The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Chondroid Syringoma of the Foot: A Rare Diagnosis Khaled Madi, DPM 1, Alicia Attanasio, DPM 1, Fejzo Cecunjanin, DPM 1, Roberto A. Garcia, MD 2, Alexander Vidershayn, MD 3, Jeffrey V. Lucido, DPM, FACFAS 4 1
Resident Physician, Department of Podiatric Medicine and Surgery, Lutheran Medical Center, Brooklyn, NY Associate Professor, Division of Bone and Soft Tissue Pathology, Department of Pathology, Mount Sinai School of Medicine, New York, NY 3 Attending Radiologist, Department of Radiology, Lutheran Medical Center, Brooklyn, NY 4 Chief, Department of Podiatric Medicine and Surgery, and Director, Podiatric Medical Education, Lutheran Medical Center, Brooklyn, NY 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Chondroid syringoma is a rare tumor with the potential for malignant transformation and distant metastasis. The site of predilection for benign chondroid syringoma is the head and neck region, and it is less likely to involve the foot. In contrast, malignant chondroid syringoma is more commonly encountered in the extremities and is characterized by rapid growth, local invasion, and distant metastasis. We report an unusual case of benign chondroid syringoma in a 47-year-old female who presented with a 20-year history of a mass in her left foot to bring such cases to the attention of foot and ankle specialists. We highlight the histologic diagnosis and surgical procedures with a 6-month postoperative follow-up period. It is unlikely that a treating physician would anticipate this histologic tumor type, considering the rarity of the condition, the long history of this patient’s lesion, and the benign presentation in the extremities. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: benign lower extremity malignant neoplasm pleomorphic adenoma skin tumor
Pleomorphic adenoma, or chondroid syringoma (CS), is a rare benign skin appendageal tumor (1,2). Originally described by Bilmuth in 1859, Hirsch and Helwig (3) were the first to use the term “chondroid syringoma” to this tumor type in the early 1960s and described the presence of sweat gland elements in cartilaginous stroma (4–6). CS is rare among primary skin tumors, with a reported incidence of 2 cm, a rapidly growing mass, or the development of pain in a previously painless mass (3). In our patient, the indications for excision were the patient’s report of recent relative rapid enlargement of the lesion in the 2 years before her July 2012 visit and the atypical presentation of the lesion on MRI. Because of the potential for malignant transformation, total excision of CS is the preferred treatment modality for the benign form of the tumor. For malignant CS, the recommended treatment is wide resection of the tumor with regional lymph node dissection (3,17,21,27). Because it is a lobulated type of tumor, it has been recommended to include normal tissue margins to ensure that the entire tumor has been removed (5,28). Although local radiotherapy is often unsuccessful, skeletal metastasis has been shown to respond to radiotherapy. Combination
