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Case Report *Corresponding author Iraj Z. Afzal, Pathology department, American University of the Caribbean, 1 University Drive at Jordan Road Case Report of 74-Year- Cupecoy, St. Maarten, USA, Tel: 216 504 6672; Email: iraj. [email protected] Submitted: 01 November 2018 Old Female with Microcystic Accepted: 22 November 2018 Published: 26 November 2018 Adnexal Carcinoma, a Rare and Copyright © 2018 Afzal et al. ISSN: 2373-9819 Locally Invasive Neoplasm, OPEN ACCESS Keywords • Microcystic, adnexal, carcinoma, sclerosing, sweat, with Multiple Recurrences and duct, rare, neoplasm, females, white, elderly, Mohs, micrographic, surgery, radiotherapy, recurrence, metastasis, wide, excision, carcinoma, malignant, Review of the Literature syringoma, syringoid, trichofolliculoma, perineural, invasion, skin Iraj Z. Afzal*, Dominik Dabrowski, David Haddock, Andrea Batshon, and Mohamad Aziz Department of Pathology, American University of the Caribbean, USA
Abstract Microcystic adnexal carcinomas (MAC) are a very rare form of locally invading neoplasms. This paper reports a case of a 74-year-old female diagnosed with a MAC neoplasm localized to the left upper cheek; she was treated with both surgery and radiotherapy. The patient had two recurrences after surgical excisions with the second excision being coupled with radiotherapy. This report asses the rarity of this disease, which may lead to misdiagnosis, and the optimal treatment to minimize the possibility of known high recurrence rates. MAC is not considered a highly metastatic neoplasm; however, potential for metastasis exists, as discussed in this case.
ABBREVIATIONS MAC: Microcystic Adnexal Carcinoma; BAP: Black/Asian/ [1]. Due to its rarity, this cancer is commonly misdiagnosed; Rustemeyer et al., described a case of MAC as desmoplastic trichoepithelioma for over four years due to the indistinguishable Pacific-Islander; Other: All Races Not Encompassed Under White features [3]. Recurrence has been reported to occur even after a or BAP; SEER: Surveillance, Epidemiology, and End Results; MMS: periodCASE ofPRESENTATION 30 years [4]. MohsINTRODUCTION Micrographic Surgery
We report a case of MAC in a 74-year-old Caucasian woman; Microcystic adnexal carcinoma (MAC), also known as she presented with a slow growing, crusty, painless, plaque sclerosing sweat duct carcinoma, malignant syringoma, syringoid like 2 cm lesion on the left upper cheek. A small biopsy was carcinoma, and trichofolliculoma with perineural invasion, is a obtained and pathological evaluation showed nests and cysts of rare type of skin cancer. It typically presents with aggressive local cytologically uniform, squamoid cells randomly dispersed in a invasion of eccrine sweat glands and exhibits small keratinizing dense edematous collagenous stroma (Figure 1). In some areas, cysts, apocrine differentiation, and well-defined ducts [1]. They branching of tubular structures and aggregation of neoplastic are considered to have keratinocytic origins, thanks to in-vitro cells gave commalike shapes. The microcysts contained studies, but this still remains a question of further investigation lamellated keratinaceous-like material resembling hair matrix, [2]. Sweat gland malignancies are considered to be rare and and some areas demonstrated extensive squamous metaplasia. represent solely 0.005% of all malignant epithelial neoplasms Despite MAC was suspected, the limited biopsy sample did not [2]. 85% of MAC cases present in the head and neck region, allow definitive pathological diagnosis and additional sampling exhibiting preference for the per orbital skin and centro facial was requested for further evaluation. The diagnosis was region (with an inclination towards the left side of the face)[2,1]. consistent with a sclerosing adnexal neoplasm, the differential It is commonly presented in women in their sixth and seventh diagnosis included: desmoplastic trichoepithelioma, sclerosing decade of life [3]. MACs are capable of infiltrating muscle tissues or morpheaform basal cell carcinoma, and syringoma, rare and peripheral nerve fibers; typical treatment consists of surgery form of basosquamous or even squamous cell carcinoma, and since radiotherapy results inaincreased probability of recurrence epithelial-myoepithelial carcinoma. An excisional biopsy was Cite this article: Afzal IZ, Dabrowski D, Haddock D, Batshon A, Aziz M (2018) Case Report of 74-Year-Old Female with Microcystic Adnexal Carcinoma, a Rare and Locally Invasive Neoplasm, with Multiple Recurrences and Review of the Literature. JSM Clin Case Rep 6(5): 1164. Afzal et al. (2018) Email: [email protected]
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performed and the 2 cm mass was removed, which showed a being in white male patients (Table 1 and Figure 2) [5]. The depth of 8mm from the skin surface; it was 1mm from the deep remaining 9% of cases are characterized in Table 1 and Figure 2. margin. Pathological evaluation of the excised mass showed all A case report was published in 2016 exhibiting MAC in a Chinese features noted in the initial biopsy, but in addition, clear cellular patient from the Hainan province of China; this is one of three and architectural malignant features were noted. Moderately cases ever reported in the Chinese population [2] as the other 2 differentiated squamous cell carcinoma in the superficial layers cases were reported by Fang et al., in 2009 [6]. Similarly, the first was seen merging with a syringomatous carcinoma focally. ever reported case of MAC in an African-American man was in Perineural invasion was present. Immunohistochemical analysis 2001 by Peterson et al. [7]. was consistent with syringomatous carcinoma (positive for While the disease is more prominent in whites (particularly p63, CK5/6, CK14 and questionable positive reaction with females), the