Indian Journal of Dermatology
E–CASE REPORT
Year
: 2013  |  Volume : 58  |  Issue : 3  |  Page : 245-

Giant chondroid syringoma radiologically mimicking malignancy


Belkiz Uyar1, Aynur Solak2, Neslin Sahin2, Hüsnü Bugdayci3,  
1 Department of Dermatology, Sifa University, Fevzipasa Bulvar? Basmane, Izmir, Turkey
2 Department of Radiology, Sifa University, Fevzipasa Bulvar? Basmane, Izmir, Turkey
3 Department of Pathology, Sifa University, Fevzipasa Bulvar? Basmane, Izmir, Turkey

Correspondence Address:
Belkiz Uyar
Department of Dermatology, 35240, 172/2 Fevzipasa Bulvar? Basmane, Izmir
Turkey

Abstract

Chondroid syringoma, or mixed tumor of skin, is a relatively rare, usually benign sweat gland tumor, most often seen in the head-and-neck region. Rare malignant examples have been reported, commonly involving the extremities. We report here a case radiologically mimicking a malignant neoplasm, but histologically-proven benign subcutaneous chondroid syringoma, arising in the anterior aspect of the upper thigh of a 59-year-old male.



How to cite this article:
Uyar B, Solak A, Sahin N, Bugdayci H. Giant chondroid syringoma radiologically mimicking malignancy.Indian J Dermatol 2013;58:245-245


How to cite this URL:
Uyar B, Solak A, Sahin N, Bugdayci H. Giant chondroid syringoma radiologically mimicking malignancy. Indian J Dermatol [serial online] 2013 [cited 2019 Sep 22 ];58:245-245
Available from: http://www.e-ijd.org/text.asp?2013/58/3/245/110879


Full Text

 Introduction



Chondroid syringoma is a relatively rare, benign, skin appendage tumor. The head and neck regions are common sites where intra-dermal or subcutaneous firm nodules of 0.5-3 cm are found. [1]

Although its histological findings are well-described, the radiological features of chondroid syringoma have been reported in only few cases.

 Case Report



A 59-year-old man presented with a painless mass on the anterior aspect of the upper thigh with a slow enlargement over the past 5 years [Figure 1]. Dermatological examination showed a relatively firm, mobile 5 × 3 cm nodule covered by normal skin. The patient was otherwise healthy. Laboratory studies including complete blood count, erythrocyte sedimentation rate (ESR), urine analysis, aspartate aminotransferase (AST), alanine aminotransferase (ALT), blood urea, creatinine were normal. The findings were suggestive of lipoma or liposarcoma. Sonographic examination revealed mixed, echogenic solid mass measuring approximately 4.5 × 3 × 2 cm. On Doppler ultrasound, there were vessels predominantly at the periphery of the mass. Magnetic resonance images (MRI) revealed a 4.7 × 2.9 × 2.2 cm, well-circumscribed, lobular mass that showed heterogeneous enhancement predominantly in the peripheral portion of the mass after intravenous contrast administration [Figure 2]. Diffusion-weighted imaging (DWI) showed areas of increased signal intensity that were indicative of a highly cellular tumor [Figure 3]. According to the MRI findings, we considered benign subcutaneous lipomatous tumors with cystic and solid components such as angiolipoma or fibrolipoma or well-circumscribed low-grade soft tissue liposarcoma without surrounding tissue extension in our differential diagnosis. Because the vascularity of the lesion and heterogeneous pattern with contrast enhancement on MRI examination, we excluded lipoma.{Figure 1}{Figure 2}{Figure 3}

We decided to perform trucut biopsy. Histopathological examination revealed a group of cells, which have eosinophilic cytoplasm and regular small nuclei, exhibited epithelial-like pattern in the myxoid stroma. Many of the properties were lipomatous. However, as adipocytes were variable in size and focally showed a lipoblast-like appearance, some tumor areas were reminiscent of a well-differentiated lipoma-like liposarcoma [Figure 4].{Figure 4}

