Case and Research Letters
Eccrine Carcinoma: The role of Mohs Micrographic Surgery and Review of the Literature
Carcinoma ductal ecrino: papel de la cirugía de Mohs y revisión de la literatura
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Lorente-Luna, E. Jiménez Blázquez, C. Sánchez Herreros, J. Cuevas Santos" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Lorente-Luna" "email" => array:1 [ 0 => "m.lorente.luna@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E. Jiménez" "apellidos" => "Blázquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C. Sánchez" "apellidos" => "Herreros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J. Cuevas" "apellidos" => "Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Central de la Defensa Gómez-Ulla, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Carcinoma ductal ecrino: papel de la cirugía de Mohs y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1446 "Ancho" => 1400 "Tamanyo" => 372174 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical images. A, Design of the rotation flap on the cheek. B, Result immediately after surgery. Rotation flap and Burow graft. C, Lateral view. Result 45 days after surgery. D, Frontal view. Result 45 days after surgery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Eccrine ductal carcinoma (EDC) is a rare adnexal neoplasm that arises from the eccrine glands. It accounts for 0.01% of all skin tumors.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The classification of the adnexal tumors is complex and the nomenclature confusing.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Traditionally, adnexal tumors have been considered to present an aggressive behavior.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 37-year-old man who was referred to our department for surgical excision of a well-defined, pink-colored tumor measuring 2.8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm on the left cheek (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The lesion, which had first appeared 2 years earlier, extended to deeper planes, and was diagnosed as an EDC. Soft-tissue ultrasound, magnetic resonance imaging, and positron emission tomography were performed and showed no deep involvement or distant spread. The excision of the lesion was extended to the muscle plane and a stage of Mohs micrographic surgery was performed for routine processing (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Histology of the surgical specimen showed an intensely sclerotic epithelial tumor that infiltrated to the muscle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Structures with a ductal appearance and areas of squamous differentiation were observed within the tumor (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Immunohistochemistry was positive for low molecular weight (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C) and high molecular weight (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>D) cytokeratins and CD10 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>E), and the cell proliferation index was low (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>F). No tumor nests were detected in the specimen sent for routine study. Surgical reconstruction was performed in a second operation using a rotation flap from the cheek and a Burow graft (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>, A and B), with good cosmetic and functional results (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>, C and D). A year after surgery the patient remains disease free.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">EDC is the most common type of adnexal tumor arising from the eccrine glands<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and is included in the group of tumors of uncertain behavior.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Because of the small number of cases published, the prognosis remains unknown; the tumor appears to be locally aggressive but with a low probability of metastatic spread. Avraham et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> analyzed more than 200 adnexal tumors with eccrine differentiation, and the majority were found to be in stage <span class="elsevierStyleSmallCaps">i</span>. Clinically, these are slow-growing, erythematous-violaceous tumors that may ulcerate. The clinical and histological differential diagnosis is broad. EDCs are more common in middle-aged and older men and arise preferentially on the scalp, trunk, and limbs.