DR CIRO SOARES (Orcid ID : 0000-0002-6861-6640)

Accepted Article
Article type : Original Article

Sebaceous adenocarcinomas of the major salivary glands: a

clinicopathologic analysis of 10 cases

Short running title: Sebaceous adenocarcinomas of salivary gland origin

Ciro Dantas Soares1, Thayná Melo Lima Morais1, Roman Carlos2, Jacks Jorge 1, Oslei

Paes de Almeida1, Maria Goretti Freire de Carvalho3, Albina Messias Milani Altemani4

1. Department of Oral Diagnosis, Area of Pathology, Piracicaba Dental School,

University of Campinas, Piracicaba, São Paulo, Brazil.

2. Pathology Division, Centro Clínico de Cabeza y Cuello/Hospital Herrera

Llerandi, Guatemala City, Guatemala.

3. Private Pathology Service, Natal, Rio Grande do Norte, Brazil.

4. Department of Pathology, Faculty of Medical Sciences, University of Campinas,

Campinas, São Paulo, Brazil.

Financial support: FAPESP #2015/25905-1 and #2017/16102-8.

Corresponding Author:

Ciro Dantas Soares

This article has been accepted for publication and undergone full peer review but has
not been through the copyediting, typesetting, pagination and proofreading process,
which may lead to differences between this version and the Version of Record. Please
cite this article as doi: 10.1111/his.13664
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 Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas

Av. Limeira, 901, Areião - 13414-903 Piracicaba, SP, Brazil

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E-mail address: ciro.dss@gmail.com

Disclose any potential conflict of interest: The authors declare no conflict of interest.

Abstract

Aims: Sebaceous carcinomas are uncommon malignant cutaneous tumours originating

from the pilosebaceous unit. Although its occurrence is mostly common in periocular

glands, other anatomic regions of the head and neck may be affected, including major

and minor salivary glands.

Methods and results: We describe a series of sebaceous adenocarcinomas of the of the

parotid and submandibular glands. The mean age was 62.1 (31-90) years. Two patients

(20%) presented regional or distant metastasis to mandible and lungs. All cases were

positive for cytokeratins (AE1AE3 and CK-5), epithelial membrane antigen, and

adipophilin; negative for androgen receptor, Factor XIIIa, S-100, vimentin, and

perforin. MutL Homolog 1 (MLH1) and MutS Homolog 2 (MSH2) were expressed in

the nuclei of most tumour cells, and one case showed loss of MSH2 expression.

Proliferative index (assessed by Ki-67 expression) and microvessel density (CD34-

positive vessels) were higher in metastasis-associated cases. P63 expression was noticed

in the periphery of the tumour nests, in the basaloid cells, with a mean of 69.2% nuclear

positivity.

Conclusions: The sebaceous adenocarcinoma of salivary glands is considered rare and

may show an unfavourable outcome; therefore, its correct diagnosis may be

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 challenging. For this reason, immunohistochemical studies, the adipophilin, in

particular, constitute an important diagnostic tool.

Accepted Article
Keywords: Sebaceous adenocarcinoma, salivary glands, adipophilin.

Introduction

The sebaceous glands are exocrine glands of the skin found in high number on
the face and scalp1. It is a holocrine gland that secretes “sebum” that helps protecting
the skin against dehydration. Recently, it has been recognized as a delivery system of
antioxidants and antimicrobial lipids, highlighting its immunological effects2. Other
tissues may contain ectopic sebaceous glands, such as the parotid, submandibular and
minor salivary glands3,4. In the oral mucosa, sebaceous glands are named “Fordyce
granules”5.

Sebaceous gland lesions range from reactive hyperplastic conditions, to benign

and malignant tumours6, which may rarely be associated with the Muir-Torre syndrome,
a subset of Lynch syndrome, often called hereditary nonpolyposis colorectal cancer7,8.
Patients with Muir-Torre syndrome demonstrate a benign or malignant sebaceous
neoplasm in association with visceral malignancies (colorectal, upper gastrointestinal,
endometrial and urological malignant neoplasms)9. This syndrome is very rare, with
about 205 cases reported to date; and frequently, the underlying genetic abnormality is a
germline mutation in the DNA mismatch repair (MMR) genes, particularly, the MutL
Homolog 1 (MLH1) and MutS Homolog 2 (MSH2)10.

