invasive adenocarcinoma. Regional lymph node metastasis was confirmed by pathological examination in 4 patients. Follow up was available for 9 patients, ranging from 3 to 112 months. Three patients died of the disease within 1 year after recurrences. CONCLUSIONS Because of high rates of regional lymph node metastasis and mortality in our patients, clinical behavior of SCACP seems to be more aggressive than that previously reported.
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Affiliation(s)
- Yan Zhang
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yun-Yi Kong
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Xu Cai
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Xu-Xia Shen
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jin-Cheng Kong
- Department of Pathology, First People's Hospital, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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11
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Syringocystadenocarcinoma Papilliferum In Situ-Like Changes in Extramammary Paget Disease: A Report of 11 Cases. Am J Dermatopathol 2017; 38:882-886. [PMID: 26863065 DOI: 10.1097/dad.0000000000000554] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors report 11 cases of extramammary Paget disease (EMPD), all of which also demonstrated a combination of histological changes highly reminiscent of syringocystadenocarcinoma papilliferum in situ. In addition to the classical features of EMPD, characterized by the intraepidermal spread of individually dispersed neoplastic cells with ample cytoplasm, many of which contained mucin, there were areas of acanthosis with the substitution of spinous layer keratinocytes by neoplastic cells, whereas the native basal cell layer was intact. In addition to acanthosis (and sometimes papillomatosis), the dermal papillae showed a prominent infiltrate of plasma cells, completing the resemblance to syringocystadenocarcinoma papilliferum in situ; this similarity was further enhanced in 2 cases, which showed conspicuous gland formation. One additional case showed multifocal dermal proliferations compatible with eccrine syringofibroadenoma (syringofibroadenomatous hyperplasia). The changes described herein seem to be relatively rare in EMPD, and they can represent a diagnostic pitfall, as evidenced by 2 cases that were originally misinterpreted as syringocystadenocarcinoma papilliferum in situ. Clinically, these microscopic changes sometimes corresponded to nodular lesions, which were specifically noted to have a papillated erosive surface.
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12
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Syringocystadenocarcinoma Papilliferum In Situ, a Variant of Cutaneous Adenocarcinoma In Situ: A Case Report With Literature Review. Am J Dermatopathol 2016; 38:762-5. [DOI: 10.1097/dad.0000000000000687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Chandramouli M, Sarma D, Tejaswy K, Rodrigues G. Syringocystadenoma Papilliferum of the Scalp Arising from a Nevus Sebaceous. J Cutan Aesthet Surg 2016; 9:204-206. [PMID: 27761094 PMCID: PMC5064688 DOI: 10.4103/0974-2077.191656] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Syringocystadenoma papilliferum (SCAP) is a rare, benign tumour with varied presentations that arises from the apocrine glands and at times can lead to a diagnostic dilemma. A 53-year-old male presented with a 40-year history of a scalp nodule and a recent 2-year change in its character, and a sanguinopurulent discharge. Examination revealed a 4 cm × 2 cm firm nodule upon left side of the scalp vertex, actively discharging pus and blood. No regional lymph nodes were noticeably palpable. Incision biopsy performed elsewhere showed evidence of a squamous cell carcinoma-in-situ. He underwent a wide local excision with a bilobed flap reconstruction. Histopathologically, the lesion was reported to be SCAP. On follow-up, the patient has since remained asymptomatic with an acceptable cosmetic recovery.
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Affiliation(s)
- Mathangi Chandramouli
- Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Digvijay Sarma
- Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Kapil Tejaswy
- Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Gabriel Rodrigues
- Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
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