Introduction

Patient information

- DOB: 16/01/1987 (35 years)

- Gender: Female

History

- Presenting complaint: mass in right buttock

Clinical findings

- Non-tender
- Soft lesion

Investigations

- Cystic lesion
- MRI: 5x3.7cm in dimention well-defined bilobed cystic lesion noted at site of the palpable lump
within the subcutaneous tissue in the right gluteal regions. Well-definied lesion with enhancing
intramural nodule, mixed features that do not suggest lipoma. Recommendation: correlation
with core biopsy
- Ultrasound: 4x3.6x2.8cm low erogenic cystic lesion extending from epidermal to subcutaneous
tissue with two soft tissue component within it, both show vascular channels. Recommendation:
hemorrhagic hemangioma with two feeding arteries

Treatment

- Complete excision: - well circumscribed, unencapsulated lobulated cystic mass with variably
sized nests and nodule of epithelial cells within the mid dermis. Fibrovascular hyalinized stroma
is noted. No mitosis or atypical features seens, no evidence of dysplasia or malignancy. Mass
5x5x3cm. Cyst attacged with skin measure 4x1.7cm, filled with mucinous material.
Discussion

Conclusion

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772521/ - 1

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1524-4725.1994.tb00155.x - 2

https://pubmed.ncbi.nlm.nih.gov/21993337/ - 3

https://pubmed.ncbi.nlm.nih.gov/19076620/ - 4

https://pubmed.ncbi.nlm.nih.gov/29079171/ - 5

https://www.karger.com/Article/FullText/489255 - 6

notes:

- Rare benign sweat gland tumour

- Common areas affected: head, neck, trunk, and extremities regions
- Occurs as solitary or cystic neoplasm
- Mostly females in 4-8th decade of life, most common in 6th decade
- Male to female ratio 1:2
- Physical examination: reddish multiobulated pedinculated fleshy mass, thickening of overlying
skin, mass freely mobile, non-compressible and non-pulsatile
- Differentials: achromic melanoma, lymphoma, lymphoma, squamous cell carcinoma, merkell cell
carcinoma, metastasis, hidroademoa, cutaneous cylindroma
- Investigations: incsisional biopsy to exclude malignant disease
- Histopathological examination: Consistent with nodular hidroadenoma - epithelial tumour
proliferation with solid and cystic components made of clear cells surrounded by myoepithelial
cells, trabecular structures. Rare cytonuclear atypia and mitosis patterns noted.
 - Therapeutic intervention: surgical intervention – elliptical excision with wide margins – follow
up: reevaluation in clinic 1 month after discharge, routine follow up 3, 6, and 12 months to
check for recurrence
- Conclusion – potential of aggressive behavior, wide surgical excision with appropriate margins to
prevent local recurrence, close follow up recommended

- Difficult to distinguish benign from malignant hidroadenoma, emphasizes the benefits of Mohs
surgery for large or recurrent tumours
- Suggested use of the Mohs micrographic surgery for recurrent or large hidroadenoma – access
can be difficult

- Usually clinically appears as small, solitary , nodular, superficial dermal lesion with intact
overlying skin
- Some tumours may exhibit ulceration on the surface or serous fluid leakage
- Many cases described with deceptively benign hisotlofical appearances, but aggressive behavior
which make difficult the distinction between hidradenocarcinoma and hidradenoma

- Grows slowly over a long period of time, but often experiences an accelerated growth phase
- Histological evaluation: anaplastic cells involving the epidermis and infiltrating the dermis
- Metastasis to regional lymph nodes distally occurs in significant number of cases – recently
sentinel lymph node biopsy has begun to be investigated as a staging tool
- Treatment modalities: standard excision, Mohs micrographic surgery (MMS), chemotherapy and
radiation therapy
- MSS has the greatest likelihood of clear margins and cure in absence of regional and distant
metastases

- Diagnosis occasionally difficult because it shares histological features with other cutaneous
appendage tumours
- CRTC1-MAML2 fusion gene recently reported in hidradenomas, with the fusion transcript being
demonstrate in approximately 50% of cases, however limited information is available regarding
 its clinical significance. 39 cases histologically diagnosed as hidradenoma were reviewed. CRTC1-
MAML2 fusion was detected in 10 out of 39 tumors (26%) and CRTC3-MAML2 fusion in 2 out of
the 39 cases (5%).
- Conclusion: CRT1/3-MAML2 fusion gene analysis can be a useful method for diagnosing
hidradenoma. Considering the histological and genetic similarity to mucoepidermoid carcinoma,
hidradenoma may be a cutaneous counterpart of salivary gland mucoepidermoid carcinoma

- Differentials: chronic expanding hematoma, hemangioma, schwannoma, benign skin tumours

- Histology: variable histomorphological patterns: clear cell hidradenoma, solid-cystic
hidroadenoma, clear cell acrospiroma, eccrine acropsiroma
- Changes in overlying skin: smooth, thickened, ulcerated, or blue/red coloured
- MRI features: well-circumscribed, lobulated, subcutaneous cystic or solid mass.
- PET/C T useful in differentiating malignant from benign lesions and for excluding distant
metastasis
- In this study PET/CT showed hypermetabolic activity in the small area of the lesion,
corresponding to the area of malignant transformation
- Treatment: most agreed upon conclusion for the treatment is wide local excision with negative
margins – wide local excision with at least 2-3cm advocated. If cannot be achieved because of
anatomical or functional conditions, Mohs micrographic surgery can be used.
- Prophylactic lymph node dissection has been reported, because of the high tendency for
regional lymph node metastasis – this aggressive approach controversial as long-term benefits
not clearly demonstrated – further studies required to determine if procedure results in survival
benefit or local control
- Radiotherapy can be considered by surgery is not feasible or negative surgical margins cannot
be achieved, but its impact is still debatable – some reports show radiation may have a role in
preventing local recurrence while in others, radio-resistance has been observed
- Importance of surgery has been established, however the role of loco-regional
lymphadenectomy and adjuvant therapy with radiotherapy or chemotherapy has yet to be fully
determined
- Strict follow up using MRI and PET/CT is warranted