Sebaceous cell carcinoma of the eyelid and the human immunodeficiency virus

Sebaceous carcinoma masquerading as ocular mucous membrane pemphigoid

Sebaceous carcinoma is a known mimicker of benign conditions, leading to frequent delays in diagnosis and proper treatment. We present two patients with chronic cicatrizing conjunctivitis initially diagnosed as ocular mucous membrane pemphigoid (MMP) and later found to have sebaceous carcinoma. Both patients presented with unilateral conjunctivitis that failed to improve with topical and systemic therapy, eventually developing fornix foreshortening and extensive symblepharon. Case 1 was diagnosed with ocular MMP based on clinical features alone, while Case 2 was diagnosed with biopsy-negative disease. Months to years later, both patients developed lid lesions found to be sebaceous carcinoma and underwent exenteration. As diagnosis and treatment of ocular MMP without positive direct immunofluorescence testing becomes increasingly accepted, clinicians should consider sebaceous carcinoma as the initial diagnosis or as a developing phenomenon during immunosuppression in the setting of chronic inflammation. A low threshold for repeat biopsy should be maintained.

Adnexal neoplasms of the eye

Adnexal neoplasms of the eyelid encompass a wide variety of benign and malignant tumors of sebaceous, follicular, and sweat gland origin. Due to the specialized structures of the eyelid, these neoplasms present differently when compared with those of other locations. Although most dermatologists and ophthalmologists are familiar with the commonly reported adnexal tumors of the eyelid, such as hidrocystoma, pilomatrixoma, and sebaceous carcinoma, many other adnexal neoplasms have been reported at this unique anatomic site. Accurate and timely identification of these neoplasms is essential, as alterations of eyelid anatomy and function can have a negative impact on eye health, vision, and quality of life. We review the clinical and histopathologic features of common and rare eyelid adnexal neoplasms and discuss proposed treatment options.

Malignant lesions of the caruncle

Caruncle malignancy is rare, but signs of disease can be easily missed by both patients and clinicians. There is significant potential for significant morbidity and even mortality from delayed diagnosis and treatment. Clinical features of primary malignant cancer include rapid growth, pigment deposition, ulcerated surface and bleeding. Malignant diagnoses include lymphoproliferative disease, basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma and malignant melanoma. Increased pigmentation is associated with melanoma, yellow coloured deposition with sebaceous carcinoma and a salmon-pink hue with lymphoproliferative disease. Treatment involves excision with margin control which may necessitate exenteration. Metastases to cervical and preauricular lymph nodes has been reported.

A rare giant extraocular, anterior chest wall sebaceous carcinoma

BACKGROUND

Sebaceous carcinoma (SC) is a rare aggressive cutaneous malignant tumour. It accounts for less than 1 % of all cutaneous malignant tumours. Sebaceous carcinomas are divided into ocular and extraocular constituting 75 % and 25 % respectively. The most common extraocular site is parotid gland. Chest wall is a rare site of this tumour.

CASE PRESENTATION

In line with SCARE criteria (Agha et al., 2018 [1]), this report is a case of a 45-year-old African male patient who presented with a two-year history of a large right anterior chest wall tumour. He reported that the tumour started as a small lump, which grew gradually over a two-year period. The patient reported no history of visceral malignancy and radiation exposure. However, his risk factors were age and immunosuppression in the form of Human Immunodeficiency Virus (HIV). The tumour was initially diagnosed as sebaceous adenocarcinoma by incisional biopsy before the patient had been referred to the treating team a year before. Excision of the tumour with wide margins was undertaken, and histology results confirmed sebaceous carcinoma.

DISCUSSION

Sebaceous carcinoma is a rare and aggressive adnexal tumour. It is categorized as ocular and extraocular. Of these two, the more common is extraocular. The chest wall is a rare site for this tumour. The definitive diagnosis of this kind of tumour is done by tissue biopsy. In dealing with this tumour, surgical excision with wide margins is the standard treatment.

