|Year : 2018 | Volume
| Issue : 1 | Page : 69-70
Poorly differentiated cutaneous adenocarcinoma masquerading as scrofuloderma
Balakrishnan Nirmal1, Renu George1, Mandeep Singh Bindra2
1 Department of Dermatology, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||22-May-2018|
Dr. Balakrishnan Nirmal
Department of Dermatology-Unit 1, Christian Medical College, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
We report the case of a 60-year-old male presented with axillary swelling of 18 months duration with ulceration and cervical lymphadenopathy of 3 months duration with a clinical diagnosis of scrofuloderma. Histopathology showed dermis infiltrated by sheets, nests, and clusters of polygonal cells with markedly pleomorphic mitotically active nuclei suggestive of a more sinister condition, poorly differentiated cutaneous adenocarcinoma either primary or metastasis from breast. The condition is reported for its rarity from male breast and the need to consider it as a differential diagnosis in similar clinical presentation.
Keywords: Adenocarcinoma, cutaneous, scrofuloderma
|How to cite this article:|
Nirmal B, George R, Bindra MS. Poorly differentiated cutaneous adenocarcinoma masquerading as scrofuloderma. Indian J Dermatopathol Diagn Dermatol 2018;5:69-70
|How to cite this URL:|
Nirmal B, George R, Bindra MS. Poorly differentiated cutaneous adenocarcinoma masquerading as scrofuloderma. Indian J Dermatopathol Diagn Dermatol [serial online] 2018 [cited 2019 May 24];5:69-70. Available from: http://www.ijdpdd.com/text.asp?2018/5/1/69/232958
| Introduction|| |
Cutaneous apocrine adenocarcinoma can be primary or can arise secondary to metastasis from breast. Differentiation of primary cutaneous apocrine adenocarcinoma from cutaneous metastases from breast carcinoma is difficult based on histology as both share overlapping immunohistochemical profiles. Primary cutaneous apocrine adenocarcinoma arises from apocrine glands or modifies apocrine glands such as Moll's and ceruminous glands. Cutaneous metastases from breast can result from contiguous, hematogenous, lymphatic spread, and direct implantation during surgery. The most common clinical presentation is nodule arising from thoracic wall and abdomen which can ulcerate due to pressure of tumor on skin surface. In most cases, cutaneous metastasis usually occurs late in the disease course but, at times, can be the presenting sign of the underlying undetected malignancy. It can mimic a wide variety of clinical conditions. Hence, a thorough clinical examination coupled with histopathology and imaging studies helps in its detection.
| Case Report|| |
A 60-year-old male from Tripura, India, presented with painless swelling in the right axilla for 18 months and ulceration of size 5 cm × 4 cm for 6 months [Figure 1] There was also right cervical lymphadenopathy of 3 months duration, which was nontender and firm in consistency. He was treated at his local place as hidradenitis suppurativa (HS) with oral antibiotics and retinoids with minimal benefit. Our clinical diagnosis was scrofuloderma based on ulceration preceded by axillary swelling and associated cervical lymphadenopathy.
|Figure 1: Photograph showing ulceration with purulent discharge on the right axilla|
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Skin biopsy from ulcer edge showed dermis infiltrated by sheets, nests, and clusters of polygonal cells with markedly pleomorphic mitotically active nuclei suggestive of primary cutaneous apocrine adenocarcinoma or metastatic cutaneous adenocarcinoma from the breast [Figure 2]. Immunohistochemistry showed positivity for pancytokeratin and estrogen receptor [Figure 3]; and negative staining for HMB45 and Melan A. Mycobacterial culture from tissue was negative.
|Figure 2: Photomicrograph showing dermis infiltrated by sheets, nests, and clusters of polygonal cells with markedly pleomorphic mitotically active nuclei (a) H and E, ×100 (b) H and E, ×200|
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|Figure 3: Photomicrograph showing immunohistochemistry positivity for (a) pancytokeratin (×100) (b) estrogen receptor (×100)|
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Ultrasound of the right axilla showed a relatively well-defined heterogeneous lesion with irregular margins with hypoechoic internal areas suggesting necrotic component. On color Doppler, there was significant internal vascularity within the lesion. These imaging features represent metastatic lymphadenopathy. The patient was not willing for further investigations to stage the disease and was started on oral tamoxifen by medical oncology department.
