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Home , Acrospiroma, Hidradenocarcinoma, Hidradenoma

ANTICANCER RESEARCH 26: 2217-2220 (2006)

Malignant : A Report of Two Cases and Review of the Literature

I.E. LIAPAKIS1, D.P. KORKOLIS2, A. KOUTSOUMBI3, A. FIDA3, G. KOKKALIS1 and P.P. VASSILOPOULOS2

1Department of Plastic and Reconstructive Surgery, 2First Department of Surgical Oncology and 3Department of Surgical Pathology, Hellenic Anticancer Institute, "Saint Savvas" Hospital, Athens, Greece

Abstract. Introduction: Malignant tumors of the sweat glands difficult (1). Clear cell hidradenoma is an extremely rare are very rare. Clear cell hidradenoma is a lesion with tumor with less than 50 cases reported (2, 3). histopathological features resembling those of eccrine poroma The cases of two patients, suffering from aggressive and eccrine . The biological behavior of the tumor dermal lesions invading the abdominal wall and the axillary is aggressive, with local recurrences reported in more than 50% region, are described here. Surgical resection and of the surgically-treated cases. Materials and Methods: Two histopathological examination ascertained the presence of patients are presented, the first with tumor in the right axillary malignant clear cell hidradenoma. In addition to these region, the second with a recurrent tumor of the abdominal cases, a review of the literature is also presented. wall. The first patient underwent wide excision with clear margins and axillary lymph node dissection and the second Case Reports patient underwent wide excision of the primary lesion and bilateral inguinal node dissection due to palpable nodes. Patient 1. Patient 1 was a 68-year-old Caucasian male who had Results: The patients had uneventful postoperative courses. No undergone excision of a rapidly growing, ulcerous lesion of the additional treatment was administered. However, sixteen anterior surface of the abdominal wall in another hospital. months after surgery, patient 2 developed extensive and massive Histology revealed an eccrine spiradenoma of the sweat glands recurrence involving almost the whole abdominal wall. with squamous differentiation and intense desmoplastic Although he had received several chemotherapeutic agents, the reaction. The tumor had invaded the dermal lymphatic vessels disease had a relentless course and the patient succumbed two and the subcutaneous fat. The margins of resection were free and a half years following surgery. Conclusion: Malignant of disease. During the following six months, the patient tumors of the sweat glands are very rare with no developed multiple satellite nodules and was admitted to our discrete clinical characteristics. It is necessary to suspect any institution for further diagnosis and treatment. The complete lesion which shows evidence of enlargement and to verify its blood work up, as well as a CT scan of the abdomen and chest, status by histological evaluation. Additional resection is were normal. Lymphoscintigraphy, however, was positive for generally required, with at least 2-cm clear margins, since bilateral inguinal nodal disease. Fine-needle aspiration biopsy surgery is the only effective treatment. of both the skin lesions and enlarged inguinal nodes was positive for malignancy, suggesting a poorly-differentiated, Malignant tumors of the sweat glands represent rare metastatic adenocarcinoma. The patient underwent wide local oncological entities, characterized by non-specific clinical excision of the abdominal wall nodules with 2-cm margins of presentation and equivocal pathological features. Their resection, as well as formal bilateral inguinal lymph- precise diagnosis and histological classification can be very adenectomy. From the pathology report the presence of a clear cell hidradenoma arising from the sweat glands, with multiple nodal metastases, was ascertained (Figure 1). No adjuvant treatment was given. The patient died nine months later from Correspondence to: Dimitris P. Korkolis, MD, Ph.D., 22 Socratous disseminated disease. St., 1st Floor, Kifissia 14561 Athens, Greece. Tel: +30 210 8083 743, Fax: +30 210 8012 689, Cell: 6937 30 7272, e-mail: [email protected] Patient 2. The second patient was a 45-year-old Caucasian male who had undergone excisional biopsy of a whitish Key Words: tumor, malignant hidradenoma, eccrine lump, 2 cm in size, arising in the right axillary region. The poroma, spiradenoma. histopathological examination was suggestive of a nodular