CONCLUSION

Sebaceous carcinoma is a rare aggressive malignant tumour originating from sebaceous gland. Early diagnosis and wide excision with negative margins improves survival.

Risk Factors for Local Recurrence or Metastasis of Eyelid Sebaceous Gland Carcinoma After Wide Excision With Paraffin Section Control

PURPOSE

To identify risk factors for local recurrence and metastasis of sebaceous gland carcinoma (SGC) after wide excision with paraffin section control.

DESIGN

Retrospective, observational case-control study.

METHODS

Setting: Single institution.

PATIENT POPULATION

Thirty-four patients with SGC who had undergone excision with 5-mm surgical margins and paraffin section pathologic analysis. Observational Procedures: The following were considered potential risk factors for local recurrence/metastasis of SGC: patient's sex, patient's age, initial diagnosis at other clinics, topical treatments at other clinics, interval between appearance of symptoms and referral to our institution, tumor location, tumor origin, tumor presentation pattern, T category, tumor size, presence/or absence of pagetoid spread, tumor differentiation, mitosis grade, growth pattern. Logistic regression analysis was performed to identify the actual risk factors.

MAIN OUTCOME MEASURES

Risk factors for local recurrence or metastasis of SGC after wide excision with paraffin section control.

RESULTS

Involvement of both upper and lower eyelids, topical treatments at other clinics, multicentric origin, diffuse pattern, stage T3a, large tumor size, and a nonlobular pattern significantly influenced local recurrence/metastasis (P < .050). Pagetoid spread tended to affect local recurrence/metastasis (P = .052). The other items did not significantly influence local recurrence/metastasis (P > .050).

CONCLUSIONS

This study identified risk factors for local recurrence or metastasis of SGC after wide excision with paraffin section pathologic analysis. The results of this study will be helpful to surgeons when planning additional management, such as map biopsy or adjuvant treatment.

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.

Excision and delayed reconstruction with paraffin section histopathological analysis for periocular sebaceous carcinoma

PURPOSE

To evaluate the use of excision and delayed reconstruction with rapid paraffin section analysis in patients with sebaceous carcinoma (SC) of the periocular region.

METHODS

A retrospective study of patients with SC. Patients were identified from a contemporaneously maintained database and medical notes reviewed. Data were collected on known risk factors. Standard management started with conjunctival mapping biopsies. The tumor was excised with a 3-mm clinical margin and sent in formalin for histopathological analysis. The patient went home with dressings and returned 3 days later. Further excision or reconstruction was performed as indicated. Follow-up data were collected.

RESULTS

Seventeen patients had excision and delayed reconstruction with paraffin section control. Ten had clear margins after 1 excision, and 7 were clear after 2 excisions. Reconstructive technique varied according to the defect. Three patients developed further tumor. One of these had a local recurrence treated with further excision and reconstruction. One developed a multicentric tumor with regional metastasis, and the third patient developed distant metastasis. Two patients died from SC. Average follow up was 5 years (2-9 years).

CONCLUSIONS

Excision and delayed reconstruction using paraffin section histopathological analysis are in widespread use for the management of basal cell carcinomas in the periocular region. While some authors advocate the use of Mohs' micrographic surgery in patients with SC, this technique has been questioned due to the possible misinterpretation of subtle intraepithelial pagetoid spread with frozen section analysis. To preserve the function of the eyelid and ease of reconstruction, it is important to try and preserve as much healthy tissue as possible while effecting a successful excision. Excision and delayed reconstruction offer an excellent option for the management of this rare and highly malignant tumor.

Extra ocular sebaceous adenocarcinoma in HIV-positive patient--case report

Sebaceous adenocarcinoma is a rare adnexal tumor that can affect the skin and is divided into ocular, a more common form and extra ocular, of a rarer occurrence. We report the case of a patient diagnosed with Acquired Immune Deficiency Syndrome (AIDS) who developed an extra ocular, bulky and fast-growing sebaceous adenocarcinoma on the face. The literature has suggested that transplanted patients and HIV-positive patients have an excess risk for developing adnexal tumors, including sebaceous adenocarcinoma.

