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A rare cutaneous tumor of the axilla: Apocrine adenocarcinoma Karaca S, Kulac M, Sahin O, Esme H, Solak O, Aktepe F - Indian J Dermatol
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CASE REPORT
Year : 2007  |  Volume : 52  |  Issue : 1  |  Page : 50-52
A rare cutaneous tumor of the axilla: Apocrine adenocarcinoma


1 Department of Dermatology, School of Medicine, Afyon Kocatepe University, Afyon, Turkey
2 Department of Pathology, School of Medicine, Afyon Kocatepe University, Afyon, Turkey
3 Department of Chest Surgery, School of Medicine, Afyon Kocatepe University, Afyon, Turkey

Correspondence Address:
Semsettin Karaca
Department of Dermatology, Afyon Kocatepe University, School of Medicine, Afyon
Turkey
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DOI: 10.4103/0019-5154.31926

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   Abstract  

Sweat gland neoplasms are rare with approximately 200 cases of eccrine sweat gland and less than 50 cases of apocrine gland carcinoma being reported in the worldwide literature. More than half of the reported cases with apocrine adenocarcinoma had lymph node metastases at the time of diagnosis. We report a case of a 56-year-old man, presented with a left axillary slow-growing seven year old painless nodule. Histopathological examination revealed an invasive apocrine adenocarcinoma with lymph node metastases. The patient successfully treated with total excision and radiotherapy. Apocrine adenocarcinoma is a rare malignancy with high metastatic potential that occurs mostly in the axilla. Physicians should be aware of this entity while differentiating cutaneous tumor located on the axillary region.


Keywords: Apocrine carcinoma, axillary nodule, eccrine sweat gland tumor, radiotherapy


How to cite this article:
Karaca S, Kulac M, Sahin O, Esme H, Solak O, Aktepe F. A rare cutaneous tumor of the axilla: Apocrine adenocarcinoma. Indian J Dermatol 2007;52:50-2

How to cite this URL:
Karaca S, Kulac M, Sahin O, Esme H, Solak O, Aktepe F. A rare cutaneous tumor of the axilla: Apocrine adenocarcinoma. Indian J Dermatol [serial online] 2007 [cited 2014 Mar 7];52:50-2. Available from: http://www.e-ijd.org/text.asp?2007/52/1/50/31926



   Introduction   Top


Apocrine adenocarcinoma of the skin is a rare malignant tumor, which usually presents as a single nodule in the axilla. It has also been described on the scalp, nipple, trunk, ano-genital region, wrist and fingertip, foot, toe, lip, ear, chest and eyelid.[1],[2],[3]

Apocrine tumors are generally believed to arise from normal or modified apocrine glands. However, Paties et al[4] have stated that apocrine differentiation in skin tumors does not indicate an exclusive origin from the apocrine sweat glands. In addition, because of their indolent nature, more than half of patients with apocrine adenocarcinoma have lymph node metastasis at the time of diagnosis.[3] The tumors are rarely suggested clinically and diagnosis through histopathology is often serendipitous.[5] Wide surgical excision with or without lymph node excision is the first step of treatment. In this case study, we report a patient with apocrine adenocarcinoma that arose in the left axilla with axillary lymph node metastases.


   Case Report   Top


A 56-year-old man was referred for evaluation of seven-year-old slowly growing left axillary nodule. On examination there was a firm reddish, nontender nodule of 5 x 2 cm, fixed to the skin and slightly ulcerated in the left axillary fold [Figure - 1]. No palpable nodule was detected beneath the lesion, nor was swollen lymph nodes found in the axilla. Other physical examination was within normal limits. Histopathological examination of a skin punch biopsy revealed apocrine adenocarcinoma. CT scan showed lymphadenopathies of the left axilla, but no pulmonary, mediastinal or upper abdominal pathology. Ultrasound examination of both breast and abdominopelvic region was essentially normal.

The lesion was widely excised, including a 2 cm margin of uninvolved skin and the underlying tissue up to the subcutaneous fat with axillary lymphadenectomy clinically. Histologically, the base surgical limit of the tumor was 1.5 cm, the far limit of the tumor was 1.9 mm and the close limit of the tumor was 1.7 mm. The patient received 56 Gy radiotherapy to his left axillae in a single daily fraction of 200 cGy, five days per week in 28 fractions, with parallel opposed (AP-PA) fields using Co 60 treatment machine six weeks after surgery.

Histopathologic examination revealed an invasive tumour located between the reticular dermis and the subcutaneous fat, forming nests of tubular structures of different sizes and forms. The most superficial tubules were related to the follicular infundibulum. Morphologically, the deeper tubules became smaller. Well-developed glandular lumina were present. The cytoplasm of the tumor cells was strongly eosinophilic and apocrine secretion was evident on the luminal edge of the tubular structures [Figure - 2],[Figure - 3]. The neoplastic cells had a hyperchromatic nucleus and frequent mitotic figures [Figure - 4]. The tumor showed perineural and perivascular extension. The histopathologic study of the adenopathies of the axillary region proved positive in 3 of the 15 lymph nodes analyzed. After eight months of follow-up, subsequent to the completion of radiotherapy, there was no evidence of recurrence at the lesion site. This time limit however, is not enough to comment about prognosis and further follow-up study of the patient will be carried out.


