Sebaceous gland carcinoma of the head and neck: The Princess Margaret Hospital experience

Treatment of sebaceous carcinoma with Mohs micrographic surgery versus wide local excision: a systematic review

Sebaceous carcinoma (SC) is a rare neoplasm affecting periocular and extraocular sites. If inadequately treated, it can recur and cause morbidity. Specific management guidelines have not been established. Wide local excision (WLE) has been traditionally used; however, Mohs micrographic surgery (MMS) can be advantageous because of complete margin assessment and tissue-sparing nature. This analysis aims to systematically review the surgical modalities used for the management of SC. Articles meeting eligibility criteria were identified using MEDLINE (via PubMed), Embase, Cochrane, and Scopus databases. All studies investigating surgical management of SC with WLE or MMS were considered. Seventy studies met inclusion criteria, including retrospective cohort studies, case series, and case reports. WLE was used in 32 studies, MMS in 29, and MMS and WLE in 9. Subgroup analysis showed that MMS has lower recurrence rates. For WLE, local, regional, and distant recurrence rates were 23.4%, 13.3%, and 11.0%, respectively, and for MMS, 6.8%, 4.3%, and 4.6%, respectively. Patients treated with WLE were more likely to have local recurrence than patients treated with MMS (P = 0.001). WLE cases were more likely to have a regional (P = 0.05) and distant recurrence (P = 0.001). Limitations of the study include heterogeneity of case reports, case series, and retrospective studies, variable follow-up times between the two groups, and large tumors included in the WLE category. In addition, disease-specific survival was not evaluated. MMS cases showed a superior outcome for local, regional, and distant recurrence, making it a good option for the management of SC.

Clinical Outcomes in Sebaceous Carcinoma: A Retrospective Two-Center Cohort Study

BACKGROUND

Sebaceous carcinoma (SC) is a rare, potentially recurrent, and life-threatening cutaneous malignancy that can be associated with Muir-Torre syndrome (MTS), a DNA mismatch repair-driven genodermatosis. Earlier studies examining factors associated with recurrence have focused on periocular tumors only.

OBJECTIVE

Examine outcomes of SC and identify factors associated with recurrence.

MATERIALS AND METHODS

Retrospective study from 2 tertiary care centers.

RESULTS

Sixty-seven cases from 63 patients were identified, including 7 cases of MTS and 13 arising in the context of immunosuppression. Fifty-five cases (82.1%) were treated with complete circumferential peripheral and deep margin assessment (CCPDMA) methods. Five recurrences developed during the postoperative period. On univariate analysis, periocular location (odds ratio [OR] 7.6, p = .0410), and lesion size ≥2 cm (OR 9.6, p = .005) were associated with recurrence, whereas CCPDMA (OR 0.052, p = .0006) was inversely associated with recurrence. On multivariate analysis, only lesion size ≥2 cm (OR 9.6, p = .0233) and CCPDMA approaches (OR 0.052, p = .007) were significant.

CONCLUSION

Non-complete circumferential peripheral and deep margin assessment methods and large lesion size were independent risk factors predicting recurrence, whereas anatomic subtype and MTS status were not. These findings can assist in identifying SC cases that may benefit from more aggressive treatment and closer surveillance.

Prognostic risk factors and nomogram construction for sebaceous carcinoma: A population-based analysis

Background

Sebaceous gland carcinoma (SGC) is a rare tumor for which there are currently no effective tools to predict patient outcomes. We analyzed the clinical and pathological prognostic risk factors of sebaceous carcinoma based on population data and created a nomogram of related risk factors, which can more accurately predict the 3-, 5-, and 10-year overall survival (OS) rates of patients.

Methods

SGC patients between 2004 and 2015 were collected from the Surveillance, Epidemiology, and End Results (SEER) database and randomly assigned to training and validation cohorts. Relevant risk factors were identified by univariate and multivariate COX hazards regression methods and combined to produce a correlation nomogram. The concordance index (C-index), the area under the receiver operating characteristic (AUC) curve, and calibration plots have demonstrated the predictive power of the nomogram. Decision curve analysis (DCA) was used to measure nomograms in clinical practice.

