Neoplasias Sebaceas

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Histopathology. Author manuscript; available in PMC 2011 January 1.
Published in final edited form as:
NIH-PA Author Manuscript
Histopathology. 2010 January ; 56(1): 133–147. doi:10.1111/j.1365-2559.2009.03454.x.
Sebaceous neoplasia and the Muir–Torre syndrome: important

connections with clinical implications
Sara C Shalin, Stephen Lyle1, Eduardo Calonje2, and Alexander J F Lazar3
Department of Pathology, Baylor College of Medicine, Houston, TX and 1 Department of Cancer

Biology, University of Massachusetts Medical Center, Worcester, MA, USA 2 St John’s Institute of
Dermatology, St Thomas’ Hospital, London, UK 3 Departments of Pathology and Dermatology,
Section of Dermatopathology, The University of Texas M. D. Anderson Cancer Center, Houston,
TX, USA
Abstract
Sebaceous neoplasia comprises a spectrum ranging from benign to malignant. Proper histological
identification is important for treatment, prognosis and potential association with the Muir–Torre
syndrome (MTS). Our increased understanding of the significance and pathogenesis of these
tumours has led to improved risk stratification, screening recommendations, and treatment of
patients with an initial presentation of a sebaceous tumour. This review focuses on the diagnostic
and histological features of sebaceous lesions, the MTS, and recent insights into the molecular
pathogenesis of sebaceous tumorigenesis.
Keywords
mismatch repair deficiency; Muir–Torre syndrome; sebaceoma; sebaceous adenoma; sebaceous
carcinoma; sebaceous hyperplasia
Sebaceous glands
Sebaceous glands are associated with the hair follicle, arising at the junction of the inferior
portion of the follicle infundibulum and the isthmus. Normal sebaceous glands are
composed of lobular acini lined on the periphery by a thin layer of flattened to cuboidal
basaloid, or germinative, cells with scant cytoplasm (Figure 1A). The inner portions of
sebaceous glands are composed of mature sebocytes—cells with a centrally-located, often
scalloped or indented nucleus and multivacuolated cytoplasm due to the accumulation of
lipid secretions.1 Sebaceous glands, found in higher concentrations on the head and neck
region, are responsible for the production of sebum, a lipid-rich secretion with a variety of
postulated functions.2, 3 These structures are androgen-sensitive and typically become more
prominent during puberty.4 Developing sebaceous glands have been shown to variably
express cytokeratin (CK) 15, which marks potential multipotent stem cells of the
pilosebaceous unit and more recently has been shown to be present within sebaceous
neoplasms as well.5, 6
Address for correspondence: Alexander Lazar, MD/PhD, The University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe
Blvd- Unit 85, Houston, TX 77030-5009, USA. alazar@mdanderson.org.
Shalin et al. Page 2
Ectopic sebaceous glands

Although most often associated with hair follicles, ectopic sebaceous glands arising
independent of follicular structures are well described. These lesions may arise as small 1–3-
mm yellow-to-white papules occurring on mucosal surfaces, namely the lips and genital
regions, where they are referred to as Fordyce spots. Similar lesions on the female breast are
called Montgomery tubercles. These are common enough at these sites in the population that
they can be considered variants of normal. Ectopic sebaceous glands arising in a variety of
more unusual locations, including the oesophagus, vagina, cervix, thymus and penis, have
been the subject of numerous case reports.7–12 These generally appear to be of no
consequence.
Sebaceous hyperplasia
Sebaceous hyperplasia is the benign overabundance of normal-appearing sebaceous lobules.
Clinically, these lesions are small, usually < 5 mm in greatest dimension. They are generally
flesh-coloured papules, usually with a central depression or umbilication. Their clinical
appearance, along with their predilection for the face, is the basis for periodic clinical
confusion with basal cell carcinoma. Histological examination of these lesions reveals
superficial sebaceous lobules surrounding a centrally dilated pore or follicular structure, the
correlate of the central umbilication13 (Figure 1B). Sebaceous lobules are increased in
number but not dramatically in size, occupy a more superficial position in the dermis, but
have only two layers of peripherally located basaloid or germinative cells. Treatment of
sebaceous hyperplasia is not required, but may be achieved with conservative excision if it
becomes a cosmetic issue or clinically confused with a more concerning lesion.
The development of sebaceous hyperplasia has been associated with immunosuppression,

