Perforin expression in eyelid sebaceous carcinomas: a useful and specific immunomarker for the differential diagnosis of eyelid carcinomas

Periocular sebaceous carcinoma: updates in the diagnosis, treatment, staging, and management

Periocular sebaceous carcinoma (PSC) is a rare, aggressive, and potentially metastatic adnexal malignancy. Due to the ability of PSC to resemble several benign and malignant conditions, diagnosis is often delayed or mistaken. In addition, even with a known diagnosis, choosing the right treatment is still an open debate. For this reason, we decided to review the most up-to-date literature on PSC and propose a dedicated procedural protocol to help clinicians when dealing with PSC. A PubMed search was carried out using the terms "Sebaceous Carcinoma", "Adnexal Periocular Cancer", "Sebaceous Carcinoma AND eyelid", "Periocular Sebaceous Carcinoma", and "Ocular Adnexa". Pertinent studies published in English from 1997 up to December 2022 were compared to the selection criteria and if suitable, included in this review. Through the initial search, 84 articles were selected. Of these, 36 were included in the final study. Several papers explored different diagnostic and therapeutic strategies regarding PSC diagnosis and management. In light of the current literature review and the multidisciplinary experience of three clinical centers, a dedicated procedural protocol is proposed. PSC diagnosis may be achieved through accurate clinical evaluation, but it requires histopathologic confirmation, which can be challenging. Dermoscopy, in vivo reflectance confocal microscopy, and optical coherence tomography may facilitate PSC clinical examination, while immunohistochemistry stains may support histological diagnosis. Appropriate disease staging is necessary before choosing the treatment, as local disease requires radically different treatment compared to advanced disease. In addition, recent innovations in nonsurgical treatments, including radio-chemotherapy, immunotherapy, and targeted therapy, may be a viable option in the most challenging cases.

Intraoral sebaceous carcinoma: A rare presentation on the tongue and review of the literature

Intraoral sebaceous carcinoma (SC) is exceedingly rare, especially in the tongue. We reported the clinicopathological and immunohistochemical features of a rare SC case in a 59-year-old male who presented a painful ulcer on the tongue's posterior region. Microscopically, the tumor was composed of atypical basaloid cells with round to oval nuclei and prominent nucleoli arranged in lobes showing prominent sebaceous differentiation and areas of holocrine secretion. Immunohistochemistry showed positivity for pan-cytokeratin AE1/AE3 and epithelial membrane antigen (EMA) and negativity for cytokeratin 7 (CK7). The sebaceous cells were positive for adipophilin and perforin. Wide surgical excision followed by adjuvant chemotherapy and radiotherapy was performed. Careful histopathological analysis of these lesions is crucial to ensure a correct diagnosis. Due to the aggressive behavior of SCs, early diagnosis and treatment are essential to increase the patient's survival time. To the best of our knowledge, this is the second case of SC in the tongue.

Intraepithelial growth pattern for eyelid sebaceous carcinoma: a cohort of 214 patients from a single institution

AIMS

To determine the distribution of three different intraepithelial growth patterns (pagetoid, bowenoid and papillary) in eyelid sebaceous carcinoma (SC) and correlate them with the clinical characteristics and prognosis.

METHODS

A retrospective cohort study. The medical charts and pathological sections were retrospectively reviewed. All eligible patients were followed up for recurrence, metastasis and tumour-related mortality. The clinical significance of each intraepithelial growth pattern was determined by Cox regression.

RESULTS

Of the 214 patients, 67 (31%) presented with intraepithelial invasion, among them, 34 (16%) were pagetoid, 27 (13%) were bowenoid and 6 (2.8%) were papillary. Patients of pagetoid intraepithelial spread showed significantly longer diagnostic delay (p=0.001) and more initial misdiagnoses of blepharitis (p=0.035). After a median follow-up period of 34.0 months, 67 (46%) patients in the non-intraepithelial group, 17 (50%) in the pagetoid group, 8 (30%) in the bowenoid group and 2 (33%) in the papillary group recurred. And 30 (20%) patients in the non-intraepithelial group, 9 (27%) in the pagetoid group and 4 (15%) in the bowenoid group developed metastasis. Moreover, 15 (10%) patients in the non-intraepithelial group, 6 (18%) in the pagetoid group and 1 (3.7%) in the bowenoid group died of SC. Cox regression indicated that pagetoid intraepithelial growth pattern was remarkably associated with increased chances of tumour-related mortality (HR=2.95, 95% CI 1.14 to 7.64, p=0.026).

