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Mucinous carcinoma of the skin
Mucinous carcinoma of the skin Darius J. Karimipour, MD, a Timothy M. Johnson, MD, a, b Sewon Kang, MD, a Timothy S. Wang, MD, a and Lori Lowe, MD a, c Ann Arbor, Michigan Primary mucinous carcinoma of the skin is a rare adnexal neoplasm with sweat gland differentiation. We describe a case of primary mucinous carcinoma of the skin and characterize its clinical and histologic features. Mucinous carcinoma can occur in noncutaneous visceral sites and may metastasize to the skin. Thus it is important to exclude the possibility of a noncutaneous visceral primary tumor before diagnosing primary mucinous carcinoma of the skin. (J Am Acad Dermatol 1996;34:323-6.)
Primary mucinous carcinoma of the skin is a rare adnexal neoplasm, presumably of eccrine origin. 1-3 Since the disease was first described by Lennox et al.,4 74 cases have been reported in the English language literature.l-28 We describe a case of primary mucinous carcinoma of the skin and review its clinical and histologic features.
CASE REPORT
A 54-year-old white woman had a 3-year history of a slowly growing, nontender lesion on the scalp. Examination revealed a blue-gray, firm, translucent nodule 2.2 cm x 1.6 cm, on the right side of the parietal-occipital SCalp.
Examination of a biopsy specimen demonstrated numerous small islands of epithelial tumor cells "floating" in lakes of slightly basophilic mucin. The tumor cells contained centrally located, round to oval, slightly hyperchromatic nuclei with eosinophilic cytoplasm. Cytoplasmic vacuoles were occasionally noted. In focal areas, a cribriform pattern was apparent. Ductule lumina formations were also present, but rare, within tumor islands. Mitotic figures were absent. Thin fibrous septa separated the large pools of mucin (Figs. 1 and 2). These features are characteristic of mucinous carcinoma.
ORTHO
This article is made possible through an educational grant from the Dermatological Division, Ortho Pharmaceutical Corporation.
From the Departments of Dermatology, a Otorhinolaryngology and Surgery (Plastic Surgery), b and Pathologyf University of Michigan, Ann Arbor. Reprint requests: Timothy M. Johnson, MD, University of Michigan, Deparlment of Dermatology, 1910-0314 Tanbman Center, Ann Arbor, MI 48109. Copyright © 1996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0 16/4/75398
The lesion was excised with a 1 cm margin through the galea aponeurotica to the periosteum. The margins were free of tumor. Further evaluation showed no evidence of malignant disease elsewhere. The patient had no recurrence after 9 months. DISCUSSION
Primary mucinous carcinoma of the skin is a rare adnexal neoplasm with sweat gland differentiation. The average age at occurrence is 61 years (range, 8 to 84 years). The incidence in men is twice that in women. The tumor has been observed in whites (62%), blacks (34%), and Asians (4%). The eyelid (44%) is the most common site, followed by the face (21%), scalp (15 %), axilla (8%), chest (5%), and foot (4%). Primary mucinous carcinoma has also occurred on the neck (1%) and abdomen (1%), and in the inguinal region (1%). The average tumor is 2.0 cm in diameter (range, 0.4 cm to 12 cm). 1-2s The clinical characteristics of primary mucinous carcinoma vary. Typically, it is a small, nontender, flesh-colored, subcutaneous or cutaneous nodule. The tumor has also been described as ulcerating, tender, lobulated, pink, tan, or blue, with or without telangiectases. The most frequent preoperative diagnoses reported include epidermoid cyst, sebaceous carcinoma, cystic basal cell carcinoma, squamous cell carcinoma, neuroma, lacrimal sac tumor, and pilomatricoma.ll, 25 On average, patients note the neoplasm 3 years before they report it to a physician (range, 2 weeks to 20 years). Primary mucinous carcinoma of the skin has distinctive histologic, histochemical, and ultrasmactural features. Hematoxylin and eosin-stained sections display delicate fibrovascular trabeculae that enclose 323
324
Journal of the American Academy of Dermatology February 1997
Karimipour et aL
i
Fig. 1. Primary mucinous carcinoma with numerous small tumor islands floating in pools of mucin. (Hematoxylin-eosin stain; x40.)
