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Siringoma de vulva: una presentacion inusual. Aspectos clinicos, histopatologicos e inmunohistoquimicos.

Syringoma of vulva: an unusual presentation. Clinical, morphological and immunohistochemnical aspects.

INTRODUCTION

Syringoma is a benign adnexal tumor derived from intraepitelial sweat gland ducts, which occur at puberty or at midlife (1). Their occurrence is twice more common in women than men. However, further lesions can develop later in life, and reported cases range between the first and sixth decades of life (2, 3). Syringoma mainly appears on the periorbital area, especially at the lower eyelids and malar areas (1); it may also be found on the scalp, forehead, neck, anterior chest, upper abdomen and extremities (3-5). The lesions usually are bilateral and symmetrically distributed (6). Clinically, syringomas appear as small, multiple, firm, skin-colored-to-yellowish papules, 1 to 3 mm in diameter (2).

Syringoma on the genital area is a rare condition in females and males with only few vulvar cases reported in the literature to date (7). Vulvar syringoma mostly occurrs in young women after puberty (8). Some patients report pruritus during the menstrual period (8).

The aim of this report was to describe the clinical, histopathological and immunohistochemical features of one case of vulvar syringoma.

CASE

A 34-years-old woman consulted her gynecologist because she observed the appearance of numerous yellow-white asymptomatic papules on the vulva. The patient noted that the papules began to show up 10 months before. The only symptom that she reported was an increase of sweating in the external genitals.

Gynecological examination showed multiple skin-colored, discrete, asymptomatic, firm papules distributed symmetrically on the labia majora. The size of the lesions varied from 1 mm to 3 mm. Some papules were coalesced or grouped together forming conglomerations of 0.5 to 1 cm, involving both labia majora as shown in figure 1a. Also, flesh-colored and tiny papules were observed on her lower eyelids and on the front part of her neck (Figs. 1b and 1c).

A skin biopsy was taken from a typical lesion or papule on the labia majora for histological and immunohistochemical studies.

Paraffin block obtained from the skin biopsy of the lesion on the labia majora was cut with a microtome. The 4[micro], sections obtained were stained with haematoxylineosin and analyzed under a light microscope (Leica DM 100). Additional sections were cut for immunohistochemistry. Deparaffinization and rehydration of tissue sections were done with xylene and graded alcohol series, respectively. After microwave heat-pre-treatment in the high pH target retrieval solution (Dako, Denmark), slides were immersed in 0.3% [H.sub.2][O.sub.2] for 20 minutes to block the endogenous peroxidase activity. After washing, slides were incubated for 1 hour at room temperature with monoclonal antibodies against: 1. Wide spectrum cytokeratin, clone AE1/AE3

(Dako, Denmark) at a dilution of 1:100; 2. Cytokeratin 7 (CK 7), clone OV-TL (Dako, Denmark) at a dilution of 1:50; 3. Carcino-embryonic antigen (CEA), clone II-7 (Dako, Denmark) at a dilution of 1:50; and 4. p53 protein, clone DO-7 (Dako, Denmark) at a dilution of 1:100. The two-step visualization system EnVision[TM] and diaminobenzidine (DAB) chromogenic (both from Dako, Denmark) were used to visualize the immunohistochemistry reaction.

Histological examination showed small sweat duct-like glandular and solid epithelial nests embedded in a fibrotic stroma in the dermis, many of them had the characteristic tadpole configuration of a syringoma (Fig. 2a). Fig. 2b showed two types of cells within the tumor or cyst small cuboidal cells, typical ductal epithelium with eccentrically located nuclei, and a distinct second population of cells with clear, vacuolated cytoplasm. Some ducts contained amorphous secretion within the lumen. Many tumor cells had abundant periodic acid, Schiff-positive cytoplasm, suggesting accumulation of glycogen.

The immunohistochemical staining was positive to wide spectrum of antigens: cytokeratin, cytokeratin 7 and carcinoembryonic antigen (CEA) (Figs. 3a and 3b). It was negative to P53 staining as it shows in Fig. 3c.

DISCUSSION

Syringoma was first described by Kaposi and Biesiadeki in 1874 as Lymphangioma Tuberosum Multiplex (9). As it was mentioned previously, the syringoma is a benign adnexal tumor derived from the intraepithelial eccrine duct. It may present as single or multiple papules, predominantly in women at puberty or later in life, commonly involving the face, especially the eyelids, in 0.6% of the population (1). There is an increased frequency of this tumor among oriental females, patients with Down's Syndrome and diabetes mellitus, especially the clear-cell syringoma (2, 10, 11). Although there are reports in the literature describing families with a history of this disease (2, 12, 13). Syringomas are typically non-regressing and asymptomatic lesions (14). The clinical diagnosis of syringoma is confirmed by the histopathological examination of a biopsy of the lesion. Monoclonal antikeratin antibody tests, electron microscopy, and immunohistochemical tests confirmed the intraepidermal eccrine gland nature of this disease (2, 12).

