Biomarkers in Sebaceous Gland Carcinomas - handouts.uscap.org · Biomarkers in Sebaceous Gland Carcinomas Disclosure of Relevant Financial Relationships Dr. Sander R. Dubovy declares

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Biomarkers in Sebaceous Gland CarcinomasSander R. Dubovy, MDProfessor of Ophthalmology and PathologyVictor T. Curtin Chair in Ophthalmology Florida Lions Ocular Pathology LaboratoryBascom Palmer Eye InstituteUniversity of Miami Miller School of Medicine

Biomarkers in Sebaceous Gland Carcinomas

Disclosure of Relevant Financial Relationships

USCAP requires that all planners (Education Committee) in a position to

influence or control the content of CME disclose any relevant financial

relationship WITH COMMERCIAL INTERESTS which they or their

spouse/partner have, or have had, within the past 12 months, which relates to

the content of this educational activity and creates a conflict of interest.


Disclosure of Relevant Financial Relationships

Dr. Sander R. Dubovy declares he has no conflict(s) of interest

to disclose.


Outline• Introduction to sebaceous cell carcinoma• Incidence, demographics, risk factors• Ocular origins• Gross pathology• Microscopic pathology• Immunohistochemistry• Management• Cases


Introduction• Sebaceous carcinoma (SC) is a malignant neoplasm that arises from

the sebaceous glands, most commonly in the periocular areas.

• Clinical manifestations are often mistaken for benign conditions andthus proper diagnosis and management is delayed.

• Metastases to regional lymph nodes and other sites are common.

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Introduction• Pathologists should be aware of the varied clinical

manifestations, histopathological morphology and various biomarkers used for accurate diagnosis.

• Overview of the most important factors in periocular sebaceous carcinomas and biomarkers.


Sebaceous Gland• Composed of two types of cells:

• Peripheral basophilic cells• Sebocytes: Central foamy/vacuolated cytoplasm


Definitions• Sebaceous carcinoma (sebaceous gland carcinoma,

sebaceous cell carcinoma) is a malignant neoplasm that arises from the sebaceous glands.

• Glands in these areas are named: • Meibomian glands (eyelid) • Zeis glands (cilia)

• Sebocytes:• Foamy cells within the gland• Produce sebum to regulate tear evaporation• Precursor cell of sebaceous carcinoma


Extraorbital primary locations• 75% of the cases arise in the ocular adnexae.

• Approximately 25% of sebaceous carcinomas arise from an extraocular region

• Parotid gland is the most common location.

• These tumors arise from two possible cells: pluripotent cells with capacity for sebaceous differentiation or from ectopic sebaceous cells that developed during embryogenesis

Shields JA, Demirci H, Marr BP, Eagle RC, Shields CL. Sebaceous carcinoma of the ocular region: a review. SurvOphthalmol. 2005;50(2):103-22.


Extraorbital primary locations• Other reported locations include:

• submandibular glands• extremities• toes • penis• chest• sole of foot• external auditory canal • ear• anterior neck region

• Wide variety of anatomical locations of this neoplasm.

Ghosh, Sudip Kumar; Bandyopadhyay, Debabrata; Gupta, Sandipan; Chatterjee, Gobinda; & Ghosh, Arghyaprasun. (2008). Rapidly growing extraocular sebaceous carcinoma occurring during pregnancy: A case report. Dermatology Online Journal, 14(8).


Incidence• Periocular skin neoplasms account for 5-10% of all skin

malignancies in the United States. • Basal cell carcinoma - 90% of malignant eyelid tumors• Sebaceous cell carcinoma - 5% of eyelid tumors • Squamous cell carcinoma - 4% of eyelid tumors • Melanoma - 1% of eyelid tumors

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Incidence• Incidence of sebaceous carcinoma is 0.5/million in the

Caucasian population older than 20-years-old in the US.

• Reports from China, India and other Asian countries indicate incidence of 31.2% - 39% of eyelid malignancies

Mulay K, Aggarwal E, White VA. Periocular sebaceous gland carcinoma: A comprehensive review. Saudi J Ophthalmol. 2013;27(3):159-65.


Demographics and Risk Factors

• Age: Mean age at diagnosis has ranged from 57 years to 72 years.

• Sung details a case of one of the youngest patient on the literature to develop sebaceous carcinoma without syndromic disease at age 32.

• Sex: Approximately 70% of the sebaceous carcinomas occur in females.


Demographics and Risk Factors• Irradiation: Several reports of patients with prior

history of irradiation due to hereditary retinoblastoma treatment, acne, cutaneous hemangioma and eczema.

http://iopscience.iop.org/article/10.1088/0031-9155/57/22/7741https://www.cancer.gov/types/retinoblastoma/patient/retinoblastoma-treatment-pdq Biomarkers in Sebaceous Gland Carcinomas

• Rundle details a case in which a patient developed sebaceous gland carcinoma after being subject to irradiation for bilateral retinoblastoma.

• The carcinogenic effects of irradiation are well documented.

