Chemotherapy of metastatic sweat gland carcinoma. A retrospective review

Lymph Node Metastases from Non-Melanoma Skin Cancer of the Head and Neck

Non-melanoma skin cancer (NMSC) represents the most common malignancy in the world, comprising exceedingly common lesions such as basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) and rare lesions such as Merkel cell carcinoma. Risk factors are widely recognized and include ultraviolet (UV) light exposure, radiation exposure, immunosuppression, and many others. As a whole, survival and functional outcomes are favorable, but each histopathological subtype of NMSC behaves differently. Treatment regimens for the primary site usually include wide surgical excision and neck dissection in cases of clinically involved metastatic lymph nodes. The elective management of draining nodal basins, however, is a contested topic. Nearly all subtypes, excluding BCC, have a significant risk of lymphatic metastases, and have been studied with regard to sentinel lymph node biopsy (SLNB) and elective neck dissection. To date, no studies have definitively established a true single standard of care, as exists for melanoma, for any of the NMSCs. As a result, the authors have sought to summarize the current literature and identify indications and management options for the management of the cervical lymphatics for each major subtype of NMSC. Further research remains critically necessary in order to develop complete treatment algorithms.

When to sweat: A history of chemotherapy in malignant sweat gland tumors. A unique case report and literature review

Sarcomatoid sweat gland carcinomas are rare among cutaneous cancers, with less than 20 cases described. A 54-year-old woman with sarcomatoid sweat gland carcinoma of the right upper extremity suffered extensive recurrence at 15 months, unresponsive to chemotherapy. There is no standard treatment or chemotherapy regimens for metastatic sweat gland carcinoma.

Intergluteal Cleft Eccrine Porocarcinoma with Metastasis to Inguinal Region and Lung: Case Report and Review of the Literature

Eccrine porocarcinoma (EPC) is an infrequent cutaneous neoplasm, and was described in 1963 by Pinkus and Mehregan. It is a rare type of skin tumor (0.005-0.01% of all skin tumors). Less than 300 cases have been described in the entire world medical literature. To our knowledge, no case of intergluteal cleft EPC has been reported in the literature in English and Spanish to date, so this would be the first reported case of such pathology. Metastatic EPC is less frequent, since only <10% of metastatic type have been reported and the rest as localized disease. The primary treatment of choice is surgical wide local excision of the tumor with histological confirmation of tumor-free margins. Prognosis is difficult to determine because of the rarity of EPC and the variations in natural history. There are no data to support the use of adjuvant chemotherapy or radiotherapy, and there are currently no agreed criteria to define patients at high risk of relapse. We present a 67-year-old man with intergluteal cleft eccrine tumor by biopsy. Metastasis to left inguinal region and lung was reported by contrasted abdominal and chest computed tomography. He started chemotherapy based on etoposide, vincristine, carboplatin. A review of pertinent literature is provided.

Updates on the Systemic Treatment of Advanced Non-melanoma Skin Cancer

Non-melanoma skin cancers (NMSCs), which represent a diverse group of cutaneous malignancies, are the most common forms of human neoplasia. The incidence of these diseases is increasing due to a number of factors, including that of increasing human lifespans. The majority of NMSCs are basal cell carcinomas (BCC) and cutaneous squamous cell carcinomas (cSCC), with the remainder being various rare skin cancers, including extramammary Paget's disease (EMPD), Merkel cell carcinoma (MCC), and several skin adnexal carcinomas. Of these, MCC usually shows aggressive behavior with a high mortality rate. On the other hand, BCC, cSCC, EMPD, and skin adnexal tumors usually show an indolent clinical course and metastasize only rarely. Nevertheless, the metastatic forms of these tumors commonly lead to poor patient outcome. A definitive management strategy for the treatment of advanced NMSC has not been established, mainly due to their rarity and lack of reliable information based on well-controlled randomized trials. Chemotherapeutic regimens for treatment of these diseases have been mainly based on the observations of isolated, small case series or clinical trials with a limited numbers of patients. However, accumulating evidence regarding their pathobiological backgrounds as well as recent advances in molecular biotechnology have facilitated the development of novel drugs for treatment of these diseases. Over the past decade, the U.S. Food and Drug Administration has approved several molecular targeting therapies, including Hedgehog inhibitors for BCC, monoclonal antibodies targeting anti-programmed death ligand-1 and anti- programmed cell death 1 (PD-1) for MCC, and anti-PD-1 for cSCC. Here, we review their clinical utility and discuss updated systemic treatment strategies for advanced NMSC.

