What exactly is sebaceous adenoma? Sheng Chen, MD, PhD Dept of Pathology North Shore-LIJ Health...

What exactly is sebaceous adenoma?

Sheng Chen, MD, PhDDept of PathologyNorth Shore-LIJ Health System, NY

What is your diagnosis?

Sebaceous adenoma Sebaceous carcinoma Sebaceous neoplasm

Adenoma vs. carcinoma

Definition of terms

Adenoma Benign neoplasm of glandular tissue

Carcioma Malignant epithelial neoplasm, when

used unmodified usually meaning invasive carcinoma

Historical Perspective

1974: Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer.

Historical Perspective

95 cases, extraocular 46 classified as seb adenoma

Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer, 1974

Historical Perspective

Seb adenoma, clinical Distribution: 70% head M:F = 2.5:1 Size: 46% <5 mm, rare >5 cm Duration: months to years Mean age: 60.5 yrs F/U ranging 0.5 to 18 yrs 3 recurrence and no metastasis

Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer, 1974

Historical Perspective

Seb adenoma, microscopic Multilobulated Often replace epidermis Sharp circumscription, often with capsule Presence of maturing seb cells Nuclei enlarged, may contain nucleoli Slight nuclear pleomorphism Occasional mitotic figures

Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer, 1974

Historical Perspective

Textbooks Weedon’s Lever’s WHO

A. B. Ackerman (1936 – 2008)

Bernie’s view Ackerman

Seb adenoma until 1998

Bernie’s view

1998: Nussen and Ackerman. Sebaceous “adenoma” is sebaceous carcinoma. Dermatopath: Prac & Conc.

Bernie’s view

Nussen and Ackerman. Sebaceous “adenoma” is sebaceous carcinoma. Dermatopath: Prac & Conc, 1998.

“In the course of preparation of a second edition of a volume titled Neoplasms with Sebaceous Differentiation, we… were struck by the illogic of the judgment that the cystic sebaceous neoplasm… was related to conventional sebaceous adenoma... Scrutiny again, after a period of several years, of examples of "cystic sebaceous adenoma" pictured in Neoplasms with Sebaceous Differentiation, 1994 (and in the book devoted to Clues to Diagnosis in Dermatopathology,1991) and of new biopsy material received in our laboratory, made us realize that the histopathologic features were not those of an adenoma, but of a very well differentiated carcinoma i.e., cystic sebaceous carcinoma.”

Bernie’s view Reasons for the conclusion

1. Confluence of aggregations of neoplastic cells that results in an anastomosing pattern

2. Crowded nuclei of immature sebocytes3. Slight pleomorphism of nuclei of immature

sebocytes4. Heterochromia of nuclei of immature sebocytes5. Many sebocytes, especially immature ones but

even some mature ones, in mitosis6. Some mitotic figures abnormal7. Many individual sebocytes necrotic as indicated

by pyknosis and karyorrhexis8. Incipient necrosis en masse sometimes

Nussen and Ackerman. Sebaceous “adenoma” is sebaceous carcinoma. Dermatopath: Prac & Conc, 1998.

Bernie’s view

Nussen and Ackerman. Sebaceous “adenoma” is sebaceous carcinoma. Dermatopath: Prac & Conc, 1998.

“In short, in our judgment, so-called cystic sebaceous adenoma is really sebaceous carcinoma. Having concluded that, we began to rethink the subject of conventional, i.e., non-cystic, sebaceous adenoma and to review sections of specimens that had been given that designation, both in various publications and by us at our own microscope…In conclusion, we now think that what has long been known as ‘sebaceous adenoma’ is sebaceous carcinoma.”

Bernie’s view 2009 - Hashmi and Ackerman

“We contend that…what universally is termed ‘sebaceous adenoma’ actually is a superficial sebaceous carcinoma.”

Hashmi and Ackerman. New Insights: Sebaceous neoplasms in Muir-Torre syndrome—carcinomas all! Dermatopath: Prac & Conc, 2009.

2009

Which one?

Seb carcinoma?Seb adenoma?

Adenoma vs. carcinoma

Zelger and Hurt agreed with the view that the so-called seb adenoma is seb carcinoma

Hurt mentioned others’ disagreement “In my experience talking with

colleagues in the field, many do not hold this point of view.”

Burgdorf, Zelger, Hurt. Book review. Dermatopathol: Pract and Conc, 2009

Adenoma vs.carcinoma Burgdorf expressed uncertainty:

“An area where I both agree and disagree… is the nature of the sebaceous proliferations in Muir-Torre syndrome . . . They rely on a variety of histological features ranging for disordered overall architecture to increased mitoses to characterize all the sebaceous tumors in Muir-Torre syndrome as carcinomas. From a purely morphological viewpoint this may be correct, but it not true clinically as very few such lesions behave in a malignant fashion… We chose a neutral name because we realized the cytological features were disturbing but that the pattern of a solitary well-circumscribed tumor was benign.”

Burgdorf, Zelger, Hurt. Book review. Dermatopathol: Pract and Conc, 2009

Same lesion, different diagnosis

Sebaceous adenoma Sebaceous carcinoma Sebaceous neoplasm

Adenoma vs. carcinoma

A different view

Seb adenoma is really seb carcinoma in situ

A different view

Why seb carcinoma in situ architectural features of confinement

well defined border and smooth outline, findings indicating the neoplastic cells still confined in epithelium

cytologic features of malignancy enlarging of nuclei, increase of n/c ratio,

hyperchromasia, decrease of maturation, increase of mitotic activity

A different view

Why seb carcinoma in situ architectural features of benignancy and

cytologic features of malignancy fit the exact definition of carcinoma in

situ introduced by Broders in 1932

Historical Perspective Seb adenoma, microscopic

Slight nuclear pleomorphism and occasional mitotic figures

“It is these features that make separation of the sebaceous adenoma from sebaceous carcinoma difficult, since the separation is made on the basis of these features as well as on a pattern of infiltrative growth. The latter criterion is subject to variation in interpretation.”

Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer, 1974

Sir Percivall Pott 1714 – 1788, was an English surgeon, one

of the founders of orthopedic surgery, and the first scientist to demonstrate that a cancer may be caused by an environmental carcinogen.

"Clear and precise definition of disease, and the application of such names to them as are expressive of their true and real nature, are of more consequence than they are generally imagined to be; untrue or imperfect ones occasion false ideas, and false ideas are generally followed by erroneous practice."

- Sir Percival Pott, 1765

Seb carcinoma in situ

Reflect the true nature Leads to correct management

Simple excision brings 100% cure

Conclusion

In summary, for the reasons stated here, the so-called sebaceous adenoma, is neither adenoma nor

invasive carcinoma, but sebaceous carcinoma in situ.