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Conjunctival apocrine fibroadenoma
COS 2012 CORRESPONDENCE Conjunctival apocrine fibroadenoma A 27-year-old female presented with a 2-month history of a small black lesion on the left lower lid below the tarsal conjunctiva. She had undergone bilateral photorefractive keratectomy previously, and her visual acuity was 20/20 in both eyes. The ophthalmologist favoured a diagnosis of a cyst or a foreign body, although a melanocytic lesion could not be excluded. Because the lesion was thought to be growing and she had a family history of melanoma, it was excised.
HISTOPATHOLOGY The specimen consisted of 2 pieces of tan-brown tissue measuring 1.0 and 1.5 mm. The smaller piece consisted of normal tarsus and overlying conjunctival epithelium. The second was a nodule of loose myxoid tissue containing bland spindle cells. This was covered by an epithelial layer 2 cells thick, which in places formed papillae, suggesting it might be part of a cyst wall (Fig. 1). From the surface there were epithelial downgrowths into the stroma, which formed ductular structures with an outer myoepithelial layer and an inner cuboidal layer showing apocrine differentiation (Fig. 2). Some apocrine snouts were also seen on the surface epithelium. There was no mitotic activity in either the epithelium or stroma. Histochemical studies revealed periodic acid Schiff (PAS)-positive, diastase-resistant granules in the apical cytoplasm of the epithelial cells, consistent with apocrine differentiation. The luminal cells expressed epithelial membrane antigen (EMA) and gross cystic disease fluid protein (GCDFP) (Fig. 3), both characteristic markers of apocrine epithelium, in the cytoplasm and estrogen receptor (ER) and progesterone receptor (PR) in the nuclei. The abluminal layer expressed smooth muscle actin and p63, consistent with myoepithelium. The lesion was reported as an apocrine fibroadenoma (AFA) arising in conjunctiva.
Fig. 1 — Nodule of myxoid tissue with papillary excrescences on surface. Ductal epithelium, possibly lining a cyst, covers the surface and forms downgrowths into the stroma. Hematoxylin and eosin stain.
less common. They are typically located in the anogenital region of young females, but some cases have been reported in facial skin.1 A subcutaneous AFA has been described in the medial upper eyelid of a 45-year-old female.2 This formed a painless white papule, 5 mm across, that fluctuated in size and had been present for much of her life. Another AFA on the bridge of the nose occurred in a 75-year-old male.3 Our case occurred in a young woman but is unique in that it appears to have arisen beneath the epithelium of the palpebral conjunctiva where apocrine glands are not encountered. Proliferation and metaplasia of local epithelial elements or evolution of the lesion from ectopic epithelial nests could explain the phenomenon. The apocrine nature of the fibroadenoma was confirmed by the presence of apocrine snouts on the surface of the epithelium, as well as the presence of PAS-positive granules in the apical cytoplasm, and the expression of
DISCUSSION The commonest apocrine lesion of periocular skin is the cystadenoma (hidrocystoma). If large, this may present clinically as a bluish nodule, as a result of the Tyndall effect. The black colour of the conjunctival fibroadenoma may reflect the fact that the lesion appeared to be partly cystic (Fig. 1), and because of the apocrine secretions, its contents would behave as a colloidal solution and display the Tyndall effect. The myxoid stroma of the fibroadenoma may also have behaved as a colloidal solution. Other cutaneous apocrine tumours, for example, syringocystadenoma papilliferum, are considerably less common than the cystadenoma. AFAs of the skin, which contain glandular and stromal elements that mimic fibroadenoma of the breast, are even
Fig. 2 — Ductal structures lined by epithelial cells with surface apocrine snouts (arrows) and abluminal myoepithelial layer. Hematoxylin and eosin stain. CAN J OPHTHALMOL — VOL. 48, NO. 1, FEBRUARY 2013
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COS 2012 Correspondence shows apocrine features. Benign mixed tumours have been described in accessory lacrimal glands and ectopic subconjunctival lacrimal gland tissue.4
J. Godfrey Heathcote, Babak Maleki, Noreen M. Walsh Dalhousie University, Halifax, N.S. Correspondence to: J. Godfrey Heathcote, FRCPC: [email protected]
REFERENCES
Fig. 3 — Expression of gross cystic disease fluid protein by apocrine epithelium (immunoperoxidase).
EMA and GCDFP. The expression of ER and PR in the epithelial cells was surprising, because these receptors are not expressed in normal apocrine epithelium. It may reflect the sex of the patient: ER and PR were not expressed in the fibroadenoma of facial skin described by Liu et al.,3 but that patient was male. The principal differential diagnosis in our case is a benign mixed tumour, in which the epithelium often
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CAN J OPHTHALMOL — VOL. 48, NO. 1, FEBRUARY 2013
1. Van der Putte SCJ. Mammary-like glands of the vulva and their disorders. Int J Gyn Pathol. 1994;13:150-60. 2. Pantanowitz L, Lyle S, Tahan SR. Fibroadenoma of the eyelid. Am J Dermatopathol. 2002;24:225-9. 3. Liu H-N, Chang Y-T, Chen C-C, Yang A-H. Facial apocrine fibroadenoma in man: a rare finding. Am J Dermatopathol. 2007;29: 274-278. 4. Patyal S, Banarji A, Bhadauria M, Gurunadh VS. Pleomorphic adenoma of a subconjunctival ectopic lacrimal gland. Indian J Ophthalmol. 2010;58:245-7.