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Figure 1. Microscopical image of the clear cell hidradenoma arising from the anterior abdominal wall. A) Elements of tubular and solid neoplastic configuration arising in the vicinity of a follicle. B) Malignant cells with clear, transparent cytoplasm and round nucleus. Figure 2. Histological features of the axillary hidradenoma. A) Malignant cells with eosinophilic cytoplasm and nuclear atypia. B) Intradermal development of malignancy and separation from the epidermis with a hidradenoma with clear cells and a low grade of malignancy fibrous sheath. (Figure 2). The patient was then admitted to the hospital for a complete wide resection and radical axillary lymph- adenectomy. The pathology report revealed no residual relapse with faster growth and invasion of the surrounding disease or nodal metastases. Six months after resection, the tissues. In most cases, no epidermal participation is patient is doing well with no evidence of recurrence. encountered. Hidradenoma usually affects middle-aged women, although its malignant form shows no age or gender Discussion predilection (6-8). Malignant hidradenoma is usually found in the scalp, face The recognition of hidradenoma as a distinct entity was first or anterior surface of the trunk. Regional lymphadenopathy, reported in 1941 by Mayer, whereas the term “clear cell with or without serous discharge, may develop years after hidradenoma” was proposed in 1954 by Keasby and Hadley initial treatment. Wong et al. (5) described three patients (4). The malignant form of hidradenoma is extremely rare, suffering from clear cell hidradenoma who developed with less than 50 cases ever reported in the literature. All metastatic disease in the regional lymphatic basins 8-22 these cases were characterized by a significant rate of years after initial surgical extirpation. locoregional recurrence. Some patients developed distant Histologically, clear cell hidradenoma seems to originate metastatic spread as well (3, 5). The disease is usually from the ductal epithelium of the sweat glands, whereas expressed as a small intradermal mass which remains histogenetically it appears to represent a transitional inactive for a long period of time before increasing in size. tumor, sharing features of eccrine poroma and eccrine Its aggressive behavior is more apparent after each local spiradenoma (6).

2218 Liapakis et al: Malignant Hidradenoma

Currently, there is no clear distinction between eccrine no atypia or increased nuclear mitoses were found. The and apocrine glands, or between their malignant precise identification of a benign or malignant hidradenoma, counterparts. The characterization of a sweat gland tumor, based on pathological examination, was not possible. Similar however, as of eccrine or apocrine origin, still remains findings were noted in other case reports of clear cell useful (9, 10). In general, clear cell hidradenoma is hidradenoma (20-25). considered to have an eccrine background, although quite Surgical excision remains the therapeutic modality of recently Gianotti and Alessi (11) supported an apocrine choice. Wong et al. (5) supported wide surgical resection histology based on their own series of five consecutive cases. with a least 2 cm of clear margins for both primary disease Clear cell hidradenoma consists of two main cell and local recurrences. Elective regional lymphadenectomy subpopulations. The first one is composed of round or after lymphoscintigraphy should also be performed. The polygonic cells with round nuclei and clear cytoplasm, which role of sentinel lymph node biopsy in the treatment of is the result of abundant glycogen storage. The second malignant hidradenoma is controversial. Locoregional subpopulation consists of multifaceted cells comprised of recurrence even after wide surgical excision has been oval nuclei and basophilic cytoplasm evenly arranged at the reported in more than 50% of cases, although overall and periphery of the first cellular line (12). Clear cells may be disease-free survival rates are hard to determine as the also seen in other, more frequent malignancies of the head result of the very limited number of reported cases (18). and neck, such as squamous and basaloid tumors, as well as Adjuvant chemotherapy and radiotherapy have no impact in metastatic deposits of renal cell carcinoma (6). in local control or survival (26). The recognition of the eccrine origin of a malignant In conclusion, malignant clear cell hidradenoma is a rare hidradenoma may be accomplished through specific oncological entity, with no particular clinical or immunohistochemical techniques, a positive PAS stain, as histopathological features. It should be included in the well as with the presence of lobules with epidermal differential diagnosis of dermal lesions with an aggressive differentiation (5, 13-15). behavior and multiple recurrences, despite aggressive Clear cell hidradenoma may contain keratinocytes surgical treatment. forming keratin congregates (13). In addition, some cystic configurations noted on the specimen most probably References represent empty spaces between degenerated cells rather than ductal formations of the tumor itself (6). 1 Ansai S, Koseki S, Hozumi À and Kondo S: Assessment of cellular prol›feration of eccrine acrospiromas and eccrine sweat Malignant clear cell hidradenoma usually develops de novo gland carcinomas by AgNOR counting and immunohistochemical and invades the dermis and subcutaneous tissue. Surprisingly, demonstration of proliferating cell nuclear antigen (PCNA) and it might share significant histopathological features with its ∫i67. Clin ∂xp Dermatol 20: 27-34, 1995. benign form. The mitotic index may not be representative or 2 Volmar KE, Cummings TJ, Wang WH, Creager AJ, Tyler DS may affect only a small cellular subpopulation. Thereafter, and Xie HB: Clear cell hidradenoma: a mimic of metastatic the diagnosis of malignancy through standard pathological clear cell tumors. Arch Pathol Lab Med 5: 113-116, 2005. examination may prove extremely difficult (16). 3 AshJey J, Smith-Reed ª and Chernys ∞: Sweat gland carcinoma. Case report and review of the literature. Dermatol In our small series, it was interesting to note that, in Surg 23: 129-133, 1997. contrast to the final diagnosis, previous pathology reports had 4 Keasby LE and Hadley GG: Clear cell hidradenoma. Cancer 7: ascertained the presence of an eccrine spiradenoma. The 934-951, 1954. latter is a of the sweat glands with similar 5 Wong ∆À, Suster S, Nogita ∆, Duncan LM, Dickersin RG and clinical presentation and equivocal enzyme reactions, which Mihm MC: Clear cell eccrine carcinomas of the skin. ∞ clinico- pose tremendous diagnostic dilemmas (12). Because of the pathologic study of nine patients. Cancer 73: 1631-1643, 1994. rarity of these oncological entities, as well as their 6 Lever WF and Schaumburg-Lever G: Histopathology of the Skin. 6th Edition. JB Lippincot, Philadelphia, pp. 557-585, 1983. histopathological similarity, it is almost impossible to define 7 Lopez-Burbano LF, Cimorra GA, Gonzalez-Peirona ∂ and whether a malignant clear cell hidradenoma had been A/Faro J: Malignant clear-cell hidradenoma. PRS 80: 300- developed from a benign eccrine spiradenoma or was the 303, 1986. correct diagnosis from the beginning. 8 Champion RH, Burton JL and Ebling FJG (eds.): Rook/ The most recent reports support the fact that malignant Wílkinson/Ebling. Textbook of Dermatology, 5th Edition, clear cell hidradenoma should be considered as a distinct Blackwell Scientific Publications, Oxford pp. 1515-1518, 1992. entity rather than the result of a malignant transformation of 9 Hashimoto ∫ and Lever ∫F: Eccrine poroma: histochemical and electron microscopic studies. J Invest Derm 43(1964): 237- its benign type, underlining the importance of a precise initial 247, 1964. diagnosis (7, 17). Rosen et al. (19) presented a case of a clear 10 Stavrianos SD, WiIson GR, McLean NR and Soames JV: cell hidradenoma of the eyelid complicated by multiple Adnexal adenocarcinoma of the upper Iip. Int J Oral Maxillofac recurrences and invasion of nearby structures. Histologically, Surg 25: 196-198, 1996.