The sebaceous carcinoma (SC) is uncommon and most cutaneous cases occur in
the periocular region6. In the past, SCs were divided into two main groups: (a)
periocular SC, corresponding to 75% of the cases showing an aggressive clinical
behaviour; and (b) extraocular SC, corresponding to 25% of the cases, with less
aggressive behavior11. However, it was demonstrated that both groups of SC may
present aggressive behaviour and potential for regional and/or distant metastasis12,13.
Although SCs most commonly involve the head and neck, its occurrence in salivary
glands is particularly rare14.

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 Sebaceous adenocarcinomas on major salivary glands are very rare and their
pathogenesis and biological behaviour is not yet well-established. To the best of our
knowledge, this is the largest series to analyse the clinical, histopathologic, and
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immunophenotypic features of sebaceous adenocarcinomas occurring in the parotid and
submandibular glands.

Methods

This study was conducted in full accordance with the ethical principles of the
World Medical Association Declaration of Helsinki, and study approval was obtained
from the University of Campinas Institutional Review Board.

Ten cases of sebaceous adenocarcinomas originating in major salivary glands

were retrospectively retrieved from 3 pathology services between 1999 and 2015. The
patients were staged according with the seventh edition of the American Joint
Committee on Cancer TNM Staging Manual15. In the metastatic cases, both sites were
evaluated, the primary tumour and metastasis. 5-µm paraffin sections were obtained
from each case, haematoxylin and eosin-stained, and diagnosis was reviewed and
confirmed by immunohistochemistry (IHC).

Table 1 shows the antibodies, dilutions and antigen retrieval methods used in the
IHC studies. Briefly, 3-µm paraffin sections were deparaffinized and washed with
Phosphate-Buffered Saline (PBS), pH 7.4. The endogenous peroxidase blocking was
performed with a single 15-minute bath of 10% H2O2. The slides were incubated
overnight with the primary antibodies, then incubation was performed with the
ADVANCE HRP visualization system (DAKO, Carpinteria, CA, USA).
Diaminobenzidine chromogenic substrate (DAB; Sigma-Aldrich, St Louis, Missouri,
USA) was used for IHC reactions. Finally, the slides were counterstained with Carazzi’s
haematoxylin for 3 minutes.

Selected slides were scanned into high-resolution images using the Aperio
ScanScope CS Slide Scanner (Aperio Technologies Inc, Vista, CA, USA). To determine
the microvessel density (MVD), a digital analysis using the Microvessel Analysis v1
algorithm (Aperio Technologies Inc) was performed, considering the total of CD34-
positive vessels. The final values of MVD were expressed as the number of positive

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 vessels per unit area (vessels/mm²). In addition, the cellular proliferative index (CPI)
was also determined by digital analysis, considering the number of Ki67-positive
neoplastic cells. For this purpose, the images were analysed using the Aperio IHC
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Nuclear Image (Aperio Technologies Inc). The values of the cellular proliferative index
were expressed in percentage [% of Ki67-positive cells]. Similarly, a count number of
MLH1- and MSH2-positive nuclei was performed. The positivity index was assessed by
digital analysis and expressed in percentage [% of MLH1 or MSH2-positive nuclei].

Results

Clinical features

Ten patients with salivary gland sebaceous adenocarcinoma were considered for
this study. Sebaceous adenocarcinomas occurred in 6 women and 4 men, with a
male:female ratio of 1:1.5 and mean age of 62.1 years (SD 15.2, range 31–90). Two
cases (20%) presented distant metastasis. Eight cases (80%) were in the parotid gland
and two cases (20%) in the submandibular gland. One female patient was diagnosed
with submandibular gland sebaceous adenocarcinoma and three months later, an ovary
cancer disseminated to peritoneum was detected, clinically characterizing the Muir-
Torre Syndrome.

