Management of Unusual Cutaneous Malignancies: Atypical Fibroxanthoma, Malignant Fibrous Histiocytoma, Sebaceous Carcinoma, Extramammary Paget Disease

Pleomorphic dermal sarcoma: it might be rare but it exists

Pleomorphic dermal sarcoma (PDS) is a rare mesenchymal tissue tumor. Its differential diagnosis from similar tumors, such as low differentiated squamous cell carcinoma, fibrosarcoma, desmoplastic melanoma, atypical fibroxanthoma (AFX), may be difficult, as they have similar clinical and histological presentation. We present a case of an 83-year-old man exhibiting an exophytic scalp lesion. Excision of the lesion was performed, ensuring clear surgical margins and pathologic examination revealed an invasive pleomorphic dermal sarcoma. This case highlights a rare case of a large pleomorphic dermal sarcoma, and it discusses the histological, molecular features, its differential diagnosis and management of PDS.

Vulval extra-mammary Paget's disease: the master of disguise revealed

Extra-mammary Paget's disease is a rare cancer affecting the anogenital region and can present with a myriad of symptoms. In women, the diagnosis of Paget's disease can be challenging as it mimics several other vulval conditions. It is important to promptly recognise this disease because of its potential association with synchronous tumours, such as colorectal adenocarcinoma. The mainstay of treatment is with immunomodulating therapies or surgery, but unfortunately the risk of recurrence is high and appears to be independent of treatment choice and tissue margin status. There is growing evidence to move away from traditional surgical excision to using topical therapy, such as imiquimod, as surgery can often be extensive and disfiguring with a prolonged recovery time. There is considerable psychosexual and physical morbidity associated with Paget's disease, largely owing to multiple surgical recurrences. As recurrences can occur several years after the initial presentation, long-term follow up of patients is recommended.

Extramammary Paget's Disease in the Genital Area of a Male: A Case Report and Review of the Literature

Extramammary Paget's disease (EMPD) is an uncommon intraepithelial malignancy that is rarely found in the male. Currently, there is very little knowledge pertaining to EMPD imaging, particularly in cases that involve the scrotum. Here, a 67-year-old man with lichenification on his left scrotum confirmed to be EMPD was reviewed. Bloodwork did not return a positive result, but syphilis-specific antibodies were found. Conventional high-frequency ultrasound (US) and contrast-enhanced ultrasound (CEUS) imaging were utilized to determine the lesion size and blood perfusion. In the present case, the lesion's size and involvement were vividly depicted by CEUS, while results obtained by conventional US were grossly underestimated. Consequently, multimodal imaging assessment is likely to provide more accurate diagnoses for uncommon diseases, such as EMPD, and to aid in clinical decision-making.

Surgical excision margins for fibrohistiocytic tumors, including atypical fibroxanthoma and undifferentiated pleomorphic sarcoma: A probability model based on a systematic review

BACKGROUND

Mohs micrographic surgery or wide local excision is the treatment of choice for fibrohistiocytic tumors with metastatic potential, including atypical fibroxanthoma (AFX) and cutaneous undifferentiated pleomorphic sarcoma (cUPS). Since margin clearance is the strongest predictor of clinical recurrence, improved recommendations for appropriate surgical margins help delineate uniform excision margins when intraoperative margin assessment is not available.

OBJECTIVE

To determine appropriate surgical wide local excision margins for AFX and cUPS.

METHODS

Literature search (Ovid MEDLINE, Embase, Web of Science, and Cochrane Library from inception to March 2020) to detect case-level data. Estimation of margins required using a mathematical model based on extracted cases without recurrences.

RESULTS

Probabilistic modeling based on 100 cases extracted from 37 studies showed peripheral clearance margin (ie, wide local excision margin) calculated to clear 95% of all tumors was 2 cm for AFX and 3 cm for cUPS. AFX tumors 1 cm or less required a margin of 1 cm.

LIMITATIONS

Data were extracted from published cases.

CONCLUSIONS

Atypical fibroxanthoma removed with at least a 2-cm peripheral excision margin is less likely to recur. Smaller tumors 1 cm or less can be treated with a more conservative margin. Margin-control surgical techniques are recommended to ensure complete removal while minimizing surgical morbidity.

Progression of the atypical fibroxanthoma to pleomorphic dermal sarcoma in a heart transplant patient

An 82-year-old man presented with a right scalp lesion which had been increasing in size. The patient's medical history was significant for a heart transplant 25 years before, and he was on chronic immunosuppression. Biopsy of the lesion showed atypical fibroxanthoma. The patient underwent an excision of the lesion with split thickness skin graft. Pathology showed fibroxanthoma with negative margins. Over the next 9 months, the patient developed new lesions, which were also excised to negative margins. However, with each new lesion, the histology demonstrated increasing dysplasia and ultimately pleomorphic sarcoma. The patient had a metastatic workup with CT of the chest, which was negative, and he underwent a radical scalpectomy, split thickness skin graft placement and adjuvant radiation therapy. The patient has not developed any new scalp lesions and no evidence of metastasis.

