Viewpoints in dermatology • Correspondence
Correspondence
Primary eccrine carcinoma treated with Mohs micrographic surgery and adjuvant radiotherapy doi: 10.1111/ced.12422 We report a challenging case of primary eccrine ductal carcinoma of the right parietal scalp, which was treated with Mohs micrographic surgery (MMS) and adjuvant radiotherapy. A fit and well 84-year-old woman initially presented to the general surgeons with a 4-year history of three discrete nodules over her right parietal scalp. Two of these nodules were excised as they had become itchy and painful. Two months later, the patient had developed multiple nodules around the excision scars (Fig. 1a). Histology of the two excised nodules showed the dermis to be extensively infiltrated with cribiform nests of cells with central lumina (Fig. 2a). Elsewhere in the dermis and subcutis were nests and cords of tumour cells. The tumour cells were medium-sized polygonal cells with eosinophilic cytoplasm and moderately pleiomorphic central ovoid nuclei. Immunohistochemistry showed the tumour cells to be strongly positive for cytokeratin 7, oestrogen and progesterone receptors, and gross cystic disease fluid protein, and negative for cytokeratin 20. These histological findings are compatible with either primary eccrine ductal carcinoma or metastatic carcinoma of the breast. Thorough investigation including computed tomography (CT) of the chest, abdomen and pelvis, mammography and breast ultrasongraphy did not reveal a primary breast carcinoma or metastases elsewhere. A diagnosis of primary eccrine ductal carcinoma was subsequently made. T1-weighted magnetic resonance imaging of the head revealed the tumour, which extended into the subcutaneous fat and deep to the periosteum, although no overt bony cortical erosion was identified (Fig. 2b). The tumour measured 65 9 40 mm. Although the peripheral margins were clear after four stages of Mohs micrographic surgery (MMS), the deep margin remained positive for tumour down to the periosteum. The post-MMS defect on the right parietal scalp measured 80 9 55 mm (Fig. 1b), and was subsequently closed with a skin graft from the right thigh 6 weeks later. Three months after the graft had settled, the area was treated with adjuvant single-phase radiotherapy at a total dose of 55 Gy in 20 fractions. Follow-up imaging with
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Clinical and Experimental Dermatology (2015) 40, pp204–212
whole-body FDG positron emission tomography (PET)/CT was performed at 3 months and 16 months following radiotherapy, and showed no local or metastatic fluorodeoxyglucose-avid disease. The patient remains in remission 2.5 years after MMS and over 2 years after radiotherapy. Eccrine carcinomas are rare adnexal tumours that account for < 0.01% of all cutaneous tumours.1 Characteristically, they are invasive and have high rates of local recurrence.1–3 This group of tumours is also reported to have up to a 60% rate of metastases.3 Wildermore et al. 3 concluded that MMS reduces the rate of recurrence of
(a)
(b)
Figure 1 (a) Nodules and scars on the right parietal scalp prior
to Mohs micrographic surgery. (b) Post-Mohs defect; periosteal curettings were still positive for tumour.
ª 2014 British Association of Dermatologists
Correspondence
(a)
of its rarity. After extensive multidisciplinary team discussion, the decision was made to opt for radiotherapy after MMS rather than surgery to remove the outer table of the skull in the affected area, as the patient was not keen on further surgery. The case highlights the difficulties in treatment of locally aggressive eccrine carcinomas that cannot be completely excised by MMS alone. A. Chandrakumar,1 D. Veitch,1 I. Proctor,2 S. Hughes,2 and C. M. Perrett1 1 Dermatology and 2Histopathology Departments, University College Hospital London, London, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 20 April 2014
References (b)
1 Terushkin E, Leffell DJ, Futoryan T et al. Squamoid eccrine ductal carcinoma: a case report and review of the literature. Am J Dermatopath 2010; 32: 287–92. 2 Halachmi S, Lapidoth M. Approach to the rare eccrine tumors. Dermatol Surg 2011; 37: 1194–5. 3 Wildermore JK, Lee JB, Humphreys TR. Mohs surgery for malignant eccrine neoplasms. Dermatol Surg 2004; 30: 1574–9.
