Keywords
papillary carcinoma - cutaneous nodular lesion of nose
Introduction
The nose is an exposed and highly visible area of the face. Therefore, cutaneous lesions
of nose are very easily noticed by the patients themselves and other people. The high
concentration of sebaceous glands, increased ultraviolet radiation exposure, and genetic
abnormalities account for the various benign and malignant cutaneous lesions of the
nose such as rhinophyma, hemangioma, squamous cell carcinoma, melanoma, basal cell
carcinoma, etc.[1]
Papillary carcinoma, also known as digital papillary adenocarcinoma, is a rare tumor
of the sweat glands, which is mainly localized to the digits. The presence of such
a lesion in the face is very rare. Herein, we report a cutaneous nodular lesion on
the dorsum of the nose, which was surgically excised. On histopathological examination,
the patient was diagnosed with papillary carcinoma. The case is presented in view
of its rarity.
Case History
An 80-year-old female patient presented to the ENT OPD with a painless growth on the
dorsum of the nose since 2 years, which was insidious in onset. It was initially small
and had progressively increased to its present size. There was no history of trauma
or any other swelling in other parts of the body. There was no history of weight loss
or loss of appetite. On local examination, a large solitary, solid, irregular-shaped,
nodular, pinkish red colored growth was noted on the dorsum of the nose. The growth
was about 4 × 5 cm in size, nontender, firm in consistency, with well-defined edges,
had restricted mobility, and did not bleed on touch ([Fig. 1]). Anterior rhinoscopy examination did not reveal any abnormality. Diagnostic nasal
endoscopy was done, and no abnormalities were noted. Paranasal sinus examination was
within normal limits. There was no palpable lymphadenopathy. Rest of the ENT examination
was within normal limits. Preoperative blood investigations and chest X-ray were done,
and COVID-19 reverse transcriptase polymerase chain reaction (RTPCR) test was done,
which was negative. Wide excision of lesion was performed, taking a 1 cm healthy margin,
and primary closure was done. The excised specimen was sent for histopathology examination,
which gave a diagnosis of papillary carcinoma ([Figs. 2] and [3]). Patient was followed-up for 8 months ([Fig. 4]) and no recurrence was noted.
Fig. 1 Preoperative clinical picture.
Fig. 2 (40x hematoxylin and eosin [H&E]).
Fig. 3 (10x lower power hematoxylin and eosin [H&E]). Sections show a solid to cystic tumor
arranged in lobules with focal papillary projections. The tumor cells are highly pleomorphic,
oval to polygonal in shape with vesicular chromatin, and prominent nucleoli. Variable
amount of bubbly cytoplasm with vacuoles is seen. Focal areas of necrosis and lymphoid
aggregation is noted. The tumor is limited to surface and papillary dermis.
Fig. 4 Postoperative follow-up image at 8 months.
Discussion
Papillary carcinoma is a rare malignant tumor of sweat glands, which is usually located
on the digits. It is also known by the term digital papillary adenocarcinoma. It is
a rare neoplasm of the eccrine sweat gland cells.
The primary tumor commonly presents as a slow-growing solitary mass, usually between
the nail bed and distal interphalangeal joint.[2] There were few instances of cases being reported at unusual sites such as the lips
and ears[3].In our case, the lesion was also located at an atypical location on the dorsum of
nose, presenting as a nodular growth.
The tumor has an aggressive course in terms of local invasion, with a 14% chance of
metastasis.[2] The most common site for metastasis is lung, whereas lymph nodes, brain, skin, bones,
and kidneys are the other sites.[3] In our case, there were no finding of pulmonary metastasis on chest X-ray.
As the tumour has a high-recurrence rate, the recommended treatment is one of wide
local excision of the primary tumor, but no objective margin is defined in the literature.[2]
[4] There were few reports in which Mohs micrographic surgery was performed as excision
after punch biopsy[4]
[5] and as a reexcision procedure[6].
Sentinel node biopsy may be done for staging of the tumor to potentially identify
patients who may avail benefit of lymph node dissection thereafter[7]
[8]
There is no evidence available to support the use of positron emission tomography
(PET) imaging, chemotherapy, or radiotherapy.[2]
[8]
Confirmation of the diagnosis is by histopathology. The characteristic histologic
features include tubuloalveolar and ductal structures, with areas of papillary projections
protruding into cystic lumina. The stroma varied from thin fibrous septae to areas
of dense hyalinized collagen.
Close patient follow-up is recommended for all such cases of papillary carcinoma.
We have followed-up the case for 8 months and no recurrence has been noted.
Conclusion
Lesions such as papillary carcinoma are rare differential diagnosis of cutaneous lesions
on the dorsum of the nose but should always be kept in mind while evaluating such
lesions