1. Zimmerman LE, Sobin LK. Histological Typing of Tumour of the Eye and Its Adnexa. International Histological Classification of Tumour, No. 24, World Health Organization, Geneva, 1980. 2. Agrawal A, Kumar A, Sinha AK, Kumar B, Sabira KC. Chondroid syringoma. Singapore Med J 49:e33–e34, 2008. 3. Hirsch P, Helwig EB. Chondroid syringoma: mixed tumor of skin, salivary gland type. Arch Dermatol 84:835–847, 1961. 4. Yavuzer R, Basterzi Y, Sari A, Bir F, Sezer C. Chondroid syringoma: a diagnosis more frequent than expected. Dermatol Surg 29:179–181, 2003. 5. Bekerecioglu M, Tercan M, Karakok M, Atik B. Benign chondroid syringoma: a confusing clinical diagnosis. Eur J Plast Surg 25:316–318, 2002. 6. Hardisson D, Linares MD, Nistal M. Giant chondroid syringoma of the axilla. J Cutan Med Surg 3:115–117, 1998. €hnle K, Obers V, Lakhoo M, Saadia R. Chondroid syringoma of the 7. Sliwa-Ha abdominal wall: a case report and review of the literature. S Afr J Surg 34:46–48, 1996. 8. Kitazawa T, Hataya Y, Matsuo K. Chondroid syringoma of the orbit. Ann Plast Surg 42:100–102, 1999. 9. Poku JW, Sant GR, Ucci AA. Chondroid syringoma of the scrotum. J Int Med Res 24:482–486, 1996. 10. Nemoto K, Kato N, Arino H. Chondroid syringoma of the hand. Scand J Plast Reconstr Surg Hand Surg 36:379–381, 2002. n G, Monteagudo C, Martin JM, Ramo n D, Alonso V, Jord 11. Villalo a E. Chondroid syringoma: a clinical and histological review of eight cases. Actas Dermosifiliogr 97:573–577, 2006. 12. Barnett MD, Marc KW, Zuretti A, Mesia L, Emery RS, Berson AM. Recurrent malignant chondroid syringoma of the foot: a case report and review of the literature. Am J Clin Oncol 23:227–232, 2000. 13. Hakan S, Ersoy B, Tezel E. Benign chondroid syringoma: atypical presentation of a rare eccrine tumor. J Foot Ankle Surg 50:364–366, 2011. 14. Shashikala P, Chandrashekhar HR, Sharma S, Suresh KK. Malignant chondroid syringoma. Indian J Dermatol Venereol Leprol 70:175–176, 2004. 15. Borman H, Deniz M, Ertas NM, Arıkan U, Colak A. Chondroid syringoma of the hand. Scand J Plast Reconstr Surg Hand Surg 43:291–293, 2009. 16. Beals TC, Nickisch F, Teman C, Florell SR, Layfield LJ. Chondroid syringoma: case report of a highly unusual foot tumor. Foot Ankle Int 31:333–335, 2010. 17. Jaimovich L, Arcuri S, Toganaccioli O, Zeitlin E, Woscoff A. Chondroid syringoma. J Dermatol 11:570–576, 1984. € mu € s M, Koc¸er U. An unusual chondroid syringoma. Dermatol 18. Sungur N, Uysal A, Gu Surg 29:977–979, 2003. 19. Elder D, Elenitsas R, Ragsdale BD. Tumors of the epidermal appendages. In: Lever’s Histopathology of the Skin, Lippincott-Raven, New York, 1997, pp. 747–804.
6
K. Madi et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
20. Seenu V, Goel AK, Shukla NK, Prakash MB, Mohan R. Malignant chondroid syringoma of scalp with cervical lymph node metastasis. J Assoc Physicians India 44:565–566, 1996. 21. Steinmetz JC, Russo BA, Ginsburg RE. Malignant chondroid syringoma with widespread metastasis. J Am Acad Dermatol 22:845–847, 1990. 22. Ishimura E, Iwamoto H, Kobashi Y, Yamabe H, Ichijima K. Malignant chondroid syringoma: report of a case with widespread metastasis and review of pertinent literature. Cancer 52:1966–1973, 1983. 23. Khan K. Chondroid syringoma: a case with unusual cytological findings. Indian J Dermatol 58:157, 2013. 24. Redono C, Rocamora A, Villoria F, Garcia M. Malignant mixed tumor of the skin: malignant chondroid syringoma. Cancer 49:1690–1696, 1982.