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical differential diagnosis includes basal cell carcinoma, squamous cell carcinoma, skin metastases, cutaneous lymphomas, and amelanotic melanoma. The diagnosis is histological. The architecture of these tumors resembles that of ductal carcinoma of the breast, with nests and cords of cells, a variable degree of glandular differentiation, and infiltration of the adjacent tissues.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> EDCs typically stain positive for carcinoembryonic antigen, epithelial membrane antigen, and cytokeratins 5/6.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Isolated cases with squamous differentiation have been reported<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5,6</span></a>; the origin of these tumors is controversial and it has been suggested that they may be squamous cell carcinomas arising in the tubules.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> This confusion is probably due to the complexity of their diagnosis, which will have led to underdiagnosis. The histological differential diagnosis includes other adnexal tumors, squamous cell carcinoma in those cases with extensive squamous differentiation, and a possible collision between squamous cell carcinoma and EDC.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Imaging studies for staging have not been standardized, though screening for local invasion and distant spread is recommended. Because EDC is such a rare tumor, it has been included in the TNM staging for squamous cell carcinoma.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Recommended treatment is by surgical excision of the tumor with negative margins, either by radical surgical excision or using Mohs micrographic surgery.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> Although margin width has not been defined,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> margins should be broad because of the tendency to underestimate the size of the tumor.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Margins between 1 and 2<span class="elsevierStyleHsp" style=""></span>cm have been sought in the majority of cases. Mohs micrographic surgery has been used with good results in other adnexal tumors,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> although reports have not specified whether fresh-tissue or fixed-tissue techniques were used. Some authors use 2<span class="elsevierStyleHsp" style=""></span>mm layers of resection,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> others use 5<span class="elsevierStyleHsp" style=""></span>mm,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> and some even support excising an additional layer after obtaining a tumor-free result.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Comparing the 2 techniques, no local recurrences have been detected in the few cases treated by Mohs micrographic surgery, whereas recurrence rates of up to 70% have been reported after wide surgical excision,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> although the follow-up periods have been short. With respect to adjuvant treatment, these tumors have been shown to respond poorly to radiation therapy<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and chemotherapy. Adjuvant radiation therapy has not been shown to increase survival.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, EDC is probably a less aggressive tumor than has been thought, but local recurrence is common. The squamous variant appears to be more common than has been reported in the literature and is probably underdiagnosed. In our opinion, Mohs micrographic surgery is a good therapeutic option for EDC, but diagnostic-therapeutic algorithms still need to be developed.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-12-02" "fechaAceptado" => "2015-03-25" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lorente Luna M, Jiménez Blázquez E, Sánchez Herreros C, Cuevas Santos J. Carcinoma ductal ecrino: papel de la cirugía de Mohs y revisión de la literatura. Actas Dermosifiliogr. 2016;107:73–76.