Rising referrals for suspected paediatric melanoma: appropriate referral criteria need to be defined doi: 10.1111/ced.12434
Figure 2 (a) Nests and cords of tumour cells in the dermis and
subcutis. The dermis was extensively infiltrated with cribiform nests of cells with central lumina. (b) Tumour cells were mediumsized polygonal cells with eosinophilic cytoplasm and moderately pleiomorphic central ovoid nuclei. Haematoxylin and eosin, original magnification 9 10; (b) 9 40. (b) T1-weighted magnetic resonance imaging scan, showing the tumour on the right parietal scalp extending to the periosteum with no overt cortical erosion.
these tumours compared with wide local excision. There are no consensus guidelines regarding the role of adjuvant radiotherapy in primary eccrine carcinoma because
ª 2014 British Association of Dermatologists
The ‘two week rule’ (TWR) referral system for suspected cancer in adults and children was introduced in England and Wales between 1999 and 2000. All patients with a suspected cancer have to be seen by a specialist within 2 weeks of referral by their GP; a standard referral proforma is used for suspected skin cancer (melanoma and squamous cell carcinoma).1 Previous surveys of adult referrals have shown that only 50% of melanomas are actually referred by the TWR system, and that only 8–10% of pigmented lesions are found to be melanomas.2,3 Revision of the current adult TWR proforma has been suggested. We therefore sought to examine whether the TWR proforma served as a robust referral tool for suspected melanoma in children. We undertook a retrospective analysis of 3 years of TWR referral data to the Bristol Children’s Hospital; 327 children were referred between 2009 and 2011 with suspected cancer, and of these, 79 (24%) were referred with pigmented lesions as possible malignant melanoma. Mean age of these patients was 9.5 years (range 2 months to 15 years). Four patients (5%) had a skin biopsy taken, and none were given a diagnosis of melanoma or other skin cancer.
Clinical and Experimental Dermatology (2015) 40, pp204–212
205
Correspondence
Primary eccrine carcinoma treated with Mohs micrographic surgery and adjuvant radiotherapy doi: 10.1111/ced.12422 We report a challenging case of primary eccrine ductal carcinoma of the right parietal scalp, which was treated with Mohs micrographic surgery (MMS) and adjuvant radiotherapy. A fit and well 84-year-old woman initially presented to the general surgeons with a 4-year history of three discrete nodules over her right parietal scalp. Two of these nodules were excised as they had become itchy and painful. Two months later, the patient had developed multiple nodules around the excision scars (Fig. 1a). Histology of the two excised nodules showed the dermis to be extensively infiltrated with cribiform nests of cells with central lumina (Fig. 2a). Elsewhere in the dermis and subcutis were nests and cords of tumour cells. The tumour cells were medium-sized polygonal cells with eosinophilic cytoplasm and moderately pleiomorphic central ovoid nuclei. Immunohistochemistry showed the tumour cells to be strongly positive for cytokeratin 7, oestrogen and progesterone receptors, and gross cystic disease fluid protein, and negative for cytokeratin 20. These histological findings are compatible with either primary eccrine ductal carcinoma or metastatic carcinoma of the breast. Thorough investigation including computed tomography (CT) of the chest, abdomen and pelvis, mammography and breast ultrasongraphy did not reveal a primary breast carcinoma or metastases elsewhere. A diagnosis of primary eccrine ductal carcinoma was subsequently made. T1-weighted magnetic resonance imaging of the head revealed the tumour, which extended into the subcutaneous fat and deep to the periosteum, although no overt bony cortical erosion was identified (Fig. 2b). The tumour measured 65 9 40 mm. Although the peripheral margins were clear after four stages of Mohs micrographic surgery (MMS), the deep margin remained positive for tumour down to the periosteum. The post-MMS defect on the right parietal scalp measured 80 9 55 mm (Fig. 1b), and was subsequently closed with a skin graft from the right thigh 6 weeks later. Three months after the graft had settled, the area was treated with adjuvant single-phase radiotherapy at a total dose of 55 Gy in 20 fractions. Follow-up imaging with
204
Clinical and Experimental Dermatology (2015) 40, pp204–212
whole-body FDG positron emission tomography (PET)/CT was performed at 3 months and 16 months following radiotherapy, and showed no local or metastatic fluorodeoxyglucose-avid disease. The patient remains in remission 2.5 years after MMS and over 2 years after radiotherapy. Eccrine carcinomas are rare adnexal tumours that account for < 0.01% of all cutaneous tumours.1 Characteristically, they are invasive and have high rates of local recurrence.1–3 This group of tumours is also reported to have up to a 60% rate of metastases.3 Wildermore et al. 3 concluded that MMS reduces the rate of recurrence of
(a)
(b)
Figure 1 (a) Nodules and scars on the right parietal scalp prior
to Mohs micrographic surgery. (b) Post-Mohs defect; periosteal curettings were still positive for tumour.
