Slowly Growing, Ulcerating Nodule on the Posterior Ankle

DIAGNOSTIC DILEMMAS
TE
Slowly Growing, Ulcerating Nodule
on the Posterior Ankle
WOUNDS 2011;23(10):320–321
U
D
D
O
N
O
T
Address correspondence to:
Jennifer Powers, MD
Boston University School of
Medicine
Dept. of Dermatology
609 Albany St.
Boston, MA 02118
617-638-5500
jennifer.powers@bmc.org
A 34-year-old Haitian man presented with a 1-year history of a gradually enlarging, ulcerating nodule on the right posterior ankle that bled after trauma.
The patient denied any history of prior trauma at the site of the lesion and
foreign travel.There were no HIV risk factors or personal or family history of
skin cancer.The patient was otherwise healthy with no additional complaints.
Physical examination revealed a 1.4 cm firm, hyperpigmented nodule with
a yellow crateriform center on the right posterior ankle (Figure 1). A punch
biopsy was performed (Figures 2, 3).
Histopathologic examination revealed a superficial and mid-dermal, multinodular proliferation of bland epithelioid cells with occasional foci of ductal
differentiation embedded in a fibrotic stroma. Focal epidermal connection
and mucinous metaplasia were noted. Immunohistochemical stains revealed
diffuse positive staining of the lesional cells with cytokeratins (high and low)
and variable positivity with epithelial membrane antigen (EMA), as well as
negative S100P. Fungal, viral, and mycobacterial tissue cultures were negative
and RPR was non-reactive. Bacterial tissue culture was positive for Prevotella
oris and Staphylococcus aureus.
PL
From the Department of
Dermatology, Boston University
School of Medicine, Boston,
Massachusetts
Presentation
IC
A
Jennifer Gloeckner Powers, MD; Daniel D. Miller, MD;
Meera Mahalingam, MD; Tania J. Phillips, MD
320
Diagnosis
Clear cell hidradenoma (nodular hidradenoma [NHA]).
Discussion
Also known as eccrine acrospiroma, clear-cell hidradenoma, solid-cystic
hidradenoma and eccrine hidradenoma, NHA is commonly located on the
head, neck, or trunk, but, as noted here, can present on the lower extremities.
It typically appears in the fourth to the eighth decades of life as a solitary
dermal nodule up to 2 cm in diameter that may be cystic or ulcerative with
exudate.1–4 On dermoscopy, NHA is associated with amorphous whitish areas,
linear vessels, hairpin vessels, and reddish purple areas (corresponding to the
cystic spaces with hemorrhage evident histopathologically).1
Prototypic histopathological features of NHA, seen in the present case,
include a well-circumscribed dermal lobule, occasionally extending into the
subcutis, containing solid and cystic areas with foci of ductal differentiation
and “decapitation” secretion—the latter favoring the more recent view of
NHA being of apocrine histogenesis.5 The solid portions of the tumor may
WOUNDS www.woundsresearch.com
Diagnostic Dilemmas.indd 320
10/5/11 10:28 AM
Figure 2. At low power (4x), wellcircumscribed dermal lobules are
seen.
cer, and, in such cases, a biopsy is absolutely essential to
cinching the diagnosis.
PL
demonstrate a biphasic cellular population of uniform
polygonal clear cells with small dark eccentrically located
nuclei and small round cells with eosinophilic cytoplasm
and vesicular nuclei.6 The clear-cells are PAS-positive and
diastase-digestible, indicating their glycogen content.2 Immunohistochemical studies reveal positive staining of the
lesional cells for pancytokeratin, CEA, CAM5,2 and EMA.3
This case highlights a histologic variant of NHA, the mucinous hidradenoma, which has only been described in
isolated case reports.7,8
Though diagnosis of NHA can only be confirmed by
a biopsy, some reports indicate that duplex ultrasonography can successfully reveal the cystic features of this
entity prior to performing an invasive procedure.5,9 In addition, MRI has been used for surgical planning in particularly large lesions located over the knee or the ankle.3,4
Treatment with surgical excision results in extremely low
recurrence rates.3–5
Figure 3. At high power (40x), there
are solid and cystic areas with foci of
ductal differentiation and “decapitation” secretion, consistent with nodular hidradenoma.
IC
Figure 1. Hyperpigmented nodule with
a yellow crateriform center on the
right posterior ankle.
A
TE
Powers et al
References
N
O
T
D
U
1. Yoshida Y, Nakashima K, Yamamoto O. Dermoscopic features of clear cell hidradenoma. Dermatology.
2008;217(3):250–251.
2. Schweitzer WJ, Goldin HM, Bronson DM, Brody PE. Ulcerated tumor on the scalp. Arch Dermatol. 1989;125(7):987–
988.
3. Yu G, Goodloe S, D’Angelis CA, McGrath BE, Chen F. Giant clear cell hidradenoma of the knee. J Cutan Pathol.
2009;37(9):e37–41.
4. Collman DR, Blasko M, Alonzo J, Stess R. Clear cell hidradenoma of the ankle. J Foot Ankle Surg. 2007;46(5):387–
393.
5. Faulhaber D, Wörle B, Trautner B, Sander CA. Clear cell
hidradenoma in a young girl. J Am Acad Dermatol.
2000;42(4):693–695.
6. Ahmed TSS, Del Priore J, Seykora JT.Tumors of the Epidermal Appendages. In: Elder DE, ed. Lever’s Histopathology
of the Skin. 10th ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2009:852–900.
7. Goh SG, Carr R, Dayrit JF, Calonje E. Mucinous hidradenoma: a report of three cases. J Cutan Pathol.
2007;34(6):497–502.
8. Fitzgibbon JF,Googe PB.Mucinous differentiation in adnexal sweat gland tumors. J Cutan Pathol. 1996;23(3):259–
263.
9. Cho KE, Son EJ, Kim JA, et al. Clear cell hidradenoma of
the axilla: a case report with literature review. Korean J
Radiol. 2010;11(4):490–492.
Treatment
D
O
Because of the positive bacterial cultures, the patient
was given cephalexin (500 mg) by mouth three times
daily for 10 days. In this case, surgical excision was performed primarily to alleviate the patient’s symptoms. Patient has had no regrowth of the nodule at more than 16
months follow-up.
Conclusion
This case reminds clinicians of the entity of the nodular hidradenoma, a benign adnexal neoplasm, which does
not threaten life but which can require surgical management for patient discomfort. A neoplasm should always
be considered in the differential of any nonhealing ul-
Vol. 23, No. 10 October 2011
Diagnostic Dilemmas.indd 321
321
10/4/11 3:50 PM