specifically noted to occur in renal transplant patients treated with cyclosporin.14–16
Although the pathogenesis of sebaceous hyperplasia is not well understood and its origin as
either a reactive or neoplastic process is not well established, possible contributing factors
may include androgenic stimulation, ultraviolet radiation, and immunosuppression.14
Unlike many of the entities discussed subsequently, sebaceous hyperplasia does not appear
to be definitively linked to Muir–Torre syndrome (MTS). Deficits in mismatch repair genes,
a frequent finding in cases of MTS, are generally not identified in cases of sebaceous
hyperplasia.17, 18 Case reports documenting an association between sebaceous hyperplasia
and internal malignancy are found within the literature;19 however, these reports may
simply reflect the underlying frequency of this diagnosis within the general population.
Sebaceous adenoma
Sebaceous adenomas are benign sebaceous tumours that clinically appear as tan, pink, or
yellow nodules or papules, usually about 5 mm in greatest dimension. Like most sebaceous
proliferations, these tumours typically arise on the head and neck regions of older
individuals, although occurrence in many other locations has been documented.20–22
Sebaceous adenomas maintain a lobular and organoid architecture, and often show
connection with or replacement of the overlying squamous epithelium (Figure 2A). There is
an expansion and increased prominence of the peripherally located basaloid cells compared
with sebaceous hyperplasia23 (Figure 2). This increase in the number of germinative cells is
a key discriminator between the categories of sebaceous hyperplasia and sebaceous
adenomas or sebaceomas. Sebaceous adenomas show variably expanded basaloid cells, with
more than the normal two cell layers seen in normal sebaceous glands and sebaceous
hyperplasia, but by convention are < 50% of the tumour cell volume (> 50% basaloid cell
content is seen in sebaceoma). Sebaceous adenomas thus also maintain a prominent
population of mature sebocytes often concentrated in the central portion of the neoplasm,

making their sebaceous differentiation conspicuous in most cases and imparting an organoid
quality to the tumour. Noticeable cytological atypia or significantly increased mitotic rate
should prompt a re-evaluation of the diagnosis, as these features are generally minimal.23–
25 These tumours are well circumscribed and often lobular.
Clinically, sebaceous adenomas may be mistaken for basal cell carcinoma. Histologically,
the differential diagnosis of sebaceous adenoma includes other lesions with clear cytoplasm,
including clear cell variations of eccrine, melanocytic, keratinocytic or xanthomatous
lesions, as well as metastatic lesions such as renal cell carcinoma, or perhaps other lesions
with sebaceous differentiation. The characteristic bubbly or multivacuolated cytoplasm and
crenated nuclei of mature sebocytes coupled with the germinative cells should be helpful
features on histological examination (Figure 2D), but immunohistochemical staining may be
helpful for particularly difficult lesions (further discussion below).
Sebaceous adenomas are felt to be benign lesions, yet common practice is complete
extirpation by conservative excision. The established association between the presence of
sebaceous adenomas and MTS deserves reference within issued pathology reports so that
patients can be appropriately evaluated for possible additional syndrome findings as
discussed further below.
Sebaceoma
Clinically, sebaceomas appear similar to sebaceous adenomas, although perhaps slightly

larger in size, ranging from 5 to 30 mm in greatest diameter with a fleshy yellow to orange
colour. Similar to other sebaceous tumours, these lesions typically arise in the head and neck
region.26, 27
The histology of sebaceoma differs from that of sebaceous adenoma in that the germinative,
basaloid cells predominate over the mature sebocytes, with > 50% of the tumour cells being
basaloid (Figure 3). Furthermore, sebaceomas typically lose the organoid quality seen in
sebaceous adenomas, resulting in a seemingly haphazard placement of mature sebocytes
without the sense of central maturation usually encountered in adenomas. Mature sebocytes
may be focal and scarce (Figure 3B). Sebaceomas can rest entirely within the dermis or
display overlying connection to the epidermis. Ductal structures and squamous
differentiation may also be present.28 Despite the loss of organoid quality, these lesions
generally maintain circumscription and symmetry.28 Mitotic figures may be present within
the basaloid cells, but the lesions maintain an overall well-circumscribed architecture
without significant cytological atypia. More recently, cytological atypia and mitoses,
including atypical forms, have been suggested to occur rarely in sebaceous neoplasms that
are otherwise characteristic of benign sebaceomas, although this has been accompanied with
controversy.24, 25 Of note, sebaceomas (and sebaceous lesions in general) do not display

peripheral pallisading of basaloid nuclei or the retraction from the surrounding stroma that is
present in basal cell carcinomas, which may aid in distinguishing these lesions.27–29
Additionally, various histological patterns have been described within the spectrum of
sebaceomas, including carcinoid-like, rippled and reticulated patterns.30–32
Sebaceomas are generally treated by conservative excision. Like sebaceous adenomas,

sebaceomas are considered part of the spectrum of MTS. Clinically and histologically,
sebaceomas have overlap with sebaceous adenomas and together form the benign end of the
spectrum of sebaceous neoplasia associated with the MTS. While the many similarities
between these two tumours suggest that they could be conceptualized as a continuum of
sebaceous neoplasia, it is appropriate to distinguish sebaceoma because the higher basaloid
content can cause confusion with non-sebaceous tumours such as basal cell carcinoma and
also sebaceous carcinoma.