Oral Capecitabine Achieves Response in Metastatic Eccrine Carcinoma

The low prevalence rate and limited literature on eccrine carcinoma (EC) pose a challenge to properly diagnosing and treating this rare malignancy. EC lesions tend to present similarly to other cutaneous neoplasms and dermatitis-like conditions. Efficacious treatment guidelines have not been established for patients diagnosed with EC, and few treatment regimens have demonstrated clinical benefit. Due to the high metastatic potential of EC, recognizing the clinical presentation, properly diagnosing, and utilizing beneficial treatment options are important for managing this disease. We report a case of a 66-year-old female who presented with lesions that her primary care provider misdiagnosed as basal cell carcinoma. The disease responded poorly to taxane- and platinum-based chemotherapies as well as an isolated limb perfusion of an alkylating agent. However, continuous dosing of oral capecitabine achieved an 18-month period of progression free survival (PFS) and ameliorated quality of life. We wish to highlight this rare disease and discuss presentation, diagnosis, and management as it is most often misdiagnosed leading to advanced metastatic disease when patients present to the oncologist. In addition, it is crucial to study and report potentially efficacious regimens considering the lack of clinical trials in this disease.

Treatment of Malignant Cutaneous Adnexal Neoplasms

Malignant cutaneous adnexal neoplasms form a group of rare, typically low-grade-malignancy carcinomas with follicular, sebaceous, apocrine, or eccrine differentiation or a combination of the first 3 subtypes. Their clinical presentation is usually unremarkable, and biopsy is required to establish the differentiation subtype and the definitive diagnosis. Due to their rarity, no clear consensus has been reached on which treatment is most effective. Mohs micrographic surgery is considered to be the best option to prevent recurrence in the majority of patients. Radiotherapy and chemotherapy have been studied in very few cases and have rarely been shown to be effective.

Malignant acrospiroma of chest and abdominal wall treated with chemotherapy

Acrospiroma denotes a group of benign ductal tumours of the eccrine sweat glands that may or may not be connected to the skin. Although various eccrine sweat gland tumours including benign acrospiroma are widely reviewed, malignant acrospiroma is rarely reported. Malignant acrospiroma have the propensity to recur locally and metastasizes to regional lymph nodes. The primary treatment is wide local excision with or without lymph node dissection. Local radiation is added in the presence of high risk features to reduce the risk of recurrence. We describe a case of a malignant acrospiroma involving wide areas of chest and abdominal wall with metastases to bilateral axillary lymph nodes in a 47 year old man showing minimal clinical response to combination chemotherapy and paclitaxel.

Sunitinib efficacy in the treatment of metastatic skin adnexal carcinomas: report of two patients with hidradenocarcinoma and trichoblastic carcinoma

BACKGROUND

Adnexal carcinomas are rare and diverse cutaneous tumours. They are locally aggressive and have the potential for distant metastasis. Metastatic adnexal carcinomas are very resistant to conventional chemotherapies. Sunitinib, an oral tyrosine kinase inhibitor, is reportedly effective for the treatment of various solid cancers. Its use in adnexal carcinomas has never been reported.

OBSERVATIONS

The first patient had metastatic clear cell hidradenocarcinoma and was stabilized over 8 months with sunitinib, before she relapsed. The second patient had a metastatic malignant hair follicle tumour (trichoblastic carcinoma) and achieved a partial remission with sunitinib, and disease stabilized after 10 months. Dynamic contrast-enhanced ultrasound (DCE-US) performed to evaluate tumour vascularization during treatment depicted a dramatic and early decrease in the tumour blood volume.