   Discussion   Top


Sweat gland neoplasms are rare with approximately 200 cases of eccrine sweat gland and less than 50 cases of apocrine gland carcinoma being reported in the literature worldwide.[2],[5],[6] Normal apocrine glands are limited to the anogenital region, the mammary areola and the axilla ceruminous gland in the external auditory canal, Moll's gland in the eyelids and are under the control of sexual hormones.[3],[5] Patients with apocrine adenocarcinoma are usually above 50 years of age, with a mean age of 57.9 years (range, 25-91 years) in the largest series.[7] Apocrine gland carcinoma demonstrates a slight male preponderance (5: 4, male: female), with no clearly defined racial or ethnic predilection.[8]

Primary axillary apocrine adenocarcinoma must be distinguished from metastatic breast cancer, carcinoma arising in ectopic breast tissue and extramammary Paget disease.[3] The treatment of apocrine adenocarcinomas consists of wide surgical excision with a 1-2 cm free margin of normal tissue along with regional lymph node dissection in the presence of clinically positive nodes.[2],[3] However, small, well-differentiated apocrine adenocarcinoma arising in functionally or cosmetically important locations, such as the eyelid, fingertip or lip, may be effectively treated with Mohs' micrographic surgery without impacting on the oncologic outcome.[9] Although, radiotherapy has limited value in the treatment of apocrine carcinoma,[1] we performed primary local radiation therapy as a supplement to aggressive surgery because of the presence of positive lymph nodes in the axillary fold.

The prognostic factors for apocrine adenocarcinoma are relatively poor and include size, histological type, lymph node involvement and distant metastasis. The disease free survival rate for 10 years in the absence of metastasis to the lymph nodes is reported to be 56%. This percentage, however, drops to 9% if lymph node metastasis is involved.[6],[10]

This unusual case demonstrated that apocrine adenocarcinoma diagnosis is important for axillary lesions because of its rarity and poor prognosis. Consequently, dermatologists should be aware of the possibility of apocrine adenocarcinoma while differentiating cutaneous tumor located in the axillary region.

 
   References   Top

1. Sevilla B, Botella R, Silvestre JF, Banuls J, Massuti B, Aranda I, et al . Axillary apocrine adenocarcinoma associated with pancreatic adenocarcinoma. J Eur Acad Dermatol Venereol 1997;9:74-5.  Back to cited text no. 1      
2. Santos-Juanes J, Bernaldo de Quiros JF, Galache Osuna C, Sanchez del Rio J, Allende MT, Folgueras MV, et al . Apocrine carcinoma, adenopathies and raised TAG-72 serum tumour marker. Dermatol Surg 2004;30:566-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3. Chamberlain RS, Huber K, White JC, Travaglino-Parda R. Apocrine gland carcinoma of the axilla: Review of the literature and recommendations for treatment. Am J Clin Oncol 1999;22:131-5.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4. Paties C, Taccagni GL, Papotti M, Valente G, Zangrandi A, Aloi F. Apocrine carcinoma of the skin. A clinicopathologic, immunocytochemical, and ultrastructural study. Cancer 1993;71:375-81.  Back to cited text no. 4      
5. Chintamani, Sharma R, Badran R, Singhal V, Saxena S, Bansal A. Metastatic sweat gland adenocarcinoma: A clinico-pathological dilemma. World J Surg Oncol 2003;1:13.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6. Mitts DL, Smith MT, Russell L, Bannayan GA, Cruz AB Jr. Sweat gland adenocarcinoma: A clinico-pathological reappraisal. J Surg Oncol 1976;8:23-9.  Back to cited text no. 6  [PUBMED]    
7. Warkel RL, Helwig EB. Apocrine gland adenoma and adenocarcinoma of the axilla. Arch Dermatol 1978;114:198-203.  Back to cited text no. 7  [PUBMED]    
8. Cooper PH. Carcinomas of sweat glands. Pathol Annual 1987;22:83-124.  Back to cited text no. 8  [PUBMED]    
9. Dhawan SS, Nanda VS, Grekin S, Rabinovitz HS. Apocrine adenocarcinoma: A case report and review of the literature. J Dermatol Surg Oncol 1990;16:468-70.  Back to cited text no. 9  [PUBMED]    
10. el-Domeiri AA, Brasfield RD, Huvos AG, Strong EW. Sweat gland carcinoma: A clinico-pathological study of 83 patients. Am Surg 1971;173:270-4.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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    Abstract
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    Case Report
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