|Year : 2021 | Volume
| Issue : 4 | Page : 222-223
Squamoid eccrine ductal carcinoma: A report of two cases
Jen-Hao Hsu1, Chia-Hsiang Chung1, Jen-Yu Wang1, Yu-Hung Wu2, Pa-Fan Hsiao3
1 Department of Dermatology, MacKay Memorial Hospital, Taipei, Taiwan
2 Department of Dermatology, MacKay Memorial Hospital, Taipei; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
3 Department of Dermatology, MacKay Memorial Hospital, Taipei; Department of Medicine, MacKay Medical College, New Taipei City; Department of Cosmetic Applications and Management, MacKay Medicine, Nursing and Management College, Taipei, Taiwan
|Date of Submission||09-Sep-2021|
|Date of Decision||22-Oct-2021|
|Date of Acceptance||09-Nov-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Pa-Fan Hsiao
Department of Dermatology, MacKay Memorial Hospital, Taipei
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hsu JH, Chung CH, Wang JY, Wu YH, Hsiao PF. Squamoid eccrine ductal carcinoma: A report of two cases. Dermatol Sin 2021;39:222-3
Squamoid eccrine ductal carcinoma (SEDC) is an uncommon adnexal carcinoma that has been recently added to the WHO Classification of Skin Tumors in 2018. It has rarely been reported in Asia, and this study reports two cases of SEDC. An 81-year-old man presented with an eroded skin-colored painless indurated papule, measuring 1 cm × 1 cm, on the right temporal area for several months [Figure 1]a. He underwent excision surgery. On histopathological examination of the surgical specimen, there were superficially connected squamous differentiated structures with multiple irregularly infiltrating tumor islands, strands, cords, ductal, or glandular structures in the sclerotic stroma and ulceration [Figure 1]b and [Figure 1]c. These tumor islands infiltrated the deep dermis [Figure 1]d, proximal to the subcutaneous tissue. On immunohistochemistry, the tumor cells were positive for carcinoembryonic antigen (CEA) [Figure 1]e, epithelial membrane antigen (EMA), p40, and p63. They were weakly positive for Ber-EP4 and negative for gross cystic disease fluid protein 15 (GCDFP-15). The histopathological diagnosis was SEDC, and the resected margin of the lesion was confirmed to be free of tumor cells. No recurrence was noted during the subsequent 12-month follow-up.
|Figure 1: Case 1. (a) A skin-colored eroded papule on the right temporal area. (b) Histopathologically, there is an ill-defined infiltrated tumor with central ulceration. A biphasic pattern of (c) squamous and (d) ductal differentiation over the superficial and deeper part of the dermis. (e) The tumor islands were positive for the carcinoembryonic antigen stain. (Original magnification, H and E, b × 20; b × 100; c × 200; carcinoembryonic antigen, e × 200).|
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An 87-year-old woman presented with a poorly healing ulcerated hard nodule without tenderness, measuring 0.5 cm × 0.1 cm, on her right lateral malleolus [Figure 2]a. Excision was performed. On histopathological examination of the excised specimen, there was an irregular downward proliferation of atypical squamoid cells from the epidermis of the upper part of the tumor [Figure 2]b. Multiple small lobules, strands, and cords of tumor islands were found to diffusely infiltrate the entire sclerotic dermis [Figure 2]c and [Figure 2]d, with perineural invasion [Figure 2]e. The ductal structures were positive for CEA and EMA on immunohistochemistry. Cytokeratin 7 staining highlighted few tumor cells. The tumor cells were negative for GCDFP-15, estrogen receptor, and progesterone receptor. Wide excision with a 1-cm margin was performed, and the area was covered with an artificial dermis. No recurrence was noted during the 4-month postoperative follow-up.
|Figure 2: Case 2. (a) A skin-colored nodule with central ulceration and elevated border on the right lateral malleolus. (b) Histopathologically, there is an ill-defined infiltrated tumor with central ulceration. A biphasic pattern of (c) squamous and (d) ductal differentiation over the superficial and deeper part of the dermis. The tumor islands are embedded in the sclerotic stroma. (e) Perineural invasion was identified in the deep dermis. (Original magnification, H and E, b × 20; b × 100; c × 200; e × 400).|
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SEDC is a rare subtype of eccrine ductal carcinoma with squamous differentiation., The tumor mainly affects older adults with a median age of 79.5 years (range: 10–96 years). SEDCs present as nodules or ulcerated plaques with a predilection for the head and neck, followed by the extremities rather than the trunk. It has clinically nonspecific findings that are difficult to discriminate from those of squamous cell carcinoma (SCC). On histopathology, SEDCs exhibit a characteristic biphasic pattern., The upper part of the tumor exhibits squamous differentiation and is connected to the epidermis. It stains positive for CK5/6, p40, p63, and Ber-EP4 on immunohistochemistry.,,, In the deeper portion, there is ductal differentiation with glandular tissue infiltration, which stains positively for CEA and EMA. Occasionally, tumor necrosis (23%), perineural invasion (26%), and lymphovascular invasion (6%) may be observed. Our cases had the characteristic biphasic pattern, and the second case exhibited perineural invasion.
SEDC is difficult to diagnose using a superficial biopsy. The most important differential diagnoses include SCC, eccrine porocarcinoma, microcystic adnexal carcinoma, and syringoid eccrine carcinoma. SCC lacks ductal structures. Eccrine porocarcinoma can have both squamous and ductal differentiation but lack the characteristic biphasic pattern of SEDC. Microcystic adnexal carcinoma has keratocysts, perifollicular keratinization, and ductal structures but lacks epidermal connection or squamous differentiation. Syringoid eccrine carcinoma contains ductal structures but lacks squamous structures.
Recent studies have suggested the aggressive potential of SEDCs. The treatment options include traditional wide excision, radiotherapy, and Mohs micrographic surgery (MMS).,,, However, wide excision with clear margins is preferred because there is limited experience with the other treatment options. The recurrence rates of SEDC, treated with traditional excision and MMS, were 10%–70% and 0%–5%, respectively. Kim et al. used MMS and obtained a narrow margin of 2 mm, which effectively treated facial SEDC. The largest case series in 2016 observed local recurrence in 25% of cases and regional lymph node metastasis in 13% of cases. In this study, both patients underwent traditional wide excision, as suggested by the current publications. MMS or adjuvant radiotherapy should be considered when the patients exhibit signs of recurrence. No clinical recurrence was noted in both cases.
In conclusion, SEDC is a rare disease that should be considered a differential diagnosis for ulcerated nodules. Adequate wide excision, MMS, and regular follow-up are necessary to prevent further recurrence and progression.
This study is approved by Institutional Review Board of MacKay Memorial Hospital (approval number 21MMHIS280e; approval date: 2021.09.03). The patient consent is waived by IRB.
Financial support and sponsorship
Conflicts of interest
Dr. Pa-Fan Hsiao and Dr. Yu-Hung Wu, editorial board members at Dermatologica Sinica, had no roles in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
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[Figure 1], [Figure 2]