CONCLUSIONS

Sunitinib was effective in controlling the disease in our two patients. DCE-US using linear raw data may have an early predictive value for tumour response to sunitinib. Further studies involving larger cohorts of patients are warranted in order to confirm the efficacy of sunitinib in these rare tumours.

Antitumour activity of paclitaxel and interferon-alpha in a case of metastatic eccrine porocarcinoma

BACKGROUND

Eccrine porocarcinoma (EP) is a rare malignant tumour arising in the acrosyringium, with about 50% of the cases developing local recurrence or metastatic disease. No standard therapy protocols for metastatic disease exist. In the past, only short remissions were achieved by applying combinations of cytotoxic agents, which were associated with severe side-effects.

AIM OF THE STUDY

In the case reported here, the aim was to find a protocol with fewer side-effects for a patient who was not willing to undergo extensive polychemotherapy.

SUBJECT

A 67-year-old male patient with local recurrence and regional lymph node metastases after resection of EP was treated with a combination of interferon-alpha (IFN-alpha) 9 million units s.c. three times per week and paclitaxel 100 mg/m(2) weekly i.v., which shows a side-effect profile similar to taxotere and is used in the treatment of a variety of neoplasms such as advanced squamous cell carcinoma.

MAIN OUTCOME

This less aggressive treatment was tolerated well and the patient responded with minor remission and long-term stable disease.

[Simultaneaous bilateral pulmonary metastasectomy of carcinoma of the sweat glands]

A 51-year-old woman with carcinoma of the right axillary sweat glands was treated by radical surgery and radiotherapy. Six years later she developed multiple bilateral lung metastases. Nine nodes were resected from both lungs using a clamshell approach (bilateral transsternal, anterolateral thoracotomy). After surgery, the patient received 6 cycles of adjuvant chemotherapy with cisplatin and 5-fluoruracil. Three years after treatment, no intrathoracic recurrences had occurred and the patient was asymptomatic, with good quality of life.

Malignant Eccrine Acrospiroma with Metastasis to the Parotid

Malignant eccrine acrospiromas are rare. Clinically, they resemble other cutaneous lesions. A high index of suspicion must be maintained in cases of histologically benign eccrine acrospiromas for three reasons: (1) malignant transformation can occur, (2) the presence of both benign and malignant tissue can lead to a false-negative diagnosis if only the benign component is obtained in the biopsy specimen, and (3) benign-appearing tumors can recur locally or metastasize. The primary treatment is wide local excision with or without lymph node dissection. The efficacy of adjuvant chemotherapy and radiation therapy requires further investigation. We describe a case of malignant eccrine acrospiroma in an 80-year-old man, and we review the literature on this tumor, with emphasis on the differential diagnosis.

Metastatic eccrine porocarcinoma: response to docetaxel (Taxotere) chemotherapy

BACKGROUND

Eccrine porocarcinoma is an uncommon neoplasm of the intra-epidermal sweat gland duct.

PATIENTS AND METHODS

A case of eccrine porocarcinoma in a female renal transplant patient aged 45 years is described with a review of pertinent literature.

RESULTS

The primary tumour was highly pleomorphic. In places large and small cells merged and focally the former component infiltrated the epidermis in a manner akin to Paget's disease of the breast. The majority of the tumour was high grade; using the modified Bloom and Richardson grading system, usually applied to mammary ductal carcinomas, the tumour graded as 3. Metastatic disease developed nine months following primary surgical treatment. The metastatic eccrine porocarcinoma was resistant to epirubicin but responded to docetaxel chemotherapy.

CONCLUSIONS

There are no data to support the use of adjuvant therapy in the management of eccrine porocarcinoma. The use of the modified Bloom and Richardson grading system may define cases at high risk of relapse in which adjuvant therapy might be considered. Metastatic eccrine porocarcinoma has proven resistant to many chemotherapeutic agents. We report the first use of docetaxel in the management of this disease. The treatment was well tolerated and resulted in marked symptomatic and radiological responses. Treatment with docetaxel should be considered in future cases of this rare tumour.