Regarding the treatment, the two tumours of the submandibular gland were
treated with gland resection. Four parotid tumours were removed surgically with
chemotherapy and radiotherapy. Neck dissection was performed in 3 patients, 2
received postoperative radiotherapy, and 4 patients were treated by adjuvant
chemotherapy. One patient was considered inoperable.

Clinical follow-up data were available in 7 out of the 10 cases (70%, 4 women
and 3 men; follow-up information on 3 patients was unavailable. One patient out of the
initial (10%) lives to date with no evidence of recurrent or metastatic disease in the
follow-up period of the last 2 years; 2 patients live to date with recurrent and metastatic
disease (20%), and 4 died due to disseminated cancer (40%). The clinical data of the
sebaceous adenocarcinomas patients are summarized in Table 2.

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 Microscopic findings

Microscopically, the salivary glands sebaceous adenocarcinomas consisted of

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nests of variable sizes and islands of polyhedral epithelial cells (round to oval). These
cells exhibited ample and clear cytoplasm containing sebaceous secretions
(intracytoplasmic fat droplets). In the epithelial nests periphery, the cells were of
basaloid pattern, with scarce cytoplasm. Sebaceous holocrine secretion was clearly
observed in three cases (Fig. 1). Table 3 shows the main morphological features of
sebaceous adenocarcinomas studied in this series. Neural invasion was found in two
cases.

Immunohistochemical findings

All cases were diffusely positive for CK-5 and EMA (Fig. 2A), mainly in the
well-differentiated areas. CK-7 was positive in areas of ductal differentiation, while
CK-14 was found in the basaloid cells, surrounding the clear epithelial nests.
Expression of P63 was predominantly observed in the nuclei of immature sebocytes at
nests’ periphery, with positivity index ranging from 31 to 91%, mean of 69.2% (Fig.
2B). Neoplastic cells, for all cases, were positive for adipophilin, showing a
vesicular/droplets pattern in the cytoplasm of sebaceous neoplastic cells (Fig. 2C and
2D). In two primary lesions with metastasis and high-grade transformation, a diffuse
and granular expression of adipophilin was observed.

The cellular proliferative index assessed by Ki67 expression was higher in the
metastatic than in non-metastatic sebaceous adenocarcinomas, with values of 75-90%
and 8-24% respectively. The MVD, assessed by CD34-positive vessels count, was
higher in the two primary cases associated with metastasis than in non-metastatic cases.
Overall, neoplastic cells were negative for smooth muscle actin, calponin, Factor XIIIa,
S-100, CEA, ER, PR and AR. In addition, periodic acid-Schiff (PAS) stain, PAS with
diastase and mucicarmine were negative in all cases. Immunohistochemical data is
shown in Table 3. The mean expression of MLH1 was 63% (28 to 83%) for neoplastic
cells, and 57% for MSH2 (2 to 80%) (Table 3, Fig. 2E and F). One case evidenced loss
of MSH2 expression, and lower MLH1 expression compared with the other sebaceous

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 adenocarcinomas (Fig. 2G and H). MLH1 and MSH2 nuclear expressions in the normal
striated ducts and acinar cells of the salivary glands served as internal controls.
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Discussion

The sebaceous carcinoma (SC) occurs in the skin, particularly in the eyelid16-18.
Extraocular SCs are uncommon, and most cases occur in the head and neck area19.
However, in the salivary glands it is exceptionally rare, with only 50 cases reported to
date20-22. This tumour is recognized as sebaceous adenocarcinomas when occurring in
salivary glands. Sebaceous adenocarcinomas of the salivary glands tend to be aggressive
with recurrences and high metastatic potential12,13,23. This series of 10 cases of
sebaceous adenocarcinomas of the parotid and submandibular glands seems to be the
largest series of the literature.

