INTRODUCTION

Chondroid syringoma (CS) is an uncommon benign skin adnexal tumor, with a reported percentage ranged from 0.01% to 0.1%. It is encountered in any body region but most frequently occurs in the head and neck parts, and characterized by slow growing, skin colored-red, painless, small single, nodule, not attached to the deeper tissue, rarely measuring more than 2 cm in diameter [1,2]. The age of presentation ranged between 20 and 60 years, with a small male preponderance was observed [2]. Furthermost of cases are benign, however, the extremities are the usual sites predisposed to recurrence, malignant transformation, as well as metastasis [3,4]. CS rarely occurs in the eyelids and brow area, and the clinical features are less commonly made the diagnosis, while histological diagnosis can be challenging in absence of characteristic findings [1].

The histopathologic finding of CS corresponds to cutaneous mixed tumor or pleomorphic adenoma, because it comprises of variable architecture both epithelial and mesenchymal element [5], containing sweat gland components marked by epithelial tubules exist within a cartilaginous, fibrous, myxoid, and even an infrequent adipocytic stroma [6]. Based on microscopic studies, tumors composed of tubular lumina lined by a single layer of cuboidal cells are regarded to be of eccrine origin, while tumors with stromal components consisting of bilayered strands of epithelial cells are considered as having an apocrine origin [7].

Herein, this report highlighted another interesting, rare case of chondroid syringoma affecting the eyelid-brow junction, and describes its clinical and histopathological characteristics, together with a review of the existing literature.

CASE REPORT

A 75-year-old Iraqi man presented to the dermatological unite for a single enlarging, protruded nodule involved the inferior border of the medial head of the left eyebrow, along with the upper eyelid skin (the eyelid-brow interval). In the beginning, the patient noticed an evolving skin lesion over 2-years prior to seeking dermatologic consultation, and he described no significant alteration in its color and texture over that time, apart from a gradual increase in size and covering hair loss. Similarly, there was no history of extreme sun exposure, smoking, or associated symptoms. Moreover, he had no prior dermatologic or non-dermatologic malignancy and no systemic illness. Clinical examination revealed a firm, raised, 0.6 × 0.6 × 0.7 cm dome-shaped lobulated nodule involving the left eyelid-brow interval. It was a painless, skin-colored, mobile lesion, and had no tenderness, bleeding, discharge, or associated inflammatory signs. Subsequently, preoperative assessment was done, and under local anesthesia, he underwent surgical resection of the left eyelid-brow mass, protected in formalin solution, and referred for histopathological study (Figs 1a and 1b). The possible clinical differential diagnoses were chondroid syringoma, nodular hidradenoma, syringocystadenoma papilliferum, epidermal inclusion cyst, schwannoma, neurofibroma, pilomatrixoma, cutaneous T-cell lymphoma, or nodular basal cell carcinoma.

Figure 1: A 75-year-old man presented with a single enlarging, protruding nodule, involved the inferior border of the eyelid-brow interval. (a) anterior view, (b) 3 months after surgical resection.

Histology revealed a slight epidermal acanthosis and a well-demarcated deep dermal unencapsulated mass separated completely from the epidermis. This dermal mass, composed of hyalinized myxoid stroma, contains nests and strands of polygonal, spindle and fatty cells arranged in nesting and linear structures. This myxoid stroma is pink to gray in color contain bland chondrocytes. Furthermore, the epithelial component contains cystic and ductal structures, with one or two cell layers of epithelium lining, some of them filled with pink secretions and the others with decapitation secretions. No atypia or malignancy (Figs 2a – 2d).

Figure 2: Histopathological photos of CS consisting chiefly of a well-demarcated deep dermal unencapsulated mass, composed of hyalinized myxoid stroma, containing nests and strands of polygonal, spindle, and fatty cells arranged in nesting and linear structures (H&E; a, b, c with × 100, d with × 400).

The clinical and histopathological features were compatible with mixed eccrine and apocrine types of CS. The tumor underwent complete surgical resection with a 2mm safety margin to ensure that there was no sign of any remaining lesion. Patients had no evidence of tumor recurrence at 7 months of follow-up. Informed consent was obtained from the patient for publication with the interrelated photos.

DISCUSSION

CS originates from eccrine or apocrine sweat glands [8]; it is very rare to present over the eyebrow zone. Currently, this study underlines clinical and histopathological characteristics of another interesting, rare case of CS affecting the eyelid-brow junction, as well as reviewing all eight mentioned cases in the literature of CS of the eyelid-brow interval (Table 1).

Table 1: Reported cases of chondroid syringoma affecting the eyelid-brow junction.

CS is characterized by a single, painless, slow-growing, intradermal or subcutaneous tumor, mainly affecting the head and neck [14]. CS presented as a gradually growing, nontender, firm intracutaneous or subcutaneous nodule ranging in size from 0.5 to 3.0 cm [15]. The involvement of the right or left eyebrow has been published in patients aged between 20 to 77 years, and women are more common than men (Table 1). The presented case is considered the ninth case involving the eyelid-brow and documents a case of a 75-year-old male patient who had single slowly enlarging in the size, painless, protruded 0.7 cm nodule over the left eyelid-brow, and the main presentation of the tumors was for cosmetic purpose. CS shared similar clinical features to dermal nevus, epidermal cyst, dermoid cyst, schwannoma, neurofibroma, and hair follicle tumors, including pilomatrixoma, in addition to basal cell carcinoma.

