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LETTER TO EDITOR  
Year : 2013  |  Volume : 56  |  Issue : 3  |  Page : 331-333
Diagnostic dilemma in a malignant cutaneous adnexal tumor


Department of Pathology, Mamatha Medical College, Andhra Pradesh, India

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Date of Web Publication24-Oct-2013
 

How to cite this article:
Yalavarthi S, Rangarao S P, Kumar S S, Supriya M. Diagnostic dilemma in a malignant cutaneous adnexal tumor . Indian J Pathol Microbiol 2013;56:331-3

How to cite this URL:
Yalavarthi S, Rangarao S P, Kumar S S, Supriya M. Diagnostic dilemma in a malignant cutaneous adnexal tumor . Indian J Pathol Microbiol [serial online] 2013 [cited 2020 Sep 23];56:331-3. Available from: http://www.ijpmonline.org/text.asp?2013/56/3/331/120423


Sir,

Malignant eccrine neoplasms are exceedingly rare, account for only 0.005% of all skin tumors and often not diagnosed clinically or misinterpreted as soft tissue neoplasms and are encountered as a histological surprise. [1]

We reported a case of an elderly patient, presented with recurrent inframammary swelling, which was clinically and radiologically misinterpreted as soft tissue sarcoma, but pathologically, features were suggestive of malignant eccrine neoplasm.

A 75-year-old lady was admitted in surgical ward with a complaint of left inframammary swelling since 1 year. She had similar complaint in the past and underwent surgery 8 years back. Previous records were unavailable. A 5 × 5 cm hard, spherical, freely mobile, left inframammary swelling, fixed to skin was noted. Fine needle aspiration was done and features were suggestive of malignant neoplasm.

Histopathology of partly skin covered, lobulated, solid, homogenous, grayish white mass revealed normal epidermis, and tumor tissue arranged in lobules, trabeculae, ribbons, cords was noted in the deep dermis. The individual tumor cells are round with vacuolated cytoplasm with round to oval, monotonous, vesicular nuclei with clumped chromatin. Few atypical mitotic figures observed (5-6/ hpf) [Figure 1]. Based on these findings a differential diagnosis of small round cell tumor probably skin adnexal tumor, neuroendocrine neoplasm or metastatic carcinoma to skin was made. A battery of tests was done to arrive at specific diagnosis. It was negative for PAS stain, CK 20 negative, vimentin strongly positive, negative for CD 99, S100, Synaptophysin, LCA, CD-10 and Desmin [Figure 2].
Figure 1a and b: Sections show tumor tissue is arranged in lobules, trabeculae, ribbons (H and E, ×100). (c) High power view showing monotonous appearance of tumor cells and mitotic figures (Hand E, ×400). Inset: Mitoti c fi gures (H and E, ×1000)

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Figure 2: Sections show tumor tissue which is (a) PAS negative (b) cytokeratin negative (c) vimenti n positive (H and E, ×400)

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Because of local recurrence, lobular pattern simulating metastatic carcinoma particularly breast, high mitotic activity, PAS negativity, vimentin positivity, and with exclusion of other possible malignancies, the tumor was diagnosed as malignant eccrine neoplasm possibly malignant eccrine spiradenoma.

Malignant eccrine spiradenomas (MES) can arise from a preexisting eccrine spiradenoma after a variable latent period. [2] In the absence of a benign focus, the tumor with carcino-sarcoma pattern can be confused microscopically with other malignancies such as squamous cell carcinoma, synovial sarcoma, and metastatic carcinomas. [3]

Here, the present case had no benign focus and exhibited features of malignancy and misinterpreted as above said malignancies. In our case, there was a possibility of an undiagnosed benign component in previous surgeries, because the patient had a long (eight year) history and indolent behavior.

Immunohistochemical and ultrastructural analysis revealed sarcomatous areas, which were positive for Vimentin, negative for smooth muscle Actin (SMA) and Desmin. [3],[5] There was no evidence of epithelial differentiation in the sarcomatous areas. [4] In contrast, benign sweat gland tumors show co-expression of vimentin and alpha-smooth muscle actin. [5]

Immunohistochemically, the present case was vimentin positive and desmin negative, which implied its malignant nature of eccrine tumor, and the tumor was predominantly composed of sarcomatous pattern.

Due to nonspecific clinical presentation, indolent behavior and higher recurrence rates, the malignant eccrine neoplasms were misinterpreted clinically and managed differently. So, in case of recurrent neoplasms, the eccrine malignant neoplasm should be considered as one of the differential diagnosis.

 
   References Top

1.Marenda SA, Otto RA. Adnexal carcinomas of the skin. Otolaryngol Clin North Am 1993;26:87-116.   Back to cited text no. 1
    
2.Berçin S, Kutluhan A, Metin A, Süren D. Malignant eccrine spiradenoma on the lateral margin of nose as an infrequent localization. Indian J Dermatol 2009;54:173-5.  Back to cited text no. 2
    
3.Singhal N, Bansal C, Singh RP, Attri AK. Malignant eccrine spiradenoma: A case report. Egypt Dermatol Online J 2009;5:13.  Back to cited text no. 3
    
4.McCluggage WG, Fon LJ, O'Rourke D, Ismail M, Hill CM, Parks TG, et al. Malignant eccrine spiradenoma with carcinomatous and sarcomatous elements. J Clin Pathol 1997;50:871-3.  Back to cited text no. 4
    
5.Eckert F, de Viragh PA, Schmid U. Coexpression of cytokeratin and vimentin intermediate filaments in benign and malignant sweat gland tumors. J Cutan Pathol 1994;21:140-50.  Back to cited text no. 5
    

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Correspondence Address:
Sushma Yalavarthi
Department of Pathology, Mamatha Medical College, Khammam (Dt)
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.120423

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