The first vulvar syringoma was reported by Carneiro et al in 1972(15). Vulvar syringoma is mainly found in women during their reproductive years, less common during adolescence and very rare in elder patients, up to the sixth decade (2, 8, 16, 17). Huang et al. (8) believe that vulvar syringoma is not very rare and may be underreported; since it is not recognized by patients and clinicians (2, 16). Because vulvar syringoma has been described in association with extragenital lesions, examination of the rest of the body, especially the eyelids and malar areas, is necessary when a suspected vulvar syringoma is found. Likewise, examination of the vulvar area is mandatory when a syringoma is found outside the genital area (2, 8).

Commonly, vulvar syringoma is asymptomatic. However, they can produce vulvar pruritus (18, 19). Huang et al. (8) reported vulvar pruritus in 72% of their cases, seven cases experienced aggravated pruritus during the summer time or during the menstrual period. This case did not have any difference with other reported cases in the literature except that our patient did not have vulvar pruritus, but she mentioned to have increased sweating in the vulvar area.

The clinical differential diagnosis for vulvar syringoma is broad and should exclude such diseases as epidermal cyst, steatocystoma multiplex, lymphangioma circumstriptum, chronic lichen simplex, angiokeratoma in Fox-Fordyce disease, senile angioma, condyloma acuminatum, candidiasis, scabies, pediculosis, allergic and irritant contact dermatitis, psoriasis and lichen sclerosus et atrophicus (2, 7, 8, 19-21).

It has been hypothesized that the growth of the syringoma is under hormonal influence, based on observations that they increase in size during pregnancy, menstrual period, use of oral contraceptives, and during puberty (22). However, the reports are controversial. Wallace and Smoller (22) demonstrated the positive staining of progesterone receptor (PR) expression in eight of nine cases of extragenital syringoma. Huang et al. (8) did not find positive staining of PR and estrogen receptor (ER) expression in syringoma and peripheral vulvar tissue. Also Tarver et al. (23) did not detect ER nor PR on the vulvar syringoma. These results suggested that the syringoma was not under estrogen o progesterone control or regulated by them (8). The immunohistochemical study in this case, using markers of sweat gland tumors, such as CK7 and CEA showed the same result than in previous reports (24, 25).

There are few cases of vulvar syringoma reported in Latin-American (21, 26, 27). As far as we know, after we reviewed and investigated the literature, this is the first case ever reported in Venezuela.

Treatment of syringoma may not be necessary, but when they are symptomatic, surgery is the preferred method (17), and it is often performed on visible areas of the body for cosmetic reasons (2). Surgical methods of treating vulvar syringoma include local excision, cryotherapy, electrosurgery and carbon dioxide laser therapy. Medical therapy is unsuccessful. Therapies with steroids did not improve syringoma (2, 22).

In conclusion, vulvar syringoma usually occurs as a multiple flesh-colored or brownish papules on both sides of labia majora of women in their third decade, it is not rare and it is usually underreported. Its diagnosis should be considered when the patient complains of vulvar pruritus and sweating.

REFERENCES

(1.) Elder D, Elenitsas R, Ragsdale BD. Tumors of the epidermal appendages. In Elder D, Elenitsas R, Jawoorsky C, Johnson B Jr, editors. Lever's histopathology of the skin. Philadelphia: Lippincott-Raven; 1997, p: 778-779.

(2.) Miranda JJ, Shahabi S, Salih S, Bahtiyar OM. Vulvar syringoma, report of a case and review of the literature. Yale J Bio Med 2002; 207-210.

(3.) Van Den Boek H, Lundquist CD. Syringomas of the upper extremities with the onset in the sixty decade. J Am Acad Dermatol 1982; 6:534-536.

(4.) Shelley WB, Wood MG. Occult syringomas of scalp associated with progressive hair loss. Arch Dermatol 1980; 116:843-844.

(5.) Tagami H, Inoue F, Yamada M, Egami K. Syringoma of the forehead. Int J Dermatol 1983; 22:113-114.

(6.) Thomas J, Majmudar B, Gorelkin L. Syringoma localized to the vulva. Arch Dermatol 1979; 115:95-96.

(7.) Dereli T, Turk BG, Kazandi AC. Syringomas of the vulva. Int J Gynaecol Obstet 2007; 99(1):65-66.

(8.) Huang YH, Chuang YH, Kuo T, Yang LCh, Hong HS. Vulvar syringoma: A clinicopathological and immunohistologic study of 18 patients and results of treatment. J Am Acad Dermatol 2003; 48(5):735-739.

(9.) Kaposi M. Hebra diseases of the skin. Lynphangioma tuberosum multiplex. London. The New Syndedham Society. 1874: 3:386.