Expression of structurally unaltered androgen receptor in extramammary Paget's disease

Extramammary Paget's disease (EMPD) is an uncommon neoplasm of the skin that shows differentiation to an apocrine sweat gland. Although we previously showed that erbB-2 overexpression may play a part in the progression of EMPD, molecular genetic defects underlying the development of EMPD are poorly understood. In the study described here, we examined androgen receptor expression and gene alterations in 30 cases of EMPD without internal malignancy. Immunohistochemistry revealed that 24 of 30 (80%) cases of EMPD variably expressed nuclear androgen receptor. Semi-quantitation of receptor content by scoring immunostained sections showed no difference between in situ (n = 17) and invasive (n = 13) EMPD tumors. Androgen receptor expression was also observed in four of six lymph node metastases. In these lymph nodes, expression of androgen receptor mRNA was confirmed by reverse transcriptase-polymerase chain reaction. Direct sequencing of exon 2 through exon 8, which encodes DNA- and hormone-binding domains of the androgen receptor gene, revealed no mutation in any of the 10 advanced stage tumors. Neither amplification nor deletion of the androgen receptor gene locus was detected by dual color fluorescence in situ hybridization analysis in 14 tumors. The present findings showing frequent expression of structurally unaltered androgen receptor in an advanced stage of EMPD may provide a rational basis for hormone therapy, which is widely used in the treatment of metastatic prostate cancer and androgen receptor-positive breast cancer recurrence.

Ductal Eccrine Carcinoma Arising in the Postaural Area

We describe the case of a 64-year-old man with a 1-year history of a postaural mass, which was diagnosed as ductal eccrine carcinoma. We also briefly describe the characteristics and treatment of this rare entity.

A case of metastatic extramammary Paget's disease that responded to combination chemotherapy

Extramammary Paget's disease is considered to be a malignant tumor originating from the sweat glands. Some cases of extramammary Paget's disease infiltrate the dermis and metastasize to the regional lymph nodes. No standard treatment has been established for advanced cases. Few previous studies of the treatment for metastatic Paget's disease have revealed an effective regimen. The prognosis of metastasized cases is very poor. We encountered a patient in whom extramammary Paget's disease had metastasized to the lymph nodes beyond the regional lymph nodes and systemic chemotherapy was partially effective. Combination chemotherapy consisted of mitomycin C 3.5 mg/m2 and epirubicin 50 mg/m2 on day 1, vincristine 0.6 mg/m2 on days 1 and 7, cisplatin 30 mg/m2 from days 1 to 3, and 5-fluorouracil 350 mg/m2 from days 3 to 7. After two courses of chemotherapy, the metastatic lymph nodes decreased in size by more than 90% compared to that before chemotherapy. We defined the treatment effect of this regimen as a partial response (PR). Microscopic examination of the resected lymph nodes revealed replacement of metastatic lesions by fibrous tissue, suggesting a therapeutic effect. Anorexia, alopecia, and leukopenia (neutropenia) have been reported as toxicities, but all were tolerated. Our results may provide useful indications for the management of this tumor. This particular combination chemotherapy is recommended for extramammary Paget's disease patients with systemic nodal metastases.

A sweat-gland tumor metastasizing to the axilla: report of a case

Sclerosing sweat-duct carcinoma is a rare malignancy of the skin. We herein present the case of a 68-year-old Japanese man who developed sclerosing sweat-duct carcinoma 2 years after undergoing local excision of a primary tumor in his right arm. Firm nodules appeared in the right axilla, which were revealed by surgical resection to be metastases. This rare tumor grows slowly but usually metastasizes to the regional lymph nodes, whereupon they are often associated with a poor prognosis. As the effectiveness of chemotherapy and radiotherapy against this neoplasm remains unclear, we recommend that the disease should initially be aggressively treated by surgery, which would also be indicated for any metastatic lesions.

