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Case Number : Case 1886 - 21 Aug - Dr Limin Yu

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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70 yo F, right neck lesion


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Admin_Dermpath

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Morning all! Dr Carr commented on Friday's case 

 

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Raul Perret

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The lesion that is partially excised shows well circumscribed tubular structures covered by an epithelium with multilineage differentiation. I think what we are seeing is the top of a hidradenoma, but to be honest I thought also of tubular adenoma. I think the latter tends to be a more simple lesion in general and mucinous metaplasia (as we see in this case) is not reported in this entity. If someone could help me clarify if the criteria I mentioned are correct I would really appreciate.

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Raul Perret

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Forgot to mention that hidradenoma has a solid component too whereas tubular adenoma by definition shows ony tubules. 

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urmilapandey

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given that this is a neck lesion, i would also consider a low grade mucoepidermoid carcinoma of salivary gland origin

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vincenzo polizzi

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What about an apocrine hidrocystoma (or cystadenoma) with mucinous metaplasia?

The neck is an unusual site, and I think it should be a prudent behavior to rule out a mts of acinic cell carcinoma of salivary glands, but the lesion is well circumscribed and it seems to see some myoepitelial row around the cysts, so  agree with Raul: a sweat gland adenoma, probably apocrine cystadenoma. 

PS. glad to share the same consideration with Urmilapandey. 

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Robledo F. Rocha

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Tubular adenoma. Metaplastic changes do occur in this sweat gland tumor, and I don't think the not-yet-described-in-literature presence of luminal mucinous cells invalidates the hypothesis if the diagnostic criteria for tubular adenoma can be found. The difficult here is the solid islands adjacent to the dilated tubules, which I interpret as tubules tangentially cutted.

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Raul Perret

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53 minutes ago, Robledo F. Rocha said:

Tubular adenoma. Metaplastic changes do occur in this sweat gland tumor, and I don't think the not-yet-described-in-literature presence of luminal mucinous cells invalidates the hypothesis if the diagnostic criteria for tubular adenoma can be found. The difficult here is the solid islands adjacent to the dilated tubules, which I interpret as tubules tangentially cutted.

Dear Robledo, in everyday practice would you discard hidradenoma considering this is a partial excision? Thanks in advance for your answer

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Sasi Attili

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9 hours ago, urmilapandey said:

given that this is a neck lesion, i would also consider a low grade mucoepidermoid carcinoma of salivary gland origin

This is what I wondered too. Also, is mucoepidermoid carcinoma of the thyroid a possibility? Do we need IHC or is this just  a clear cut case of Hidradenoma? Look forward to the answer!

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Robledo F. Rocha

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4 hours ago, Raul Perret said:

Dear Robledo, in everyday practice would you discard hidradenoma considering this is a partial excision? Thanks in advance for your answer

No, dear Raul, I cannot rule out hidradenoma dealing with an incomplete excision such as this one. I favor tubular adenoma because no definitive solid component nor sclero-hyaline stroma couldn't be found. On the other hand, this lesion presents with a tubular growth pattern, with a suggestion of outer myoepithelial cell layer (to be confirmed by immunostaining), and is encased by a fibrous stroma sharply demarcated from the surrounding dermis.

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Limin Yu

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Thank everyone for the insightful discussion. This is a low grade mucoepidermoid carcinoma. It's largely cystic, consisting of mucous, epidermoid and intermediate cells. This case was kindly provided by Dr. John Cai in Florida. 

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Sasi Attili

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On 8/21/2017 at 23:52, Sasi Attili said:

This is what I wondered too. Also, is mucoepidermoid carcinoma of the thyroid a possibility? Do we need IHC or is this just  a clear cut case of Hidradenoma? Look forward to the answer!

Can anyone please advice?

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vincenzo polizzi

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This is what I wondered too. Also, is mucoepidermoid carcinoma of the thyroid a possibility? Do we need IHC or is this just  a clear cut case of Hidradenoma? Look forward to the answer!

Can anyone please advice?

Ok. I’m now convinced about the mucoepidermoid carcinoma diagnosis. I was thinking of a sweat glands apocrine adenoma/cystadenoma/hidradenoma and similar because of the clear cells component which must instead be considered as intermediate/clear cells in the contest of mucoepidermoid carcinoma. 

I don’t think this could be a mucoepidermoid carcinoma from thyroid because that one is a sclerosing variant with high grade atypia and massive eosinophilic infiltrate. This looks like a typical low grade mec from salivary glands or a primitive skin neoplasia. 

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Robledo F. Rocha

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Primary cutaneous mucoepidermoid carcinoma is a controversial entity, probably corresponding to a squamous cell carcinoma with mucinous differentiation. I believe the present case is a primary submandibular salivary gland tumor with direct extension to the skin.

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