Results

A total of 2844 eligible patients were randomly assigned to 70% of the training group (n=1990) and 30% of the validation group (n=854) in this study. The derived meaningful prognostic factors were applied to the establishment of the nomogram. The C-index for OS was 0.725 (95% CI: 0.706-0.741) in the training cohort and 0.710 (95% CI: 0.683-0.737) in the validation cohort. The AUC and calibration plots of 3-, 5-, and 10-year OS rates showed that the nomogram had good predictive power. DCA demonstrated that the nomogram constructed in this study could provide a clinical net benefit.

Conclusion

We created a novel nomogram of prognostic factors for SGC, which more accurately and comprehensively predicted 3-, 5-, and 10-year OS in SGC patients. This can help clinicians identify high-risk patients as early as possible, carry out personalized treatment, follow-up, and monitoring, and improve the survival rate of SGC patients.

Clinical Features and Prognosis of Young and Middle-Aged Adults With Skin Sebaceous Adenocarcinoma

BACKGROUND

Sebaceous adenocarcinoma (SAC) mostly occurs in the elderly, and SAC in young and middle-aged population is inadequately investigated.

OBJECTIVE

To explore the clinical features and prognosis of young and middle-aged adults with SAC.

MATERIALS AND METHODS

Patients with skin SAC between ages 18 and 59 years from the Surveillance, Epidemiology, and End Results database (1975-2016) were eligible for this study.

RESULTS

Seven hundred thirty-nine cases were identified. The proportion of extraocular SAC in the nonelderly increased from 1975-2005 to 2006-2016 ( p = .001), male predominance was observed in overall patients whereas female predominance in Asian population, and young patients had more head and neck SAC than middle-aged patients ( p = .014). The prognosis of young patients was better than middle-aged patients ( p = .004). Other independent prognostic factors included sex, marital status, tumor size, surgery, chemotherapy, and multiple primary cancer history.

CONCLUSION

An increasing proportion of extraocular SAC was observed in young and middle-aged patients, and the young developed more head and neck SAC than the middle-aged. Female predominance was found in Asian population, and female patients had better prognosis. Younger age and married status indicated better prognosis, and around 20% of young and middle-aged patients might have poorer survival because of Muir-Torre syndrome.

Sebaceous Carcinoma of the Eyelid: A Systematic Review and Meta-Analysis

BACKGROUND

Sebaceous carcinoma (SC) of the eyelid is a rare, aggressive malignancy associated with high rates of recurrence, metastasis, and tumor-related mortality.

OBJECTIVE

Provide a collective analysis of clinical presentations, management techniques, and outcomes, and compare outcomes of common treatment methods.

METHODS AND MATERIALS

Observational studies reporting management and outcomes of SC of the eyelid were included. Patient and clinical data were extracted, and meta-analysis of proportions was performed.

RESULTS

One thousand three hundred thirty-three subjects were included with a mean age of 65.2 years and 803 (60.2%) women. Of 647 initial diagnoses reported, 277 (42.8%) were correct, and the mean diagnostic delay was 14.7 months (range 8.5-34.8). The tumor location was reported in 1,246 subjects and involved the upper eyelid in 780 (62.6%), lower eyelid in 409 (32.8%), and 57 (4.8%) involved both. Overall rates of recurrence, metastasis, and tumor-related mortality were 15.9%, 12.1%, and 6.2%, respectively. There were no statistically significant differences in wide local excision (WLE) versus Mohs micrographic surgery (MMS) outcomes.

CONCLUSION

Sebaceous carcinoma of the eyelid is more common in women, on the upper eyelid, and is frequently misdiagnosed initially. Rate of recurrence, metastasis, and tumor-related mortality were similar in subjects managed with WLE versus MMS.