• The irradiation could affect the remaining RB gene and thus predispose the patient for secondary malignancies. • Osteosarcoma• Cutaneous melanoma• Sebaceous gland carcinoma


Ocular origins• Meibomian glands: Most common origin

• Upper eyelid is affected in 75% • Lower eyelid 22%• Conjunctiva 2%• Caruncle 2%

http://www.pathologyoutlines.com/topic/eyeeyelidanatomy.htmlShields JA, et al. Sebaceous Carcinoma of the Eyelids: Personal Experience with 60 Cases. Ophthalmology 2004;111:2151-2157. Biomarkers in Sebaceous Gland Carcinomas

• Retrospective study of 104 cases of sebaceous carcinoma of the ocular adnexa with at least 5 years’ follow-up

• Various clinicopathologic features that indicate poor prognosis were identified

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Biomarkers in Sebaceous Gland Carcinomas Biomarkers in Sebaceous Gland Carcinomas


Ocular origins• Zeis glands: Glands associated with cilia: 10% of SC of the

eyelid. • Caruncle: 5-10% of all SC (abundant sebaceous glands). • Conjunctiva: SC of the conjunctiva with no involvement of the

nearby skin structures (rare).


Clinical Features• Commonly can masquerade as a benign condition,

blepharitis/chalazion (“masquerade syndrome”)• Resulting in a delay in diagnosis.

• Increases the chance of local recurrence, metastasis, and death.


Clinical Presentation

• Solitary nodule

• Diffuse pseudoinflammatory pattern

• Pedunculated lesion

• Caruncular mass

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Clinical Features• Solitary eyelid nodule: Most common clinical

manifestation• Painless, firm, sessile to round, subcutaneous

nodule in the eyelid. • Yellow color due to the presence of lipid. • Loss of cilia (madarosis).



• Solitary nodule



• Caruncular mass


Clinical Features• Diffuse pseudo-inflammatory pattern: The second most

common presentation. • Diffuse unilateral thickening of the eyelid. • Most likely to extend to the epithelium • SC must be ruled out in an older patient with unilateral

blepharitis that does not respond to standard treatment.

Case initially diagnosed as a chronic blepharoconjunctivitis

https://www.reviewofophthalmology.com/article/eyelid-lesions-diagnosis-and-t t t



• Solitary nodule



• Caruncular mass


Clinical Features• Pedunculated lesion: SC may become pedunculated with

keratinization and possess a cutaneous horn appearance. • Most common ocular location is the eyelid margin, from the

gland of Zeis.

Pedunculated lesion of the axilla

http://www.actasdermo.org/en/extraocular-sebaceous-carcinoma-a-report/articulo/S1578219012003113/



• Solitary nodule



• Caruncular mass

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Clinical FeaturesCaruncular mass: Irregular, yellow mass in the medial canthal lesion. May replace the entire eyelid and involve the orbit.

http://www.aaopt.org/optometry-and-vision-science-ovs-announces-preview-march-2014


Gross Pathology• Yellow color due to the lipid deposition.

• Specimens may show origin in the tarsal plate.


Gross Pathology



Microscopic Pathology• Cells with finely vacuolated, frothy cytoplasm• Pleomorphism and high nuclear mitotic rate are frequent features• Tumor cells often have hyperchromatic, atypical nuclei with foamy

cytoplasm

Biomarkers in Sebaceous Gland CarcinomasInvolvement of sebaceous glands

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•Vacuolated cytoplasm

•Mitotic figures

•Pleomorphic nuclei


Microscopic Pathology• A characteristic feature of SC is its ability to exhibit intraepithelial

spread into conjunctival, eyelid and corneal epithelium, this occurs in 44-80% of the cases (pagetoid spread).

Jakobiec FA, Mendoza PR. Eyelid sebaceous carcinoma: clinicopathologic and multiparametric immunohistochemical analysis that includes adipophilin. Am J Ophthalmol. 2014;157(1):186-208.e2.


Microscopic Pathology• Lobular pattern: Occurs more frequently and looks like a

normal sebaceous gland with undifferentiated cells in the periphery, and well-differentiated lipid producing cells centrally.


Microscopic Pathology• Comedocarcinoma: Lobules show large necrotic central core

with peripheral viable cells.


Microscopic Pathology• Papillary: Occurs in conjunctiva SC, with papillary projections

and sebaceous differentiation.


Microscopic Pathology• Papillary: Occurs in conjunctiva SC, with papillary projections

and sebaceous differentiation.

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Methods of Spread• Epithelial involvement: SC has been shown to exhibit flat,

superficial involvement of the eyelid or conjunctival epithelium.

• Pagetoid spread because of the morphological similarity of pagetoid spread of intraductal breast carcinoma.


Pagetoid spread


Full‐thickness Pagetoidinvolvement of epithelium

Involvement of sebaceous glands


• Pagetoid spread of malignant cells is common


Methods of Spread• Regional metastasis: Most common route of metastasis is via

lymphatic channels to regional lymph nodes. • SC of the upper eyelid tends to invade the preauricular and parotid

nodes. • SC of the lower eyelids tend to metastasize to the submandibular and

cervical nodes.

• Distant metastasis: Organs most commonly involved are lung, liver, bone, and brain.


Methods of Spread• Corneal invasion: Sebaceous carcinoma with pagetoid

spread from the bulbar conjunctiva to the corneal epithelium and stroma

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Methods of SpreadPerineural invasion


AJCC Cancer Staging

• Pathological classification• Tumor type• Differentiation (grade)• Completeness of tumor removal • Greatest tumor dimension• Tumor margins


AJCC Cancer Staging - 8th edition

• Size < 10 mm, 20 mm

• Tarsal plate

• Eyelid margin

• Invasion of ocular or orbital structures


AJCC Cancer Staging - 8th edition

• Size < 10 mm, 20 mm

• Tarsal plate

• Eyelid margin

• Invasion of ocular or orbital structures


AJCC Staging - 8th edition


AJCC Staging – 8th edition

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Biomarkers in Sebaceous Gland Carcinomas Biomarkers in Sebaceous Gland CarcinomasGrade I Grade II Grade III


