Transcript NS-LIJ Powerpoint Template

What exactly is sebaceous
adenoma?
Sheng Chen, MD, PhD
Dept of Pathology
North Shore-LIJ Health System, NY
What is your diagnosis?
 Sebaceous adenoma
 Sebaceous carcinoma
 Sebaceous neoplasm
 Adenoma vs. carcinoma
Definition of terms
 Adenoma
 Benign neoplasm of glandular tissue
 Carcioma
 Malignant epithelial neoplasm, when
used unmodified usually meaning
invasive carcinoma
Historical Perspective
 1974: Rulon and Helwig. Cutaneous
sebaceous neoplasms. Cancer.
Historical Perspective
 95 cases, extraocular
 46 classified as seb adenoma
Rulon and Helwig. Cutaneous sebaceous
neoplasms. Cancer, 1974
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
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
Historical Perspective
 Textbooks
 Weedon’s
 Lever’s
 WHO
A. B. Ackerman
(1936 – 2008)
Bernie’s view
 Ackerman
 Seb adenoma until
1998
Bernie’s view
 1998: Nussen and Ackerman.
Sebaceous “adenoma” is sebaceous
carcinoma. Dermatopath: Prac &
Conc.
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.
Bernie’s view
 Reasons for the conclusion
1. Confluence of aggregations of neoplastic cells
that results in an anastomosing pattern
2. Crowded nuclei of immature sebocytes
3. Slight pleomorphism of nuclei of immature
sebocytes
4. Heterochromia of nuclei of immature sebocytes
5. Many sebocytes, especially immature ones but
even some mature ones, in mitosis
6. Some mitotic figures abnormal
7. Many individual sebocytes necrotic as indicated
by pyknosis and karyorrhexis
8. Incipient necrosis en masse sometimes
Nussen and Ackerman. Sebaceous “adenoma” is
sebaceous carcinoma. Dermatopath: Prac & Conc, 1998.
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.
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.
2009
Which one?
Seb adenoma?
Seb carcinoma?
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
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 MuirTorre 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
Same lesion, different diagnosis
 Sebaceous adenoma
 Sebaceous carcinoma
 Sebaceous neoplasm
 Adenoma vs. carcinoma
A different view
 Seb adenoma is really seb carcinoma
in situ
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
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
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
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.
"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
Seb carcinoma in situ
 Reflect the true nature
 Leads to correct management
 Simple excision brings 100% cure
Conclusion
 In summary, for the reasons stated
here, the so-called sebaceous
adenoma, is neither adenoma nor
invasive carcinoma, but sebaceous
carcinoma in situ.