Fig. 2. Epithelial tumor island cells contain uniform oval nucleus and focally vacuolated cytoplasm. Note ductal lumina formation. (Hematoxylin-eosin stain;
x400.) pools of pale-staining mucin. Small, irregularly shaped clusters of tumor cells form islands within the mucin. The tumor cells have a centrally placed, round to cuboidal nucleus and an eosinophilic, occasionally vacuolated cytoplasm. Mitoses are uncommon. Ductule lumina may be present. Metastatic mucinous adenocarcinoma may be histologically indistinguishable from primary mucinous carcinoma. Histochemically, the tumor produces an acid mucopolysaccharide with a characteristic staining pattern. The results of alcian blue staining are positive at pH 2.4 and negative at pH 0.4.1, 3 Mucicarmine stain and the colloidal iron reaction also have positive results. The mucin is sensitive to digestion with sialidase but is resistant to diastase and hyaluronidase. These results are consistent with the presence of sialomucin. Enzyme histochemistry reveals strongly positive reactions with succinate dehydrogenase and phosphorylase, consistent with eccrine differentiation. 1 Primary mucinous carcinoma has
been reported to stain for low molecular cytokeratin, S-100 protein, and carcinoembryonic antigen. 2s Carson et al. 28 speculated that this neoplasm may arise from an apocrine structure or that eccrine ducts may undergo apocrine metaplasia. These hypotheses were based on two cases that demonstrated positive staining for both oL-lactalbumin and gross cystic disease fluid protein-15. Ultrastmcturally, primary mucinous carcinoma demonstrates three cell types in the rumor islands: a peripheral dark cell with secretory vesicles, presumably containing sialomucin; a central and less well-differentiated pale cell with fewer secretory vesicles; and an intermediate cell. 1 The neoplasm has a tendency for slow growth, local recurrence, and infrequent metastasis. 1-3,23 Recurrence developed at least once after tumor excision in 19 (28%) of the 67 cases suitable for analysis. Multiple recurrences are not uncommon. 3, 23
Journal of the American Academy of Dermatology Volume 36, Number 2, Part 2
Most authors recommend surgical excision to treat primary mucinous carcinoma of the skin. 8' 13, 23, 25 Surgical margins were indicated for only 4 of the 75 cases reported, including ours. These margins ranged from 0.3 cm (one case) to 1.0 cm (three cases). 1°, 13 Neither recurrence nor metastasis occurred in these four cases after 9 months to 3 years. Radiotherapy and chemotherapy appear ineffective in treating primary mucinous carcinoma and its metastases. 27 Metastases developed in 8 of the 75 cases (11%) of primary mucinous carcinoma. 2' 3, 7,17, 19,20, 26, 27 This incidence is relatively low compared with that for sweat gland carcinoma, which has a reported metastatic rate approaching 50%. 13 In seven of the eight cases, the cancer metastasized solely to nearby regional lymph nodes, z' 3, 7, 17, 19, 20, 26, 27 In the remaining case, there was metastasis to sites distant from the primary tumor. 27 Of the eight tumors that metastasized, three (38%) were located in the axilla, three (38%) had a period of rapid growth before metastasis, and two (25%) had an ulcerated primary tumor. The primary tumor had been present from 2 months to 12 years before metastasizing. The high degree of cellular differentiation, intercellular cohesion, mucin production, and avascularity may contribute to the relatively low metastatic rate. 1,2, 13 Careful follow-up consisting of a review of systems and physical examination with attention to regional lymph nodes is recommended. The patient should also be taught the importance of monthly lymph node self-examination. Mucinous adenocarcinoma may also occur in other sites, including breast, 29,3° gastrointestinal tract,3v33 ovary,34, 35 lung,36,37 and prostate. 38 Hence, the possibility that the primary tumor is at another site should be considered, to exclude the possibility of metastatic mucinous carcinoma before a diagnosis of primary mucinous carcinoma of the skin is made. REFERENCES
1. Headington JT. Primary mucinous carcinoma of skin. Histochemistry and electron microscopy. Cancer 1977;39: 1055-63. 2. Mendoza S, Helwig EB. Mucinous (adenocystic) carcinoma of the skin. Arch Dermatol 1971;103:68-78. 3. Wright JD, Font RL. Mucinous sweat gland adenocarcinoma of eyelid. A clinicopathologic study of 21 cases with histochemical and electron microscopic observations. Cancer 1979;44:1757-68. 4. Lennox B, Pearse AGE, Richards HGH. Mucin-secreting tumors of the skin: with special reference to the so-called mixed-salivary tumour of the skin and its relation to hidradenoma. J Pathol Bacteriol 1952;64:865-80.