Generally, CS occurred in the head and neck region. The tumor frequently affects the cheek, nose, and upper lip, but it might also occur on the scalp, forehead, brow, and upper eyelid; and very rarely it has been elucidated to affect the lower eyelid and the orbit [15]. Additionally, the presented neoplasm showed focal and asymmetric eyebrow hair loss, a finding that should increase suspicion of an underlying growth. Occasionally, this result has been described in only one case among all previously reported patients [11].

The approach to a single eyebrow nodule may be exciting and should include consideration of the histopathology, helping differentiate among the suspected diseases such as chondroid syringoma, nodular hidradenoma, syringocystadenoma papilliferum, epidermal inclusion cyst, schwannoma, neurofibroma, pilomatrixoma, cutaneous T-cell lymphoma, or nodular basal cell carcinoma. Previous studies revealed the histological features of chondroid syringoma, which consist of mainly of a well-circumscribed nonencapsulated dermal mass containing island of basophilic chondroid cells with myxoid stroma, epithelial and myoepithelial cells, including glands, ducts, cysts, reticular lace-like networks, and nests [2,16]. The present case was formerly designated a well-predictable tumor with a typical recognized histology, apart from the presence of both eccrine and apocrine sweat gland cells in the tumor stroma.

The standard treatment of choice for CS is complete surgical excision, including an edge of at least 3-4 mm of normal adjacent tissue to avoid recurrence, which is expected to occur following incomplete excision or only electrodessication. Few previously identified cases showed no recurrence following 1 to 2 years after excisional biopsy [7,15]. The patient in the present study sought medical advice, and a complete surgical resection of the tumor was performed with a 2-mm safety margin, to ensure that there was no sign of any remaining lesion, as well as to prevent the serious damage of the underlying structure; and there was no evidence of tumor recurrence after 7-months of follow up. Although CS are benign, they can quite rarely experience malignant transformation [12]. The histopathological features and immunohistochemistry, if required, have been considered for the distinction.

CONCLUSION

Chondroid syringoma of the eyelid-brow junction is very rarely seen in daily clinical practice. Several cases were reported in the literature. It is characterized by a single painless, slowly enlarging, hairless neoplasm, and should be regarded as differential diagnosis of skin tumors of the eyelid-brow zone. Histopathological findings ruled out malignancy and showed a pleomorphic dermal mass contains tubular lumina of both eccrine and apocrine origin. Moreover, surgical removal with a 2-mm safety margin of the tumor followed by primary closure was achieved satisfactory outcomes in the presenting case.

REFERENCES

1.  Gündüz K, Demirel S, Heper AO, Günalp İ. A rare case of atypical chondroid syringoma of the lower eyelid and review of the literature. Surv Ophthalmol. 2006;51:280-5.

2.  Boujguenna I, Badja S, Jaafari M, Abdouh S, Boukis F. Chondroid syringoma:case series. J Surg Case Rep. 2025;2025:rjaf187.

3.  Aoun A, Dufrenot-Petitjean-Roget L, Amazan E, et al. Cutaneous chondroid syringoma. Ann Pathol. 2015;35:275-80.

4.  Madi K, Attanasio A, Cecunjanin F, Garcia RA, et al. Chondroid syringoma of the foot:a rare diagnosis. J Foot Ankle Surg. 2016;55:373-8.

5.  Agarwal R, Kulhria A, Singh K, Agarwal D. Cytodiagnosis of chondroid syringoma-series of three cases. Diagn Cytopathol. 2021;49:E374-E7.

6.  Yavuzer R, Başterzi Y, Sari A, Bir F, Sezer C. Chondroid syringoma:a diagnosis more frequent than expected. Dermatol Surg. 2003;29:179-81.

7.  Mandeville JT, Roh JH, Woog JJ, et al. Cutaneous benign mixed tumor (chondroid syringoma) of the eyelid:clinical presentation and management. Ophthalmic Plast Reconstr Surg. 2004;20(2):110-6.

8.  Rasheed FS, Alelyani RH, Alazzmi HA, et al. A Unique Presentation Site of Pleomorphic Adenoma in a Young Woman:A Case Report. Plast Reconstr Surg Glob Open. 2024;12:e5662.

9.  Yamamoto O, Yasuda H. An immunohistochemical study of the apocrine type of cutaneous mixed tumors with special reference to their follicular and sebaceous differentiation. J Cutan Pathol. 1999;26:232-41.

10.  Walls AC, Deng A, Geist DE. Mohs micrographic surgery for recurrent chondroid syringoma of the eyebrow. Dermatol Surg. 2012;38:800-2.

11.  Charles NC, Patel P. Eyebrow madarosis reflecting an intradermal neoplasm:pleomorphic adenoma, a rare brow tumour. Can J Ophthalmol. 2016;51:e84-e5.

12.  Chauvel-Picard J, Pierrefeu A, Harou O, et al. Unusual cystic lesion of the eyebrow:a case report of malignant chondroid syringoma. J Stomatol Oral Maxillofac Surg. 2018;119:232-5.

13.  Walvekar PV, Jakati S, Bothra N, Kaliki S. Isolated eyelid chondroid syringoma:a study of two cases. BMJ Case Rep. 2021;14(12):e245354. DOI:10.1136/bcr-2021-245354

14.  Shirzadeh E, Ghasemi Aryan A. Giant chondroid syringoma of the upper na-sal orbital rim. Iranian J Med Sciences. 2015;29:192-4.

15.  Dutton JJ, Fowler AM. Botulinum toxin in ophthalmology. Surv Ophthalmol. 2007;52(1):13-31.

16.  Khalifa E. Sharquie, Aljaf A, Adil R. Alsaadawi. chondroid syringoma mimicking keratoacanthoma. J Pak Assoc Dermatol. 2023;33:745-7.