CONCLUSIONS

Intraepithelial tumour invasion was presented in nearly one third of patients with eyelid SC. Pagetoid intraepithelial neoplasia, the predominant growth pattern, significantly increased the risk of tumour-related mortality. Meticulous histopathological intraepithelial examination is recommended for every patient of eyelid SC. Special attention should be paid to those with pagetoid invasion, who may require more intensive managements.

Concomitant Orbital Tumours: Small Lymphocytic Lymphoma Involving the Lacrimal Gland of a Patient with Clinical Diagnoses of Muir-Torre Syndrome and Extensive Sebaceous Gland Carcinoma of the Ipsilateral Eyelid

Background/Aims

We present a case of 2 concomitant tumours, i.e., a sebaceous carcinoma (SC) and a small lymphocytic lymphoma (SLL), in the lacrimal gland of a patient with Muir-Torre syndrome.

Methods

Clinical history, orbital examination, diagnostic biopsy, excisional biopsy, and histopathologic analysis were utilized.

Results

An 89-year-old female presented to the eye casualty with corneal ulcer, anterior uveitis, proptosis, and restricted ocular motility. She has a clinical history of breast cancer, colon carcinoma, and SC of the eyelid, which had been resected completely 2 years before. Clinical examination, imaging, and diagnostic biopsy confirmed orbital SC recurrence. Exenteration and subsequent histopathologic analysis of the specimen revealed lymphocytic infiltrates consistent with SLL within the lacrimal gland.

Conclusion

We report for the first time a case of a patient with Muir-Torre syndrome who developed an orbital recurrent SC with an incidental finding of a lacrimal gland B non-Hodgkin lymphoma consistent with SLL. Clinicians should be aware of the possibility of this coexistence of multiple cancer types in patients with sebaceous carcinoma and Muir-Torre syndrome.

Programmed death receptor Ligand 1 expression in eyelid sebaceous carcinoma: a consecutive case series of 41 patients

PURPOSE

A limited number of therapies are available for patients with metastatic eyelid sebaceous carcinoma (SC). Programmed death receptor Ligand 1 (PD-L1) expression and its clinical significance in sebaceous cell carcinoma are presently unknown. This study aimed to evaluate the expression level of PD-L1 in SC.

METHODS

This single centre, retrospective, and comparative study was conducted at the Ninth People's Hospital between August 1, 2013 and September 1, 2016. Twenty primary, 11 recurrent, and 10 lymph node metastatic eyelid SCs of 41 consecutive patients and paired control eyelid samples were enrolled in the study. Immunohistochemical staining of PD-L1 was performed on slides containing SC embedded in paraffin wax. Patient clinical characteristics and PD-L1 expression related to SC prognostic values were evaluated.

RESULTS

Of the 41 patients with eyelid SCs, 58.5% (24/41) were female, and 41.5% (17/41) were male. A total of 43.9% (18/41) were left-sided, and 56.1% (23/41) were right-sided. A total of 2.4% (1/41) of the SCs were located at the canthus, 51.2% (21/41) were located at the upper eyelid, 41.5% (17/41) were located at the lower eyelids, and 2.4% (1/41) invaded the lacrimal sac. A total of 24.4% of the SCs were metastatic (10/41), 48.8% (20/41) were primary tumours, and 26.8% (11/41) resulted from recurrence. A total of 48.8% (20/41) were moderately graded and 51.2% (21/41) were poorly graded. Programmed death receptor Ligand 1 (PD-L1) positive expression was found in 20 (48.8%) cases. Programmed death receptor Ligand 1 (PD-L1) expression was observed on the tumour cell membrane. Higher expression of PD-L1 was correlated with metastatic cases when compared with primary cases (F = 6.69, p = 0.001). There was a higher expression of PD-L1 in the poorly differentiated group compared with the moderately graded group (57.1% poorly graded versus 45.0% moderately graded).

CONCLUSION AND RELEVANCE

Inhibition of PD-L1 expression may be a therapeutic option for metastatic eyelid SCs, although this hypothesis needs to be tested in future clinical trials.

Lacrimal Sac Sebaceous Carcinoma

Sebaceous carcinoma is an aggressive malignancy with a high mortality rate that commonly arises in the periorbital area. Rarely, the lacrimal apparatus may be involved by either contiguous or noncontiguous spread. The authors describe 2 unusual cases of sebaceous carcinoma in the lacrimal sac, presenting as a medial canthal mass simulating chronic dacryocystitis. In Case 1, the sebaceous carcinoma occurred primarily in the lacrimal sac, in the absence of concurrent or previous ocular adnexal sebaceous neoplasia. Mapping biopsies found no evidence of intraepithelial disease. Case 2 developed a late noncontiguous disease recurrence involving the lacrimal sac 5 years postprimary resection of an ipsilateral eyelid sebaceous carcinoma. These cases demonstrate atypical mode of spread of sebaceous carcinoma in lacrimal excretory system. It is important to regard the nasolacrimal drainage system as a potential reservoir for neoplastic sebaceous cells and minimize the risk of tumor cell dissemination during surgical management of eyelid or conjunctival sebaceous cell tumors.