GradingGrade IV


• Retrospective, clinicopathologic study• Evaluated cytopathologic features and

immunohistochemistry of eyelid sebaceous carcinoma in 12 patients

• EMA, Ber-EP4, p53, Ki-67, and adipophilin

• Cytoplasmic and nuclear characteristics correlated with immunohistochemical results


Biomarkers in Sebaceous Gland CarcinomasJakobiec FA, Mendoza PR. Eyelid sebaceous carcinoma: clinicopathologic and multiparametric immunohistochemical analysis that includes adipophilin. Am J Ophthalmol. 2014;157(1):186-208.e2. Biomarkers in Sebaceous Gland Carcinomas

Recommended Approach• Microscopic examination

raises the prospect of SC

• Immunostaining for both EMA and p53

• If either EMA or p53 is positive then confirm with adipophilinstaining

• A negative androgen receptor result can be used to rule out SC in a poorly differentiated tumor


EMA p53

adipophilin

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• A large variation of biomarkers exists with questionable utility.

• Experienced pathologists can usually confirm the diagnosis using morphology and immunohistochemistry is not necessary.


Immunohistochemistry• Plaza et al. studied 27 cases of SC

• Tissue microarray technique.

• Compared IHC results to 21 control cases of basal cell carcinoma (BCC) and 22 control cases of squamous cell carcinoma (SCC).

• EMA• CK7• Ber-EP4• Factor XIIIA• Androgen receptor• p53 • Adipophilin• Progesterone receptor membrane component 1 (PGRMC1)• Squalene synthase (SQS)• Alpha/beta hydrolase domain-containing protein 5 (ABHD5)


Epithelial membrane antigen• EMA – Glycoprotein with

extensive O-linked glycosylation of its extracellular domain.

• Product of MUC1 gene

• Overexpression of the MUC1 gene is often associated with colon, breast, ovarian, lung and pancreatic cancers.

• Membrane staining

Jakobiec FA, Mendoza PR. Eyelid Sebaceous Carcinoma: Clinicopathologic and Multiparametric Immunohistochemical Analysis That Includes Adipophilin. Am J Ophthalmol. 2014


EMA• Commonly used as a

marker to evaluate: • Epithelial carcinomas• Meningioma • Paget disease • Systemic anaplastic

large cell lymphoma vs cutaneous anaplastic large cell lymphoma

http://www.pathologyoutlines.com/topic/stainsema.html

Optic nerve sheath meningioma

Biomarkers in Sebaceous Gland CarcinomasJakobiec FA, Mendoza PR. Eyelid Sebaceous Carcinoma: Clinicopathologic and Multiparametric Immunohistochemical Analysis That Includes Adipophilin. Am J O hth l l 2014

Sebaceous Carcinoma - EMA


EMA in Sebaceous Carcinoma• In the series by Plaza et al., 27/27 SCs

were EMA-positive (100%).

• In 4 cases of SC, EMA was only focally and irregularly positive because these cases represented poorly differentiated lesions.

• All cases of BCC (21/21, 100%) were negative.

• SCC expressed EMA in 16/22 (72.72%) of cases.

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EMA

Plaza JA et al. Role of ImmunoSebaceous Carcinoma: A Clinicopathologic and histochemistry in the Diagnosis ofImmunohistochemical Study. Am J Dermatopathol 2015;37:809–821.Biomarkers in Sebaceous Gland Carcinomas

EMA in Sebaceous Carcinoma• EMA is useful in differentiating SC from BCC.

• EMA alone is not useful in differentiating SC from SCC.

Plaza JA et al. Role of ImmunoSebaceous Carcinoma: A Clinicopathologic and histochemistry in the Diagnosis ofImmunohistochemical Study. Am J Dermatopathol 2015;37:809–821.


EMA


CK7• Cytokeratin 7 is an intermediate filament

protein

• Low molecular cytokeratin (54 kDa)

• Found in breast, lung, ovary, and urothelium but usually not in the GI tract or in stratified squamous epithelium

• It is often used in conjunction with cytokeratin 20 in distinguishing ovarian, pulmonary, and breast carcinomas (CK7+) from colon carcinomas (CK7-).

Cytokeratin 7 shows cytoplasmic positivity in epithelial cell nests in a Brenner tumor.

Kriplani D, Patel MM. Immunohistochemistry: A diagnostic aid in differentiating primary epithelial ovarian tumors and tumors metastatic to the ovary. South Asian J Cancer. 2013 Oct-Dec; 2(4): 254–258.


CK7 in Sebaceous Carcinoma• Plaza et al. found that

• 24/27 (88.8%) of cases of SC• 2/22 (9%) of SCC• 6/21 (28.5%) of BCC expressed

CK7.

• May be valuable in differentiating SC from SCC in most instances.

• CK7 is not a reliable marker to separate SC from BCC.

Plaza JA et al. Role of ImmunoSebaceous Carcinoma: A Clinicopathologic and histochemistry in the Diagnosis ofImmunohistochemical Study. Am J Dermatopathol 2015;37:809–821.Biomarkers in Sebaceous Gland Carcinomas

CK7 - SC

Plaza JA et al. Role of ImmunoSebaceous Carcinoma: A Clinicopathologic and histochemistry in the Diagnosis ofImmunohistochemicalStudy. Am J Dermatopathol 2015;37:809–821.

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CK7 - SCC


CK7- BCC


CK7


Ber-EP4• EpCam (CD326) is a

transmembrane epithelial adhesion molecule present on all non-squamous epithelial cells.