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1063 "Ancho" => 699 "Tamanyo" => 166569 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Clinical image of the lesion on the left cheek. The tumor measures 3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.5<span class="elsevierStyleHsp" style=""></span>cm, has a pink surface, and shows signs of extension to deeper planes. B, Clinical image. Surgical excision of the tumor and design of the first stage of Mohs micrographic surgery (5<span class="elsevierStyleHsp" style=""></span>mm).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2081 "Ancho" => 1800 "Tamanyo" => 1071862 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histology. A, Low magnification showing a dense, nonencapsulated infiltrate that reaches the muscle layer. Hematoxylin-eosin (H&E), original magnification ×4. B, Detail of the fibrous stroma, with the presence of glandular lumens and cells grouped in cords. Note the squamous differentiation. H&E, original magnification ×40. C, Immunohistochemistry. Positivity for low molecular weight cytokeratins. Original magnification ×10. D, Immunohistochemistry. Positivity for high molecular weight cytokeratins. Original magnification ×10. E, Immunohistochemistry. Positivity for CD10. Original magnification, ×10. F, Immunohistochemistry. Stain for Ki67. Note the low cell proliferation index. Original magnification, ×10.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1446 "Ancho" => 1400 "Tamanyo" => 372174 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical images. A, Design of the rotation flap on the cheek. B, Result immediately after surgery. Rotation flap and Burow graft. C, Lateral view. Result 45 days after surgery. D, Frontal view. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 4 | 14 |
| 2024 October | 92 | 45 | 137 |
| 2024 September | 105 | 34 | 139 |
| 2024 August | 182 | 72 | 254 |
| 2024 July | 173 | 37 | 210 |
| 2024 June | 118 | 30 | 148 |
| 2024 May | 97 | 29 | 126 |
| 2024 April | 111 | 24 | 135 |
| 2024 March | 115 | 22 | 137 |
| 2024 February | 101 | 37 | 138 |
| 2024 January | 89 | 28 | 117 |
| 2023 December | 102 | 23 | 125 |
| 2023 November | 108 | 33 | 141 |
| 2023 October | 93 | 28 | 121 |
| 2023 September | 82 | 33 | 115 |
| 2023 August | 65 | 11 | 76 |
| 2023 July | 78 | 32 | 110 |
| 2023 June | 99 | 19 | 118 |
| 2023 May | 75 | 18 | 93 |
| 2023 April | 75 | 23 | 98 |
| 2023 March | 71 | 20 | 91 |
| 2023 February | 69 | 18 | 87 |
| 2023 January | 74 | 27 | 101 |
| 2022 December | 71 | 31 | 102 |
| 2022 November | 43 | 30 | 73 |
| 2022 October | 25 | 23 | 48 |
| 2022 September | 37 | 46 | 83 |
| 2022 August | 25 | 41 | 66 |
| 2022 July | 31 | 44 | 75 |
| 2022 June | 46 | 29 | 75 |
| 2022 May | 32 | 40 | 72 |
| 2022 April | 44 | 40 | 84 |
| 2022 March | 48 | 51 | 99 |
| 2022 February | 36 | 34 | 70 |
| 2022 January | 33 | 33 | 66 |
| 2021 December | 38 | 36 | 74 |
| 2021 November | 37 | 47 | 84 |
| 2021 October | 47 | 53 | 100 |
| 2021 September | 47 | 47 | 94 |
| 2021 August | 41 | 30 | 71 |
| 2021 July | 29 | 33 | 62 |
| 2021 June | 32 | 40 | 72 |
| 2021 May | 29 | 34 | 63 |
| 2021 April | 55 | 60 | 115 |
| 2021 March | 43 | 18 | 61 |
| 2021 February | 58 | 31 | 89 |
| 2021 January | 38 | 18 | 56 |
| 2020 December | 27 | 20 | 47 |
| 2020 November | 34 | 28 | 62 |
| 2020 October | 30 | 4 | 34 |
| 2020 September | 27 | 14 | 41 |
| 2020 August | 15 | 20 | 35 |
| 2020 July | 28 | 21 | 49 |
| 2020 June | 17 | 30 | 47 |
| 2020 May | 13 | 22 | 35 |
| 2020 April | 27 | 20 | 47 |
| 2020 March | 16 | 20 | 36 |
| 2020 February | 3 | 4 | 7 |
| 2020 January | 4 | 4 | 8 |
| 2019 December | 8 | 5 | 13 |
| 2019 November | 4 | 5 | 9 |
| 2019 October | 0 | 4 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 6 | 0 | 6 |
| 2019 April | 2 | 7 | 9 |
| 2019 March | 4 | 3 | 7 |
| 2019 February | 3 | 0 | 3 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 8 | 0 | 8 |
| 2018 September | 7 | 0 | 7 |
| 2018 March | 2 | 1 | 3 |
| 2018 February | 24 | 1 | 25 |
| 2018 January | 27 | 7 | 34 |
| 2017 December | 34 | 8 | 42 |
| 2017 November | 19 | 2 | 21 |
| 2017 October | 23 | 8 | 31 |
| 2017 September | 28 | 5 | 33 |
| 2017 August | 23 | 8 | 31 |
| 2017 July | 19 | 14 | 33 |
| 2017 June | 18 | 17 | 35 |
| 2017 May | 19 | 10 | 29 |
| 2017 April | 22 | 17 | 39 |
| 2017 March | 23 | 30 | 53 |
| 2017 February | 17 | 5 | 22 |
| 2017 January | 17 | 4 | 21 |
| 2016 December | 27 | 8 | 35 |
| 2016 November | 26 | 15 | 41 |
| 2016 October | 13 | 11 | 24 |
| 2016 June | 0 | 3 | 3 |
| 2016 May | 0 | 4 | 4 |
| 2016 February | 0 | 1 | 1 |
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