The patient underwent surgical excision of the mass. Histologically, the tumor was confined to the subcutaneous tissue. The adjacent tissue appeared normal. There were irregular epithelial nests and tubuloalveolar structures in a chondromyxoid stroma. There was also abundant fibrolipomatous stroma. There were foreign body reactions against the epidermoid cysts within the tumor and surrounding tissue. There were no atypical mitoses or necrosis [Figure 5]a and b.{Figure 5}

 Discussion



Chondroid syringoma is a relatively rare, benign, skin appendageal tumor. The head and neck regions are common sites; less commonly, axillary region, hand, foot, abdomen, penis, vulva, scrotum can be involved. [1],[2]

Chondroid syringoma usually presents as a solitary, asymptomatic, intracutaneous or subcutaneous nodule, mainly seen in middle-aged or older males. [2],[3] The size is usually between 0.5 and 3 cm, but it may be very large. [2],[3] Most chondroid syringomas are benign with a slow progression over years. [4] In our case, the mass enlarged slowly over 5 years. Malignancy in CS is rare. [4],[5] Malignant lesions are usually larger than 3 cm, but benign one measuring 10 cm is also reported. [4]

Histologically, a wide variety of structures may be found in chondroid syringoma of skin. Eccrine types have multiple small syringoid elements and are rich in mucin. In the apocrine type, lesions have follicular or sebaceous elements as well as larger dilated branching glanduler elements. The mesenchymal component can show chondroid differentiation or even metaplastic ossification. [6] In our case, there was abundant lipomatous stroma that made diagnostic difficulty in radiological imaging and histopathological examination.

Previous case reports have described the MR imaging findings of benign and malignant chondroid syringomas. [7],[8],[9] Although the MR imaging appearance of chondroid syringoma is relatively non-specific, MR imaging generally may allow characterization of the origin of tissue components in the tumor and depiction of the extent and relationships of the lesion to adjacent structures. In our case, the signal intensity characteristics of the lesion (heterogeneous lesion of mixed fat and fluid-like intensity), while not specific for chondroid syringoma, allowed for some analysis of the consistency of the tumor.

The benign neoplasms of the subcutaneous tissue that may have similar appearances with our case include superficial lipoma and variants of lipoma (angiolipoma, myolipoma, spindle-cell and pleomorphic lipoma, chondroid lipoma, and hibernoma). Although subcutaneous in location, superficial lipoma consists entirely of fat, unlike our lesion. Variants of lipoma are commonly heterogeneous and include more than one type of tissue, which may be fat, muscle, chondroid matrix, vascular elements, or myxoid tissue with calcification and hemorrhage. [4],[10] Due to the presence of vascular channels on Doppler examination, angiolipoma was considered in our case.

The malignant tumors that may bear similar characteristics with mixed tumor of the skin include well-differentiated liposarcoma, myxoid liposarcoma, extraskeletal myxoid chondrosarcoma, myxofibrosarcoma, and malignant peripheral nerve sheath tumors. [10]

After tru-cut biopsy, we considered many of the above entities in the differential diagnosis. But excisional biopsy allowed definitive diagnosis of chondroid syringoma based on the morphological features. There were no cytologic atypia, increased mitotic figures, tumor necrosis, or infiltrative margins, thus excluding malignant chondroid syringoma.

The mixed fat and fluid-like signal intensity lesion of skin is somewhat of a diagnostic enigma due to its non-specific imaging and histologic presentation. Clearly a soft tissue lesion of mixed fat and fluid-like signal intensity, as in this case, while not pathognomonic for chondroid syringoma, allows for a limited differential diagnosis. As this case shows, chondroid syringoma should be included in the differential diagnosis of a slowly growing, nodular heterogeneous mass in the skin or subcutaneous tissue. Final diagnosis, however, requires careful histopathologic examination.

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