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taken to surgery.
The patient was placed prone on the operating table with her chest supported by bolsters, her head supported on a Mayfield horseshoe head rest and the mass supported on a Mayo stand. The head and mass were shaved and prepped. An initial elliptical incision was made 4 cm from the base of the stalk and exposed a subcutaneous high pressure arteriovenous network with no fewer than 5 large feeding vessels. This same pattern was demonstrated in each quadrant around the stalk and precluded obtaining proximal control.
Alternatively, 3 rubber shod Kelly clamps were placed around the stalk. Two were placed most proximal to the scalp and 1 placed approximately 2 cm distal to that. The lesion and most distal Kelly clamp was then resected with a scalpel blade. The middle clamp was opened, the skin retracted and the vessels treated with vascular clips and suture ligatures. The most proximal clamp was removed and without the need for further hemostasis the scalp was oversewn leaving a 1.5 cm stalk. The patient was transferred to her room in stable condition. A three week follow up demonstrated a well healed involuted stump.
The pathology specimen weighing 1227 grams revealed a flat yellow granular surface with scattered areas of hemorrhagic necrosis on multiple cut sections. Histology sections exhibited irregular islands of tumor cells with cystic spaces amount a dense fibrous stroma of
basaloid cells. In some areas the solid cords extended from the cystic spaces, giving the appearance of tadpoles. The chords were one or more cells thick and composed of small uniformed, hyperchromatic nuclei with an eosinophilic and very infrequent vacuolated cytoplasm. There were areas of mitosis and nuclear and cytoplasmic pleomorphism. There was no keratinization, however, perineural invasion was present. The tumor infiltrated the dermis and subcutaneous tissue (fig 3). It is not known whether there was periosteal invasion of the skull. The stalk did not contain tumor free margins and no further biopsy was done after the initial operation. There was the presence of periodic acid Schiff (PAS) positive, diastase resistant granules and phosphorylase and succinic dehydrogenase with indicated that the tumor was eccrine in origin.
DISCUSSION
There are several pathological reviews of carcinoma of the sweat glands (1-5) and even fewer cases of eccrine epithelioma (6-9). The lack of rigid criteria and unusual occurrence have led the lesions to be classified as different entities i.e. adenoma, epithelioma and carcinoma. Since general classification appears multiple it is not surprising that the differentiation of each classification should be confusing. It is not in the scope of this paper to present such criteria.
Clinically, eccrine epithelioma occurs in the elderly, has a predilection for the scalp and upper limb, a female predominance (Continued on page 57)
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