25. Kakuta M, Tsuboi R, Yamazaki M, Sakuna M, Yoshikata R, Ogawa H. Giant mixed tumor of the face. J Dermatol 23:369–371, 1996. 26. Headington JT. Mixed tumors of the skin: eccrine and apocrine types. Arch Dermatol 84:989–996, 1961. 27. Sivamani R, Wadhera A, Craig E. Chondroid syringoma: case report and review of the literature. Dermatol Online J 12:8, 2006. 28. Ryu JK, Jin W, Kim GY, Lee JH. Sonographic and magnetic resonance imaging findings of a chondroid syringoma of the heel: case report and literature review. J Ultrasound Med 26:1435–1439, 2007. 29. Jerajani HR, Amladi ST. Skin tumors and lymphoproliferative disorders. In: IADVL Textbook and Atlas of Dermatology, pp. 1149–1244, edited by RG Valia, AR Valia, Bhalani Publishing House, Mumbai, 2001.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Chondroid Syringoma of the Foot: A Rare Diagnosis Khaled Madi, DPM 1, Alicia Attanasio, DPM 1, Fejzo Cecunjanin, DPM 1, Roberto A. Garcia, MD 2, Alexander Vidershayn, MD 3, Jeffrey V. Lucido, DPM, FACFAS 4 1
Resident Physician, Department of Podiatric Medicine and Surgery, Lutheran Medical Center, Brooklyn, NY Associate Professor, Division of Bone and Soft Tissue Pathology, Department of Pathology, Mount Sinai School of Medicine, New York, NY 3 Attending Radiologist, Department of Radiology, Lutheran Medical Center, Brooklyn, NY 4 Chief, Department of Podiatric Medicine and Surgery, and Director, Podiatric Medical Education, Lutheran Medical Center, Brooklyn, NY 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Chondroid syringoma is a rare tumor with the potential for malignant transformation and distant metastasis. The site of predilection for benign chondroid syringoma is the head and neck region, and it is less likely to involve the foot. In contrast, malignant chondroid syringoma is more commonly encountered in the extremities and is characterized by rapid growth, local invasion, and distant metastasis. We report an unusual case of benign chondroid syringoma in a 47-year-old female who presented with a 20-year history of a mass in her left foot to bring such cases to the attention of foot and ankle specialists. We highlight the histologic diagnosis and surgical procedures with a 6-month postoperative follow-up period. It is unlikely that a treating physician would anticipate this histologic tumor type, considering the rarity of the condition, the long history of this patient’s lesion, and the benign presentation in the extremities. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: benign lower extremity malignant neoplasm pleomorphic adenoma skin tumor
Pleomorphic adenoma, or chondroid syringoma (CS), is a rare benign skin appendageal tumor (1,2). Originally described by Bilmuth in 1859, Hirsch and Helwig (3) were the first to use the term “chondroid syringoma” to this tumor type in the early 1960s and described the presence of sweat gland elements in cartilaginous stroma (4–6). CS is rare among primary skin tumors, with a reported incidence of 2 cm, a rapidly growing mass, or the development of pain in a previously painless mass (3). In our patient, the indications for excision were the patient’s report of recent relative rapid enlargement of the lesion in the 2 years before her July 2012 visit and the atypical presentation of the lesion on MRI. Because of the potential for malignant transformation, total excision of CS is the preferred treatment modality for the benign form of the tumor. For malignant CS, the recommended treatment is wide resection of the tumor with regional lymph node dissection (3,17,21,27). Because it is a lobulated type of tumor, it has been recommended to include normal tissue margins to ensure that the entire tumor has been removed (5,28). Although local radiotherapy is often unsuccessful, skeletal metastasis has been shown to respond to radiotherapy. Combination
