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Elderly woman with prior breast cancer presents with growing skin lesion
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The patient is an 87-year-old Caucasian female who was referred for a lesion in her right flank. She had noticed this lesion approximately 2 years ago. It started as a pimple and had slowly increased in size. Over the last few months, she has been having pain for which she initially took baby aspirin and currently takes acetaminophen, resulting in some improvement in her pain.
Past medical history is significant for left breast infiltrating ductal carcinoma — which was diagnosed 20 years ago — glaucoma and trigeminal neuralgia. She had undergone a total mastectomy for her breast cancer. She did not receive adjuvant chemotherapy or radiation. She had tried hormonal therapy for a couple of months but discontinued it due to side effects. The pathology of her initial breast cancer could not be obtained.
Her medications include carbamazepine, latanoprost eye drops and Tylenol PM. She has 20-pack year smoking history but quit 20 years ago. She lives alone in her house and is independent in all her activities. Her daughter lives in the same city and checks on her periodically.
Review of systems was significant for pain in the area of the skin lesion with not much improvement with Tylenol. On exam, a raised erythematous, fleshy lesion was seen on the right side of the abdomen along the mid axillary line approximately 3 x 2 cm in size. The lesion was fixed to the underlying rib. Her breast exam revealed no palpable masses on her right breast. Her left breast mastectomy site did not show any evidence of local recurrence. The rest of her exam was within normal limits.
She underwent a biopsy in early March and pathology was consistent with a moderately-differentiated dermal carcinoma that extends to the margins of resection. Pathologists said that this tumor could also represent a metastatic lesion (in particular, carcinoma of the breast can have this appearance). Immunostains for ER and PR were strongly positive (100%). She was felt to be a high-risk candidate for resection. Patient did not want to try radiation therapy or chemotherapy. Patient was also reluctant to take narcotic pain medications because of medication sensitivity. Patient was started on tamoxifen 20 mg daily, which she is tolerating well.
Case discussion
Eccrine sweat glands are one of the major sweat glands found in humans that are distributed over the entire body surface. They play an important role in temperature regulation. They are most dense on palms and soles and are innervated by sympathetic fibers.
Eccrine carcinomas are rare carcinomas of the sweat glands. They represent a mixed group of malignant eccrine tumors that may arise de novo or by malignant transformation of a pre-existing benign eccrine tumor. Clinically, they arise as a single, painless, firm nodular mass, reddish purple in color. Ulceration is uncommon. They have a slight female preponderance.
Eccrine carcinoma is chiefly a tumor of the elderly. They are mostly seen in patients older than 50 years. They are mostly within 2 cm to 3 cm in size, but can vary between 1 cm and 10 cm. These tumors show a preference to the head and neck area but cases have also been reported in the trunk and lower extremities. There are case reports of these tumors arising several years after radiation therapy, but in most cases the etiology is unknown.
Diagnosis of eccrine carcinoma is by histopathologic examination. They are formed of cohesive basaloid epithelial cells and show an invasive architectural pattern and significant cytologic pleomorphism with eccrine differentiation. The histology may vary considerably from well-differentiated papillary structures to undifferentiated tumors. Most tumors are recognizable as adenocarcinomas with remnants of sweat gland structures. Sweat gland carcinomas must be differentiated from other primary adenocarcinomas and metastatic breast adenocarcinomas.
Approximately 50% of sweat gland carcinomas are cured by wide local excision. Local recurrence is common and is seen in two-thirds of patients. The 5- and 10-year survival rates for patients with no lymph node involvement are 67% and 56%, respectively. Distant metastases occur in 50% of the cases and they are often fatal. These tumors are often resistant to chemotherapy or radiotherapy although there are case reports of response to chemotherapy. Radiation therapy has been used to palliate pain from bone metastases. There has been a case report of partial response and palliation of symptoms from use of tamoxifen in two patients.
Our patient is 87 years old and would not tolerate surgery or chemotherapy. She did not want radiation. Tamoxifen is a relatively nontoxic systemic therapy. Based on the case report of response to tamoxifen, it seems the most reasonable option for her because her tumor was strongly estrogen receptor positive.
She has a history of breast carcinoma 20 years ago; the estrogen receptor status of her initial breast cancer is unknown. Although isolated metastatic breast carcinoma of the skin is a possibility, the time interval between the original tumor and the metastasic lesion makes it less likely.
Although the patient is tolerating tamoxifen very well, it has yet to be seen if she will respond to the treatment.
Ramya Varadarajan, MD, is a consultant at Regional Hematology and Oncology PA, Helen Graham Cancer Center, Newark, Delaware. She reports no relevant financial disclosures.
For more information:
- Coonley CJ. Chemotherapy of metastatic sweat gland carcinoma. J Surg Oncol.1986;31:26-30.
- Sridhar KS. Response of eccrine adenocarcinoma to tamoxifen. Cancer. 1989:64:366-370.