• Ber-EP4 targets EpCam

EpCAM staining in breast carcinoma

http://www.abcam.com/epcam-antibody-ber-ep4-ab7504.html#description_images_1Biomarkers in Sebaceous Gland Carcinomas

Ber-EP4• Membranous staining

• Sensitive and specific for lung adenocarcinoma (positive) vs. mesothelioma (negative)

• Distinguishes metastatic adenocarcinoma to liver or cholangiocarcinoma (positive) from hepatocellular carcinoma (usually negative)

Carella R et al. Immunohistochemical Panels for Differentiating Epithelial Malignant Mesothelioma From Lung Adenocarcinoma. Am J Surg Path. 2001.

Membrane reactivity in lung adenocarcinoma


Ber-EP4 in Sebaceous Carcinoma• Plaza et al. showed:

• 7/27 (25.9%) of SC expressed Ber-EP4 • 21/21 (100%) of BCC cases are positive

(diffusely and strongly positive) • 22/22 (100%) of SCC are negative

• This suggests that Ber-EP4 is a reliable marker in differentiating SC (EMA+/Ber-EP4 +/-) from BCC (EMA-/Ber-EP4+) and SCC (EMA+/- /Ber-EP4-)

• When used with other markers.


Ber-EP4 in Sebaceous Carcinoma

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Ber-EP4


Factor XIIIA

• Component of the final stages of the clotting cascade.

• Acts on fibrin to form cross links between fibrin molecules to form an insoluble clot.

https://upload.wikimedia.org/wikipedia/commons/thumb/3/31/Stabilisation_de_la_fibrine_par_le_factor_XIII.png/260px-Stabilisation_de_la_fibrine_par_le_factor_XIII.png


Factor XIIIA• Nuclear staining• Positive staining in:

• Soft tissue: benign fibrous histiocytoma and variants, malignant fibrous histiocytoma

• Calcifying fibrous tumor• Verruciform xanthoma • Atypical fibroxanthoma, hemangiopericytoma,

myofibroblastoma in lymph nodes, pleomorphic hyalinizing angiectatic tumor, storiform collagenoma

• Cervix: angiomyxoma• CNS: Erdheim-Chester disease


• Clark et al. found consistent, strong nuclear staining in normal, hyperplastic and neoplastic sebocytes

• He concluded: Useful marker to differentiate sebaceous from squamous carcinoma analyzing staining pattern.

Biomarkers in Sebaceous Gland CarcinomasClark LN et al. Nuclear factor XIIIa staining (clone AC-1A1 mouse monoclonal) is a highly sensitive marker of sebaceous differentiation in normal and neoplastic sebocytes. J Cutan Pathol. 2016.

Factor XIIIA


Factor XIIIA

Clark LN et al. Nuclear factor XIIIa staining (clone AC-1A1 mouse monoclonal) is a highly sensitive marker of sebaceous differentiation in normal and neoplastic sebocytes. J Cutan Pathol. 2016.

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Factor XIIIA• Plaza et al. found that none of the SC (0/27), BCC (0/21), or SCC (0/22) expressed Factor XIIIA.

• Discrepancy in these findings may be attributed to the clone or dilution of the antibody used.



Factor XIIIA


Androgen Receptor• The androgen

receptor dimer binds to a specific sequence of DNA.

• Results in up- or down-regulation of specific gene transcription.

• Insulin-like growth factor I receptor (IGF-1R).


• Sensitive marker for sebaceous carcinoma• AR positive in 19/19 (100%) cases of SC• AR positive in 6/18 (33.3%) cases of BCC • AR positive in 0/18 (0%) cases of squamous cell

carcinoma

• Along with other markers and morphology, AR can be helpful in the differentiation of SC from SCC and BCC.


Androgen Receptor on Sebaceous Carcinoma

• Plaza et al. found different results compared to other studies

• 9/27 (33.3%) of the SC cases were positive.

• 3/21 (14.2%) of BCC cases were positive.

• 0/22 (0%) of SCC were positive.

• They concluded that nuclear expression of androgen receptor can be seen in BCC cases in a similar percentage.

• Not a valuable marker to differentiate SC from BCC.


Androgen Receptor

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p53 as a marker • Tumor suppressor gene

• Induces cell cycle arrest • DNA repair or to force the cell to undergo apoptosis.

• Differentiate malignant conditions (p53+) • Carcinoma in situ • Invasive carcinoma• Others

• Reactive and metaplastic conditions (p53-)


p53 in Sebaceous Carcinoma

• Plaza et al. found that: • SC cases 12/27 (44.4%) expressed p53

• BCC cases 4/21 (19%) expressed p53

• SCC cases 3/22 (13.6%) expressed p53

• Not a recommended diagnostic marker in the differential diagnosis of SC, BCC, and SCC.


p53


• Retrospective case series. Fourteen specimens were analyzed for p53 gene mutations with PCR and Sequencher.

• Seven of 14 (50%) sebaceous carcinoma samples were found to have p53 gene mutations.

• None of the samples had tandem mutations, which are caused by UV exposure. Therefore it is consistent with the belief that the development of SC is a UV-independent process.

• No statistically significant trend was found between the presence of p53 mutations and metastasis, recurrence, tumor size, TNM stage, and pagetoidspread.