Can J Ophthalmol 2013;48:69–70 0008-4182/13/$-see front matter & 2013 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2012.11.014
HISTOPATHOLOGY The specimen consisted of 2 pieces of tan-brown tissue measuring 1.0 and 1.5 mm. The smaller piece consisted of normal tarsus and overlying conjunctival epithelium. The second was a nodule of loose myxoid tissue containing bland spindle cells. This was covered by an epithelial layer 2 cells thick, which in places formed papillae, suggesting it might be part of a cyst wall (Fig. 1). From the surface there were epithelial downgrowths into the stroma, which formed ductular structures with an outer myoepithelial layer and an inner cuboidal layer showing apocrine differentiation (Fig. 2). Some apocrine snouts were also seen on the surface epithelium. There was no mitotic activity in either the epithelium or stroma. Histochemical studies revealed periodic acid Schiff (PAS)-positive, diastase-resistant granules in the apical cytoplasm of the epithelial cells, consistent with apocrine differentiation. The luminal cells expressed epithelial membrane antigen (EMA) and gross cystic disease fluid protein (GCDFP) (Fig. 3), both characteristic markers of apocrine epithelium, in the cytoplasm and estrogen receptor (ER) and progesterone receptor (PR) in the nuclei. The abluminal layer expressed smooth muscle actin and p63, consistent with myoepithelium. The lesion was reported as an apocrine fibroadenoma (AFA) arising in conjunctiva.
Fig. 1 — Nodule of myxoid tissue with papillary excrescences on surface. Ductal epithelium, possibly lining a cyst, covers the surface and forms downgrowths into the stroma. Hematoxylin and eosin stain.
less common. They are typically located in the anogenital region of young females, but some cases have been reported in facial skin.1 A subcutaneous AFA has been described in the medial upper eyelid of a 45-year-old female.2 This formed a painless white papule, 5 mm across, that fluctuated in size and had been present for much of her life. Another AFA on the bridge of the nose occurred in a 75-year-old male.3 Our case occurred in a young woman but is unique in that it appears to have arisen beneath the epithelium of the palpebral conjunctiva where apocrine glands are not encountered. Proliferation and metaplasia of local epithelial elements or evolution of the lesion from ectopic epithelial nests could explain the phenomenon. The apocrine nature of the fibroadenoma was confirmed by the presence of apocrine snouts on the surface of the epithelium, as well as the presence of PAS-positive granules in the apical cytoplasm, and the expression of
DISCUSSION The commonest apocrine lesion of periocular skin is the cystadenoma (hidrocystoma). If large, this may present clinically as a bluish nodule, as a result of the Tyndall effect. The black colour of the conjunctival fibroadenoma may reflect the fact that the lesion appeared to be partly cystic (Fig. 1), and because of the apocrine secretions, its contents would behave as a colloidal solution and display the Tyndall effect. The myxoid stroma of the fibroadenoma may also have behaved as a colloidal solution. Other cutaneous apocrine tumours, for example, syringocystadenoma papilliferum, are considerably less common than the cystadenoma. AFAs of the skin, which contain glandular and stromal elements that mimic fibroadenoma of the breast, are even
Fig. 2 — Ductal structures lined by epithelial cells with surface apocrine snouts (arrows) and abluminal myoepithelial layer. Hematoxylin and eosin stain. CAN J OPHTHALMOL — VOL. 48, NO. 1, FEBRUARY 2013
69
COS 2012 Correspondence shows apocrine features. Benign mixed tumours have been described in accessory lacrimal glands and ectopic subconjunctival lacrimal gland tissue.4
J. Godfrey Heathcote, Babak Maleki, Noreen M. Walsh Dalhousie University, Halifax, N.S. Correspondence to: J. Godfrey Heathcote, FRCPC: [email protected]
REFERENCES
Fig. 3 — Expression of gross cystic disease fluid protein by apocrine epithelium (immunoperoxidase).
EMA and GCDFP. The expression of ER and PR in the epithelial cells was surprising, because these receptors are not expressed in normal apocrine epithelium. It may reflect the sex of the patient: ER and PR were not expressed in the fibroadenoma of facial skin described by Liu et al.,3 but that patient was male. The principal differential diagnosis in our case is a benign mixed tumour, in which the epithelium often
70
CAN J OPHTHALMOL — VOL. 48, NO. 1, FEBRUARY 2013
1. Van der Putte SCJ. Mammary-like glands of the vulva and their disorders. Int J Gyn Pathol. 1994;13:150-60. 2. Pantanowitz L, Lyle S, Tahan SR. Fibroadenoma of the eyelid. Am J Dermatopathol. 2002;24:225-9. 3. Liu H-N, Chang Y-T, Chen C-C, Yang A-H. Facial apocrine fibroadenoma in man: a rare finding. Am J Dermatopathol. 2007;29: 274-278. 4. Patyal S, Banarji A, Bhadauria M, Gurunadh VS. Pleomorphic adenoma of a subconjunctival ectopic lacrimal gland. Indian J Ophthalmol. 2010;58:245-7.
Can J Ophthalmol 2013;48:69–70 0008-4182/13/$-see front matter & 2013 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2012.11.014