| Discussion|| |
Primary cutaneous apocrine adenocarcinoma arising from areas rich in apocrine glands has to be differentiated from neoplasms with apocrine differentiation, viz., metastatic apocrine breast carcinoma, apocrine carcinoma from ectopic breast tissue, mucinous carcinoma, and apocrine adenoma. Immunohistochemistry is an adjunctive tool to differentiate primary apocrine adenocarcinoma from metastatic apocrine breast carcinoma. Immunophenotype of estrogen receptor+ or progesterone receptor+ or herceptin+ would favor a metastasis, whereas primary invasive apocrine neoplasms are triple negative; however, profiles can be overlapping.
Metastasis to skin occurs in about 10% of patients with internal malignancies and sometimes can be the presenting sign. Usually, they portend a poor prognosis. However, in comparison to metastasis from other internal organs, prognosis of breast secondaries is relatively better. The various clinical presentations of breast secondaries include nodules, ulceration, cancer en cuirasse, inflammatory carcinoma, sclerodermiform plaques, erysipeloid infiltration, palpebral nodules, and alopecia. Hence, it can mimic a wide range of clinical conditions. Our case was treated as HS at his local place as the disease presented as subcutaneous nodules in axilla, a site for apocrine glands. Our first diagnosis was scrofuloderma as there was associated cervical lymphadenopathy which is usually absent in HS. Scrofuloderma is caused due to direct skin invasion of bacilli arising from tuberculosis of the underlying lymph nodes, epididymis, or bones. In India, scrofuloderma is the second most common form of cutaneous tuberculosis after lupus vulgaris. Scrofuloderma masquerading as HS has been reported in literature. We report this case as cutaneous adenocarcinoma can mimic many clinical conditions and needs a high index of suspicion. Histopathological confirmation is essential in these cases as it can reveal a more sinister condition beneath.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Bittencourt Mde J, Carvalho AH, Nascimento BA, Freitas LK, Parijós AM. Cutaneous metastasis of a breast cancer diagnosed 13 years before. An Bras Dermatol 2015;90:134-7.
Apalla Z, Chassioti V, Ioannides D, Sotiriou E, Papadopoulou D, Lallas A, et al.
Zosteriform cutaneous metastasis of breast carcinoma in a male patient. Int J Dermatol 2014;53:e358-9.
Gan EY, Chio MT, Tan WP. A retrospective review of cutaneous metastases at the national skin centre Singapore. Australas J Dermatol 2015;56:1-6.
Piris A, Peng Y, Boussahmain C, Essary LR, Gudewicz TM, Hoang MP, et al.
Cutaneous and mammary apocrine carcinomas have different immunoprofiles. Hum Pathol 2014;45:320-6.
Fernandez-Flores A. Cutaneous metastases from breast carcinoma: Calretinin expression and estrogen, progesterone and Her2/neu status of the metastases, compared to primary cutaneous apocrine tumors. Rom J Morphol Embryol 2013;54:695-9.
Siqueira VR, Frota AS, Maia IL, Queiroz HM, Valença Júnior JT, Accioly Filho JW, et al.
Cutaneous involvement as the initial presentation of metastatic breast adenocarcinoma-case report. An Bras Dermatol 2014;89:960-3.
Ozkan S, Gürler N, Fetil E, Atabey N, Günes AT. Scrofuloderma. Int J Dermatol 1998;37:606-8.
Padmavathy L, Lakshmana R, Ethirajan N, Manohar U, Krishnaswamy BK. Scrofuloderma: A clinicopathological and epidemiological study. Indian J Dermatol Venereol Leprol 2008;74:700.
] [Full text]
Müller H, Eisendle K, Zelger B, Zangerle R. Bilateral scrofuloderma of the axilla masquerading as hidradenitis suppurativa. Acta Derm Venereol 2008;88:629-30.
[Figure 1], [Figure 2], [Figure 3]