Case Report: A challenging diagnosis of an apocrine sweat gland carcinoma

The differential diagnosis for an axillary mass in a patient with a previously treated malignancy is broad and definitive tissue diagnosis is required to guide treatment and surveillance strategies. We present the case of a 76-year-old African American male with a history of prostate cancer who presented with a left axillary mass two years after achieving remission from his prostate malignancy. Due to the diagnostic challenge, this excisional biopsy was reviewed at four different academic centers. Although no universal consensus among these institutions' pathologists, but in the context of clinical presentation and anatomic location, the overall clinical findings are consistent with apocrine sweat gland carcinoma. The mass was treated with complete local surgical excision, though regional lymph node metastasis occurred 2 years later. Multimodal treatment with surgery and radiation was done with removal of regional metastasis and no distant disease was identified. Primary apocrine carcinoma is a rare cutaneous neoplasm with less than 100 reported cases in the literature. A combination of clinical history and presentation, histomorphology, anatomical location, and immunohistochemistry is used to support the diagnosis and ultimately drive management.

Recurrent and convolutional neural networks for sequential multispectral optoacoustic tomography (MSOT) imaging

Multispectral optoacoustic tomography (MSOT) is a beneficial technique for diagnosing and analyzing biological samples since it provides meticulous details in anatomy and physiology. However, acquiring high through-plane resolution volumetric MSOT is time-consuming. Here, we propose a deep learning model based on hybrid recurrent and convolutional neural networks to generate sequential cross-sectional images for an MSOT system. This system provides three modalities (MSOT, ultrasound, and optoacoustic imaging of a specific exogenous contrast agent) in a single scan. This study used ICG-conjugated nanoworms particles (NWs-ICG) as the contrast agent. Instead of acquiring seven images with a step size of 0.1 mm, we can receive two images with a step size of 0.6 mm as input for the proposed deep learning model. The deep learning model can generate five other images with a step size of 0.1 mm between these two input images meaning we can reduce acquisition time by approximately 71%.

Impact of Nanomedicine in Women's Metastatic Breast Cancer

Metastatic breast cancer is responsible for 90% of mortalities among women suffering from various types of breast cancers. Traditional cancer treatments such as chemotherapy and radiation therapy can cause significant side effects and may not be effective in many cases. However, recent advances in nanomedicine have shown great promise in the treatment of metastatic breast cancer. For example, nanomedicine demonstrated robust capacity in detection of metastatic cancers at early stages (i.e., before the metastatic cells leave the initial tumor site), which gives clinicians a timely option to change their treatment process (for example, instead of endocrine therapy they may use chemotherapy). Here recent advances in nanomedicine technology in the identification and treatment of metastatic breast cancers are reviewed.

Abstract 3879: Inhibition of CXCR4 driven colorectal cancer progression by Nef-M1 peptide

Introduction: The Nef-M1 peptide (Nef-M1) competes effectively with the natural ligand of CXCR4, SDF-1α, and exhibits anti-tumorigenic activity in human colorectal cancer (CRC). However, the molecular mechanisms of action of Nef-M1 on CRC remain unclear. In this study, we evaluated the inhibition of CXCR4 driven molecular signaling mechanisms that is involved in CRC progression.

Experimental Design: Cell line derived xenografts (CDX), patient derived explant (PDE) and in vitro cell based models were used to examine the mechanisms of action of Nef-M1. The severe combined immunodeficient (SCID) mice with tumor were treated intraperitoneally with either Nef-M1 or scrambled amino acids sequence Nef-M1 (sNef-M1) that is the control. Preparation of CRC tissue, explant complete media, and cultures and treatment for 48 hours were performed for the PDE study. Sections from tumors were evaluated by immunostaining (IHC) for signaling proteins thus, implicating CRC progression. Western blot (WB) analyses were also performed on lysates of both cell lines and tumors to assess the effect of Nef-M1 on the signaling pathways that promote CRC progression.