Other sebaceous lesions and terminology

Numerous additional terms have been introduced into the literature, which may encompass
the various sebaceous neoplasms. These terms, including “sebaceous epithelioma” and
“sebomatricoma”, have variably included sebaceous adenomas, sebaceomas, and non-
sebaceous tumours such as basal cell carcinoma with sebaceous differentiation. In addition
to a lack of well-defined diagnostic features for these lesions, there has also been
disagreement and confusion regarding malignant potential, particularly in the case of the
sebaceous epithelioma.33–35 Furthermore, these broad terms do not clearly distinguish the
sebaceous tumours most likely to be associated with the MTS35. These terms do have some
limited degree of support within the literature, but the terms sebaceous adenoma and
sebaceoma as defined above will encompass the vast majority of benign sebaceous lesions
encountered, although the histological spectrum certainly admits to variation. Conceptually,
one could certainly view sebaceomas as “cellular” sebaceous adenomas given their similar
clinical contexts and significance. However, sebaceoma is a well-defined entity and it
recognizes lesions with prominent basaloid features and sometimes more prominent mitoses
as benign and markers of the MTS.
Other rare sebaceous neoplasms include superficial epithelioma with sebaceous

differentiation and mantleoma. Superficial epithelioma with sebaceous differentiation is
rarely described, but a recent report suggests that it may be more common than previously
thought.35, 36 It is a benign entity composed of a plate-like epidermal growth with
thickened, anastamosing rete ridges and interposing lobules of basaloid cells and mature
sebocytes.36, 37 Mantleoma is described as a benign folliculocentric tumour with sebaceous
differentiation that is thought to replicate the follicular mantle.38 Fibrofolliculomas and
trichodiscomas, benign tumours seen in Birt–Hogg–Dube syndrome, are considered by some
to show mantle differentiation as well, and may represent overlap with mantleoma.39
Perhaps due to their rarity, neither superficial epithelioma with sebaceous differentiation nor
mantleoma has a well-defined relationship with MTS, although one patient with superficial
epithelioma with sebaceous differentiation reported an internal malignancy.36
Sebaceous carcinoma
Sebaceous carcinomas are traditionally segregated into two categories: periocular and
extraocular. The distinction is important, as malignant sebaceous tumours are more likely to
occur in the periocular region (as opposed to adenomas or sebaceomas), and these appear to
be less often associated with MTS than their extraocular counterparts.40
Periocular sebaceous carcinoma

Sebaceous carcinomas of the periocular region can arise from the meibomian glands, the
glands of Zeis, or sebaceous glands of the eyelid. These tumours comprise approximately
three-quarters of all sebaceous carcinomas, arising between the sixth and eighth decades of
life with an equal gender distribution in the contemporary literature.41–43 They are the
second or third most common eyelid malignancies after basal cell carcinoma (and squamous
cell carcinoma), depending on the published series.44, 45 A recent large retrospective study
on the epidemiological factors of sebaceous carcinoma noted a decreased incidence in
persons with black skin.40 Clinically, sebaceous carcinoma may appear as a painless,
rounded nodule, more often on the upper eyelid and usually without ulceration (Figure 4A).
Periocular sebaceous carcinoma may be mistaken clinically for an inflammatory condition
such as chalazion or blepharoconjuntivitis, resulting in delay in diagnosis. Misdiagnosis as a
more indolent malignancy such as squamous or basal cell carcinoma can lead to suboptimal
initial clinical management.41, 46, 47 A “tigroid” appearance of the conjunctiva near the
eyelid margin, due to excreted lipid material from sebaceous ducts, may alert the clinician to

the possibility of a sebaceous carcinoma.42 Metastatic spread to lymph nodes is not

uncommon, and mortality has been reported up to 20%.48 More recent retrospective studies
indicate considerably lower mortality, perhaps owing to earlier recognition allowing
application of more effective local excision.41, 42
Histologically, periocular sebaceous carcinomas often demonstrate an infiltrative

architectural pattern within the dermis and extension into the superficial skeletal muscle and
subcutis of the eyelid. The tumour cells are enlarged and sometimes pleomorphic basaloid
cells with hyperchromatic nuclei and frequent mitotic figures, some of which may be
atypical (Figure 4). Depending on the degree of differentiation, sebaceous carcinomas may
show obvious or only focal mature sebocytes49. Intraepithelial or pagetoid spread is a
frequent feature that is rarely encountered in extraocular cases (Figure 4C). In interpreting
small biopsy specimens, it should be noted that benign sebaceous neoplasms are not
common in the periocular region, and the identification of sebaceous differentiation in such
a lesion should prompt strong consideration of malignancy.26
Extraocular sebaceous carcinoma

