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CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 2  |  Page : 145-148  

Cytological features of malignant eccrine acrospiroma presenting as a soft tissue mass axilla: A rare sweat gland tumor with histologic correlation


1 Department of Pathology, U P Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India
2 Department of Pharmacology, U P Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India
3 Department of Department of Pathology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Department of Pathology, M M Institute of Medical Sciences and Research, Kumarhati, Solan, Himachal Pradesh, India

Date of Submission24-Feb-2014
Date of Acceptance30-Aug-2014
Date of Web Publication18-May-2015

Correspondence Address:
Pinki Pandey
Type 5, B 301, New Campus, U P Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-516X.157173

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   Abstract 

Malignant eccrine acrospiroma is an infrequent, highly malignant primary skin tumor derived from eccrine sweat glands. Though fine-needle aspiration cytology (FNAC) is a well-established diagnostic tool, but if a skin adnexal tumor or primary skin lesion is suspected clinically, the usual approach is biopsy due to easy accessibility. Being itself rare, cytologic features of this lesion is hardly encountered in case reports. As a result, very little is known about the appearance of adnexal tumors like malignant eccrine acrospiroma on fine-needle aspiration samples. A 50-year-old man presented with swelling in the left axilla, clinically suspected to be a soft tissue sarcoma. Fine-needle aspiration was advised, and a cytological diagnosis of malignant eccrine acrospiroma was rendered which was later confirmed on histological examination. Rapid, accurate diagnosis of these tumors is imperative as they have very poor prognosis and an aggressive course with recurrence and/or metastasis. FNAC plays a decisive and easy diagnostic modality in these unusual, rare cases of highly malignant primary skin tumor, and awareness of the lesions is indispensable in their management.

Keywords: Aspiration cytology, clear-cell hidradenocarcinoma, fine-needle, malignant eccrine acrospiroma, sweat gland tumor


How to cite this article:
Pandey P, Dixit A, Chandra S, Tanwar A. Cytological features of malignant eccrine acrospiroma presenting as a soft tissue mass axilla: A rare sweat gland tumor with histologic correlation. Int J App Basic Med Res 2015;5:145-8

How to cite this URL:
Pandey P, Dixit A, Chandra S, Tanwar A. Cytological features of malignant eccrine acrospiroma presenting as a soft tissue mass axilla: A rare sweat gland tumor with histologic correlation. Int J App Basic Med Res [serial online] 2015 [cited 2020 May 25];5:145-8. Available from: http://www.ijabmr.org/text.asp?2015/5/2/145/157173


   Introduction Top


Malignant eccrine acrospiroma is a rare, aggressive tumor of eccrine sweat gland origin. Since its first description in 1954 by Keasbey and Hadley, [1] several names have been used in the literature to designate this entity, including clear-cell hidradenocarcinoma, malignant clear-cell hidradenoma, malignant clear-cell acrospiroma, clear-cell eccrine carcinoma, nodular hidradenocarcinoma, malignant nodular clear-cell hidradenoma, and mucoepidermoid hidradenocarcinoma. It is a rare tumor with a predilection for the face and extremities, [2] but may appear in any area. It seems to be slightly more frequent in women than in men, with the mean age of 50 years, but cases have been also reported in children [3] and neonates. [4]

We hereby describe a case that was diagnosed as malignant eccrine acrospiroma presenting as a soft tissue mass of axilla on fine-needle aspiration cytology (FNAC), and was later confirmed on histological examination. An attempt is made to document the cytological features of malignant eccrine acrospiroma in the present case with discussion of differential diagnosis.


   Case Report Top


A 50-year-old man presented with a swelling in the left axilla of 2 months duration. Initially, it was a small swelling that had increased progressively and reached a size of 7 cm × 5 cm. The patient was febrile on and off for last 2 months. He had no significant past or medical history. There was no regional lymphadenopathy; general physical and systemic examination was within normal limits. Local examination of left axilla revealed a large, firm, nontender pedunculated swelling of size 7 cm × 5 cm. Skin overlying the swelling was inflamed and ulcerated. With a clinico-radiological diagnosis of soft tissue sarcoma, the patient was referred for FNAC.