[Current diagnostics and therapy recommendations for ocular basal cell carcinoma]

The treatment options for basal cell carcinoma (BCC) have recently been augmented with the introduction of novel chemotherapeutic drugs. New S2 guidelines on the disease have also been published. The aim of this article is to present a comprehensive state of the art description of the features of ocular BCC and an overview of the various therapeutic options. Particular emphasis is placed on the clinical signs, the diagnostic tools to identify periocular BCC and interpretation of the different histopathological subtypes. Tumor staging, TNM classification, interdisciplinary tumor conference reviews as well as psycho-oncological services play an important role in patients with pronounced periocular BCC. Surgical removal with a histological R0 resection is an important component of therapy options in this disease and includes the microsurgical excision into healthy tissue and the subsequent covering of the defect. A special focus of this article is the treatment of locally extensive and metastasized BCC.

Sebaceous lesions of the skin

Sebaceous differentiation is commonly seen in cutaneous neoplasms, both in the context of lesions showing predominantly sebaceous differentiation (e.g., sebaceous adenoma, sebaceoma and sebaceous carcinoma), or as more focal sebaceous components in neoplasms with other primary lines of differentiation. Sebaceous changes can also be a component of benign cystic lesions or epidermal tumours, and sebaceous hyperplasia is commonly encountered. This review is intended to provide an overview of the cutaneous lesions with sebaceous differentiation, with a particular emphasis on facilitating histological diagnosis of neoplasms. In addition, the role of immunohistochemical studies is outlined, as well as the evaluation of potential cases of Muir-Torre syndrome.

Sebaceous gland carcinoma of the ocular adnexa - variability in clinical and histological appearance with analysis of immunohistochemical staining patterns

PURPOSE

The purpose of the study was to evaluate the characteristics of sebaceous gland carcinoma (SGC) of the ocular adnexae, which is due to a high variability in clinical, histological and immunohistochemical characteristics often challenging to diagnose.

METHODS

Records of six patients with SGC were reviewed, who underwent surgical excision and who were histologically diagnosed with SGC. For comparison, there were specimens from four patients with basal cell carcinoma (BCC) and four patients with squamous cell carcinoma (SCC). Histological and immunohistochemical analysis included stains for HE, cytokeratins (CKpan, Cam5.2), epithelial membrane antigen (EMA), androgen receptor (AR441), perforin and adipophilin.

RESULTS

SGC's were located in the upper (n = 2) or lower (n = 4) eyelid and were associated with various presenting clinical signs including chalazion-like lesions with pyogenic granuloma (n = 1), papillomatous conjunctival tumors (n = 3), a hyperkeratotic exophytic neoplasm (n = 1) and an ulcerating crusted lesion resembling chronic blepharitis (n = 1). The treatment was tumor resection, followed (if necessary) by adjuvant therapy with topical Mitomycin C (n = 2). Histologic characteristics included basophilic pleomorphic cells with vacuolated cytoplasm, prominent nucleoli, mitotic figures and in some cases pagetoid spread (n = 2). CKpan, EMA and Cam5.2 showed strong positive immunoreactivity in all specimens (SGC, BCC, SCC). Perforin immunostaining showed a varying, but overall weak, non-specific cytoplasmatic staining reaction in all lesions. AR441 positivity was noted with variable intensity in almost all lesions and in particular in pagetoid spread in contrast to non-tumor cells. Adipophilin showed an annular staining of lipid granules in immature sebaceous cells in SGC in contrast to a more granular staining pattern in BCC and SCC.

CONCLUSION

SGCs display a variety of clinical signs and may mimic many other lesions. Tumor resection, followed by histological and immunohistochemical analysis, leads to the diagnosis and initiation of the proper treatment regimen. Herein, immunohistochemistry showed an unequivocal profile in SGC and did not allow for an exact differentiation from BCC and SCC by immunohistochemical means only. An extended evaluation of HE stains remains essential. However, immunohistochemistry can make relevant contributions to the diagnosis of SGC, especially in cases of inconclusive histology, by positive staining for adipophilin in immature sebaceous cells or by AR441 labeling in cases of pagetoid spread.

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.