Karimipour et al.
325
5. Baandrup U, Sogaard H. Mucinous (adenocystic) carcinoma of the skin. Dennatologica 1982;164:338-42. 6. Balin AK, Fine RM, Golitz LE. Mucinous carcinoma. J Dermatol Surg Oncol 1988;14:521-4. 7. Berg JW, McDivitt RW. Pathology of sweat gland carcinoma. Pathol Annu 1968;3:123-44. 8. Cohen KL, Peiffer RL, Lipper S. Mucinous sweat gland adenocarcinoma of the eyelid. Am J Ophthalmol 1981; 92:183-8. 9. Eckert F, Schmid U, Hardmeier T, et al. Cytokeratin expression in mucinous sweat gland carcinomas: an immunohistochemical analysis of four cases. Histopathology 1992;21:161-5. 10. Fukamizu H, Tomita K, Inoue K, et al. Primary mucinous carcinoma of the skin. J Dermatol Surg Oncol 1993; 19:625-8. 11. Gardner TW, O'Grady RB. Mucinous adenocarcinoma of the eyelid. Arch Ophthalmol 1984;102:912. 12. Geraci TL, Jenkinson S, Janis L, et al. Mucinous (adenocystic) sweat gland carcinoma of the great toe. J Foot Surg 1987;26:520-3. 13. Grossman JR, Izuno GT. Primary mucinous (adenocystic) carcinoma of the skin. Arch Dermatol 1974;110:274-6. 14. Katoh N, Hirano S, Hosokawa Y, et al. Mucinous carcinoma of the skin: report of a case with DNA cytofluorimetric study. J Dermatol 1994;21:117-21. 15. Kavanagh GM, Rigby HS, Archer CB. Giant primary mucinous sweat gland carcinoma of the scalp. Clin Exp Dermatol 1993; 18:375-7. 16. Mehregan AH, Hashimoto K, Rahbari H. Eccrine adenocarcinoma: a clinicopathologic study of 35 cases. Arch Dennatol 1983;119:104-14. 17. Metz J, Filipp N, Metz G. Mucinoses Carcinom der Ekkrinen Schweissdrusen. Z Hautkr 1974;49:963-74. 18. Miller WL. Sweat gland carcinoma: a clinicopathologic problem. Am J Clin Pathol 1967;47:767-80. 19. Pilgrim JP, Wolfish PS, Kloss SG, et al. Primary mucinous carcinoma of the skin with metastases to the lymph nodes. Am J Dermatopathol 1985;7:461-9. 20. Rao KV, Tikku I, Kapur BML, et al. Invasive primary mucinous carcinoma of the skin. Int Surg 1978;63:16870. 21. Rodriguez MM, Lubowitz RM, Shannon GM. Mucinous (adenocystic) carcinoma of the eyelid. Arch Ophthalmol 1973;89:493-4. 22. Sanke RF. Primary mucinous adenocarcinoma of the eyelid. Ophthalmic Surg 1989;20:668-71. 23. Santa-Cruz DJ, Meyers JH, Gnepp DR, et al. Primary mucinous carcinoma of the skin. Br J Dermatol 1978;98:64553. 24. Thomas JW, Fu YS, Levine MR. Primary mucinous sweat gland carcinoma of the eyelid simulating metastatic carcinoma. Am J Ophthalmol 1979;87:29-33. 25. Weber PJ, Hevia O, Gretzula JC, et al. Primary mucinous carcinoma. J Dennatol Surg Oncol 1988;14:170-2. 26. Wolfe JJ, Segerberg LH. Metastasizing sweat gland carcinoma of the scalp involving the Wansverse sinus. Am J Surg 1954;88:849-51. 27. Yeung KY, Stinson JC. Mucinous (adenocystic) carcinoma of sweat glands with widespread metastasis: case report with ultrasmactural study. Cancer 1977;39:2556-62. 28. Carson HJ, Guttuso P, Raslan WF, et al. Mucinous carcinoma of the eyelid: an immunohistochemical study. Am J Dermatopathol 1995;17:494-8. 29. Azzopardi JG. Problems relating to certain histological types of carcinoma. In: Azzopardi JG, editor. Problems
326
30.