Malignant eccrine spiradenoma. Case report and review of the literature

Malignant eccrine spiradenoma is an exceedingly rare tumor. A case of a 72-year-old women with this highly aggressive malignancy arising from a long-standing lower leg lesion is reported. Management during the course of disease included surgery, radiation therapy (RT), hyperthermic limb perfusion chemotherapy, and chemotherapy. The patient died of her disease, with widespread metastatic disease 20 months after the diagnosis. A review of the literature is presented, and treatment considerations are summarized.

Metastasizing eccrine porocarcinoma: report of a case and review of the literature

Eccrine porocarcinoma is a rare malignant tumor arising from the intraepidermal ductal portion of the eccrine sweat gland (acrosyringium). It usually affects older persons and is located most commonly on the lower extremities. We describe a 55-year-old man with an aggressive metastasizing eccrine porocarcinoma diagnosed 10 years after the primary lesion. The metastatic lesions were located in the public area and scrotum and were associated with progressive lymphedema. Several biopsy specimens revealed numerous tumor cells in the dermis and especially in the lumina of lymph and blood vessels. Immunohistochemical studies showed staining with cytokeratin KL1, epithelial membrane antigen, Ca 15-3, and Ca 19-9. Vimentin, S-100 protein, neuron specific enolase, and carcino-embryonic antigen were negative. Treatment with carbon dioxide laser failed. The use of interferon alfa-2a for 9 months stopped progression of the tumor.

Malignant clear cell hidradenoma of the upper lip

Malignant clear cell hidradenoma is an uncommon tumor of eccrine sweat gland origin that has a predilection for the head and neck. It is characterized by an indolent growth pattern yet frequently recurs following surgical excision and has a high incidence of regional and distant metastases. A case of recurrent malignant clear cell hidradenoma of the upper lip is presented. The lesion was treated with surgical excision followed by radiotherapy. The literature on this rare lesion is reviewed and treatment strategies discussed.

Surgical resection for pulmonary metastases of sweat gland carcinoma

A case of axillary sweat gland carcinoma which metastasised to both lungs six years after resection of the primary lesion is described. The lesions were resected and three years later two further pulmonary metastases were resected.

Metastatic sweat gland carcinoma: response to 5-fluorouracil infusion

A 78-year-old white male presented with metastatic sweat gland carcinoma involving regional lymph nodes, pleura, pericardium, and chest wall. A complete response of three months duration was achieved by using a 96-hour infusion of 5-fluorouracil. This is the first report of a complete response to systemic chemotherapy in metastatic sweat gland carcinoma.

Response of eccrine adenocarcinoma to tamoxifen

One of two patients with systemic metastases from a poorly differentiated eccrine adenocarcinoma of the scalp was found to have a tumor positive for estradiol receptors. In the receptor positive patient, after tamoxifen therapy, the lymph node metastasis regressed completely and was associated with full relief of pain from osseous metastases for nearly 3 years. Subsequently, progressive painful osseous metastases in the spine, skull, pelvis, and femur were palliated for shorter periods with sequential systemic therapy with megestrol acetate and fluoxymesterone. Osseous metastases were also palliated with external radiation therapy. In contrast, despite external radiation therapy, brain metastases proved fatal. Tamoxifen was ineffective in the estradiol receptor negative patient. Based on this report, it may be valuable to determine the presence of estradiol receptor protein in eccrine carcinoma as a predictor of response to hormonal therapy.

Sweat gland carcinoma with bone and visceral metastases. Prolonged complete remission lasting 16 months as a result of chemotherapy

Sweat gland carcinoma is a rare malignant tumor considered to be radio- and chemo-resistant. A case affecting a labium majorum recurred after surgical resection and was accompanied by bone and visceral metastases. After four cycles of combination chemotherapy consisting of doxorubicin, mitomycin C, vincristine and cisplatin, complete remission lasting 16 months and prolonged survival (50 months) were obtained. A review of the literature also is presented.