lesiontends to occur in specific regions; the left side MUC1; negative for S100, calponin, actin, and mucin). Seven of the face is favoured. Our patient exhibited this as she had a months later, the patient experienced recurrence at the same lesion on her left upper cheek; 74% of lesions of the 164 patients site and was surgically removed; nine months later, the patient in the SEER database analysis presented with head/neck lesions, experienced another local recurrence. She declined any further with the occurrence being highest in white females (Table 2 and surgery. Radiotherapy of the involved area was performed, and Figure 3). White males have the second highest occurrence in the theDISCUSSION patient was lost to follow-up. head and neck region (Table 2 and Figure 3). This anatomical distribution pattern is also similarly reported by Chiller et al., in their case series review of 48 case reports of MAC patients, which The case presented here highlights common epidemiological is considered to be the largest case series review in the English similarities within reported MAC patients and shows the rarity literature [1]. of the disease. Literature presents the median age at diagnosis at 67.5 years [5] and the mean age at diagnosis at 61.2 years [1]; Despite aggressive local invasion, metastasis is not the patient presented in this case was 74. MACs are considered a common within MAC patients. The present patient did not have relatively rare condition; Chen et al., concluded that approximately metastasis; however, the patient was lost to follow-up after two 350 cases are present within the English literature. MACs are local recurrences. SEER database analysis also confirms that MAC more common amongst females, favouring whites over others: metastasis is uncommon as none of the 164 patients exhibited 54.6% of cases reported in Surveillance, Epidemiology, and End metastasis [5]. Despite the rarity, there have been a few cases Results (SEER)were in white female patients with another 36.4% of metastasis; one case series review found one case of lung
Figure 1
Histopathology of microcystic adnexal carcinoma, skin biopsy of the mass, taken from the left cheek of a 74 year old woman A: Nests and cysts of squamoid cells scattered in background of dense edematous collagenous stroma, H&E at x20 magnification B: Tubular structures and aggregates of neoplastic cells, H&E at x50 magnification C: Lamellated keratinous-like material resembling hair matrix, H&E at x50 magnification D: Atypical pleom�orphic squamous cells, H&E at x100 magnification JSM Clin Case Rep 6(5): 1164 (2018) 2/5 Afzal et al. (2018) Email: [email protected]
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metastasis out of seven cases [8] while another case report found years of follow up). Their review reported that only four out of lymph node metastasis in a 63-year-old male [9]. 39 cases (10.3%) had recurrence [13]. Friedman et al., published a similar review for MMS treated MAC cases that were reported Surgery is typically used for treatment; radiotherapy is not from 1984 to 1998: it was found that no recurrence was noted in as popular due to the potential of recurrence [1]. The patient 17 cases over a period of six weeks to 36 months [14]. Leibovitch presented in this case also was surgically treated and radiotherapy et al., however, did perform MMS and had one case of recurrence was used due to recurrence post-surgery. Leibovitch et al., in their 20 patients study (5%) [10]. recommend that for treatment, radiotherapy should be avoided since MAC tumours are relatively radiotherapy resistant; surgical SEER database analysis further confirms that surgery is the excision is the best method [10]. However, standard wide local preferred treatment as 92% of the patients received surgery, excision has a recurrence rate of 40-60% [10]. Similarly, a study only 10 patients of their 164 received radiotherapy [5]. Chiller et of 15 patients by Cooper et al., reported a recurrence of 47% with al., showed that after excisions of the primary tumour, 16 of the wide excision surgery and a study of 27 patients by Sebastian et. 23 patients that were treated with wide-excision surgery were al reported a recurrence rate of 60% [11,12]. Leibovitch et al., fully cured [2]. The remaining 7 were either given micrographic suggests that this high reoccurrence may be because standard surgery or another wide local excision was preformed; only 1 histologic methods of margin control are based on “bread-loaf” patient required 4 excisions until they were cured [2]. Based on sectioning, therefore, only examining 0.2% of the margins. This is the data and recommendations of the examined literature, MMS problematic because there may be residual undetected tumours is the preferred treatment as it has low recurrence rates. [10]. As MAC is a rare tumor, and the differential diagnosis includes For this reason, Mohs micrographic surgery (MMS) is the a wide spectrum of benign and malignant entities, it can be preferred method of excision because MMS utilizes horizontal misdiagnosed as reported in the case presented by Rustemeyer en-face sectioning of the outer surface of the excised tissue. This et al., which misdiagnosed MAC as trichoepithelioma for over method allows for examination of both peripheral and deep four years [3]. It is our hope that this case report and review will margins [10]. This is backed by the fact that several case reports increase the awareness of clinicians and pathologists to this rare have been published that utilized MMS and had low recurrence tumor and the wide variety of possible differential diagnosis; rates; Snow et al., performed a literature review from 1972 for minimizing the probabilityof misdiagnosis of this entity is all MAC cases treated with MMS (39 cases with more than two essential, particularly for understanding the optimal treatment. Table 1: et al.