31.
32. 33. 34.
Joumal of the American Academy of Dermatology February 1997
Karimipour et al.
in breast pathology. London: WB Saunders, 1979:286301. Coady AT, Shousa S, Dawson PM, et al. Mucinous carcinoma of the breast: further characterization of its three subtypes. Histopathology 1989;15:617-26. McGinnis GO. Adenocarcinoma of the stomach with calcification: a case report. Gastroenterology 1960;39: 90-3. Symonds DA, Vickery AL. Mucinous carcinoma of the colon and rectum. Cancer 1976;37:1891-1900. Adachi Y, Mori M, Kido A, et al. A cfinicopathologic study of mucinous gastric carcinoma. Cancer 1992;69:866-71. Watkin W, Silva EG, Gershenson DM. Mucinous carci-
35.
36. 37.
38.
noma of the ovary: pathologic prognostic factors. Cancer 1992;69:208-12. Malloy JJ, Dockerty MB, Welch JS, et al. Papillary ovarian tumors. I. Benign tumors and serious and mucinous cystadenocarcinomas. Am J Obstet Gynecol 1965;93:867-79. Reid JD. Adenoid cystic carcinoma (cylindroma) of bronchial tree. Cancer 1952;5:685-94. Graeme-Cook F, Mark EJ. Pulmonary mucinous cystic tumors of borderline malignancy. Hum Pathol 1991 ;22:18590. Lee DW, Ro JY, Sahin AA, et al. Mucinous adenocarcinoma of the prostate with endobronchial metastasis. Am J Clin Pathol 1990;95:641-5.
Primary mucinous carcinoma of the skin is a rare adnexal neoplasm, presumably of eccrine origin. 1-3 Since the disease was first described by Lennox et al.,4 74 cases have been reported in the English language literature.l-28 We describe a case of primary mucinous carcinoma of the skin and review its clinical and histologic features.
CASE REPORT
A 54-year-old white woman had a 3-year history of a slowly growing, nontender lesion on the scalp. Examination revealed a blue-gray, firm, translucent nodule 2.2 cm x 1.6 cm, on the right side of the parietal-occipital SCalp.
Examination of a biopsy specimen demonstrated numerous small islands of epithelial tumor cells "floating" in lakes of slightly basophilic mucin. The tumor cells contained centrally located, round to oval, slightly hyperchromatic nuclei with eosinophilic cytoplasm. Cytoplasmic vacuoles were occasionally noted. In focal areas, a cribriform pattern was apparent. Ductule lumina formations were also present, but rare, within tumor islands. Mitotic figures were absent. Thin fibrous septa separated the large pools of mucin (Figs. 1 and 2). These features are characteristic of mucinous carcinoma.
ORTHO
This article is made possible through an educational grant from the Dermatological Division, Ortho Pharmaceutical Corporation.