Results: The present study revealed that PDE recapitulate multiple biological features of the disease and these were found to be very similar to the corresponding original CRC. CXCR4 overexpressing CRC cells displayed activation of CXCR4/CREB signaling as demonstrated by an increased activation of CREB, and expression of B-Myb and APOBEC3B (A3B). IHC analysis for Ub-H2B, a stem cell signaling protein that correlates with advanced disease and metastasis indicated that Nef-M1 treated CDX or PDE tumors had low expression of Ub-H2B. However, sNef-M1 treated tumors had high expression of Ub-H2B. WB analyses indicated that Nef-M1 not only suppressed the expression of Ub-H2B, but also significantly suppressed the expression of A3B. Cells expressing CXCR4 became susceptible to Nef-M1-induced inhibition of Akt, mTOR activation and Ub-H2B expression.

Conclusions: These results indicate that Nef-M1 suppresses CXCR4 driven activation of CXCR4/CREB signaling and the expression of Ub-H2B. Therefore, Nef-M1 inhibition of these signaling pathways may be a promising therapeutic strategy for CRC. This work was supported by NIH/NCI Workforce Diversity Grant R21-CA171251.

Citation Format: Venkat R. Katkoori, Zeynoire Anderson, Upender Manne, Harvey Bumpers. Inhibition of CXCR4 driven colorectal cancer progression by Nef-M1 peptide [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3879.

Abstract 781: Functional consequence of the p53 codon 72 polymorphism in colorectal cancer

Background: The codon 72 polymorphism in p53 has been implicated in colorectal cancer (CRC) and CRC health disparities. In this study, we determine the functional consequence of this polymorphism in CRC following both in-vitro cell based and in-vivo mouse model studies.

Experimental Design: Plasmids (pCMV6) that express different phenotypes of p53 [p53 wild type (wt) at codon 72 (R72wt), R72wt with mutation at codon 273 cysteine (R72273Cys), p53 mutation at codon 72 (P72wt) and P72wt with mutation at codon 273 (P72273Cys)] were constructed. We selected a CRC cell line Caco2, which does not express p53 for in vitro studies. Severe combined immunodeficient mice were inoculated with CRC cells (HT29, SW480, and LS174) to establish tumor xenografts (tumors). Tumor angiogenesis was assessed in tumors by immunostaing for CD31. Sequencing analysis for codon 72 polymorphism of p53 was performed using genomic DNA purified from tumors. Western blot (WB) or immunostaining analyses for proteins of signaling mechanisms were performed to assess the functional consequence of P72 phenotype of p53.

Results: Our study demonstrated that P72 tumors had well established vascularity, while R72 tumors had very poor vascularization. Indeed, the mean micro vessel density was higher in P72 tumors than in R72 tumors. WB analyses revealed that P72wt or mutant phenotypes effectively induced the activation of p38 and RAF/MEK/ extracellular signal-regulated kinase (ERK) MAP kinases. Up-regulation of phosphorylated SEK1/MKK4, an upstream kinase of p38 MAPK was associated with P72wt or mutant phenotypes. This activation was accompanied by up-regulation of phosphorylated-MAPKAPK-2, -Hsp27, and -CREB, downstream targets of p38 MAPK. Increased activation of CREB was found to be higher in tumors that exhibit P72 phenotype. Metastatic lesions of CRC expressed more phospho-CREB than non-metastatic lesions. Furthermore, suppression of RAF/MEK/ERK activation was significantly higher in cells that express R72wt phenotype compared to cells that express P72wt or mutant phenotypes. The expression of P72wt or mutant phenotypes displayed decreased expression of E cadherin and/or an increased expression of vimentin, fibrinectin, CD44, thereby promoting CRC metastasis.

Conclusions: These findings offer significant novel insights into the mechanism by which P72 contributes to the aggressiveness of CRC. Because P72 is over-expressed in CRC, specifically in African-American patients, these studies suggest a role for P72 in cancer health disparities. This work was supported by NIH/NCI Workforce Diversity Grant R21-CA171251.