Cutaneous mesenchymal tumors treated with Mohs micrographic surgery: a comprehensive review

Cutaneous mesenchymal tumors (CMT) are rare tumors with wide clinicopathologic heterogeneity. Treatment of malignant cutaneous mesenchymal tumors traditionally includes wide local excision (WLE), though Mohs micrographic surgery (MMS) has been increasingly used. A PubMed literature review of articles from inception until September 2019 related to malignant CMT and surgical treatment with MMS or WLE was completed. Dermatofibrosarcoma protuberans treated with MMS recurred in 1.2% of patients with no reported metastasis. Atypical fibroxanthoma treated with MMS recurred and metastasized in 2.7 and 2.5%, respectively. Undifferentiated pleomorphic sarcoma treated with MMS recurred in 32% with an unknown metastatic rate. Superficial leiomyosarcoma treated with MMS recurred in 3.8% with no reported metastasis. Cutaneous angiosarcoma and myofibrosarcoma treated with MMS have shown no recurrence or metastatic disease, but literature is sparse. The rarity of malignant CMT and the lack of comparative data on treatment make conclusive treatment recommendations difficult. However, recent literature suggests MMS is a useful option and potentially a superior treatment for primary cutaneous mesenchymal tumors.

Nasal Sebaceous Carcinoma: A Case Report and Review of the Literature

Sebaceous carcinoma arising from the nasal vestibule is exceedingly rare, with 3 cases previously reported. We have described the case of a 69-year-old man with an indolent exophytic growth on the medial aspect of his right nasal vestibule. Incisional biopsy demonstrated sebaceous carcinoma. The clinical and pathologic features, in addition to the surgical course and the postoperative outcome, are discussed. We also report our findings from a review of the reported data, focusing on the diagnosis and treatment of this rare skin malignancy.

Ultrasound Biomicroscopy and High-Frequency Ultrasound for Evaluating Extramammary Paget Disease With Pathologic Correlation

OBJECTIVES

The purpose of this study was to investigate the performance of ultrasound biomicroscopy (UBM) and high-frequency ultrasound (HFUS) in the assessment of extramammary Paget disease (EMPD) and to correlate the imaging features with pathologic findings.

METHODS

In this retrospective study, we described the imaging features from UBM and HFUS based on 17 pathologically proven EMPD cases. The performance for visualizing layer involvement by UBM and HFUS was compared. Additionally, we checked the consistency between layer involvement of the lesions on UBM images and the pathologic results. Additionally, blood flow and the status of lymph nodes were investigated with HFUS.

RESULTS

Ultrasound biomicroscopy revealed that all 17 lesions (100%) were hypoechoic and grew in a creeping form. The feature of layer involvement was shown in 10 lesions (58.8%) limited to the epidermis and 6 lesions (35.3%) involving the dermis, and the remaining lesion (5.9%) involved the full skin layers. Layer involvement was clearly displayed by UBM for all lesions (100%) but for only 5 lesions (29.4%) by HFUS (P < .001). Additionally, the layer involvement of 15 lesions (88.2%) on UBM was consistent with the pathologic results (κ = 0.746). High-frequency ultrasound revealed profuse blood flow in most lesions (64.7% [11 of 17]), and 1 case showed inguinal lymph node metastasis.

CONCLUSIONS

Combined use of UBM and HFUS can provide key information on EMPD based on ultrasound features. Comparatively, UBM provides clearer morphologic information, whereas HFUS provides information on lymph node metastasis and blood flow.

Pleomorphic Dermal Sarcoma of the Scalp

Pleomorphic dermal sarcoma (PDS) is a rare mesenchymal tissue tumor. Distinguishing PDS from similar conditions, such as atypical fibroxanthoma (AFX), its less aggressive tumor counterpart, is difficult, as they are clinically and histologically similar. We present a case of a 77-year-old man presenting with a large nodular scalp lesion of three weeks duration. Pathology revealed a 3.3 cm invasive pleomorphic dermal sarcoma. Surgical excision with 2 cm margins was performed with successful healing of the graft. This case highlights a rare case of a large pleomorphic dermal sarcoma and discusses the histological features and management of PDS.