(Ophthal Plast Reconstr Surg 2014;30:392–395)


Adipophilin

• Assists with the storage of neutral lipids within the lipid droplet

• Expressed in sebocytes and sebaceous lesions

• Membranous labeling of intracytoplasmic lipid globules

• Also expressed in: • Lactating mammary epithelium• Adrenal cortex• Steatotic hepatocytes in alcoholic cirrhosis • Renal cell carcinoma • Hepatocellular carcinomas• Pancreatic carcinomas• Prostatic carcinomas• Liposarcomas


Adipophilin

• Plaza et al. found adipophilin expression in:

• 27/27 (100%) in cases of SC

• BCC 16/21 (76.19%)

• SCC 11/22 (50%) showed a granular uptake in the cytoplasm.

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Adipophilin• The pattern of adipophilin

expression can be useful in distinguishing SC from other periocular neoplasms.

• No cases of BCC or SCC showed membranous labeling of intracytoplasmic lipid globules.


• Retrospective, histopathologic study

• Evaluated the efficacy of adipophilin immunohistochemistry in the diagnosis of sebaceous cell carcinoma of the ocular adnexal region

• 25 patients with sebaceous carcinoma, 21 with basal cell carcinoma, 22 with conjunctival squamous cell carcinoma, 9 with cutaneous squamous cell carcinoma, and 5 with conjunctival mucoepidermoid carcinoma.

Milman T, Schear MJ, Eagle RC. Diagnostic utility of adipophilin immunostain in periocular carcinomas. Ophthalmology. 2014;121(4):964-71.


Results - SC• Significantly stronger adipophilin expression, a

greater number of intracytoplasmic vacuoles, and larger vacuoles.

• The specificity and sensitivity of adipophilinimmunostaining were both 100% when more than 5% of the staining occurred in vacuoles (<95% granular staining).

• Conclusions: • Histology remains the gold standard for

diagnosis of sebaceous carcinoma.

• Immunohistochemical assessment for adipophilin is a helpful diagnostic adjunct in the assessment of ocular adnexa neoplasms presumed to be sebaceous carcinoma.

Milman T, Schear MJ, Eagle RC. Diagnostic utility of adipophilin immunostain in periocular carcinomas. Ophthalmology. 2014;121(4):964-71.Biomarkers in Sebaceous Gland Carcinomas

E, F, Moderately differentiated sebaceous carcinoma cells infiltrate the epidermis in a pagetoid pattern and demonstrate strong, diffuse immunoreactivity for adipophilin as confluent medium-sized intracytoplasmic vacuoles (red arrows) and small vacuoles and granules (black arrow).

Milman T, Schear MJ, Eagle RC. Diagnostic utility of adipophilin immunostain in periocular carcinomas. Ophthalmology. 2014;121(4):964-71.


Other lipid droplet proteins• Alpha/beta hydrolase domain-containing protein 5 (ABHDC5)

• The protein encoded by this gene belongs to a large family of proteins defined by an alpha/beta hydrolase fold

• PGRMC1: Protein which co-purifies with progesterone binding proteins in the liver and ovary.

• Squalene synthase (SQS) or farnesyl-diphosphate: farnesyl-diphosphate farnesyl transferase

• Enzyme localized to the membrane of the endoplasmic reticulum.


Other lipid droplet proteins• Plaza et al. found:

• PGRMC1 was expressed in 22/27 (81.4%) of SC

• SQS in 14/27 (51.8%) of SC• ABHD5 in 19/27 (70.3%) of SC. • BCC 0/21 (0%) or SCC 0/22 (0%)

expressed none of these markers.

• PGRMC1, SQS, and ABHD5 are therefore very specific but not very sensitive markers for the diagnosis of SC.

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• Perforin stained strongly in 9/11 (81%) of the sebaceous neoplasms • 7/9 (77.7%) of the SC • 2/2 (100%) of sebaceous adenoma

• The specificity of perforin in identifying sebaceous neoplasms versus SCC and BCC was 100% (95% CI 69–100). • Perforin better highlighted the intraepithelial

spread of SC than EMA. • The expression pattern of perforin in

sebaceous neoplasms allows the use of perforin as a new immunohistochemicalmarker for sebaceous neoplasms.

Acta Ophthalmol. 2016 Aug;94(5):e325-30


Immuno Panel that May be Helpful in Differentiating Sebaceous Cell

• CEA +/- - -

• ADP + - -

• AR + +/- -

• EMA + - +

• BerEP4 - + -

• CA19-9 +/- +/- -

• CA 15-3 + - +/-

• BRST-1 + +/- -

• CAM 5.2 + - +/-

Sebacous Carcinoma Basal Cell Carcinoma Squamous Carcinoma

Saudi Journal of Ophthalmology (2013) 27, 159–165


Summary of Immunohistochemistry

• Jakobiec et al - EMA, p53, adipophilin, androgen receptor are useful adjuncts for diagnosis of SC

• Plaza et al – adipophilin, ABHD5, PGRMC1, and SQS are novel markers specific for SC

• Adipophilin is the most sensitive

• Millman et al - pattern and intensity of adipophilinimmunostaining are helpful in distinguishing sebaceous carcinoma from other neoplasms with overlapping histology.


Differential Diagnosis• Chalazion: Painful, tender, circumscribed nodule, without

diffuse involvement that has similar appearance to SC. • Any patient with recurrent chalazia, especially in older individuals

must undergo biopsy to rule out SC.

http://www.emedicinehealth.com/chalazion_lump_in_eyelid/page4_em.htmhttp://eyepath.org.uk/atlas/chalazion/


Differential Diagnosis• Blepharitis: Common; diffuse inflammation of the eyelids• Often SC is misdiagnosed as blepharitis. • No madarosis

https://en.wikipedia.org/wiki/BlepharitisBiomarkers in Sebaceous Gland Carcinomas

Differential Diagnosis• Conjunctivitis: Diffuse SC involvement of the palpebral,

forniceal and bulbar conjunctiva can appear as a conjunctivitis. Bilateral conjunctivitis is less likely to be SC.

https://www.flickr.com/photos/jian-hua_qiao_md/11873430274

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Differential Diagnosis• Keratoconjunctivitis: As SC progresses it may involve the

corneal epithelium. It causes reactive inflammation around the neoplasms and thus it may resemble keratoconjunctivitis.