Extraocular sebaceous carcinoma is less common than its periocular counterpart, generally
still arising in the head and neck region, although other sites, including the nipple, thorax,
back, and penis, have been reported.41, 50–52 Like periocular sebaceous carcinoma,
extraocular carcinoma can be an aggressive malignancy, with varying reports as to the

incidence of metastasis and mortality.23, 41, 52 The rarity of this tumour and likely referral
bias in published series has complicated assignment of the aggressiveness of this tumour.
Clinically, these lesions may be similar to the periocular carcinomas, presenting as an

erythematous nodule or papule with or without ulceration. While many of these lesions have
both poorly circumscribed architecture and significant atypia, including pleomorphic,
enlarged basaloid cells, frequent and atypical mitoses, and foci of necrosis, some lesions
display only one or the other feature (Figure 5A). The presence of either an infiltrative
growth pattern or extreme cytological atypia should prompt the diagnosis of malignancy.24,
26 Mature sebocytes may be only focally noted and the nuclei often lack the distinctly
crenulated features seen in mature sebocytes (Figure 5B, compare with Figure 1A). Unlike
periocular disease, pagetoid spread is rare in extraocular sebaceous carcinomas.
Sebaceous carcinomas have been treated with a wide-ranging spectrum of treatment

modalities, including wide excision, adjunctive radiotherapy, and even orbital exenteration.
41, 42 More recently, Moh’s microsurgery has been performed on periocular sebaceous
carcinomas with the purported advantage of normal tissue sparing and apparently favourable
outcomes, although longer follow-up is needed.47
The use of immunohistochemistry in sebaceous neoplasia

Although the identification of unequivocal sebaceous differentiation on routine histological
examination alone will usually suffice, there are certain circumstances when the use of
immunohistochemistry may facilitate diagnosis. Several readily available
immunohistochemical stains, although non-specific, may also be helpful in the
determination of sebaceous origin. The mature sebocytes are positive for epithelial
membrane antigen (EMA) and negative for carcinoembryonic antigen. CK7 is generally
positive in the basaloid cells of sebaceous tumours.5, 53
Sebaceous tumours, because of their intracytoplasmic lipid content, will stain with Oil Red
O; however, application requires frozen tissue, as standard histological processing
eliminates lipid content.26 This stain can be rapidly performed on perioperative frozen

sections. More recently, the use of adipophilin, a protein associated with lipid vesicles, has
been described as useful in the identification of sebaceous differentiation54–56 (Figure 6).
Because of the contribution of androgen hormones to the activation of sebaceous glands,
immunostaining against the androgen receptor has also been reported as a method to
determine sebaceous differentiation.4 This stain may be particularly helpful in poorly
differentiated sebaceous carcinomas, which may lack staining for EMA and other markers,
but additional demonstrations of specificity are needed.4
Though few well-documented cases exist, basal cell carcinomas with sebaceous
differentiation frequently enter the differential diagnosis of sebaceous neoplasms,
particularly sebaceoma.29 Although the histological processing artefact of tumour retraction
from fibromyxoid stroma also indicates basal cell carcinoma, several immunostains have
been proposed to aid in differentiating these lesions. The use of EMA and Ber-EP4
immunostaining was investigated and found to be useful in the distinction between these
lesions. Nodular-type basal cell carcinomas were typically moderately or strongly positive
for Ber-EP4 and sebaceomas were almost always negative for this marker, while EMA
staining shows the opposite pattern of reactivity.57, 58 Podoplanin (D2-40) is typically
weakly and focally positive at most in basal cell carcinomas but positive in sebaceous
lesions, particularly sebaceoma.59 CK19 has also been reported to be useful in
distinguishing these lesions, with basal cell carcinomas more often displaying strong
positivity, whereas sebaceous lesions display only focal immunopositivity.60 Most of the
studies supporting these stains are small, and multiple stains should be used in a panel to
support rather than overrule the initial histological impression.
Within the spectrum of sebaceous tumours, tumorigenic and proliferative immunomarkers

may help if the malignant potential of a lesion is unclear, although histological examination
is the best standard for this determination. One study has shown that sebaceous hyperplasia,
sebaceous adenomas, and sebaceomas tended to show low levels of p53 and Ki67 (Mib-1)
positivity, while sebaceous carcinomas tended to show higher levels of nuclear p53
expression and Ki67 positivity, as well as decreased Bcl-2 expression 61. Podoplanin
(D2-40) has also been suggested as a possible marker to distinguish benign from malignant
sebaceous tumours. Sebaceomas were found to be immunopositive for podoplanin in
basaloid cells. In contrast, most carcinomas tended to be either negative or only focally
positive, although some basaloid sebaceous carcinomas were immunopositive.59
Muir–Torre syndrome and sebaceous neoplasia