Cytological findings

Highly cellular smears showed cohesive cell clusters of malignant cells composed of two cell population; polyhedral cells with dense basophilic cytoplasm along with glycogen containing pale/clear cells with a clear cytoplasm. The nuclei were cytologically pleomorphic, hyperchromatic, round to oval with coarse chromatin and prominent nucleoli. The nuclei were eccentrically located within a moderate amount of basophilic cytoplasm, with a relatively well-defined cell borders imparting a plasmacytoid appearance. There were many bi-and multinucleated cells [Figure 1]a and b]. Few cells were showing squamous differentiation. At places acinar pattern and tubule formation along with numerous mitotic figures were seen. Cytological diagnosis of malignant eccrine acrospiroma was offered. Subsequently, surgical excision with adequate margins was done and sent for histopathological examination.
Figure 1:

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Histological findings

Gross examination revealed an ulcerated skin covered well-circumscribed solid mass measuring 5 cm × 4 cm × 3 cm [Figure 1]c]. Cut section was grey-brown with areas of hemorrhage and necrosis. Microscopic examination showed a skin covered tissue revealing sharply demarcated lobules of tumor cells located in the dermis and extending into the subcutaneous tissue. There was no connection between the epidermis and the tumor. Most of the lobules were solid and some contained cystic spaces filled with homogenous, eosinophilic material and lined with a thick coat of tumor cells. Interstitial hyaline collagen changes were present around lobules. The cell population was made up of two cells types; predominantly clear cell type and fusiform cell type with eosinophilic cytoplasm [Figure 1]d]. The tumor cells were highly pleomorphic with irregular nuclear membrane, coarsely clumped nuclear chromatin, prominent nucleoli, and clear cytoplasm. Numerous mitotic figures and atypical mitotic figures were appreciated [Figure 2]. Tumor cells were seen invading into the surrounding stroma. Angioinvasion was visible along with focal areas of necrosis. No basaloid, sebaceous, or trichilemmal differentiation were noted. Periodic acid-schiff (PAS) positive diastase-resistant material was demonstrated in clear cytoplasm. Hence, a diagnosis of malignant eccrine acrospiroma was made.
Figure 2: Tissue section showing highly pleomorphic tumor cells with clear cytoplasm. Note numerous atypical mitotic figures. (H and E stain, × 400) Inset shows high glycogen content of clear cells. (Periodic acid- schiff stain, ×400)

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   Discussion Top


Malignant eccrine acrospiroma is an infrequent, highly malignant primary skin tumor derived from eccrine sweat glands. They have very poor prognosis, and an aggressive course with recurrence and/or metastasis. The neoplasm does not have any distinctive clinical features and usually presents as a slow growing solitary dermal or subcutaneous nodule and can be present for several years without apparent change. They can appear as de novo disease or as a malignant transformation of nodular hidradenoma. [4],[5] In a review by Hernández-Pérez and Cestoni-Parducci, [4] 6.7% of cases of malignant variant arose in preexisting benign nodular hidradenoma.

Diagnosis is very difficult, and often the preoperative diagnosis is incorrect, as in our patient who was diagnosed clinico-radiologically as soft tissue sarcoma. In a review of 35 cases of eccrine adenocarcinoma, Mehregan et al.[6] showed that none were diagnosed correctly preoperatively, and specifically, the two cases of nodular hidradenocarcinoma were misdiagnosed. The diagnosis is primarily based on histopathological, immunohistochemical, or ultrastructural features. These tumors, therefore, can be considered clinico-pathological dilemmas with an unpredictable biological behavior. Rarely diagnosed clinically, they are often encountered as histological surprise. [7]