Differential Diagnosis:• Basal cell carcinoma: Nodular form of BCC presents as a solitary nodule.

Generally white, with vascular elevated margins with likely ulceration. • Most commonly involves the lower eyelid


Differential Diagnosis

http://www.pathologyoutlines.com/topic/skintumornonmelanocyticbcc.html

The diffuse sclerosing or morpheaform forms of BC most closely resembles SC, with unlikely involvement of the conjunctiva.


Differential Diagnosis:

• Squamous cell carcinoma: Most common in upper lid. Associated with actinic keratosis. Conjunctival intraepithelial neoplasia (CIN) can be similar to diffuse epithelial invasion of SC.

Actinic keratosis

http://www.humpath.com/spip.php?article3854

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?29/47/30451


Differential diagnosis

http://www.visionaryeyespecialists.com.au/common-eyelid-problems/

• Squamous cell carcinoma : Arises in epithelium, infiltrates in sheets, nests and islands.

• Eosinophilic tumor with keratinization of cells and formation of keratin pearls.

• Pleomorphism and mitotic figures are common


Differential Diagnosis:• Melanoma: Nodular or diffuse growth pattern. Generally

pigmented with brown appearance, rather than the characteristic SC yellow. Amelanotic melanoma may resemble SC.

http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v4/v4c003.html

http://www.mussenhealth.us/cell-carcinoma/lentigo-maligna.html

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• Merkel cell carcinoma: Solitary subcutaneous nodule in the upper eyelid of older individuals, with red or red-blue color.

http://www.pathologyoutlines.com/topic/skintumornonmelanocyticmerkelcell.htl

http://webeye.ophth.uiowa.edu/eyeforum/cases/217-Merkel-Cell-Carcinoma-Eyelid.htm Biomarkers in Sebaceous Gland Carcinomas


• Lymphoma: More common than SC. In the eyelid area, it is usually deep to the epidermis and the skin moves freely over the lesion. Conjunctival lymphoma has characteristic “salmon patch” with no inflammatory signs that are present in SC.

http://emedicine.medscape.com/article/1219134-overview

http://www.pathologyoutlines.com/caseofweek/case281.htm


Muir-Torre Syndrome• Variant of autosomal dominant hereditary nonpolyposis

colorectal cancer (HNPCC) syndrome or Lynch syndrome.

• Incidence: HNPCC occurs in about 1/350 individuals in the general population

• Muir-Torre syndrome is evident in 9.2% of the cases and in 28% of families with HNPCC.


Muir-Torre Syndrome

• MMR genes: • Mutator S Homologue (MSH)2 • Mutator L Homologue (MLH)1 • MSH6 • Postmeiotic Segregation Increased (PMS)2


• To diagnose Muir-Torre:• One characteristic from Group A and B or• Three characteristics from Group C


Muir-Torre Syndrome: Sebaceous Adenoma

http://www.regionalderm.com/Regional_Derm/Sfiles/sebaceous_adenoma.html

• Benign growth that presents as a small, usually less than 0.5 cm in diameter (2-4 mm), smooth, yellow, speckled papules with central umbilication on the skin of the face or scalp over several months.

• Most common cutaneous manifestation of Muir-Torre (68%).

• Multilobulated tumor sharply demarcated from the surrounding tissue. Central cells contain frothy and vacuolated cytoplasm.

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Muir Torre: Sebaceoma

Distinction between sebaceous adenoma and sebaceoma may be difficult and there is an increasing tendency to regard these two tumors as part of a continuum of benign tumors

Basaloid undifferentiated sebocytes admixed with single or small clusters of mature vacuolated sebocytes.

Irregular shaped cell masses in which more than 50 percent cells are undifferentiated, basaloid cells together with significant aggregates of sebaceous cells and transitional cells


Sebaceous hyperplasia

http://www.pathologyoutlines.com/topic/skintumornonmelanocyticsenilesebaceoushyperplasia.html

A papule is an area of abnormal skin tissue that is less than 1 cm around. Usually a papule has distinct borders, and it can appear in a variety of shapes

• No malignant potential

• Risk factors: Sun exposure and old age


Sebaceous Adenoma vs. Sebaceous Carcinoma

• 94 sebaceous tumors from 92 patients• Tumors with strong p53 staining were significantly

associated with the diagnosis of sebaceous carcinoma vs benign sebaceous lesions

• Nuclear mismatch repair protein expression was intact in all lesions showing p53 alterations

• Suggests p53 dysfunction may represent a divergent pathway in these tumors

• ShalinSC, Sakharpe A, Lyle S, Lev D, Calanje, Lazar AJ P53 Staining Correlates with Tumor Type and Location in Sebaceous Neoplasms. The American Journal of Dermatopathology. 2012; 34(2): 129=138.


