Primary Cutaneous Adenoid Cystic Carcinoma Treated with Mohs Micrographic Surgery Toluidine Blue Technique RICHARD S. CHESSER, MD, MAJ, MC DAVID E. BERTLER, MD, CPT, MC
JAMESE. FITZPATRICK, MD, LTC, MC J. RAMSEY MELLETTE, MD, COL, MC A patient with primary cutaneous adenoid cystic carci-
noma treated with Mohs surgery is presented. This tumor is characterized clinically by frequent local recurrences and infrequent metastases. Histologically it demonstrates cribifon islands of tumor cells with an abundance of mucin. Because toluidine blue stains this mucin metachromatically, it may be superior to hematoxylin and eosin for identifying the presence of this tumor. We recommend Mohs micrographic surge ry with toluidine blue staining technique for the treatment of adenoid cystic carcinoma. J Dermatol Surg Oncol 1992;18:175-176.
developed male with an approximately 1.5 X 1.O-cm indurated biopsy site in the midline of his parietal scalp. There was no palpable lymphadenopathy or organomegaly. The patient underwent Mohs surgery on December 12,1989. The specimen was processed using fresh frozen tissue stained with toluidine blue. Clear margins were obtained and the defect was closed primarily. The patient is now more than 10 months postoperative and there is no evidence of recurrence or metastasis.
rimary cutaneous adenoid cystic carcinoma is one of the most rare eccrine carcinomas. Although metastases are rare, recurrences after local excision are commom Herein, we report a case of primary cutaneous adenoid cystic carcinoma treated with Mohs micrographic surgery using the fresh frozen toluidine blue technique.
Case Report A 65-year-old white male was initially seen at the United States Air Force Academy dermatology clinic with the complaint of a lump in his scalp that had been present for approximately 1 year. An incisional biopsy of the lesion revealed a cutaneous adenoid cystic carcinoma. The patient was then referred to Fitzsimons Army Medical Center for Mohs surgery. Examination revealed a well~~
From the Dermatology Semice, Department of Medicine, Fitzsimons Army Medical Center, Aurora, Colorado. Address reprint requests to: Richard S. Chesser, MD,MA], MC, Dermatology Semice, Fitzsimons A n y Medical Center, Aurora, CO 80045. The opinions or assertions contained herein are the oieros of the authors and are not to be considered as reflecting the uieros of the Department ofthe Army or the Department of Defense.
0 1992 by Elsevier Science Publishing Co., Inc. 0148-0812/92/$5.00
Review of the original biopsy revealed a specimen measuring 1.2 X 0.6 cm.The pathologic process was that of a tumor that was not connected to the epidermis and was present in the dermis and subcutaneous fat. The tumor was composed of basaloid islands that demonstrated a distinct cribiform pattern admixed with tubular or ductal areas (Figure 1). The pseudolumina contained amorphous material compatible with mucin. The central portion of the tumor revealed a large cystic space with copious mucin separated by thin strands of cells one to three layers thick. The deeper portions revealed a more cellular area With interconnected pools of much separated by thicker strands of cells. Occasional mitotic figures were present. Perineural invasion was not appreciated. The specimen was forwarded to the Armed Forces Institute of Pathology for review. The Armed Forces Institute of Pathology concurred with the diagnosis of adenoid cystic carcinoma.
Discussion Adenoid cystic carcinoma is arguably the rarest of eccrine sweat gland carcinomas.' To the best of our knowledge this is approximately the twenty-third reported case of primary cutaneous adenoid cystic carcinoma, excluding All repotted cases lesions of the external auditory 175
J Dermatol Surg Oncol 1 992;18:2 75 - I 76
176 CHESSER ET AL
Figure 1. Adenoid cystic carcinoma demonstrating basophilic islands with distinct cribiform pattern. (H&E, original magnification X40.)
Figure 2. Adenoid cystic carcinoma with cribform islands and metachromatically stained mucin. (Tohidine blue, original magnification X 100.)
occurred in adults, with the male/female ratio being approximately e q ~ a l .The ~ , ~most common locations were the chest and scalp although lesions occurred elsewhere. The clinical course of cutaneous adenoid cystic carcinoma is characterized by frequent local recurrences, with some occurring many years after excision of the primary tumor. Metastasis has been reported but is uncommon.' Because of this tendency to recur, wide local excision has been recommended as the treatment of ~ h o i c eRecently .~ a case of recurrent cutaneous adenoid cystic carcinoma was treated using Mohs micrographic s ~ r g e r yThe . ~ authors recommended Mohs surgery as an ideal way to manage this neoplasm. We firmly agree with this recommendation. In this previous case the authors preferred permanent sections over frozen sections for control of this particular tumor. We used fresh frozen sections stained with toluidine blue. Toluidine blue is a metachromatic stain that stains certain chromotropes a different color than that of the dye. Acid mucopolysaccharides stain metachromatically purple with this dye. The presence of copious amounts of hyaluronic acid within adenoid cystic carcinoma made this particular stain extremely useful in revealing the presence of tumor (Figure 2). Although the follow-up periods available for the two reported cases of adenoid cystic carcinoma treated with Mohs surgery are too short for firm conclusions, we agree that this technique is the treatment of choice for this tumor. In addition, we feel that the use of fresh frozen
toluidine blue stained specimens is particularly suitable for identifying this tumor and may be preferable to hematoxylin and eosin.
References 1. Lever WF, Schaumburg-Lever G. Histopathology of the Skin. Philadelphia: JB Lippincott Co., 1990:637. 2. Seab JA, Graham JH. Primary cutaneous adenoid cystic carcinoma. J Am acad Dermatol 1987;17:113-8. 3. Cooper PH, Adelson GL, Holthaus WH. Primary cutaneous adenoid cystic carcinoma. Arch Dermatol 1984;120:774 - 7. 4. Sanderson KV, Batten JC. Adenoid cystic carcinoma of the
scalp with pulmonary metastases. Proc R SOCMed (Lond) 1975;68:649-50.
5. Lang PG, Metcalf JS, Maize JC. Recurrent adenoid cystic carcinoma of the skin managed by microscopically controlled surgery (Mohs surgery). J Dermatol Surg Oncol 1986;12:395 - 8.
6. Logan ME, Zaim MT. Histologic stains in dermatopathology. J Am Acad Dermatol 1990;22:820-30. 7. Wick MR, Swanson PE. Primary adenoid cystic carcinoma of the skin. Am J Dermatopathol 1986;8:2-13. 8. Headington JT, Teears R, Niederhuber JE, et al. Primary adenoid cystic carcinoma of the skin. Arch Dermatol 1978;114:421-4. 9. Van der Kwast ThH, Vuzevski VD, Ramaekers F, et al. Pri-
mary cutaneous adenoid cystic carcinoma: case report, immunohistochemistry, and review of the literature. Br J Dermatol 1988;118:567-78.