ª 2014 British Association of Dermatologists
Correspondence
(a)
of its rarity. After extensive multidisciplinary team discussion, the decision was made to opt for radiotherapy after MMS rather than surgery to remove the outer table of the skull in the affected area, as the patient was not keen on further surgery. The case highlights the difficulties in treatment of locally aggressive eccrine carcinomas that cannot be completely excised by MMS alone. A. Chandrakumar,1 D. Veitch,1 I. Proctor,2 S. Hughes,2 and C. M. Perrett1 1 Dermatology and 2Histopathology Departments, University College Hospital London, London, UK E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 20 April 2014
References (b)
1 Terushkin E, Leffell DJ, Futoryan T et al. Squamoid eccrine ductal carcinoma: a case report and review of the literature. Am J Dermatopath 2010; 32: 287–92. 2 Halachmi S, Lapidoth M. Approach to the rare eccrine tumors. Dermatol Surg 2011; 37: 1194–5. 3 Wildermore JK, Lee JB, Humphreys TR. Mohs surgery for malignant eccrine neoplasms. Dermatol Surg 2004; 30: 1574–9.
Rising referrals for suspected paediatric melanoma: appropriate referral criteria need to be defined doi: 10.1111/ced.12434
Figure 2 (a) Nests and cords of tumour cells in the dermis and
subcutis. The dermis was extensively infiltrated with cribiform nests of cells with central lumina. (b) Tumour cells were mediumsized polygonal cells with eosinophilic cytoplasm and moderately pleiomorphic central ovoid nuclei. Haematoxylin and eosin, original magnification 9 10; (b) 9 40. (b) T1-weighted magnetic resonance imaging scan, showing the tumour on the right parietal scalp extending to the periosteum with no overt cortical erosion.
these tumours compared with wide local excision. There are no consensus guidelines regarding the role of adjuvant radiotherapy in primary eccrine carcinoma because
ª 2014 British Association of Dermatologists
The ‘two week rule’ (TWR) referral system for suspected cancer in adults and children was introduced in England and Wales between 1999 and 2000. All patients with a suspected cancer have to be seen by a specialist within 2 weeks of referral by their GP; a standard referral proforma is used for suspected skin cancer (melanoma and squamous cell carcinoma).1 Previous surveys of adult referrals have shown that only 50% of melanomas are actually referred by the TWR system, and that only 8–10% of pigmented lesions are found to be melanomas.2,3 Revision of the current adult TWR proforma has been suggested. We therefore sought to examine whether the TWR proforma served as a robust referral tool for suspected melanoma in children. We undertook a retrospective analysis of 3 years of TWR referral data to the Bristol Children’s Hospital; 327 children were referred between 2009 and 2011 with suspected cancer, and of these, 79 (24%) were referred with pigmented lesions as possible malignant melanoma. Mean age of these patients was 9.5 years (range 2 months to 15 years). Four patients (5%) had a skin biopsy taken, and none were given a diagnosis of melanoma or other skin cancer.
Clinical and Experimental Dermatology (2015) 40, pp204–212
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