Citation Format: Venkat R. Katkoori, Upender Manne, Harvey Bumpers. Functional consequence of the p53 codon 72 polymorphism in colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 781. doi:10.1158/1538-7445.AM2017-781

Nef-M1, a CXCR4 Peptide Antagonist, Enhances Apoptosis and Inhibits Primary Tumor Growth and Metastasis in Breast Cancer

Results from studies with animal models suggest that, in many cancers, CXCR4 is an important therapeutic target and that CXCR4 antagonists may be promising treatments for primary cancers and for metastases. The Nef protein effectively competes with CXCR4’s natural ligand, SDF-1α, and induces apoptosis. As described in this report, the Nef-M1 peptide (Nef protein amino acids 50 – 60) inhibits primary tumor growth and metastasis of breast cancer (BC). Four BC cell lines (MDA-MB-231, MDA-MB-468, MCF 7, and DU4475) and primary human mammary epithelium (HME) cells were evaluated for their response to the Nef protein and to the Nef-M1 peptide. The presence of CXCR4 receptors in these cells was determined by RT-PCR, Western blot (WB), and immunohistochemical analyses. The apoptotic effect of Nef-M1 was assessed by terminal transferase dUTP nick-end labeling (TUNEL). WBs was used to assess caspase 3 activation. BC xenografts grown in SCID mice were evaluated for the presence of CXCR4 and for their metastatic potential. CXCR4 was presented in MDA-MB-231, MCF 7, and DU 4475 BC cells but not in MDA-MB-468 BC or HME cells. Cells expressing CXCR4 and treated with Nef-M1 peptide or the Nef protein had higher rates of apoptosis than untreated cells. Caspase-3 activation increased in MDA-MB 231 cells treated with the Nef protein, the Nef 41 – 60 peptide, or Nef-M1. Nef-M1, administered to mice starting at the time of xenograft implantation, inhibited growth of primary tumors and metastatic spread. Untreated mice developed diffuse intraperitoneal metastases. We conclude that, in BCs, Nef-M1, through interaction with CXCR4, inhibits primary tumor growth and metastasis by causing apoptosis.

Feasibility of accelerated partial breast irradiation in a large inner-city public hospital

BACKGROUND

Breast conserving therapy (BCT) that include breast conserving surgery followed by adjuvant radiation therapy has revolutioned medicine by allowing women to avoid mastectomy. Accelerated partial breast irradiation (APBI) has emerged as a valid alternative to whole-breast irradiation that requires a shorter time commitment. We report our novel experience with APBI at a large public hospital that serves low-income and potentially noncompliant patients.

METHODS

A retrospective chart review was conducted of women who underwent BCT for stage 0-IIA breast cancer from August 2007 to August 2010 treated with APBI with a brachytherapy catheter.

RESULTS

Twenty-four patients (20 African American) were considered for APBI. Average age was 61 years. Four patients could not undergo APBI for technical reasons and completed whole-breast irradiation over a 5 week period. Median follow-up was 19 months. Nine patients (37.5 %) had ductal carcinoma-in-situ, and 15 patients (62.5 %) had invasive ductal carcinoma with an average tumor size of 1.1 cm. All patients had negative margins of >2 mm. Two patients (8 %) treated with the brachytherapy catheter had in-breast tumor recurrence. Thus, all 24 patients initially identified for APBI successfully completed adjuvant radiotherapy.

CONCLUSIONS

Patient compliance with postoperative irradiation is key to minimize local recurrence after BCT for breast cancer. This success with a brachytherapy catheter in underserved women in a U.S. public hospital setting indicates that outcomes of compliance and complications are comparable to nationally published results.

Improving on national quality indicators of breast cancer care in a large public hospital as a means to decrease disparities for African American women

BACKGROUND

In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for stage I, II, and III breast cancer. The purpose of this study was to document compliance with the 3 NQF breast quality indicators during 2 time intervals in a metropolitan public hospital.

MATERIALS AND METHODS

Tumor registry and medical records were used to identify patient demographics and treatments before (2005-2006) and after (2008) implementations in 2007 as a result of the NQF audit. Program changes included: hiring a dedicated medical oncology nurse practitioner, requiring the radiation oncology case manager to attend weekly multidisciplinary conferences, educating Patient Navigators of the importance of multimodal care, and providing support groups for patients addressing importance of completion of all treatment options.

RESULTS

A total of 213 female patients were diagnosed with and treated for stage I, II, or III breast cancer in 2005-2006 and 2008. Of these, 189 (89%) were African American (AA) women. Also, 70 patients of 86 (81.3%) received radiation therapy, 60 of 77 (77.9%) received or were considered for adjuvant chemotherapy, and 124 of 144 (86.1%) for hormonal therapy according to NQF indicators. After 2007, patients receiving radiation therapy increased from 75.8 to 95.8%. Patients receiving or considered for adjuvant chemotherapy or hormonal therapy increased from 73.7 to 93.7% and from 84.1 to 90.0%, respectively.