(10.) Schepis C, Siragusa M, Palazzo R, Ragusa RM, Masi G, Fabrizi G. Palpebral syringomas and Down's syndrome. Dermatology 1994; 189:248-250.

(11.) Furue A, Hori Y, Nakabayashi Y. Clear-cell syringoma. Association with diabetes mellitus. Am J Dermopathol 1984; 6: 131-138.

(12.) Hasimoto K, Gross BG, Lever WF. Syringoma: histochemical and electron microscopy studies. J Invest Dermatol 1966; 46:150-166.

(13.) Young AW, Herman EW, Tovell HM. Syringoma of the vulva: incidence, diagnosis and cause of pruritus. Obstet Gynecol 1980; 55(4):515-518.

(14.) Ghatt HJ, Proia AD, Tsoy EA. Malignant syringoma of the eyelid. Ophthalmology 1984; 91:987-989.

(15.) Carneiro SJ, Gardner HL, Knox JM. Syringoma: three cases with vulvar involvement. Obstet Gynecol 1972; 39:95-99.

(16.) Tay YK, Tham SN, Teo R. Localized vulvar syringoma-an unusual cause of prurite vulvae. Dermatology 1996; 92:62-63.

(17.) Spitzer M. Home study course: Winter 2008. J Low Genital Tract Dis 2008; 12(1):59-61.

(18.) Perez- Bustillos A, Ruiz-Gonzalez I, Delgado S, Alonso T, Ingelmo J. Siringomas Vulvares: una causa infrecuente de prurito vulvar. Actas Dermosifiliorg 2008; 99: 580-581.

(19.) Vilavella M, Bassas-Vila J, Perez-Ochoa J. Siringomas en la vulva: una causa de prurito vulvar persistente. Piel (Barc) 2012; Doi:10.1016/jpiel.2011.11.016.

(20.) Lee JH, Chang JY, Lee KH. Syringoma: a clinocopathologic and immunohistologic study and results of treatment. Yonsei Med J 2007; 48:35-40.

(21.) Tapia O, Kam S, San Martin R. Siringoma vulvar: reporte de un caso y revision de la literatura. Int J Morphol 2012; 30(3):924-926.

(22.) Wallace ML, Smoller BR. Progesterone receptor positivity supports hormonal control of syringomas. J Cutan Pathol 1995; 22:442-445.

(23.) Trager JD, Silvers J, Reed JA, Scott RA. Neck and vulvar papules in an 8 year-old girl. Arch Dermot 1999; 135:203-206.

(24.) Demirkesen C, Hoede N, Moll R. Epithelial markers and differentiation in adnexal neoplasms of the skin: an immunohistochemical study including individual cytokeratins. J Cutan Pathol 1995; 22(6): 518-535.

(25.) Kim BC, Park EJ, Kwon IH, Cho HJ, Park HR, Kim KH, Kim KJ. An immunohistochemical study of the origin of the solid strand in syringom, using carcinormbryonic antigen, epithelial membrane antigen, and cytokeratin 5. Int J Deramtol 2012; 51(7):817-822.

(26.) Ramos C, Quijano E, Carayhua D, Jimenez H, Rivera A. Siringomas vulvar y palpebral en madre e hija. Dermatol Peru 2011; 21(2):76-78.

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Recibido: 10-02-2014 Aceptado: 12-06-2014

Jose Nunez-Troconis [1,2] and Maria Elena Vilorta de Alvarado [3].

[1] department of Obstetricia and Ginecologia, Manuel Noriega Trigo Hospital. Maracaibo, Venezuela.

[2] Facultad de Medicina, Universidad del Zulia. Maracaibo, Venezuela.

[3] Laboratorio de Inmunohistoquimica y Patologia Molecular, Clinica D'Empaire. Maracaibo, Venezuela.

Coresponding author: Jose Nunez-Troconis. Apartado Postal 525. Codigo Postal 4001-A Maracaibo. Venezuela. Office Phone: 58-261-793-6093; Cell Phone: 58-414-361-5015. E-mail jtnunezt@gmail.com

Caption: Fig. 1. a.- Vulvar syringoma: multiple papulas on labia major; b.- Syringoma: multiple papulas on the lower eyelids c.- Syringoma: multiples papulas on the front part of the neck. Arrows show the papules.

Caption: Fig. 2. a.- Tubal structures lined by rows of epthelial cells of contain colloid material in their lumina (thin arrow) and ductal structures in characteristic tadpole configuration (HE, x100); b.- Presence of many vacuolated cells in ductular portion of the tumor (thick arrow) (HE, X200).

Caption: Fig. 3. a.- Immunohistochemical staining for Cytokeratin 7 positive (200X- arrow); b.- Immunohistochemical staining for CEA positive(200X-arrow); c.- Immunohistochemical staining for P53 negative(200X).
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Author:Nunez-Troconis, Jose; Vilorta de Alvarado, Maria Elena
Publication:Investigacion Clinica
Date:Mar 1, 2015
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