Distribution of MAC OccurrenceMale within Occurrence various (%) Races; Data collectedFemale from OccurrenceSEER Database (%) Analysis by PatelTotal (%) White
BAP 36.4 54.6 91.0 Other 1.6 2.4 4.0 Total (%) 2.0 3.0 5.0 40.0 60.0 100.0
100 90 80
) 70 % ( 60 e g a
t 50 n 40 erce
P 30 20 10 0 White BAP Other Total Male Occurrence (%) Female Occurrence (%) Total Occurrence
Race
Figure 2
Graph showing MAC distribution by race and gender; Data collected from SEER Database Analysis by Patel et al. JSM Clin Case Rep 6(5): 1164 (2018) 3/5 Afzal et al. (2018) Email: [email protected]
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Table 2 Upper Limb/Shoulder : Distribution of MAC LesionsHead/Neck Based Off of (%) Colour, Gender, andTrunk Anatomic (%) Location; Data collected from SEER DatabaseLower Analysis Limb/Shoulder(%) by Patel et al. (%) White Males
White Females 26.9 3.6 3.3 2.2 BAP Males 40.4 5.5 4.9 3.3 BAP Females 1.2 0.2 0.1 0.1 Other Males 1.8 0.2 0.2 0.1 Other Females 1.5 0.2 0.2 0.1 Total 74.02.2 10.00.3 9.000.3 6.000.2
80 70 60
) 50 % (
e 40 ag t
n 30
erce 20 P 10 0 White Males White BAP Males BAP Other Males Other Total Females Females Females
Head/Neck Trunk Upper Limb/Shoulder Lower Limb/Shoulder Anatomical Location
Figure 3
Graph showing MAC Distribution by Colour, Gender, and Anatomical Location; Data collected from SEER Database Analysis by Patel et al.
It can be seen here that females have a higher presentation 5. Fang W, Chen D, Shang JF, Wang F, Xiao L. [Microcystic adnexal of MAC, particularly white females. White males have a higher carcinoma: report of two cases]. Zhonghua Bing Li Xue Za Zhi. 2009; é presentation of MAC in contrast to other males. This preference 38: 59-60. for white males and females indicates a potential link between 6. Gabillot-Carr M, Weill F, Mamelle G, Kolb F, Boitier F, Petrow P, et al.
MAC and skin colour. Microcystic Adnexal Carcinoma: Report of Seven Cases Including One with Lung Metastasis. Dermatology. 2006; 212: 221-228. It can be seen here that the head and neck regions present with the highest incidence, particularly in white females and 7. Yu JB, Blitzblau RC, Patel SC, Decker RH, Wilson LD. Surveillance, Epidemiology, and End Results (SEER) Database Analysis of white males. The second most common location for MAC lesions wasREFERENCES the trunk. Microcystic Adnexal Carcinoma (Sclerosing Sweat Duct Carcinoma) of the Skin. Am J Clin Oncol. 2010; 33: 755-756.
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12. Sebastien TS, Nelson BR, Lowe L, Baker S, Johnson TM. Microcystic literature. Dermatol Surg. 2001; 27: 401-408. adnexal carcinoma. J Am Acad Dermatol. 1993; 29: 840-845. 14. Friedman PM, Friedman RH, Jiang SB, Nouri K, Amonette R, Robins
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Cite this article Afzal IZ, Dabrowski D, Haddock D, Batshon A, Aziz M (2018) Case Report of 74-Year-Old Female with Microcystic Adnexal Carcinoma, a Rare and Locally Invasive Neoplasm, with Multiple Recurrences and Review of the Literature. JSM Clin Case Rep 6(5): 1164.
JSM Clin Case Rep 6(5): 1164 (2018) 5/5