CONCLUSIONS

NQF breast cancer indicators provided a mechanism to improve compliance of multimodal treatment in our center. Raising awareness of these indicators in the multidisciplinary conference, hiring dedicated personnel, and educating patients has led to major improvements in breast cancer care.

Using National Quality Forum breast cancer indicators to measure quality of care for patients in an AVON comprehensive breast center

In April 2007, the National Quality Forum (NQF) endorsed the first nationally recognized hospital-based performance measures for quality of care for breast cancer. The aim of this study was to measure quality of care at our AVON Center for Breast Care (AVONCBC) using these indicators. We retrospectively reviewed tumor registry and medical records of females under age 70 diagnosed with breast cancer in years 2005-2006. For patients diagnosed with hormone receptor negative breast cancer, 22 of 29 (75.9%) and 28 of 32 (87.5%) were considered for or received chemotherapy in 2005 and 2006, respectively. Of those patients, 21 of 29 (72.4%) and 24 of 32 (75.0%) were considered for or received chemotherapy within the NQF 4-month period. For patients undergoing breast conserving surgery (BCS), 20 of 23 (86.9%) in 2005 and 37 of 39 (94.9%) in 2006 were referred for adjuvant radiation therapy. The proportion of patients who received radiation therapy within 1 year of diagnosis was 18 of 23 (78.2%) and 29 of 39 (74.4%) for diagnosis years 2005 and 2006, respectively. The vast majority of patients in our AVONCBC are referred to medical and/or radiation oncology for adjunctive therapy and about three-fourths receive treatment compliant with the NQF QI. To increase our compliance rate, we are developing methods to improve access to the multiple disciplines in our AVONCBC. Using the NQF indicators serves to assess hospital performance at a systems-level and as a useful method for tracking cancer quality of care.

Waiting Time for Breast Conserving Surgery Patients in a Public and a Private University Affiliated Hospital in Atlanta

Background: The time it takes for a patient to undergo the entire breast cancer pathway treatment varies for diverse patient populations in different health care settings. In this study we analyzed delay in breast cancer treatment (DBCT) for a defined population of breast cancer patients. All of the patients had identical cancer care trajectories of breast-conserving therapy (BCT) for infiltrating ductal carcinoma (IDC) or ductal carcinoma in situ (DCIS), followed by neo-adjuvant therapy in two different hospital settings; including a University-based inner-city hospital and a University-affiliated private practice hospital.Materials and Methods: A retrospective chart review of 214 patients treated from 2004 to 2008 was conducted. Five consecutive diagnostic and treatment events in a total of four time intervals (see Figure 1 below) were defined and correlated with demographic factors such as age, race, marital status, distance traveled to visit, insurance status type, and hospital type. Non-parametric Wilcoxon Rank-Sum test was used for statistical analysis.Results: The mean ages of the patients in both hospitals were similar (59.2 yrs public hospital vs. 61.9 yrs private hospital). Patients treated in the public hospital experienced greater DBCT compared to patients who were treated in the private institution (125 vs. 88 days, p < 0.001). Overall, the largest delay was the time period from diagnostic core biopsy to surgery (50 days). The only time interval that showed greater delay for African-American (AA) women compared to Caucasian women was time from final pathology diagnosis to medical oncology evaluations (26 vs. 33 days, p=0.036). Patients who were married or insured experienced less DBCT compared to patients who were not (80 vs. 117 days and 83.3 vs.167 days respectively, p < 0.001). Medicaid patients had shorter wait times in the public compared to in the private hospital (136 vs. 153 days, ns). Patients who experienced less than 90 days of delay to undergo the entire treatment traveled an average 27.3 miles (sd=76.6) for their hospital visit, while patients who experienced greater than 90 days of delay to undergo the same treatment traveled an average 14.2 miles (sd=19.9) for their hospital visit.Discussion: Differences in DBCT are multi-factorial and arise from system-based issues that vary among hospital settings along with demographic factors such as marital status and race that are independent of the hospital setting. More effective scheduling for surgical treatment and follow up appointments may reduce the wait time. In order to significantly shorten DBCT further, prospective studies are needed to evaluate the intricate connection of psychosocial and system barriers to breast cancer treatment.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3070.