Evidence-Based Screening Recommendations for Occult Cancers in the Setting of Newly Diagnosed Extramammary Paget Disease

OBJECTIVES

To identify the rates of associated and occult cancers in patients with extramammary Paget disease (EMPD) discovered using cancer screening methods at a tertiary medical center; to propose evidence-based cancer screening guidelines at the time of diagnosis of EMPD; and to clarify terminology associating EMPD with underlying malignancies.

PATIENTS AND METHODS

A retrospective review of patients with histologically confirmed EMPD presenting for care at our institution between January 1, 1992, and December 31, 2015, was performed. Both male and female patients were included. Descriptive analysis was performed.

RESULTS

A total of 161 patients met the inclusion criteria. Most (59.6%) were female patients, and the mean age at the time of EMPD diagnosis was 70.8±10.1 years. Most (82%) of the 161 patients had at least 1 cancer screening test performed, though screening practices varied widely. Of those screened for an underlying malignancy, 17 distant, noncontiguous malignancies were identified in 15 patients (11.4%), with prostate (n=5), urinary tract (n=5), and breast (n=2) malignancies found most frequently. Most malignancies were identified by urine cytology, mammography, and prostate-specific antigen blood test. Of all patients, 37 (23.0%) had an underlying contiguous malignancy identified by pathology.

CONCLUSION

All patients diagnosed with EMPD should undergo cancer screening. At minimum, evaluation should include age-appropriate screening and the addition of urine cytology, mammography, and prostate-specific antigen blood test-if not already performed-may be of particular use. An algorithm for evaluation of patients with newly diagnosed EMPD is proposed.

Incidence and Clinical Features of Rare Cutaneous Malignancies in Olmsted County, Minnesota, 2000 to 2010

BACKGROUND

The incidence of rare cutaneous malignancies is unknown. Current estimates of rare cutaneous malignancy incidences are based on broad epidemiologic data or single institution experiences, not population-based data.

OBJECTIVE

To determine the incidence of several rare nonmelanoma skin cancers.

MATERIALS AND METHODS

The authors conducted a retrospective chart review of a population-based cohort between the years 2000 and 2010. Residents of Olmsted County, Minnesota, who were diagnosed with a biopsy-proven nonmelanoma skin cancer-excluding basal cell carcinoma and squamous cell carcinoma-were included in this study. The primary outcome was tumor incidence. Additionally, the authors extracted patient demographics, tumor characteristics, treatment modalities, and outcomes.

RESULTS

The age-adjusted and sex-adjusted incidences per 100,000 persons of multiple rare cutaneous malignancies were: atypical fibroxanthoma (1.8), sebaceous carcinoma (0.8), dermatofibrosarcoma protuberans (0.4), microcystic adnexal carcinoma (0.7), eccrine carcinoma (0.4), eccrine porocarcinoma (0.2), and leiomyosarcoma (0.2).

CONCLUSION

The authors report population-based incidences and clinical characteristics for these rare cutaneous malignancies. The immune status and smoking status of patients and the treatment and outcomes of these tumors are reported. Additional studies in a broader population are needed to further define the epidemiology and outcomes of these malignancies.

Malignant cutaneous adnexal tumours of the head and neck: an update on management

Adnexal tumours form a heterogeneous group of relatively rare neoplasms. Many of them have a poor prognosis and treatment can sometimes be difficult and controversial. We summarise the latest publications relating to malignant cutaneous adnexal tumours of the head and neck, and give an update on their management. We discuss Merkel cell carcinoma and other rare malignant adnexal tumours including dermatofibrosarcoma protuberans and atypical fibroxanthoma.

Atypical fibrous histiocytoma arising in the perianal area: a case report and review of the literature

Atypical fibrous histiocytoma (AFH) is an uncommon variant of cutaneous fibrous histiocytoma that can display histologic features associated with malignancy. Fewer than 150 cases have been reported in the literature. The majority of these lesions present on the trunk and extremities of middle-aged women. Genital lesions are rare, with one documented case of vulvar AFH and another case of scrotal AFH in the literature. We report an additional case of a 68-year-old woman who was diagnosed with an AFH in an unusual location, the perianal area. Histologically, the lesion was characterized by a nodular fairly well-circumscribed proliferation of large epithelioid macrophages with scattered lymphocytes and mast cells in the background. The atypical macrophages contained enlarged markedly pleomorphic nuclei with prominent nucleoli. Scattered multinucleated "monster cells" and atypical mitoses were observed throughout the lesion. Immunologically, the lesional cells were focally positive when stained with antibodies against CD163 and Factor XIIIa. They were negative for CD34, CD31, desmin, smooth muscle actin, CAM 5.2, keratin 5/6, S100, CD3, CD20, and CD30. The constellation of histologic and immunologic features was most consistent with an AFH. To our knowledge, this case is the first perianal presentation of AFH to date.