From the Departments of Dermatology, a Otorhinolaryngology and Surgery (Plastic Surgery), b and Pathologyf University of Michigan, Ann Arbor. Reprint requests: Timothy M. Johnson, MD, University of Michigan, Deparlment of Dermatology, 1910-0314 Tanbman Center, Ann Arbor, MI 48109. Copyright © 1996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0 16/4/75398
The lesion was excised with a 1 cm margin through the galea aponeurotica to the periosteum. The margins were free of tumor. Further evaluation showed no evidence of malignant disease elsewhere. The patient had no recurrence after 9 months. DISCUSSION
Primary mucinous carcinoma of the skin is a rare adnexal neoplasm with sweat gland differentiation. The average age at occurrence is 61 years (range, 8 to 84 years). The incidence in men is twice that in women. The tumor has been observed in whites (62%), blacks (34%), and Asians (4%). The eyelid (44%) is the most common site, followed by the face (21%), scalp (15 %), axilla (8%), chest (5%), and foot (4%). Primary mucinous carcinoma has also occurred on the neck (1%) and abdomen (1%), and in the inguinal region (1%). The average tumor is 2.0 cm in diameter (range, 0.4 cm to 12 cm). 1-2s The clinical characteristics of primary mucinous carcinoma vary. Typically, it is a small, nontender, flesh-colored, subcutaneous or cutaneous nodule. The tumor has also been described as ulcerating, tender, lobulated, pink, tan, or blue, with or without telangiectases. The most frequent preoperative diagnoses reported include epidermoid cyst, sebaceous carcinoma, cystic basal cell carcinoma, squamous cell carcinoma, neuroma, lacrimal sac tumor, and pilomatricoma.ll, 25 On average, patients note the neoplasm 3 years before they report it to a physician (range, 2 weeks to 20 years). Primary mucinous carcinoma of the skin has distinctive histologic, histochemical, and ultrasmactural features. Hematoxylin and eosin-stained sections display delicate fibrovascular trabeculae that enclose 323
324
Journal of the American Academy of Dermatology February 1997
Karimipour et aL
i
Fig. 1. Primary mucinous carcinoma with numerous small tumor islands floating in pools of mucin. (Hematoxylin-eosin stain; x40.)
Fig. 2. Epithelial tumor island cells contain uniform oval nucleus and focally vacuolated cytoplasm. Note ductal lumina formation. (Hematoxylin-eosin stain;
x400.) pools of pale-staining mucin. Small, irregularly shaped clusters of tumor cells form islands within the mucin. The tumor cells have a centrally placed, round to cuboidal nucleus and an eosinophilic, occasionally vacuolated cytoplasm. Mitoses are uncommon. Ductule lumina may be present. Metastatic mucinous adenocarcinoma may be histologically indistinguishable from primary mucinous carcinoma. Histochemically, the tumor produces an acid mucopolysaccharide with a characteristic staining pattern. The results of alcian blue staining are positive at pH 2.4 and negative at pH 0.4.1, 3 Mucicarmine stain and the colloidal iron reaction also have positive results. The mucin is sensitive to digestion with sialidase but is resistant to diastase and hyaluronidase. These results are consistent with the presence of sialomucin. Enzyme histochemistry reveals strongly positive reactions with succinate dehydrogenase and phosphorylase, consistent with eccrine differentiation. 1 Primary mucinous carcinoma has