Sebaceous Adenoma


Signalling• Beta-catenin: coordination of cell-cell adhesion and gene

transcription WNT-catenin overexpression is associated with increased tumor size invasion and metastasis

• P53: overexpression associated with tumor type and location

• P21: cyclin dependent kinase inhibitor; down regulation has association with lymph node metastasis

• Shh ABCG2: maintenance of stem cells in adult tissues; sonic hedgehog pathway; overexpression associated with aggressiveness and metastasis


Signalling

• Androgen receptor: regulation of gene expression; increased activity inhibits p53 expression

• E-cadherin: suppressor of invasion and growth of epithelial cancers

• Lower expression-poor differentiation, high proliferation rate• Promoter methylation-reduced survival, size >2 cm, lymph node mets, poor

differentiation

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Management• The first step is to establish the diagnosis and determine the

extent of the disease• Skin• Conjunctiva• Cornea• Caruncle • Periocular tissue

• Palpation of head and neck nodes is advisable.

• Management options include: surgical excision, surgical excision combined with cryotherapy, topical chemotherapy, radiotherapy, amniotic membrane grafting and other techniques.


Management• Primary excisional biopsy

• It is generally preferred to perform a complete surgical excision of the lesion when the diagnosis is suspected.

• Cosmetic appearance is an issue to consider if the diagnosis is unclear

• Incisional biopsy to confirm • Excisional biopsy afterward


Management• Full-thickness, pentagonal, eyelid

resection is favorable. • Margins are 5.0 mm on the nasal and

temporal sides.


Map Biopsy• Determines extent of disease.

• Usually 10-15 biopsies are taken.

• The most common method involves: • Eversion of the eyelids and taking four specimens from the palpebral

conjunctiva• Six specimens from the bulbar conjunctiva.


Management• Cryotherapy

• Useful in cases of SC with pagetoid spread to the conjunctival surface. It is used during map biopsies and during definitive surgical excision.

• Topical chemotherapy• Has been used in select cases of pagetoid spread involving the

conjunctival epithelium.


Orbital Exenteration• Widely believed to be the best option for SC that diffusely involves the

conjunctiva and with invasion into the orbit.

• Appropriate for orbital invasion cases of SC with no evidence of distant metastasis.

• Lid-sparing exenteration is an option that must be considered if the eyelid contains no tumor• Faster healing • Better fitting prosthesis

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An 87-year-old female presented for evaluation of left eyelid redness for a couple of weeks.

Case 1


Case



Incisional Biopsy


Incisional Biopsy

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Map Biopsy


Map Biopsy


Pathology report:



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Case 2• 74-year-old female who presents with recurrent chalazion of the

left eye.

Map Biopsy


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• Sebaceous carcinoma on the eyelids, palpebral conjunctiva, fornicealconjunctival and corneal epithelium

• Marked amount of pagetoid spread.

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EMA


EMA

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CK7


CK7


Ber-EP4


Ber-EP4 –stains epithelium


p53


p53

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Androgen Receptor


Androgen Receptor


Factor XIIIA


Factor XIIIA


IHC SummaryIHC Result

EMA +++

CK7 ++

Ber-EP4 0

Androgen Receptor +

Factor XIIIA 0

p53 ++


Summary • Sebaceous cell carcinoma has high morbidity/mortality and

may be misdiagnosed as squamous cell and basal cell carcinoma

• Morphology remains most important for the diagnosis of sebaceous cell carcinoma

• Immunohistochemical stains including EMA, p53, adipophilin, and perforin; as well as CEA may be useful adjuncts in diagnosis

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References• Plaza JA, Mackinnon A, Carrillo L, Prieto VG, Sangueza M, Suster S. Role of immunohistochemistry in the diagnosis of

sebaceous carcinoma: a clinicopathologic and immunohistochemical study. Am J Dermatopathol. 2015;37(11):809-21.

• Chen WS, Chen PL, Li J, Lind AC, Lu D. Lipid synthesis and processing proteins ABHD5, PGRMC1 and squalene synthase can serve as novel immunohistochemical markers for sebaceous neoplasms and differentiate sebaceous carcinoma from sebaceomaand basal cell carcinoma with clear cell features. J Cutan Pathol. 2013;40(7):631-8.

• Asadi-amoli F, Khoshnevis F, Haeri H, Jahanzad I, Pazira R, Shahsiah R. Comparative examination of androgen receptor reactivity for differential diagnosis of sebaceous carcinoma from squamous cell and basal cell carcinoma. Am J Clin Pathol. 2010;134(1):22-6.

• Jakobiec FA, Mendoza PR. Eyelid sebaceous carcinoma: clinicopathologic and multiparametric immunohistochemical analysis that includes adipophilin. Am J Ophthalmol. 2014;157(1):186-208.e2.

• Mulay K, White VA, Shah SJ, Honavar SG. Sebaceous carcinoma: clinicopathologic features and diagnostic role of immunohistochemistry (including androgen receptor). Can J Ophthalmol. 2014;49(4):326-32.

• Ansai S, Takeichi H, Arase S, Kawana S, Kimura T. Sebaceous carcinoma: an immunohistochemical reappraisal. Am J Dermatopathol. 2011;33(6):579-87.

• Ansai S, Arase S, Kawana S, Kimura T. Immunohistochemical findings of sebaceous carcinoma and sebaceoma: retrieval of cytokeratin expression by a panel of anti-cytokeratin monoclonal antibodies. J Dermatol. 2011;38(10):951-8.

• Sramek B, Lisle A, Loy T. Immunohistochemistry in ocular carcinomas. J Cutan Pathol. 2008;35(7):641-6.

• Mittal R, Araujo I, Czanner G, Coupland SE. Perforin expression in eyelid sebaceous carcinomas: a useful and specific immunomarker for the differential diagnosis of eyelid carcinomas. Acta Ophthalmol. 2016;94(5):e325-30.