Update on the pathology, genetics and somatic landscape of sebaceous tumours

Cutaneous sebaceous neoplasms show a predilection for the head and neck area of adults and include tumours with benign behaviour, sebaceous adenoma and sebaceoma, and sebaceous carcinoma with potential for an aggressive disease course at the malignant end of the spectrum. The majority of tumours are solitary and sporadic, but a subset of tumours may be associated with Lynch syndrome, also known as hereditary non-polyposis colon cancer (HNPCC) and previously referred to as Muir-Torre syndrome (now known to be part of Lynch syndrome). This review provides an overview of the clinical and histological features of cutaneous sebaceous neoplasia with an emphasis on differentiating features and differential diagnosis. It also offers insights into the recently described molecular pathways involved in the development of sebaceous tumours and their association with Lynch syndrome.

Sebaceous carcinoma: evidence-based clinical practice guidelines

Sebaceous carcinoma usually occurs in adults older than 60 years, on the eyelid, head and neck, and trunk. In this Review, we present clinical care recommendations for sebaceous carcinoma, which were developed as a result of an expert panel evaluation of the findings of a systematic review. Key conclusions were drawn and recommendations made for diagnosis, first-line treatment, radiotherapy, and post-treatment care. For diagnosis, we concluded that deep biopsy is often required; furthermore, differential diagnoses that mimic the condition can be excluded with special histological stains. For treatment, the recommended first-line therapy is surgical removal, followed by margin assessment of the peripheral and deep tissue edges; conjunctival mapping biopsies can facilitate surgical planning. Radiotherapy can be considered for cases with nerve or lymph node involvement, and as the primary treatment in patients who are ineligible for surgery. Post-treatment clinical examination should occur every 6 months for at least 3 years. No specific systemic therapies for advanced disease can be recommended, but targeted therapies and immunotherapies are being developed.

Radiotherapy for localized sebaceous carcinoma of the eyelid: a retrospective analysis of 83 patients

The current study retrospectively analyzed the results of radiotherapy for clinically localized sebaceous carcinoma of the eyelid.We reviewed records of 83 patients with histologically confirmed sebaceous carcinoma who were treated radiotherapeutically between 1983 and 2015. Sixty-five patients (78%) were initially treated with radiotherapy of curative intent, while the remaining 18 patients underwent postoperative radiotherapy due to tumor recurrence or positive surgical margins. Thirty-seven patients belonged to T1-2, while 46 belonged to T3-4. All 83 patients were treated with radiotherapy with a median radiation dose of 60 Gy. The median follow-up period was 92.1 months (range, 2.8-310.3 months). At the time of analysis, 13 patients (15.1%) died, and 36 patients (43.3%) had local recurrence. The 7-year overall survival, freedom from neck lymph node recurrence, and local control (LC) rates for all patients were 83.5%, 75.5%, and 52.3%, respectively. Patients with a tumor size ≤10 mm had a higher 7-year LC rate than those with a tumor size >10 mm (58.8% vs 46.6%, P = 0.054). Neck lymph node recurrence was observed in 17 patients (20%) and significantly related to the tumor size. Late toxicity of an eyelid dysfunction of grade 3 was observed in 1 patient with T3 tumor. Radiotherapy for sebaceous carcinoma of the eyelid is a reasonable alternative to surgical resection for tumors <10 mm in size with few severe complications, while larger tumors should be treated with surgery if feasible.

High-dose-rate interstitial brachytherapy for a bulky sebaceous carcinoma of the eyelid: A case report

High-dose-rate interstitial brachytherapy (HDR-ISBT) achieved excellent local control of the bulky sebaceous carcinoma of the eyelid. However, we must pay attention to dose of eyelid and cornea about late toxicity of HDR-ISBT.