Eyelid sebaceous carcinoma: clinicopathologic and multiparametric immunohistochemical analysis that includes adipophilin

PURPOSE

To evaluate the fine cytopathologic features and immunohistochemistry of eyelid sebaceous carcinoma.

DESIGN

Retrospective clinicopathologic study.

METHODS

Clinical records and microscopic glass slides of 12 patients diagnosed with sebaceous carcinoma were reviewed. Paraffin-embedded tissue recuts were immunoreacted for epithelial membrane antigen (EMA), Ber-EP4, p53, Ki-67, and adipophilin for cytoplasmic lipid. Invasive growth and intraepithelial spread were analyzed separately. Cytoplasmic and nuclear characteristics were correlated with the results of the immunohistochemical profiling.

RESULTS

Five patients experienced recurrences, but no metastases or tumor-related deaths were discovered. The nuclei in 11 invasive tumor cells were typically round with finely divided, granular, or smudgy chromatin without prominent margination at the nuclear membrane; they exhibited small punctate nucleoli. Positivity for EMA (both diffuse and focal), p53 (72% of nuclei), and Ki-67 (45% proliferation index) was demonstrated. Adipophilin positivity in vesicular and granular forms was detected in paraffin sections in all invasive tumors, most prominently in moderately differentiated and well-differentiated lesions. Among 9 cases exhibiting intraepithelial extensions, 6 showed mostly granular positivity and 3 vesicular positivity. p53 identified residual atypical intraepithelial cells when conjunctival epithelial sloughing occurred.

CONCLUSIONS

Immunohistochemistry can make significant contributions to the diagnosis of sebaceous carcinoma. p53 and vesicular granular adipophilin positivity were highly reliable in supplementing the routine microscopic diagnosis of infiltrative tumors and both can be used in paraffin sections, thereby obviating cumbersome oil red O staining of frozen sections. The cells found in intraepithelial spread were strongly EMA and p53 positive, with more granular than vesicular adipophilin positivity.

Periocular sebaceous gland carcinoma: A comprehensive review

Sebaceous gland carcinoma (SGC) is a rare tumour occurring at periocular and extra-ocular sites. SGC can be a challenging diagnosis for both clinicians and pathologists. High recurrence rates and a tendency for intra-epithelial spread, locoregional and distant metastases make it important for SGC to be suspected and be included in the differential diagnosis of an eyelid lesion. Early diagnosis, that may sometimes need ancillary testing, and prompt management using a multimodal approach can help reduce morbidity and mortality in patients with SGC.

Periocular cutaneous malignancies: a review of the literature

BACKGROUND

The periocular skin is susceptible to numerous benign and malignant neoplasms. Periocular malignancies may present differently, behave more aggressively, and pose greater challenges for treatment and repair than malignancies at other cutaneous sites. Between 5% and 10% of cutaneous malignancies occur periorbitally, with basal cell carcinoma reported as the most common malignant periocular tumor, followed by squamous cell carcinoma, sebaceous gland carcinoma, cutaneous melanoma, Merkel cell carcinoma, and other rare tumors.

OBJECTIVE

To review the current literature on cutaneous malignancies of the periocular region pertaining to etiology, incidence, clinical presentation, differential diagnosis, complications, and treatment options.

MATERIALS AND METHODS

An extensive literature review was conducted using PubMed, searching for articles on periocular and periorbital cutaneous malignancies.

CONCLUSIONS

Timely diagnosis and management of periocular malignancies is essential because of their proximity to and potential to invade vital structures such as the orbit, sinuses, and brain. Surgical excision remains the standard of care for the majority of periorbital malignancies, but given the sensitive anatomic location, tissue-sparing techniques with margin control such as Mohs micrographic surgery are the preferred method for most nonmelanoma skin cancers. Depending on tumor type, other treatment modalities may include radiation, chemotherapy, cryosurgery, topical medications, and photodynamic therapy.

