Journal of Cancer Therapy, 2013, 4, 1091-1094
http://dx.doi.org/10.4236/jct.2013.46125 Published Online August 2013 (http://www.scirp.org/journal/jct) 1091
Photodynamic Therapy as Palliative Therapy for Invasive
Syringoid Eccrine Carcinoma of the Auricle: A Case Report
Claudia Gutiérrez Gómez1*, AnailAlvarez2, Ana Lilia Ruelas2, Ixchel Landgrave2,
Alfonso Vallarta3, Laura Andrade3
1Department of Plastic and Reconstructive Surgery, Medica Sur Hospital, México City, México; 2Dermatology Department, Medica
Sur Hospital, México City, México; 3Plastic Surgery Department, Medica Sur Hospital, México City, México.
Received May 9th, 2013; revised June 12th, 2013; accepted June 20th, 2013
Copyright © 2013 Claudia Gutiérrez Gómez et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Recurrent eccrine syringomatous carcinoma is an extremely rare adnexal tumor predominantly found in the head and
neck region. We present a case of a 75-year-old woman with a 7-year history of recurrent syringoid eccrine carcinoma
in the scalp and auricle. She had undergone five previous oncologic resections and declined further oncologic ablation
of the auricle, including temporal bone and external ear canal resection. We performed five sessions of palliative photo-
dynamic therapy using topical aminolevulinic acid HCL 20% (ALA) and between 25 and 33 pulses of Intense Pulsed
Light (Quantum) with an intensity of 30 Joules. The ALA incubation time was 3 hours, while the time between each
session was 4 weeks. This treatment helped to control ulceration, pain, and swellin g. We saw the patient 1 month after
the last treatment, by that time she moved and we lost contact.
Keywords: Syringoid Eccrine Carcinoma; Photodynamic Therapy
1. Introduction
Syringoid Eccrine carcinoma (SEC) is a very rare tumor.
It is very locally invasive, destructive, and is often recur-
rent. It was originally described as a basal cell tumor
with eccrine differentiation in 1969 [1].
SEC differs from basal cell carcinoma in its cytology
and enzymatic patterns. Histologically, SEC resembles
syringoma in its ductal, cystic, and comma-like ep ithelial
components. It differs from syringoma in its cellularity,
anaplasia, and deep invasiveness [2].
According to the Cru z Modified Classification System,
SEC is also known as a basal cell tumor with eccrine dif-
ferentiation, adenocarcinoma of the eccrine sweat gland,
syringealhidradenoma, atypical syringoma, sweat gland
carcinoma with syringomatous features, eccrinebasalio-
ma and eccrine syringomatous carcinoma. With a predi-
lection for the scalp, it clinically resembles basal cell
carcinoma and tends to histologically invade beyond its
gross margins [3].
The tumor presents itself in patients ranging from 1 to
86 years of age, with most cases occurring in the fifth to
seventh decades of life. Overall, these tumors occur
equally in both sexes, althou gh certain subtypes appear to
have a predilection for males or females. Most sweat
gland carcinomas grow slowly, with patients frequently
having a delayed presentation of 5 years or more. Lym-
phatic metastasis typically occurs at a rate of 20% to
24%. Regional cutaneous metastasis and hematogenous
spread have also been noted. Local recurrence occurs in
14% to 20% of cases [4]. Most patients survive beyond
10 years and usually die of another cause, although nota-
ble exceptions of death within 6 months of diagnosis due
to metastasis to the lymph nodes and lungs have been
reported.
Wide local excision and evaluation of lymph node bi-
opsy or regional lymphadenectomy samples are recom-
mended. Radiotherapy is reserved for recurrence or me-
tastatic lymph node involvement [5]. Chemotherapy is
not commonly used, although administration of trastu-
zumab has been reported in a metastatic tumor with Her-
2/neu gene amplifi ca t ion [6].
2. Case Report
A 75-year-old female patient developed a small (<1 cm)
tumor in the right temporoparietal scalp that had been
*Corresponding a uthor.