Updates on the clinical diagnosis and management of ocular sebaceous carcinoma: a brief review of the literature

Ocular sebaceous carcinoma (SC) is an exceedingly rare but aggressive malignancy that can impair patients’ visual acuity or even cause tumor-specific mortality. This tumor usually mimics chronic benign eyelid lesions, thus leading to delayed diagnosis, thereby causing high recurrence and metastasis. Ophthalmologists should be more aware of SC in order to offer correct diagnosis and treatment at the onset of symptoms. Prompt surgical excision with frozen section margin control is the mainstay of SC management after patient evaluation and accurate biopsy. Mohs micrographic surgery has been associated with better tumor control outcomes than wide local excision. Radiation therapy should be considered as adjuvant treatment for locally advanced (stage T3a or higher) or high-risk (pagetoid spread) SC, nodal metastasis, or palliative care. Cryotherapy and topical chemotherapy are used for pagetoid spread. Targeted therapy has an emerging role in more complicated cases. For lymph node and distant metastasis, combination treatments should be provided, including lymph node and neck dissection, radiation therapy, systemic chemotherapy, and even orbital exenteration. The rarity of ocular SC precludes a comprehensive perspective on standard treatment. This paper offers a brief review of recent advances in the clinical diagnosis and management of ocular SC based on current scientific literature.

Incidence and Clinical Features of Rare Cutaneous Malignancies in Olmsted County, Minnesota, 2000 to 2010

BACKGROUND

The incidence of rare cutaneous malignancies is unknown. Current estimates of rare cutaneous malignancy incidences are based on broad epidemiologic data or single institution experiences, not population-based data.

OBJECTIVE

To determine the incidence of several rare nonmelanoma skin cancers.

MATERIALS AND METHODS

The authors conducted a retrospective chart review of a population-based cohort between the years 2000 and 2010. Residents of Olmsted County, Minnesota, who were diagnosed with a biopsy-proven nonmelanoma skin cancer-excluding basal cell carcinoma and squamous cell carcinoma-were included in this study. The primary outcome was tumor incidence. Additionally, the authors extracted patient demographics, tumor characteristics, treatment modalities, and outcomes.

RESULTS

The age-adjusted and sex-adjusted incidences per 100,000 persons of multiple rare cutaneous malignancies were: atypical fibroxanthoma (1.8), sebaceous carcinoma (0.8), dermatofibrosarcoma protuberans (0.4), microcystic adnexal carcinoma (0.7), eccrine carcinoma (0.4), eccrine porocarcinoma (0.2), and leiomyosarcoma (0.2).

CONCLUSION

The authors report population-based incidences and clinical characteristics for these rare cutaneous malignancies. The immune status and smoking status of patients and the treatment and outcomes of these tumors are reported. Additional studies in a broader population are needed to further define the epidemiology and outcomes of these malignancies.

Metastatic sebaceous cell carcinoma, review of the literature and use of electrochemotherapy as possible new treatment modality

Background

Metastatic extraorbital sebaceous carcinoma is a rare event that could involve the head and neck. The treatment of choice for the initial stage of the disease is surgery and/or radiotherapy. The treatment of recurrent or advanced disease is still controversial.

Material and methods

Extensive literature search was done, and the treatment options are discussed.

Results

Results. The literature search found several treatment modalities in use for the treatment of metastatic extraorbital sebaceous carcinoma. Electrochemotherapy was not included in the reported treatments. We used this technique for a man of 85 years old with a recurrent and locally metastatic extraorbital sebaceous carcinoma of the scalp. During the period of 8 months, two sessions of electrochemotherapy were employed, which resulted in an objective response of the tumour and good quality of life.

Conclusions

Electrochemotherapy has shown to be a interesting tools for treatment of metastatic extraorbital sebaceous carcinoma when other radical options are not available or convenient.

Management Considerations in Extraocular Sebaceous Carcinoma

BACKGROUND

Extraocular sebaceous carcinoma (SC) is a rare malignancy with metastatic potential. The authors present a case of a rapidly growing extraocular SC with equivocal radiographic imaging to highlight challenges in tumor management.

OBJECTIVE

To examine the existing literature for evaluation and management recommendations of extraocular SC.

METHODS AND MATERIALS

A comprehensive review of relevant English articles in PubMed through May 2015.