Early onset sebaceous carcinoma

BACKGROUND

Ocular sebaceous carcinoma can masquerade as benign lesions resulting in delay of diagnosis. Early recognition is even more difficult in young patients where the disease rarely occurs. Here, we provide a clinicopathological correlation of ocular sebaceous carcinoma in a young individual lacking history of hereditary cancer or immunosuppression.

FINDINGS

A detailed histopathological study including p53 DNA sequencing was performed on an aggressive sebaceous carcinoma presenting in a healthy 32 year-old Caucasian woman. She had no history of retinoblastoma, evidence for a hereditary cancer syndrome, or radiation therapy. However, she potentially was at risk for excessive UV light exposure. A detailed review of the literature is also provided.A moderately well differentiated sebaceous carcinoma was established histopathologically arising from the meibomian gland of the upper eyelid. In most areas, the cytoplasm contained small but distinct Oil-red-O positive vacuoles. Direct sequencing of p53 identified a G:C→A:T mutation at a dipyrimidine site. The mutation results in substitution of arginine for the highly conserved glycine at residue 199 located at the p53 dimer-dimer interface. Energy minimization structural modeling predicts that G199R will neutralize negative charges contributed by nearby inter- and intramonomeric glutamate residues.

DISCUSSION

This study points to the importance of recognizing that sebaceous carcinoma can occur in young patients with no evidence for hereditary cancer risk or radiation therapy. The G199R substitution is anticipated to alter the stability of the p53 tetrameric complex. The role of UV light in the etiology of sebaceous carcinoma deserves further study. Our findings, taken together with those of others, suggest that different environmental factors could lead to the development of sebaceous carcinoma in different patients.

Skin cancers associated with HIV infection and solid-organ transplantation among elderly adults

Immunosuppression may be etiologic for some skin cancers. We investigated the impact of human immunodeficiency virus (HIV) infection and solid-organ transplantation on skin cancer risk. We conducted a population-based case-control study among elderly U.S. adults (non-Hispanic whites, age 67 years or older), using Surveillance, Epidemiology and End Results Medicare linked data. The study comprised 29,926 skin cancer cases (excluding basal cell and squamous cell carcinomas) and 119,704 controls, frequency-matched by gender, age and calendar year (1987-2002). Medicare claims identified solid-organ transplantation or HIV infection before cancer diagnosis/control selection. As negative controls, we evaluated other medical conditions (e.g., hypertension and depression) and cancers (breast, colon and prostate) not linked to immunosuppression. Odds ratios (ORs) compared prevalence in cases and controls, adjusted for matching factors and number of prior physician claims. Risks of Kaposi sarcoma (N = 602) and cutaneous non-Hodgkin lymphoma (N = 1,836) were increased with solid-organ transplantation (OR [95%CI]: 11.06 [5.27-23.23] and 2.27 [1.00-5.15], respectively) and HIV infection (21.58 [11.94-38.99] and 2.41 [1.05-5.52], respectively). Solid-organ transplantation was also associated with increased risks of Merkel cell carcinoma (N = 1,286; OR [95%CI] 4.95 [2.62-9.34]) and other cutaneous sarcomas (N = 972; 4.19 [1.83-9.56]). Solid-organ transplantation was nonsignificantly associated with melanoma (N = 23,974; (OR 1.36 [95%CI 0.98-1.88]). Null or weak associations were observed for negative control medical conditions and cancers. Solid-organ transplantation and HIV infection were followed by increased risk for some skin cancer subtypes among elderly adults. These results highlight the potential role of immunity in development of skin cancers.