MTS refers to the independent descriptions made more than four decades ago by Drs Muir
and Torre of sebaceous neoplasms occurring coincident with internal malignancy. We now
understand this syndrome to represent a subset of the hereditary non-polyposis colorectal

carcinoma (HNPCC) syndrome. HNPCC is an autosomal dominant cancer predisposition
syndrome due to inheritance of a defective gene encoding a DNA mismatch repair protein.
Loss of wild-type allele leads to genomic microsatellite instability (MSI).62, 63 Although
initially reported having a predisposition solely to colorectal cancer, these patients actually
show an increased risk of various malignancies, including endometrial, ovarian,
genitourinary, and small bowel cancers. Multiple primary tumours are common, and patients
typically present at earlier age with malignancy.62 Many of these patients demonstrate
germ-line mutations in genes encoding DNA mismatch repair proteins MLH1 or MSH2 and,
less commonly, MSH6, MSH3, MLH3, PMS1 and PMS2. These proteins function to detect
and repair errors in base pairing occurring during DNA replication, especially in regions of
DNA (microsatellites) characterized by repetitive mono- or dinucleotide repeats. Consistent
with the Knudson hypothesis, mismatch repair protein mutation, when paired with a second
somatic mutational “hit” of the remaining functional allele, leads to susceptibility to tumour

formation through the accumulation of base pair mismatches and increasing genomic
instability.64 The “second hit” may be through somatic mutation or methylation
suppression,65 although a small report has suggested that loss of heterozygosity by complete
allele loss is unlikely to be a common mechanism.66 Conceptually, mismatch repair genes

can be considered tumour suppressor genes.
MTS comprises a small subset (1–3%) of HNPCC families and is characterized by

sebaceous tumours or perhaps keratoacanthomas preceding or existing coincidently with
visceral malignancies.67 Because the sebaceous lesions may be the presenting feature of a
patient with MTS, increasing reports are being published regarding recommendations for
patient screening following the diagnosis of a sebaceous tumour.17, 68–72 The diagnosis of
a sebaceous neoplasm should prompt additional clinical and/or laboratory screening, and a
currently accepted method to evaluate for the functional status of mismatch repair proteins
within the sebaceous tumour is the use of immunohistochemistry with antibodies against the
commonly encountered lost mismatch repair proteins, MSH2 and MLH1, sometimes with
MSH6 as well17, 68–72 (Figure 7). A lack of nuclear imunoreactivity within tumour cells is
supportive of a mutation in the gene and has been shown to correlate well with high levels of
MSI, as assessed by the gold standard of polymerase chain reaction-based amplification and
chromatographic or electrophoretic assessment of multiple, defined microsatellite regions of
DNA73–76 (Figure 8).
Although all types of sebaceous neoplasms (with the exception of strictly defined sebaceous
hyperplasia) have been the subject of reports linking them to MTS,77–80 more recent
literature has attempted to better define a genotype–phenotype correlation of the syndrome
by confirming the presence of mutations in mismatch repair gene or loss of the encoded
proteins within sebaceous neoplasms. Interestingly, in contrast to the colorectal carcinomas
of HNPCC, the sebaceous neoplasms implicated in MTS more often display loss of MSH2
much more commonly than MLH1.17, 71, 81, 82 Isolated mutations in MSH6 are noted
exceptionally,82 but MTS has not yet been linked to isolated loss of MSH3 or PMS1. Only a
subset of sebaceous neoplasms demonstrate evidence of mismatch repair deficiency
determined by various tests, ranging from 26 to 59% overall with obvious referral bias in the
published series.17, 71, 72 Interestingly, benign sebaceous lesions (sebaceous adenomas and
sebaceomas) have been shown to have significantly higher rates of mutations than
carcinomas—either extraocular or periocular.17, 18, 82 Moreover, several reports have now
documented that loss of mismatch repair proteins is more common in sebaceous tumours
occurring outside of the head and neck region and may more strongly suggest MTS.17, 18,
71 Strong indicators of MTS include multiple sebaceous neoplasms, but only a single
cutaneous tumour can herald the syndrome. Alternative mechanisms of pathogenesis within
the spectrum of MTS may exist, since not all patients with sebaceous neoplasia and a
characteristic internal malignancy display MSI.
Additional morphological properties have been suggested to correlate with syndrome-