Prognostic significance of p53 codon 72 polymorphism differs with race in colorectal adenocarcinoma

PURPOSE

Several studies have examined the prognostic value of the codon 72 polymorphism of the p53 gene in colorectal adenocarcinoma, but none have addressed patient race/ethnicity. Therefore, this study assessed the prognostic value of this polymorphism in African American and Caucasian colorectal adenocarcinoma patients separately.

EXPERIMENTAL DESIGN

Colorectal adenocarcinomas from 137 African Americans and 236 non-Hispanic Caucasians were assessed for p53 mutations and genotyped for the codon 72 polymorphism. The phenotypes were correlated with p53 mutational status, clinicopathologic features, and patient survival using the chi(2) test and Kaplan-Meier and Cox regression models.

RESULTS

The incidence of p53 mutations was similar in African American and Caucasian patients (50% versus 54%, respectively); however, the homozygous Pro72 allele frequency was higher in African Americans (17%) as compared with Caucasians (7%). In contrast, the homozygous Arg72 allele frequency was higher in Caucasians (36%) than in African Americans (19%). In African Americans but not Caucasians, the Pro/Pro phenotype significantly correlated with a higher incidence of missense p53 mutations and with nodal metastasis. African Americans, but not Caucasians, with the Pro/Pro phenotype had significantly higher mortality (log-rank P = 0.005 versus. P = 0.886) and risk of death due to colorectal adenocarcinoma (hazard ratio, 2.15; 95% confidence interval, 1.02-4.53 versus hazard ratio, 1.60; 95% confidence interval, 0.69-3.18) than those with the phenotype Arg/Arg or Arg/Pro.

CONCLUSIONS

The higher frequency of the Pro/Pro phenotype of p53 in African American patients with colorectal adenocarcinoma is associated with an increased incidence of p53 mutations, with advanced tumor stage, and with short survival.

Characteristics and treatment modalities for African American women diagnosed with stage III breast cancer

BACKGROUND

Stage III breast cancers account for about 6% to 7% of all invasive breast cancers diagnosed annually in the United States. In African American (AA) women, the incidence of stage III breast cancers is almost double that in Caucasian women. The aim of this study was to correlate age, receptor status, nuclear grade, and differences in treatment modalities for stage III breast cancer in an inner-city hospital serving a large AA population.

METHODS

A retrospective review was performed for all stage III primary breast cancers diagnosed and or treated from 2000 to 2006.

RESULTS

: Of 840 primary invasive breast cancers, the authors identified 107 as stage III, 40.2% IIIA, 32.7% IIIB, 16.8% T4D, and 10.3% IIIC. The majority of the patients were AA (n = 93, 86.9%). Stage IIIC patients were younger (P < .05). Triple negative tumors (TNT) accounted for 29.0%. TNT were more likely among the inflammatory breast cancers (50.0%) compared with the other 3 groups (P < .05). Twenty-two patients (20.5%) refused chemotherapy, and 24 of the 91 patients (26.3%) who should have received chest wall radiation refused. There was no difference in race, marital status, religion, or age in the patients that refused chemotherapy or radiation therapy versus the majority of patients in this series who received standard care.

CONCLUSIONS

Stage III breast cancers in AA women have distinct clinical characteristics. A high number of these patients refused chemotherapy and radiation therapy. Reasons for refusal need to be better defined so strategies can be implemented to improve compliance for these advanced stage patients.

HIV Nef-M1 Effects on Colorectal Cancer Growth in Tumor-induced Spleens and Hepatic Metastasis