Grossly, they appear as nodular dermal masses with or without skin changes with a firm, fibrous appearance simulating a connective tissue tumor. [5],[8] The histology of malignant eccrine acrospiroma resembles that of its benign counterpart. The histologic features characteristically entail a prominent nodular (lobular) pattern. Usually, there is no connection between the epidermis and the tumor, but the surface epithelium may be ulcerated. The tumor may display increased mitotic activity with focal areas of necrosis. [9],[10] The reliable criteria of malignancy include infiltrative growth, presence of nuclear atypia, number of mitotic figures, predominantly solid islands, as well as perineural and angiolymphatic invasion. [11] Some authors have proposed a subclassification of malignant eccrine acrospiroma into high grade, low grade, and atypical hidradenoma with focal atypia. [6]

The neoplastic cells are usually positive for PAS but negative for PAS with diastase digestion, indicating glycogen content rather than mucin. Immunophenotypically, they show reactivity for cytokeratin (AEI/AE3, CAM5.2, CK5/6, etc.). Carcinoembryonic antigen and epithelial membrane antigen decorate the luminal border of ductal structures. They are characteristically negative for the androgen receptor and myoepithelial markers (smooth muscle actin, calponin, etc.). [12],[13]

If a skin adnexal tumor or primary skin lesion is suspected clinically, the usual approach is biopsy due to easy accessibility. However, on rare occasions, these tumors do undergo fine-needle aspiration. As a result, there is a paucity of case reports describing the cytomorphological features of adnexal tumors like malignant eccrine acrospiroma. As it is an uncommon tumor and rarely undergo aspiration, only infrequent case reports describing the cytologic features are available in the literature. [14],[15] The rarity of this neoplasm and failure to identify its morphologic features may lead to misdiagnosis. They are usually reported only after histopathological examination. In our case, the cytodiagnosis of malignant eccrine acrospiroma of the axilla was rendered on account of the presence of cohesive cell clusters, two cell patterns composed of polyhedral cells with dense cytoplasm and a basaloid appearance and glycogen containing pale/clear cells with a clear cytoplasm, tubular formation, nuclear anaplasia and increased number of mitotic figures. Later, it was confirmed by histopathology to be a malignant eccrine accrospiroma.

The histopathological differential diagnosis generally includes other tumors with clear cell change such as sebaceous carcinoma, trichilemmal carcinoma, clear cell changes in squamous cell carcinoma, balloon cell melanoma, basal cell carcinoma, porocarcinoma, and metastatic renal clear cell carcinoma. [11]

Sebaceous cell carcinoma and trichilemmal carcinoma, which may have the most overlapping features with malignant eccrine acrospiroma, both lack cuticles and show at least focally miocrovesicular cytoplasm and indented nuclei in sebaceous cell carcinoma and trichilemmal-type keratinization in trichilemmal carcinoma. Furthermore, the majority of sebaceous cell carcinoma show immunoreactivity for androgen receptor markers, which are not expressed in malignant eccrine acrospiroma. [11]

Basal cell carcinoma, clear cell changes in squamous cell carcinoma and porocarcinoma generally have an intraepidermal component, and they also lack cutiscular differentiation. [11] Balloon cell melanoma does not demonstrate squamous or cutiscular differentiation and the tumor cells are always cytokeratin negative and usually S100 and HMB45 positive. [11] While metastatic renal cell carcinoma to the skin may be nodular and composed of clear and eosinophilic epithelial cells, the presence of rich sinusoidal vascular network and often the existing history of primary renal neoplasm should help in establishing the correct diagnosis. [11]

Prognosis for malignant eccrine acrospiroma is generally very poor. The tumor has up to 50% local recurrence rate and a 60% metastatic rate within the first 2 years. [16] Metastasis favors the regional lymph nodes followed by the lung and the bone. [11] Disease-free 5-year survival has been reported at less than 30%. [16] Treatment is surgical excision with adequate margins to minimize the risk of recurrence followed by histological confirmation of adequacy of excision. [9],[17]

Malignant eccrine acrospiroma is an infrequent malignant tumor that is often misdiagnosed preoperatively, and that must be treated with aggressive multimodality therapy for increased survival. Rapid, accurate diagnosis of these tumors is imperative as they have very poor prognosis and an aggressive course with recurrence and/or metastasis. FNAC plays a decisive and easy diagnostic modality in these unusual rare cases of highly malignant primary skin tumor, and awareness of the lesions is indispensable in their management.