Sebaceous carcinoma: the great masquerader: emgerging concepts in diagnosis and treatment

Sebaceous carcinoma (SC) is a rare tumor with a high rate of local recurrence and metastasis to lymph nodes and organs. The majority of SCs occur in the periocular region frequently presenting as painless, round subcutaneous nodules with a high tendency of diffuse and invasive growth in the eyelid and conjunctiva. It frequently masquerades as inflammatory conditions or as other tumors leading to delay in diagnosis, inappropriate treatment and increased morbidity and mortality. Sebaceous carcinoma is associated with Muir-Torre syndrome, a genetic condition presenting with sebaceous skin tumors associated with internal malignancy. Therefore, SC patients must be carefully evaluated and referred to an internist or gastroenterologist when indicated. Surgery is the definitive therapy for SC. In recent years, less radical surgical strategies are being used with improved outcomes. Current studies demonstrate that Mohs micrographic surgery (MMS) provides maximal tissue conservation and lower recurrence rates. Greater awareness and understanding of SC and its behavior has led to earlier diagnosis and appropriate treatment.

Epidemiology of nonkeratinocytic skin cancers among persons with AIDS in the United States

OBJECTIVE

Immunosuppression may increase risk for some skin cancers. We evaluated skin cancer epidemiology among persons with AIDS.

DESIGN

We linked data from population-based US AIDS and cancer registries to evaluate risk of nonkeratinocytic skin cancers (melanoma, Merkel cell carcinoma, and appendageal carcinomas, including sebaceous carcinoma) in 497 142 persons with AIDS.

METHODS

Standardized incidence ratios (SIRs) were calculated to relate skin cancer risk to that in the general population. We used logistic regression to compare risk according to demographic factors, CD4 cell count, and a geographic index of ultraviolet radiation exposure.

RESULTS

From 60 months before to 60 months after AIDS onset, persons with AIDS had elevated risks of melanoma (SIR = 1.3, 95% confidence interval 1.1-1.4, n = 292 cases) and, more strongly, of Merkel cell carcinoma (SIR = 11, 95% confidence interval 6.3-17, n = 17) and sebaceous carcinoma (SIR = 8.1, 95% confidence interval 3.2-17, n = 7). Risk for appendageal carcinomas increased with progressive time relative to AIDS onset (P trend = 0.03). Risk of these skin cancers was higher in non-Hispanic whites than other racial/ethnic groups, and melanoma risk was highest among men who have sex with men. Melanoma risk was unrelated to CD4 cell count at AIDS onset (P = 0.32). Risks for melanoma and appendageal carcinomas rose with increasing ultraviolet radiation exposure (P trend <10 and P trend = 10, respectively).

CONCLUSION

Among persons with AIDS, there is a modest excess risk of melanoma, which is not strongly related to immunosuppression and may relate to ultraviolet radiation exposure. In contrast, the greatly increased risks for Merkel cell and sebaceous carcinoma suggest an etiologic role for immunosuppression.

Sebaceous carcinoma of the ocular region: a review

Sebaceous carcinoma of the ocular region is a malignant neoplasm that is being recognized more frequently and managed by innovative techniques of local resection, cryotherapy, topical chemotherapy, and radiotherapy, resulting in improved visual and systemic prognosis.

Sebaceous carcinoma and the T-antigen

Carcinomas of sebaceous glands are uncommon. They are traditionally classified into ocular and extraocular sebaceous carcinomas (SC). Ocular SC tend to be more common and more aggressive than extraocular SC. However, the latter can occasionally follow a fatal course. Histologically, SC should be classified into 1) SC in situ; 2) SC, infiltrating, low-grade with or without pagetoid spread; 3) SC, infiltrating, high-grade, with or without pagetoid spread; and 4) SC with extraocular and extracutaneous involvement, including metastases. Immunohistochemistry plays a minor role in the diagnosis of SC. Thomsen-Friedenreich (T) antigen can be a helpful tool in differentiating SC (strong T-antigen reactivity in basaloid cells) from other mimicking neoplasms (basaloid cells are T-antigen negative). The histologic differential diagnosis, pathogenesis, and management of SC are reviewed.