RESULTS

Tumor-specific staging system and management guidelines do not currently exist for extraocular SC. Mohs micrographic surgery or wide local excision are the most commonly used surgical treatments. Regional/distant metastasis occurs infrequently, but systemic workup with radiographic imaging or sentinel lymph node biopsy may be warranted in select cases. Adjuvant radiation therapy can be considered for recurrent and metastatic tumors.

CONCLUSION

Extraocular SCs present unique challenges that may benefit from multidisciplinary management. Surgical removal with negative pathologic margins is the mainstay treatment of extraocular SC. Additional studies will help clarify the optimal diagnostic workup and adjuvant treatment of patients.

Malignant cutaneous adnexal tumours of the head and neck: an update on management

Adnexal tumours form a heterogeneous group of relatively rare neoplasms. Many of them have a poor prognosis and treatment can sometimes be difficult and controversial. We summarise the latest publications relating to malignant cutaneous adnexal tumours of the head and neck, and give an update on their management. We discuss Merkel cell carcinoma and other rare malignant adnexal tumours including dermatofibrosarcoma protuberans and atypical fibroxanthoma.

Sebaceous carcinoma: review of the literature

BACKGROUND

Sebaceous carcinoma is an uncommon adnexal neoplasm with a documented capability for regional and distant metastasis. Traditionally, sebaceous carcinoma has been associated with high rates of recurrence after excision.

OBJECTIVE

To review the current literature on sebaceous carcinoma and detail its epidemiology, pathogenesis, clinical presentation, histopathology, diagnostic workup, treatment, and prognosis.

MATERIALS AND METHODS

Literature review using PubMed search for articles related to sebaceous carcinoma.

RESULTS

Sebaceous carcinoma typically presents as a painless pink or yellow nodule. Diagnosis requires histopathologic examination, and immunohistochemical analysis often assists in the differentiation of sebaceous carcinoma from other benign and malignant skin neoplasms. Sebaceous carcinoma should prompt a workup for Muir-Torre syndrome. Periorbital sebaceous carcinoma has an increased tendency for regional metastasis, although cancer-specific mortality rates are similar among all anatomic locations.

CONCLUSION

Surgery is the preferred treatment for local disease. Limited data suggest that Mohs micrographic surgery may provide superior clinical outcomes, but more research is needed regarding the long-term outcomes. Radiation and systemic chemotherapy are reserved for recurrent or metastatic disease.

Primary adenocarcinoma of the lacrimal gland with sebaceous differentiation in a 4-year-old child

Primary adenocarcinoma of the lacrimal gland with sebaceous differentiation is an extremely rare tumor. Only 11 cases have been reported in the literature, none in children. A 4-year-old girl presented with a rapidly progressing mass in the left lacrimal gland fossa. An incisional biopsy followed by partial orbital exenteration confirmed the diagnosis of adenocarcinoma with sebaceous cell differentiation. Currently, no previous reports of this malignancy in childhood have been published. This case underscores the necessity of expanding the presenting age that adenocarcinomas with sebaceous differentiation of the lacrimal gland can occur.

Long-Term Remission of an Aggressive Sebaceous Carcinoma following Chemotherapy

Sebaceous carcinoma (SC) is an uncommon neoplasm manifesting itself either in the eyelid or extraocularly in the head and neck area. Surgery is the standard of care. Irradiation is rarely proposed as monotherapy but is frequently administered as an adjuvant regimen following surgical resection. There is no known strategy concerning chemotherapeutic treatment in highly aggressive recurrent - or metastatic - forms of the disease. Our patient presented with an aggressive SC of the scalp recurring after multiple excisions and local radiotherapy. Chemotherapy with 5-fluorouracil, cisplatin and docetaxel was then initiated; 4 cycles were administered, followed by capecitabine maintenance. Shortly after starting chemotherapy, dermal lesions had completely disappeared and radiological response could be seen. The patient experienced an extended period (>20 months) of complete remission. In this report, we show an excellent response of a highly aggressive SC after a combination of chemotherapy as for head and neck cancers.