Photodynamic Therapy as Palliative Therapy for Invasive Syringoideccrine Carcinoma of the Auricle: A Case Report
1092
excised 7 years earlier and treated as a benign tumor
without histologic evaluation. Several months after the
first treatment, another tumor grew within the scar; it was
reported to be a basal cell carcinoma and was resected
with tumor-free edges. Two years later, it recurred, and
the patient underwent wide resection and coverage with a
skin graft. This time, it was diagnosed as an adenoid
sclerosant ulcerated and multicentric basal cell carci-
noma. One year later, it recurred, and the immunohis-
tological report showed recurrent SEC. A year after that,
it recurred again, and she underwent wide resection in-
cluding the upper third of the right auricle with the same
diagnosis of SEC. The tumor reappeared one year later,
and the oncologic surgeon proposed wide resection with
total amputation of the auricle and resection of part of the
temporal bone followed by coverage with a free flap. The
patient declined this ablation and requested palliative
treatment without surgery or radiotherapy. After pallia-
tive treatment, she reported no systemic signs of illness,
weight loss, or functional impairment. Her examination
results were normal.
The patient rejected surgical treatment, including
Mohs micrographic surgery (Figure 1). She underwent
five sessions of palliative photodynamic therapy for re-
current SEC of the auricle using topical aminolevulinic
acid HCL 20% (ALA) (Levulan Kerastick; Stiefel Coral
Gables Fl USA) and between 25 and 33 pulses using
Level Intense Pulsed Light (Quantum Lumenis SR 560).
The ALA incubation time was 3 hours, and 4 weeks
passed between each session. This treatment helped to
control ulceration, pain, and swelling. We saw the patient
1 month after the last treatment (Figure 2), after which
time she moved and we lost contact.
Figure 1. A 75-year-old female with a 7-year-history of re-
current ulcerated syringoid eccrine carcinoma. Pretreat-
ment view.
Figure 2. After five sessions of palliative photodynamic
therapy with satisfactory control of local ulceration and
inflammatory reaction. One month after the last session.
3. Discussion
After many recurrences and extensive surgeries including
partial auricle amputation, the patient declined further
surgical treatment. Without therapy, the course of SEC is
very slow and of long duration, but multiple recurrences
are described [1,7].
Local recurrence occurs in 14% to 20% of cases. Most
patients survive beyond 10 years and usually die of an-
other cause, although notable exceptions of death within
6 months of diagnosis due to metastasis to the lymph
nodes and lungs have been reported [4,8].
Therapy of SEC consist mainly of surgical excision [9-
17]. Nowadays, Mohsmicrographic surgery is the method
of choice for SEC [11,16,18,19] if there is no “skip” area
or evidence of multifocality and no evidence of distant
metastases. Nishiwara reports the use of chemotherapy as
initial treatment in a case that exhibited multiple distant
metastases at diagnosis. In general, chemotherapy and/or
radiation therapy have been used for metastatic sweat
gland carcinomas. Radiation treatment for sweat gland
carcinoma has been reported to be ineffective, but more
recent reports have found a role for radiation in the local
control of this disease [20-24].The role of chemothera-
phy in sweat gland carcinoma is also under debate. Both
single-agent and combination chemotherapy have been
used infrequently and, at best, have shown only a tempo-
rary benefit [22-26]. There have been a few reports in
which patients with SEC were treated with radiotherapy
for local control and bone metastases [11,27]. Nishizawa
et al. reported an extended SEC treated with seven cycles
of combination chemotherapy [28].
Photodynamic therapy for superficial skin tumors, in-
cluding basal cell carcinoma, following local application
of ALA has been described by several authors [29-31].

Photodynamic Therapy as Palliative Therapy for Invasive Syringoideccrine Carcinoma of the Auricle: A Case Report 1093
However, it has not been described for the treatment of
SEC. We believe that this case shows the utility of
photodynamic therapy as a palliative treatment for tem-
poral control of tumor activity, even if it may not work in
other clinical contest except the ones previously reported.
This alternate approach was used because of patients’
refusal to radical surgery, and there is not any previous
report of palliative treatment in this rare neoplasm.
4. Disclosure
The authors have no commercial associations or financial
disclosures with regard to this manuscript.
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