CXCR4 receptors have been implicated in tumorigenesis and proliferation, making it a potential target for colorectal cancer therapy. Expression of this chemokine receptor on cellular surfaces appears to promote metastasis by directly stimulating tumor cell migration and invasion. The receptor/ligand, CXCR4/SDF-1alpha, pair are critically important to angiogenesis and vascular remodeling which supports cancer proliferation. Our work has shown that a novel apoptotic peptide of HIV-1, Nef-M1, can act as a CXCR4 antagonist, inducing apoptosis in CXCR4 containing cells. Four colorectal tumor cell lines (HT-29, LS174t, SW480, WiDr), were evaluated for their response to Nef-M1 peptide via in vivo and in vitro. The presence of CXCR4 receptors on tumor cells was determined using immunohistochemical and RT-PCR analyses. Solid xenografts derived from tumor cell lines grown in SCID mice, were evaluated for the persistence of the receptor. Xenografts propagated in SCID mice from each of the four cell lines demonstrated high levels of receptor expression as well. The effects of Nef-M1 in vivo via splenic injected mice and subsequent hepatic metastasis also demonstrated dramatic reduction of primary tumor growth in the spleen and secondary invasion of the liver. We concluded that Nef-M1 peptide, through physical interaction(s) with CXCR4, drives apoptotic reduction in in vivo primary tumor growth and metastasis.

Morgagni hernias: an uncommon cause of chest masses in adults

Morgagni hernia is a congenital diaphragmatic hernia that occurs secondary to potential anterior medial defects in the diaphragm. Although the hernia usually is diagnosed incidentally, appearing as a mass on chest radiograph, symptoms of bowel obstruction may occur. Surgical repair is required in all cases and may be performed with either the abdominal or transthoracic approach.

The role of immunoscintigraphy in the staging and management of colorectal cancer

Colorectal cancer has continued to increase in incidence over the past 25 years. It now ranks as the second most common noncutaneous malignancy for men and women together. The projected 1995 statistics predict 153,000 new cases in the United States, with 109,000 of colonic origin and 44,000 cancers of the rectum. The shift to more proximal colonic involvement and a decrease in size of the presenting lesion is again noted. Unfortunately, the warning signals (rectal bleeding, change in bowel habits and, later, abdominal pain, distention, and weight loss), often become evident only after the tumor has progressed significantly in the patient. Despite improvements in endoscopic detection, anesthesia, pre- and postoperative care and more extensive en-bloc resections, the cure rate for all patients with colorectal cancer remains unchanged at 53 per cent at five years. Although radical resectional surgery is relied on for locoregional control of the disease, there has been an increased use of cross-sectional radiologic studies for staging of the cancer. This newer management of colorectal cancer is the result of a better understanding of the natural history and biologic behavior of the cancer. The main strategy presently is to diagnose the disease sooner, stage the cancer more accurately, select tumors that will respond to adjuvant therapy, and detect recurrences more efficiently. It is in the area of staging of the primary tumor and accurate localization of recurrences that this new modality, immunoscintigraphy, is felt to have an impact.

Eccrine porocarcinoma

Eccrine porocarcinoma, a malignancy of the eccrine sweat glands, is extremely rare. Our report and a review of the literature (70 cases) emphasize the features of this tumor. Age at time of treatment ranged from 19 to 94 years (mean 67 years). Duration of the lesion ranged from two months to 50 years; 31 (44%) had the lesion present > or = 5 years. Forty-four patients (62%) had tumors located on the extremities, 13 (19%) on the head and neck region and 12 (17%) on the trunk. All patients whose race is known were white. Primary treatment should consist of wide local excision and regional lymphadenectomy, if clinically indicated. Although there is a significant risk of cutaneous, regional lymph node, or visceral metastases, the value of elective or therapeutic regional lymphadenectomy is unknown, as is the role of adjunctive therapy.

Surgical management of advanced squamous cell skin cancers

Squamous cell cancer of the skin usually follows prolonged exposure to known carcinogens including ultraviolet light, ionizing radiation, chronic infection or irritation, chemicals, and immunologic suppression. The majority of squamous cell skin cancers metastasize infrequently and can be cured with aggressive wide local excision. However, on occasion they can be quite aggressive locally, with or without associated distant metastasis, and may require a radical surgical approach. We report a series of four male patients covering the spectrum of this disease with the following distribution: lower pole of the right ear, right posterior thigh below gluteal fold with positive inguinal nodes, lateral aspect of the foot with bone involvement, and as an incidental finding in a pilonidal cyst. We conclude that one should not hesitate to proceed with aggressive surgical resection as it may provide the only chance for cure. Finally, one should always look for lymph node metastasis, particularly with large (> 5 cm) lesions adjacent to a regional lymph node drainage basin.