2219 ANTICANCER RESEARCH 26: 2217-2220 (2006)

11 Gianotti R and Alessi ∂: Clear cell hidradenoma associated 21 Yildirim S, Akoz T, Apaydin I, Ege GA and Gideroglu K: with the folliculo-sebaceous-apocrine unit. Histologic study of Malignant clear cell hidradenoma with giant metastasis to the five cases. Am J Dermatopathol 19: 351-357, 1997. axilla. Ann Plast Surg 1: 102, 2000. 12 Hashimofo ∫, Di Bella RJ and Lever WF: Clear cell 22 Grossniklaus ∏∂ and Knight S∏: Eccrine (clear cell hidradenoma. Arch Dermatol 96: 18-38, 1967. hidradenoma) of the eyelid. Immunohistochemical and 13 Johnson µπ and Helwig ∂µ Jr: Eccrine acrospiroma. Cancer 23: ultrastructural features. Ophthalmology 98: 347-352, 1991. 641-657, 1969. 23 Herzberg AJ, Elenitsas R and Strohmeyer CR: ∞n unusual case 14 Kato ¡ and Ueno ∏: Clear cell hidradenoma: a tumor with of early malignant transformation in a spiradenoma. Dermatol basaliomatous changes in the overlying epidermis and follicular Surg 21: 731-734, 1995. infundibula of surrounding skin. J Dermatol 19: 436-442, 1992. 24 Biernat W and Biernat S: Cutaneuous adnexal carcinoma arising 15 Stout ∞ƒ and Cooley SGE: Carcinoma of sweat glands. Cancer 4: within a solitary -spiradenoma. Am J Dermatopathol 521-536, 1951. 18: 77-82, 1996. 16 Hernandez-Perez ∂ and Cruz FA: Clear cell : 25 ltoh ∆, Yamamoto ¡ and Tokunaga ª: Malignant eccrine report of an unusual case. Dermatologica 153: 249-252, 1976. spiradenoma with smooth muscle cell differentiation: 17 Ohta M, Hiramoto M, Fujii M and Togo T: Nodular hidradeno- histological and immunohistochemical study. Pathol Int 46: 887- carcinoma on the scalp of a young woman: case report and review 893, 1996. of literature. Dermatol Surg 9: 1265-1268, 2004. 26 Stromberg µV, Thorne S, Dimino-Emme L, Katz DA and 18 ∆ouma D, Laporte ª, Goosens ∞ and Ledoux ª: Malignant Rouse JW: Malignant clear cell hidradenoma: a case report and clear cell hidradenoma. Dermatology 186: 284-286, 1993. literature review. Nebr Med J 76: 166-170, 1991. 19 Rosen À, Kim µ and Yermakov V: tumor of clear cell origin involving the eyelids. Cancer 36: 1034-1041, 1975. 20 Harada T, Muraoka M, Ishii M and Wakasa K: Malignant clear- cell hidradenoma associated with pseudoepitheliomatous Received February 16, 2006 hyperplasia on the forehead. Ann Plast Surg 4: 443-444, 2003. Accepted March 31, 2006

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