 
   References Top

1.
Keasbey LE, Hadley GG. Clearcell hidradenoma; report of three cases with widespread metastases. Cancer 1954;7:934-52.  Back to cited text no. 1
    
2.
Breg JW, McDivitt RW. Pathology of sweat gland carcinoma. Pathol Annu 1968;3:123-44.  Back to cited text no. 2
    
3.
Chow CW, Campbell PE, Burry AF. Sweat gland carcinomas in children. Cancer 1984;53:1222-7.  Back to cited text no. 3
    
4.
Hernández-Pérez E, Cestoni-Parducci R. Nodular hidradenoma and hidradenocarcinoma. A 10-year review. J Am Acad Dermatol 1985;12:15-20.  Back to cited text no. 4
    
5.
Garcia-Bonafe MM, Campins MM, Redecilla PH. Malignant nodular hidradenoma on the scalp: Report of a case with fine needle aspiration cytology features and histologic correlation. Acta Cytol 2009;53:576-80.  Back to cited text no. 5
    
6.
Mehregan AH, Hashimoto K, Rahbari H. Eccrine adenocarcinoma. A clinicopathologic study of 35 cases. Arch Dermatol 1983;119:104-14.  Back to cited text no. 6
    
7.
Vaideeswar P, Madhiwale CV, Deshpande JR. Malignant hidradenoma: A rare sweat gland tumour. J Postgrad Med 1999;45:56-7.  Back to cited text no. 7
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8.
Kumar N, Verma K. Clear cell hidradenoma simulating breast carcinoma: A diagnostic pitfall in fine-needle aspiration of breast. Diagn Cytopathol 1996;15:70-2.  Back to cited text no. 8
    
9.
Amel T, Olfa G, Faten H, Makrem H, Slim BA, Moncef M. Metastatic hidradenocarcinoma: Surgery and chemotherapy. N Am J Med Sci 2009;1:372-4.  Back to cited text no. 9
    
10.
Ko CJ, Cochran AJ, Eng W, Binder SW. Hidradenocarcinoma: A histological and immunohistochemical study. J Cutan Pathol 2006;33:726-30.  Back to cited text no. 10
    
11.
Klein W, Chan E, Seykara JT. Tumors of the epidermal appendages. In: Elder DE, Elenitsas R, Johnson BL, Murphy GF, editors. Lever's Histopathology of the Skin. 9 th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 867-926.  Back to cited text no. 11
    
12.
Sierra Montenegro E, Sierra Luzuriaga G, Leone Stay G, Salazar Menéndez V, Quiñonez Auria C. Perianal nodular hidradenocarcinoma. Case report. Cir Cir 2010;78:173-6.  Back to cited text no. 12
    
13.
Park HJ, Kim YC, Cinn YW. Nodular hidradenocarcinoma with prominent squamous differentiation: Case report and immunohistochemical study. J Cutan Pathol 2000;27:423-7.  Back to cited text no. 13
    
14.
Pohar-Marinsek P, Lamovec J. Clear cell hidradenocarcinoma. Acta Dermatovenerol Alp Pannonica Adriat 2003;12:94-9.  Back to cited text no. 14
    
15.
Ray R, Dey P. Fine needle aspiration cytology of malignant hidradenoma. Acta Cytol 1993;37:842-3.  Back to cited text no. 15
    
16.
Ohta M, Hiramoto M, Fujii M, Togo T. Nodular hidradenocarcinoma on the scalp of a young woman: Case report and review of literature. Dermatol Surg 2004;30:1265-8.  Back to cited text no. 16
    
17.
Ashley I, Smith-Reed M, Chernys A. Sweat gland carcinoma. Case report and review of the literature. Dermatol Surg 1997;23:129-33.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2]


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[Pubmed] | [DOI]



 

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