been reported to stain for low molecular cytokeratin, S-100 protein, and carcinoembryonic antigen. 2s Carson et al. 28 speculated that this neoplasm may arise from an apocrine structure or that eccrine ducts may undergo apocrine metaplasia. These hypotheses were based on two cases that demonstrated positive staining for both oL-lactalbumin and gross cystic disease fluid protein-15. Ultrastmcturally, primary mucinous carcinoma demonstrates three cell types in the rumor islands: a peripheral dark cell with secretory vesicles, presumably containing sialomucin; a central and less well-differentiated pale cell with fewer secretory vesicles; and an intermediate cell. 1 The neoplasm has a tendency for slow growth, local recurrence, and infrequent metastasis. 1-3,23 Recurrence developed at least once after tumor excision in 19 (28%) of the 67 cases suitable for analysis. Multiple recurrences are not uncommon. 3, 23
Journal of the American Academy of Dermatology Volume 36, Number 2, Part 2
Most authors recommend surgical excision to treat primary mucinous carcinoma of the skin. 8' 13, 23, 25 Surgical margins were indicated for only 4 of the 75 cases reported, including ours. These margins ranged from 0.3 cm (one case) to 1.0 cm (three cases). 1°, 13 Neither recurrence nor metastasis occurred in these four cases after 9 months to 3 years. Radiotherapy and chemotherapy appear ineffective in treating primary mucinous carcinoma and its metastases. 27 Metastases developed in 8 of the 75 cases (11%) of primary mucinous carcinoma. 2' 3, 7,17, 19,20, 26, 27 This incidence is relatively low compared with that for sweat gland carcinoma, which has a reported metastatic rate approaching 50%. 13 In seven of the eight cases, the cancer metastasized solely to nearby regional lymph nodes, z' 3, 7, 17, 19, 20, 26, 27 In the remaining case, there was metastasis to sites distant from the primary tumor. 27 Of the eight tumors that metastasized, three (38%) were located in the axilla, three (38%) had a period of rapid growth before metastasis, and two (25%) had an ulcerated primary tumor. The primary tumor had been present from 2 months to 12 years before metastasizing. The high degree of cellular differentiation, intercellular cohesion, mucin production, and avascularity may contribute to the relatively low metastatic rate. 1,2, 13 Careful follow-up consisting of a review of systems and physical examination with attention to regional lymph nodes is recommended. The patient should also be taught the importance of monthly lymph node self-examination. Mucinous adenocarcinoma may also occur in other sites, including breast, 29,3° gastrointestinal tract,3v33 ovary,34, 35 lung,36,37 and prostate. 38 Hence, the possibility that the primary tumor is at another site should be considered, to exclude the possibility of metastatic mucinous carcinoma before a diagnosis of primary mucinous carcinoma of the skin is made. REFERENCES
1. Headington JT. Primary mucinous carcinoma of skin. Histochemistry and electron microscopy. Cancer 1977;39: 1055-63. 2. Mendoza S, Helwig EB. Mucinous (adenocystic) carcinoma of the skin. Arch Dermatol 1971;103:68-78. 3. Wright JD, Font RL. Mucinous sweat gland adenocarcinoma of eyelid. A clinicopathologic study of 21 cases with histochemical and electron microscopic observations. Cancer 1979;44:1757-68. 4. Lennox B, Pearse AGE, Richards HGH. Mucin-secreting tumors of the skin: with special reference to the so-called mixed-salivary tumour of the skin and its relation to hidradenoma. J Pathol Bacteriol 1952;64:865-80.
Karimipour et al.
325