associated sebaceous lesions. Keratoacanthoma-like and cystic change had both been
proposed as occurring more frequently in MTS-associated sebaceous lesions83, 84 (Figure
9). However, a recent report did not find cystic change to be statistically associated with
sebaceous tumours demonstrating loss of mismatch repair protein expression, but additional
study is needed.17 More recently, the presence of increased intratumoral lymphocytes has
been shown to correlate with MSI, similar to the feature commonly seen in colorectal
carcinomas associated with MSI.71, 85
Interestingly, mutations in the genes for mismatch repair proteins may not be the only
mechanism by which to obtain an MTS phenotype. Mutations in the gene MYH, inherited in
an autosomal recessive manner, result in an attenuated gastrointestinal polyposis phenotype,

with patients showing an increased risk of colorectal carcinoma and other cancers.86 The
protein product of MYH is involved in DNA base excision repair following DNA oxidative
damage. Several case reports have now noted the presence of sebaceous neoplasms in
patients with MYH-associated polyposis syndrome, and one paper established that these
sebaceous lesions did not exhibit MSI.87–89
Dissecting the molecular pathogenesis of sebaceous tumours

Efforts to understand the molecular pathogenesis of MTS, sebaceous neoplasia, or cutaneous
neoplasms in general have resulted in numerous transgenic mouse models. MSH2-deficient
mice, developed as a model of HNPCC, develop sebaceous tumours with MSI, mimicking
the MTS.90 MSH6-deficient mice also are reported to develop skin tumours, although
sebaceous differentiation was not specifically reported.91 The mechanisms by which the
genomic instability accompanying loss of mismatch repair proteins promotes sebaceous
tumorigenesis are not understood.
Other mouse models that develop sebaceous tumours have provided additional and
serendipitous insights into the molecular pathogenesis of sebaceous tumours. Wnt and β-
catenin signalling are integral for the proper differentiation of various tissues, and alterations
of these signalling pathways have been linked to a variety of skin and non-cutaneous
tumours.92 Cellular β-catenin levels are tightly regulated, existing in both cytosolic and
nuclear compartments. Activation of Wnt signalling causes translocation of β-catenin to the
nucleus, where it binds to proteins such as lymphocyte enhancing factor 1 (Lef-1) to permit
gene transcription (Figure 10). Activating β-catenin mutations are seen in hair follicle
tumours such as pilomatrixomas, along with up-regulation of sonic hedgehog signalling.93–
95 Conversely, a transgenic mouse expressing a defective β-catenin binding site in the Lef-1
protein (with resulting inability to activate transcription) spontaneously developed sebaceous
skin tumours.96 These Lef-1 transgenic mice show up-regulation of Indian hedgehog
protein expression (rather than sonic hedgehog), which promotes proliferation of sebaceous
precursor cells.95 Further work by this group has provided a model whereby levels of β-
catenin drive lineage specification during development. The subsequent correlate is that
aberrations in β-catenin and hedgehog signalling pathways may promote various cutaneous
tumour types.97 Notably, dual mutations in the same allele of LEF1 were found in one-third
of examined human sebaceous adenomas and sebaceomas, resulting in impaired β-catenin
binding and decreased transcriptional activity98 (Figure 10A,B). Thus, this pathway is
believed to be contributory to sebaceous tumour formation, although all of the downstream
effects have not been elucidated.
The FHIT gene encodes a member of the histidine triad proteins and appears to function as a
tumour suppressor.99 Transgenic mice heterozygous for Fhit develop a spectrum of

gastrointestinal malignancies and sebaceous lesions when exposed to carcinogens.
Importantly, these tumours do not exhibit MSI.100 Fhit has been linked to apoptosis, with
FHIT mutations resulting in defective programmed cell death 99, and, more recently, Fhit
has been shown to exert a repressive function on β-catenin transcriptional activity.101, 102
FHIT mutations have been documented in human periocular sebaceous carcinomas both
with and without concomitant MSI,103, 104 thus providing additional support for the
complex role of β-catenin signalling in sebaceous tumorigenesis.
No discussion of tumorigenesis is complete without mention of p53, the original tumour

suppressor and “guardian of the genome”. When activated by cell damage, p53 degradation
is decreased, with resultant increased transcriptional activation of genes that function in cell
cycle arrest and apoptosis programs. Mutations in the DNA binding regions of p53 are
common in skin cancers, with ultraviolet irradiation inducing predictable mutations that