1. Zimmerman LE, Sobin LK. Histological Typing of Tumour of the Eye and Its Adnexa. International Histological Classification of Tumour, No. 24, World Health Organization, Geneva, 1980. 2. Agrawal A, Kumar A, Sinha AK, Kumar B, Sabira KC. Chondroid syringoma. Singapore Med J 49:e33–e34, 2008. 3. Hirsch P, Helwig EB. Chondroid syringoma: mixed tumor of skin, salivary gland type. Arch Dermatol 84:835–847, 1961. 4. Yavuzer R, Basterzi Y, Sari A, Bir F, Sezer C. Chondroid syringoma: a diagnosis more frequent than expected. Dermatol Surg 29:179–181, 2003. 5. Bekerecioglu M, Tercan M, Karakok M, Atik B. Benign chondroid syringoma: a confusing clinical diagnosis. Eur J Plast Surg 25:316–318, 2002. 6. Hardisson D, Linares MD, Nistal M. Giant chondroid syringoma of the axilla. J Cutan Med Surg 3:115–117, 1998. €hnle K, Obers V, Lakhoo M, Saadia R. Chondroid syringoma of the 7. Sliwa-Ha abdominal wall: a case report and review of the literature. S Afr J Surg 34:46–48, 1996. 8. Kitazawa T, Hataya Y, Matsuo K. Chondroid syringoma of the orbit. Ann Plast Surg 42:100–102, 1999. 9. Poku JW, Sant GR, Ucci AA. Chondroid syringoma of the scrotum. J Int Med Res 24:482–486, 1996. 10. Nemoto K, Kato N, Arino H. Chondroid syringoma of the hand. Scand J Plast Reconstr Surg Hand Surg 36:379–381, 2002. n G, Monteagudo C, Martin JM, Ramo n D, Alonso V, Jord 11. Villalo a E. Chondroid syringoma: a clinical and histological review of eight cases. Actas Dermosifiliogr 97:573–577, 2006. 12. Barnett MD, Marc KW, Zuretti A, Mesia L, Emery RS, Berson AM. Recurrent malignant chondroid syringoma of the foot: a case report and review of the literature. Am J Clin Oncol 23:227–232, 2000. 13. Hakan S, Ersoy B, Tezel E. Benign chondroid syringoma: atypical presentation of a rare eccrine tumor. J Foot Ankle Surg 50:364–366, 2011. 14. Shashikala P, Chandrashekhar HR, Sharma S, Suresh KK. Malignant chondroid syringoma. Indian J Dermatol Venereol Leprol 70:175–176, 2004. 15. Borman H, Deniz M, Ertas NM, Arıkan U, Colak A. Chondroid syringoma of the hand. Scand J Plast Reconstr Surg Hand Surg 43:291–293, 2009. 16. Beals TC, Nickisch F, Teman C, Florell SR, Layfield LJ. Chondroid syringoma: case report of a highly unusual foot tumor. Foot Ankle Int 31:333–335, 2010. 17. Jaimovich L, Arcuri S, Toganaccioli O, Zeitlin E, Woscoff A. Chondroid syringoma. J Dermatol 11:570–576, 1984. € mu € s M, Koc¸er U. An unusual chondroid syringoma. Dermatol 18. Sungur N, Uysal A, Gu Surg 29:977–979, 2003. 19. Elder D, Elenitsas R, Ragsdale BD. Tumors of the epidermal appendages. In: Lever’s Histopathology of the Skin, Lippincott-Raven, New York, 1997, pp. 747–804.
6
K. Madi et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
20. Seenu V, Goel AK, Shukla NK, Prakash MB, Mohan R. Malignant chondroid syringoma of scalp with cervical lymph node metastasis. J Assoc Physicians India 44:565–566, 1996. 21. Steinmetz JC, Russo BA, Ginsburg RE. Malignant chondroid syringoma with widespread metastasis. J Am Acad Dermatol 22:845–847, 1990. 22. Ishimura E, Iwamoto H, Kobashi Y, Yamabe H, Ichijima K. Malignant chondroid syringoma: report of a case with widespread metastasis and review of pertinent literature. Cancer 52:1966–1973, 1983. 23. Khan K. Chondroid syringoma: a case with unusual cytological findings. Indian J Dermatol 58:157, 2013. 24. Redono C, Rocamora A, Villoria F, Garcia M. Malignant mixed tumor of the skin: malignant chondroid syringoma. Cancer 49:1690–1696, 1982.
25. Kakuta M, Tsuboi R, Yamazaki M, Sakuna M, Yoshikata R, Ogawa H. Giant mixed tumor of the face. J Dermatol 23:369–371, 1996. 26. Headington JT. Mixed tumors of the skin: eccrine and apocrine types. Arch Dermatol 84:989–996, 1961. 27. Sivamani R, Wadhera A, Craig E. Chondroid syringoma: case report and review of the literature. Dermatol Online J 12:8, 2006. 28. Ryu JK, Jin W, Kim GY, Lee JH. Sonographic and magnetic resonance imaging findings of a chondroid syringoma of the heel: case report and literature review. J Ultrasound Med 26:1435–1439, 2007. 29. Jerajani HR, Amladi ST. Skin tumors and lymphoproliferative disorders. In: IADVL Textbook and Atlas of Dermatology, pp. 1149–1244, edited by RG Valia, AR Valia, Bhalani Publishing House, Mumbai, 2001.
