SkIndia Quiz 14: Solitary painful skin-colored nodule over the chest.

A 25-year-old gentleman presented with a solitary painful mass on the right side of the lower chest for 3 years. There was no itching or history of bleeding from the lesion, neither any history of local trauma or other associated lesions. His past history and family history was unremarkable. On examination, a solitary, sharply demarcated, skin-colored, 0.5 Χ 1.5 cm, tender small nodule, soft-to-firm in consistency with smooth surface was found [Figure 1]. His general and systemic examination was normal with no lymphadenopathy. Histopathological examination was done. Under low power [Figure 2], single sharply defined bluish lobulated mass in the dermis was appreciated. Higher magnification image [Figure 3] showed intertwining epithelial cords. In addition, masses composed of granular eosinophilic material lined by two varieties of cells was also found. The cells close to center of the lobule comprised of large pale-colored nuclei and those toward the periphery had small darker nuclei.

Figure 1

Reddish brown, oval-shaped indurated nodule at the right lateral chest (close-up view)

Figure 2

Single, sharply defined, bluish encapsulated mass in the dermis (H and E, ×40)

Figure 3

Intertwining cords of epithelial cells and multiple ductal lumina containing pink granular material, surrounded by epithelial cells having large pale nuclei at the luminal side and dark small nuclei at the periphery (H and E, ×100)

ANSWER

Eccrine spiradenoma

DISCUSSION

Clinical diagnosis of some painful skin tumors is quite challenging. Nine unique tumors should be considered, the mnemonic being “BLEND AN EGG”-Blue rubber bleb naevus, Leiomyoma, Eccrine spiradenoma, Neuroma, Dermatofibroma, Angiolipoma, Neurilemmoma, Endometrioma, Glomus tumor, and Granular cell tumor.[1] Very rare worldwide, spiradenomas are among the painful tumors of the skin with characteristic histopathological findings, initially elaborated by Kersting and Helwig.[2] It is clinically characterized as a solitary, gray, pink, or blue firm, rounded, dermal nodule of 3-50 mm size, aptly called “blue balls in the dermis.”[1] Relatively uncommon, it appears mainly in young adults (15-35 years), equally in both sexes and is rarely familial.[2]

The lesions tend to arise on the head, neck, trunk, and less commonly on arms and legs. Rarely, malignant transformation has been reported. Spiradenomas can occur in Brooke-Spiegler syndrome, the defective gene being CYLD gene on chromosome 9, and manifests with cylindromas, spiradenomas, and trichoepitheliomas. In fact, spiradenomas and cylindromas can occur together commonly in the same patient.[3]

Biopsy helps in ruling out diagnosis. Treatment is surgical removal. Debulking with bipolar scissors prior to laser therapy is beneficial in surgical removal of large tumors.[4]