5. Baandrup U, Sogaard H. Mucinous (adenocystic) carcinoma of the skin. Dennatologica 1982;164:338-42. 6. Balin AK, Fine RM, Golitz LE. Mucinous carcinoma. J Dermatol Surg Oncol 1988;14:521-4. 7. Berg JW, McDivitt RW. Pathology of sweat gland carcinoma. Pathol Annu 1968;3:123-44. 8. Cohen KL, Peiffer RL, Lipper S. Mucinous sweat gland adenocarcinoma of the eyelid. Am J Ophthalmol 1981; 92:183-8. 9. Eckert F, Schmid U, Hardmeier T, et al. Cytokeratin expression in mucinous sweat gland carcinomas: an immunohistochemical analysis of four cases. Histopathology 1992;21:161-5. 10. Fukamizu H, Tomita K, Inoue K, et al. Primary mucinous carcinoma of the skin. J Dermatol Surg Oncol 1993; 19:625-8. 11. Gardner TW, O'Grady RB. Mucinous adenocarcinoma of the eyelid. Arch Ophthalmol 1984;102:912. 12. Geraci TL, Jenkinson S, Janis L, et al. Mucinous (adenocystic) sweat gland carcinoma of the great toe. J Foot Surg 1987;26:520-3. 13. Grossman JR, Izuno GT. Primary mucinous (adenocystic) carcinoma of the skin. Arch Dermatol 1974;110:274-6. 14. Katoh N, Hirano S, Hosokawa Y, et al. Mucinous carcinoma of the skin: report of a case with DNA cytofluorimetric study. J Dermatol 1994;21:117-21. 15. Kavanagh GM, Rigby HS, Archer CB. Giant primary mucinous sweat gland carcinoma of the scalp. Clin Exp Dermatol 1993; 18:375-7. 16. Mehregan AH, Hashimoto K, Rahbari H. Eccrine adenocarcinoma: a clinicopathologic study of 35 cases. Arch Dennatol 1983;119:104-14. 17. Metz J, Filipp N, Metz G. Mucinoses Carcinom der Ekkrinen Schweissdrusen. Z Hautkr 1974;49:963-74. 18. Miller WL. Sweat gland carcinoma: a clinicopathologic problem. Am J Clin Pathol 1967;47:767-80. 19. Pilgrim JP, Wolfish PS, Kloss SG, et al. Primary mucinous carcinoma of the skin with metastases to the lymph nodes. Am J Dermatopathol 1985;7:461-9. 20. Rao KV, Tikku I, Kapur BML, et al. Invasive primary mucinous carcinoma of the skin. Int Surg 1978;63:16870. 21. Rodriguez MM, Lubowitz RM, Shannon GM. Mucinous (adenocystic) carcinoma of the eyelid. Arch Ophthalmol 1973;89:493-4. 22. Sanke RF. Primary mucinous adenocarcinoma of the eyelid. Ophthalmic Surg 1989;20:668-71. 23. Santa-Cruz DJ, Meyers JH, Gnepp DR, et al. Primary mucinous carcinoma of the skin. Br J Dermatol 1978;98:64553. 24. Thomas JW, Fu YS, Levine MR. Primary mucinous sweat gland carcinoma of the eyelid simulating metastatic carcinoma. Am J Ophthalmol 1979;87:29-33. 25. Weber PJ, Hevia O, Gretzula JC, et al. Primary mucinous carcinoma. J Dennatol Surg Oncol 1988;14:170-2. 26. Wolfe JJ, Segerberg LH. Metastasizing sweat gland carcinoma of the scalp involving the Wansverse sinus. Am J Surg 1954;88:849-51. 27. Yeung KY, Stinson JC. Mucinous (adenocystic) carcinoma of sweat glands with widespread metastasis: case report with ultrasmactural study. Cancer 1977;39:2556-62. 28. Carson HJ, Guttuso P, Raslan WF, et al. Mucinous carcinoma of the eyelid: an immunohistochemical study. Am J Dermatopathol 1995;17:494-8. 29. Azzopardi JG. Problems relating to certain histological types of carcinoma. In: Azzopardi JG, editor. Problems
326
30.
31.
32. 33. 34.
Joumal of the American Academy of Dermatology February 1997
Karimipour et al.
in breast pathology. London: WB Saunders, 1979:286301. Coady AT, Shousa S, Dawson PM, et al. Mucinous carcinoma of the breast: further characterization of its three subtypes. Histopathology 1989;15:617-26. McGinnis GO. Adenocarcinoma of the stomach with calcification: a case report. Gastroenterology 1960;39: 90-3. Symonds DA, Vickery AL. Mucinous carcinoma of the colon and rectum. Cancer 1976;37:1891-1900. Adachi Y, Mori M, Kido A, et al. A cfinicopathologic study of mucinous gastric carcinoma. Cancer 1992;69:866-71. Watkin W, Silva EG, Gershenson DM. Mucinous carci-
35.
36. 37.
38.
noma of the ovary: pathologic prognostic factors. Cancer 1992;69:208-12. Malloy JJ, Dockerty MB, Welch JS, et al. Papillary ovarian tumors. I. Benign tumors and serious and mucinous cystadenocarcinomas. Am J Obstet Gynecol 1965;93:867-79. Reid JD. Adenoid cystic carcinoma (cylindroma) of bronchial tree. Cancer 1952;5:685-94. Graeme-Cook F, Mark EJ. Pulmonary mucinous cystic tumors of borderline malignancy. Hum Pathol 1991 ;22:18590. Lee DW, Ro JY, Sahin AA, et al. Mucinous adenocarcinoma of the prostate with endobronchial metastasis. Am J Clin Pathol 1990;95:641-5.