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October 2009

Slowly Enlarging Nodule on a Finger—Diagnosis

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Arch Dermatol. 2009;145(10):1183-1188. doi:10.1001/archdermatol.2009.216-b

A biopsy specimen demonstrated a multinodular dermal proliferation of tubuloalveolar and ductal structures with papillary projections into cystic spaces involving dermal and subcutaneous tissues. The basaloid cells demonstrated poor glandular differentiation with mild to moderate atypia and mitotic rate of 7 mitoses per 10 high-power fields. Some areas of necrosis were noted. Perineural or lymphatic invasion was not observed. The majority of the neoplastic cells labeled diffusely with AE1, AE3, and CAM 5.2 and focally with S-100 protein and epithelial membrane antigen. Carcinoembryonic antigen highlighted the glandular luminal cells. These findings were diagnostic of aggressive digital papillary eccrine adenocarcinoma. Differential diagnosis included an atypical syringocystadenoma papilliferum, eccrine acrospiroma, papillary eccrine adenoma, or metastatic adenocarcinoma. Magnetic resonance imaging further defined the lesion as a well-circumscribed, nonspecific, dermal and subcutaneous mass without any bony involvement. Metastatic disease was not identified on chest roentgenogram or positive electron transmission scan. Right index finger distal phalanx amputation and sentinel lymph node biopsy were performed. The amputated specimen revealed similar histological findings with negative surgical margins. Right axillary sentinel lymph node biopsy showed no microscopic evidence of metastasis. The patient has been followed up closely, and at 1 year after surgery, he shows no evidence of recurrence or metastases.