promote tumour formation by the inability to halt the cell cycle or induce apoptosis.105
Some sebaceous neoplasms, particularly carcinomas, have been shown to display increased
nuclear immunoreactivity for p53, which can correlate with mutation and/or dysregulation
of p53 signalling46, 61, 97, 106 (Figure 4D). Conversely, sebaceous tumours from
transgenic Lef-1 mutated mice consistently showed an absence of p53 protein by
immunohistochemical staining, which correlated with down-regulation of the binding
partner ARF.97 These findings were hypothesized to result in tumour promotion by
preventing nuclear accumulation and appropriate transcriptional activation of pro-apoptotic
genes by p53. Thus, p53 signalling alterations may represent an early, primary event in a
subset of sebaceous malignancies (those with nuclear accumulation of p53), while being a
downstream, secondary effect within other sebaceous tumours (those with inactivating LEF1
mutations).
Summary
Sebaceous lesions encompass a spectrum from benign, cosmetically bothersome
hyperplasias to aggressive carcinomas. Most commonly found in the head and neck region,
these lesions are united by the presence of some degree of sebaceous differentiation. The
mature sebocyte shows vacuolated cytoplasm and crenulated nuclear contours, although
immunohistochemistry to identify intracytoplasmic lipid or to support sebaceous
differentiation may be helpful in challenging cases.
Accurate identification of sebaceous lesions is important, as the diagnosis may indicate

MTS. Lesions associated with MTS frequently demonstrate mutations in genes encoding
DNA mismatch repair proteins, resulting in MSI. Although MTS-associated lesions may be
predicted by features such as tumour type (sebaceous adenoma or sebaceoma) and site (non-
head or neck location), and perhaps by morphological features such as intratumoral
lymphocytes, the identification of any sebaceous neoplasm should prompt consideration for
screening for MTS. Periocular sebaceous carcinoma is much less commonly associated with
MTS. Immunohistochemistry to evaluate the status of mismatch repair protein expression is
increasingly used on a routine basis on these tumours.71, 72
The molecular pathogenesis of sebaceous neoplasia is still being dissected. Alterations in

Wnt/β-catenin, Indian hedgehog, and p53 signalling pathways have been implicated, along
with mutations in numerous tumour suppressor genes such as FHIT, DNA mismatch repair
genes, and P53 itself. Further research will elucidate additional pathways. Improved
understanding of the normal cutaneous developmental biology is providing key insights into
the biological basis for these tumours, with hope of eventually establishing new strategies
for prevention and treatment92, 107, 108 (Figure 10C).
Acknowledgments
This work is supported by the US National Institutes of Health (1R01CA118916, S.L. & A.J.F.L.) and the M. D.
Anderson Physician Scientist Grant (A.J.F.L.). Mz. Kim Vu is thanked for expert aid in figure preparation.
Abbreviations
CK cytokeratin
EMA epithelial membrane antigen
HNPCC hereditary non-polyposis colorectal carcinoma
Lef-1 lymphocyte enhancing factor 1

MSI microsatellite instability

MTS Muir–Torre syndrome
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Figure 1.
a, Benign sebaceous lobules are bounded by a double-layered rim of small basaloid
epithelial cells. b, Sebaceous hyperplasia reveals multiple prominent sebaceous lobules
surrounding a central dell. The normal follicle and sebaceous lobules on the left illustrate
that the lobules in sebaceous hyperplasia are more superficial than normal glands.

Figure 2.
a, Sebaceous adenoma with multilobular architecture and a smooth base.
b, Higher power of a sebaceous adenoma reveals an expanded peripheral basaloid
component. c, The expansion of the basaloid component can be more subtle in sebaceous
adenoma and is often accompanied by an increased prominence of the basaloid cells as well
as an expansion of the number of cells. d, The cellularity of sebaceous adenomas ranges
from more peripheral germinative basaloid cells to more central mature sebocytes with
crenulated nuclei.

Figure 3.
a, Sebaceomas are well-circumscribed and composed primarily of basaloid cells. b, The
mature sebaceous component in sebaceoma can be rather focal.

Figure 4.
a, Periocular sebaceous carcinoma involving the lower eyelid. b, Full-thickness eyelid
excision revealing sebaceous carcinoma involving the cutaneous portion of the eyelid (upper
right). The mucosal surface is below. c, Periocular sebaceous carcinoma with pagetoid
involvement of the overlying epithelium. d, Strong, nuclear p53 expression detected by
immunohistochemistry in a periocular sebaceous carcinoma. Clinical photograph courtesy of
Dr Bita Esmaeli, UT-M. D. Anderson Cancer Center, Houston, TX, USA.