• Uhlenhake EE, Clark LN, Smoller BR, Shalin SC, Gardner JM. Nuclear factor XIIIa staining (clone AC-1A1 mouse monoclonal) is a sensitive and specific marker to discriminate sebaceous proliferations from other cutaneous clear cell neoplasms. J CutanPathol. 2016;43(8):649-56.


References• Mulay K, White VA, Shah SJ, Honavar SG. Sebaceous carcinoma: clinicopathologic features and diagnostic

role of immunohistochemistry (including androgen receptor). Can J Ophthalmol. 2014;49(4):326-32.

• Jakobiec FA, Werdich X. Androgen receptor identification in the diagnosis of eyelid sebaceous carcinomas. Am J Ophthalmol. 2014;157(3):687-96.e1-2.

• Boussahmain C, Mochel MC, Hoang MP. Perilipin and adipophilin expression in sebaceous carcinoma and mimics. Hum Pathol. 2013;44(9):1811-6.

• Milman T, Schear MJ, Eagle RC. Diagnostic utility of adipophilin immunostain in periocular carcinomas. Ophthalmology. 2014;121(4):964-71

• Shields JA, Demirci H, Marr BP, Eagle RC, Shields CL. Sebaceous carcinoma of the ocular region: a review. Surv Ophthalmol. 2005;50(2):103-22.

• Deprez M, Uffer S. Clinicopathological features of eyelid skin tumors. A retrospective study of 5504 cases and review of literature. Am J Dermatopathol. 2009;31(3):256-62.

• Dasgupta T, Wilson LD, Yu JB. A retrospective review of 1349 cases of sebaceous carcinoma. Cancer. 2009;115(1):158-65.

• Izumi M, Mukai K, Nagai T, et al. Sebaceous carcinoma of the eyelids: thirty cases from Japan. Pathol Int. 2008;58(8):483-8.

• Fan YS, Carr RA, Sanders DS, Smith AP, Lazar AJ, Calonje E. Characteristic Ber-EP4 and EMA expression in sebaceoma is immunohistochemically distinct from basal cell carcinoma. Histopathology. 2007;51(1):80-6.

• Bayer-garner IB, Givens V, Smoller B. Immunohistochemical staining for androgen receptors: a sensitive marker of sebaceous differentiation. Am J Dermatopathol. 1999;21(5):426-31.


References• Ostler DA, Prieto VG, Reed JA, Deavers MT, Lazar AJ, Ivan D. Adipophilin expression in sebaceous tumors

and other cutaneous lesions with clear cell histology: an immunohistochemical study of 117 cases. Mod Pathol. 2010;23(4):567-73.

• Poniecka AW, Alexis JB. An immunohistochemical study of basal cell carcinoma and trichoepithelioma. Am J Dermatopathol. 1999;21(4):332-6.

• Metze D, Soyer HP, Zelger B, et al. Expression of a glycoprotein of the carcinoembryonic antigen family in normal and neoplastic sebaceous glands. Limited role of carcinoembryonic antigen as a sweat gland marker. J Am Acad Dermatol. 1996;34(5 Pt 1):735-44.

• Heyderman E, Graham RM, Chapman DV, Richardson TC, Mckee PH. Epithelial markers in primary skin cancer: an immunoperoxidase study of the distribution of epithelial membrane antigen (EMA) and carcinoembryonic antigen (CEA) in 65 primary skin carcinomas. Histopathology. 1984;8(3):423-34.

• Beer TW, Shepherd P, Theaker JM. Ber EP4 and epithelial membrane antigen aid distinction of basal cell, squamous cell and basosquamous carcinomas of the skin. Histopathology. 2000;37(3):218-23.

• Clark LN, Elwood HR, Uhlenhake EE, Smoller BR, Shalin SC, Gardner JM. Nuclear factor XIIIa staining (clone AC-1A1 mouse monoclonal) is a highly sensitive marker of sebaceous differentiation in normal and neoplastic sebocytes. J Cutan Pathol. 2016;43(8):657-62.

• Khandelwal P, Liu S, Sullivan DA. Androgen regulation of gene expression in human meibomian gland and conjunctival epithelial cells. Mol Vis. 2012;18:1055-67.

• Kiyosaki K, Nakada C, Hijiya N, et al. Analysis of p53 mutations and the expression of p53 and p21WAF1/CIP1 protein in 15 cases of sebaceous carcinoma of the eyelid. Invest Ophthalmol Vis Sci. 2010;51(1):7-11.


References• Rangel J, Mccalmont TH. Intracytoplasmic adipophilin immunopositivity: a pitfall in the distinction of metastatic

renal carcinoma from sebaceous carcinoma. J Cutan Pathol. 2010;37(12):1193-5.

• Muthusamy K, Halbert G, Roberts F. Immunohistochemical staining for adipophilin, perilipin and TIP47. J ClinPathol. 2006;59(11):1166-70.

• Kass LG, Hornblass A. Sebaceous carcinoma of the ocular adnexa. Surv Ophthalmol. 1989;33(6):477-90.

• Hayashi N, Furihata M, Ohtsuki Y, Ueno H. Search for accumulation of p53 protein and detection of human papillomavirus genomes in sebaceous gland carcinoma of the eyelid. Virchows Arch. 1994;424(5):503-9.

• Rao NA, Hidayat AA, Mclean IW, Zimmerman LE. Sebaceous carcinomas of the ocular adnexa: A clinicopathologic study of 104 cases, with five-year follow-up data. Hum Pathol. 1982;13(2):113-22.


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