Population-based analysis of prognostic indicators in sebaceous carcinoma of the head and neck

OBJECTIVES/HYPOTHESIS

Due to the rarity of sebaceous carcinoma of the head and neck, few large series have been reported and prognostic factors remain largely undetermined. This study presents prognostic factors in survival in sebaceous carcinoma of the head and neck.

STUDY DESIGN

Retrospective analysis was performed using the Surveillance Epidemiology and End Results (SEER) database for patients diagnosed with sebaceous carcinoma of the head and neck (SCHN).

METHODS

Clinicopathologic, treatment data, and 5-year disease specific survival were analyzed using univariable and multivariable regression analysis and Kaplan-Meier methodology.

RESULTS

Of the 1,433 patients identified to have SCHN, 16 were node-positive (1.14%). On multivariable analysis, independent prognostic indicators were: age at diagnosis (HR = 1.03, P = .021), tumor grade (HR = 4.97, P = .038), and distant metastasis (HR = 7.52, P = .006). Nodal metastasis occurred exclusively with poorly or undifferentiated tumors and was not a significant prognostic factor on multivariable analysis.

CONCLUSION

Elderly patients and patients with poorly differentiated tumors and/or distant disease at presentation have the highest risk of disease-specific mortality. Lymph node metastasis does not appear to be an independent prognostic factor in sebaceous cell carcinoma.

Uncommon cutaneous neoplasms of the head and neck

This article concentrates on the less-common cutaneous malignancies such as merkel cell, atypical fibroxanthoma, malignant fibrous histiocytoma, dermatofibrosarcoma protuberans, microcystic adnexal carcinoma, and sebaceous carcinoma. The clinical and histopathologic descriptions of each, most current and emerging etiologies, diagnosis, staging, treatment, and prognosis are discussed.

Extramammary Paget's disease of the vulva: An annotated review of the current literature

Extramammary Paget's disease is a rare and unusual neoplastic entity that presents mainly on apocrine gland-bearing skin. The vulva is the most common site of involvement but any area of the anogenital skin can be affected. Due to its rarity, variable clinical course and deceptive histological appearance it has a high misdiagnosis rate and both gynaecologists and dermatologists have limited experience in its management. The significance of the disease lies in its association with underlying malignancy as well as its inherent ability to invade the dermis and metastasise. The management is notoriously complicated and recurrence rates are high despite aggressive surgeries. Several alternative modalities are being explored, with results that are often variable and unpredictable. This review summarises the histopathological, clinical and therapeutic features of extramammary Paget's disease of the vulva reported in recent years.

Needs assessment for Mohs micrographic surgery

Mohs micrographic surgery (MMS) is a unique technique that can offer the highest cure rates and maximum tissue conservation in the management of specific primary and recurrent skin cancers. However, there are many areas of controversy that surround MMS, including appropriate indications for its use, technical quandaries, and outcomes. Recent efforts in these areas need to be assessed to identify research gaps in MMS to help fuel further work. The usefulness of MMS and its methods for delivery need more stringent, evidence-based, rigorous study.

Clinical spectrum of atypical fibroxanthoma and undifferentiated pleomorphic sarcoma in solid organ transplant recipients: a collective experience

BACKGROUND

Atypical fibroxanthoma (AFX) and undifferentiated pleomorphic sarcoma (UPS) are uncommon, spindle cell cutaneous malignancies. Solid organ transplant recipients (SOTRs) are immunosuppressed and therefore have a higher incidence of cutaneous malignancies.

OBJECTIVE

We describe the clinical spectrum of AFX and a more-aggressive, deeper variant, UPS, in SOTRs.

MATERIALS AND METHODS

A retrospective chart review of AFX and UPS in SOTRs was implemented. Cases from Vanderbilt University, Emory University, Mayo Clinic-Jacksonville, and University of Rochester were included. A literature search included previously published cases.

RESULTS

The average age of SOTRs at time of tumor presentation was younger than typically seen in immunocompetent patients for AFX. Rates of local recurrences and metastases were higher in the SOTRs than is noted in the immunocompetent literature. Rates of recurrence were higher in those treated with excision than in those treated with Mohs micrographic surgery (MMS).

CONCLUSION

AFX and UPS may have a greater risk for recurrence, metastases, and mortality in SOTRs, in whom early treatment with MMS may demonstrate certain advantages in terms of minimizing risk of recurrence and metastasis. UPS and recurrent tumors should be staged appropriately and may respond to adjuvant radiation therapy and reduction of immunosuppression. Immunohistochemical evaluation is recommended to exclude other spindle cell tumors.