What exactly is sebaceous adenoma?

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

9. What is your diagnosis? • Sebaceous adenoma • Sebaceous carcinoma • Sebaceous neoplasm • Adenoma vs. carcinoma

10. Definition of terms • Adenoma • Benign neoplasm of glandular tissue • Carcioma • Malignant epithelial neoplasm, when used unmodified usually meaning invasive carcinoma

11. Historical Perspective • 1974: Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer.

12. Historical Perspective • 95 cases, extraocular • 46 classified as seb adenoma Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer, 1974

13. Historical Perspective • Seb adenoma, clinical • Distribution: 70% head • M:F = 2.5:1 • Size: 46% <5 mm, rare >5 cm • Duration: months to years • Mean age: 60.5 yrs • F/U ranging 0.5 to 18 yrs • 3 recurrence and no metastasis Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer, 1974

14. Historical Perspective • Seb adenoma, microscopic • Multilobulated • Often replace epidermis • Sharp circumscription, often with capsule • Presence of maturing seb cells • Nuclei enlarged, may contain nucleoli • Slight nuclear pleomorphism • Occasional mitotic figures Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer, 1974

19. Historical Perspective • Textbooks • Weedon’s • Lever’s • WHO

20. A. B. Ackerman (1936 – 2008)

21. Bernie’s view • Ackerman • Seb adenoma until 1998

22. Bernie’s view • 1998: Nussen and Ackerman. Sebaceous “adenoma” is sebaceous carcinoma.Dermatopath: Prac & Conc.

23. Bernie’s view “In the course of preparation of a second edition of a volume titled Neoplasms with Sebaceous Differentiation, we… were struck by the illogic of the judgment that the cystic sebaceous neoplasm… was related to conventional sebaceous adenoma... Scrutiny again, after a period of several years, of examples of "cystic sebaceous adenoma" pictured in Neoplasms with Sebaceous Differentiation, 1994 (and in the book devoted to Clues to Diagnosis in Dermatopathology,1991) and of new biopsy material received in our laboratory, made us realize that the histopathologic features were not those of an adenoma, but of a very well differentiated carcinoma i.e., cystic sebaceous carcinoma.” Nussen and Ackerman. Sebaceous “adenoma” is sebaceous carcinoma. Dermatopath: Prac & Conc, 1998.

24. Bernie’s view • Reasons for the conclusion • Confluence of aggregations of neoplastic cells that results in an anastomosing pattern • Crowded nuclei of immature sebocytes • Slight pleomorphism of nuclei of immature sebocytes • Heterochromia of nuclei of immature sebocytes • Many sebocytes, especially immature ones but even some mature ones, in mitosis • Some mitotic figures abnormal • Many individual sebocytes necrotic as indicated by pyknosis and karyorrhexis • Incipient necrosis en masse sometimes Nussen and Ackerman. Sebaceous “adenoma” is sebaceous carcinoma. Dermatopath: Prac & Conc, 1998.

29. Bernie’s view “In short, in our judgment, so-called cystic sebaceous adenoma is really sebaceous carcinoma. Having concluded that, we began to rethink the subject of conventional, i.e., non-cystic, sebaceous adenoma and to review sections of specimens that had been given that designation, both in various publications and by us at our own microscope…In conclusion, we now think that what has long been known as ‘sebaceous adenoma’ is sebaceous carcinoma.” Nussen and Ackerman. Sebaceous “adenoma” is sebaceous carcinoma. Dermatopath: Prac & Conc, 1998.

30. Bernie’s view • 2009 - Hashmi and Ackerman • “We contend that…what universally is termed ‘sebaceous adenoma’ actually is a superficial sebaceous carcinoma.” Hashmi and Ackerman. New Insights: Sebaceous neoplasms in Muir-Torre syndrome—carcinomas all! Dermatopath: Prac & Conc, 2009.

31. 2009

32. Which one? Seb carcinoma? Seb adenoma?

33. Adenoma vs. carcinoma • Zelger and Hurt agreed with the view that the so-called seb adenoma is seb carcinoma • Hurt mentioned others’ disagreement • “In my experience talking with colleagues in the field, many do not hold this point of view.” Burgdorf, Zelger, Hurt. Book review. Dermatopathol: Pract and Conc, 2009

34. Adenoma vs.carcinoma • Burgdorf expressed uncertainty: • “An area where I both agree and disagree… is the nature of the sebaceous proliferations in Muir-Torre syndrome . . . They rely on a variety of histological features ranging for disordered overall architecture to increased mitoses to characterize all the sebaceous tumors in Muir-Torre syndrome as carcinomas. From a purely morphological viewpoint this may be correct, but it not true clinically as very few such lesions behave in a malignant fashion… We chose a neutral name because we realized the cytological features were disturbing but that the pattern of a solitary well-circumscribed tumor was benign.” Burgdorf, Zelger, Hurt. Book review. Dermatopathol: Pract and Conc, 2009

35. Same lesion, different diagnosis • Sebaceous adenoma • Sebaceous carcinoma • Sebaceous neoplasm • Adenoma vs. carcinoma

36. A different view • Seb adenoma is really seb carcinoma in situ

37. A different view • Why seb carcinoma in situ • architectural features of confinement • well defined border and smooth outline, findings indicating the neoplastic cells still confined in epithelium • cytologic features of malignancy • enlarging of nuclei, increase of n/c ratio, hyperchromasia, decrease of maturation, increase of mitotic activity

38. A different view • Why seb carcinoma in situ • architectural features of benignancy and cytologic features of malignancy • fit the exact definition of carcinoma in situ introduced by Broders in 1932

40. Historical Perspective • Seb adenoma, microscopic • Slight nuclear pleomorphism and occasional mitotic figures • “It is these features that make separation of the sebaceous adenoma from sebaceous carcinoma difficult, since the separation is made on the basis of these features as well as on a pattern of infiltrative growth. The latter criterion is subject to variation in interpretation.” Rulon and Helwig. Cutaneous sebaceous neoplasms. Cancer, 1974

41. Sir Percivall Pott • 1714 – 1788, was an English surgeon, one of the founders of orthopedic surgery, and the first scientist to demonstrate that a cancer may be caused by an environmental carcinogen.

42. "Clear and precise definition of disease, and the application of such names to them as are expressive of their true and real nature, are of more consequence than they are generally imagined to be; untrue or imperfect ones occasion false ideas, and false ideas are generally followed by erroneous practice." - Sir Percival Pott, 1765

43. Seb carcinoma in situ • Reflect the true nature • Leads to correct management • Simple excision brings 100% cure

44. Conclusion • In summary, for the reasons stated here, the so-called sebaceous adenoma, is neither adenoma nor invasive carcinoma, but sebaceous carcinoma in situ.