Figure 5.
a, Extraocular sebaceous carcinoma showing scattered pleomorphic cells. b, Sebaceous
differentiation can be focal.

Figure 6.
Adipophilin immunohistochemistry in a normal sebaceous gland (a), sebaceoma (b) and
periocular sebaceous carcinoma (c). It is important to identify the individual outlines of the
membranes that surrounded the lipid globules within the cells for specificity. The numbers
of globules will vary and are often less in number in sebaceous carcinomas with limited
sebaceous differentiation.

Figure 7.
The sebaceous tumour (a) from this Muir–Torre patient shows nuclear expression of MLH1
(b) with loss of MSH2 (c) on immunohistochemistry. The overlying epidermis serves as an
internal positive control.

Figure 8.
The BAT26 microsatellite shows increased variability in a sebaceous tumour from a Muir–
Torre patient (lower panel) compared with normal tissue from the same patient (upper
panel). This DNA-based test uses polymerase chain reaction amplification of specific loci
with chromatographic determination of amplicon sizes to detect alterations in the length of
the tested microsatellite.

Figure 9.
a, Sebaceous adenoma with cystic features. b, Sebaceous adenoma with keratoacanthoma-
like architecture. Both of these features are thought to more specifically suggest the Muir–
Torre syndrome, but more study is needed.

Figure 10.
Dual inactivating mutations in the LEF-1 transcription factor have been documented in
benign sebaceous neoplasms (a) leading to an attenuation of Wnt signalling in tumour cells
(b). This not only promotes sebaceous differentiation, but also inhibits p53-mediated
senescence and apoptosis. c, Cutaneous stem cells reside in a specialized tissue “niche” and
are responsible for development and regeneration of epithelial structures including the
epidermis, follicle and sebaceous gland under the influence of various signalling pathways
(left). Mutations and resulting dysregulation of many of these same pathways appear to be
involved in the generation of various cutaneous tumours such as that illustrated for
sebaceous tumours (right). SHH, sonic hedgehog; IHH, Indian hedgehog; PTCH, patched.

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Histopathology. 2010 January ; 56(1): 133–147. doi:10.1111/j.1365-2559.2009.03454.x.

Sebaceous neoplasia and the Muir–Torre syndrome: important

Department of Pathology, Baylor College of Medicine, Houston, TX and 1 Department of Cancer

Ectopic sebaceous glands

The development of sebaceous hyperplasia has been associated with immunosuppression,

Histopathology. Author manuscript; available in PMC 2011 January 1.

25 These tumours are well circumscribed and often lobular.

Clinically, sebaceomas appear similar to sebaceous adenomas, although perhaps slightly

controversy.24, 25 Of note, sebaceomas (and sebaceous lesions in general) do not display

Sebaceomas are generally treated by conservative excision. Like sebaceous adenomas,

Histopathology. Author manuscript; available in PMC 2011 January 1.

Other sebaceous lesions and terminology

Other rare sebaceous neoplasms include superficial epithelioma with sebaceous

Periocular sebaceous carcinoma

Histopathology. Author manuscript; available in PMC 2011 January 1.

the possibility of a sebaceous carcinoma.42 Metastatic spread to lymph nodes is not

application of more effective local excision.41, 42

Histologically, periocular sebaceous carcinomas often demonstrate an infiltrative

Extraocular sebaceous carcinoma

extraocular carcinoma can be an aggressive malignancy, with varying reports as to the

Clinically, these lesions may be similar to the periocular carcinomas, presenting as an

Sebaceous carcinomas have been treated with a wide-ranging spectrum of treatment

The use of immunohistochemistry in sebaceous neoplasia

Histopathology. Author manuscript; available in PMC 2011 January 1.

Within the spectrum of sebaceous tumours, tumorigenic and proliferative immunomarkers

Muir–Torre syndrome and sebaceous neoplasia

understand this syndrome to represent a subset of the hereditary non-polyposis colorectal

Histopathology. Author manuscript; available in PMC 2011 January 1.

allele loss is unlikely to be a common mechanism.66 Conceptually, mismatch repair genes

MTS comprises a small subset (1–3%) of HNPCC families and is characterized by

characteristic internal malignancy display MSI.

Additional morphological properties have been suggested to correlate with syndrome-

Histopathology. Author manuscript; available in PMC 2011 January 1.

Dissecting the molecular pathogenesis of sebaceous tumours

tumour suppressor.99 Transgenic mice heterozygous for Fhit develop a spectrum of

No discussion of tumorigenesis is complete without mention of p53, the original tumour

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