Morphologically, the sebaceous carcinoma may be identified by its distinctive

microscopic findings, including cells with foamy cytoplasm and presence of holocrine
secretion. However, some cases, particularly the extraocular counterpart, including the
sebaceous adenocarcinomas of salivary gland origin, may show high-grade
transformation or unusual aspects that difficult the diagnosis. In such cases,
immunohistochemical reactions are useful, particularly regarding the adipophilin, which
is very specific and positive in all cases24. True holocrine secretion is easily identified in
ocular SCs; however, when in the salivary glands, this important microscopic finding
may be absent, but it was found in 3 of the studied cases.

Previous studies have reported that SCs demonstrate immunopositivity for

AE1/AE3 cytokeratin, EMA, breast carcinoma associated to antigen‐ 225 (CU18), CA
15.3, and androgen receptor (AR) protein, and negativity for CEA, S100 protein and
GCDFP‐ 1525, 26. Variable expression of CK14 in the immature and mature neoplastic
sebocytes has also been demonstrated25. Concerning the cytokeratin expression in this
study, the sebaceous adenocarcinomas were positive for AE1/AE3 and CK5 (diffuse
pattern), CK7 (mainly in duct-forming areas), and CK14 (in immature and mature
sebocytes). All cases were negative for CEA, AR and S100, corroborating with previous
reports25, 26. It is interesting to mention that, according to previous investigations, the
AR nuclear positivity is considered as a useful marker of ocular SCs26,27. However,

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 there are no studies of AR in salivary glands sebaceous adenocarcinomas and its
expression was negative for the studied cases, in which PR and ER expressions were
also negative.
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The adipophilin is a monoclonal antibody with high sensitivity to identify
intracellular lipid droplets expressed in normal sebocytes and in neoplastic cells of
sebaceous lesions28. In addition, it has been described as a useful marker for diagnosis
of SC29. Indeed, its expression, in addition to androgen receptor’s, are important to
distinguish SC from squamous cell carcinomas of sebaceous differentiation24. In this
study, eight cases showed membranous labelling of intracytoplasmic lipid droplets
distributed in the cytoplasm of the neoplastic cells, whereas 2 cases showed diffuse
positivity, with both cases showing distant metastases, and strong immunopositivity was
identified in the holocrine secretion, as previously described in literature29.

Recently, Tjarks et al.30 reported that Factor XIIIa (AC-1A1) nuclear expression
is a helpful marker for sebaceous differentiation and that its diagnostic utility exceeds
that of the adipophilin. However, in this research, in all cases, the neoplastic and normal
cells of adjacent sebaceous glands were consistently negative, corroborating with the
findings of Plaza et al.31, with evidence of negative expression of Factor XIIIa in 27
cases of ocular SCs. It is important to mention that a different Factor XIIIa antibody
(clone E980.1) was used in this study, in contrast to the one used in the original study
with positivity description

The epithelial membrane antigen (EMA) is a highly glycosylated transmembrane

protein, which is positive in a number of glandular or secretory carcinomas. This is a
very sensitive marker for SCs; however, its specificity is low31-33. In the current series,
all cases presented positive EMA-expression, in agreement with the reported findings of
Plaza et al31. In some cases, the expression was most evident in mature sebocytes;
however, in other cases, both mature and immature sebocytes were positive.

The differential diagnosis of sebaceous adenocarcinomas of salivary gland origin

includes malignant epithelial neoplasms showing clear cells, as mucoepidermoid
carcinoma, clear cell variant of squamous cell carcinoma and other clear cell
carcinomas and adenocarcinomas. PAS and mucicarmine are negative in sebaceous
adenocarcinomas, whereas a positive and strong Oil Red O staining of the neoplastic
cells is expected in these lesions. However, frozen sections using fresh tissue is required

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 for the latter, which may be a disadvantage. Less commonly, metastatic renal cell
carcinoma may mimic histologically sebaceous carcinomas34. However, PAX-8 and
CD10 expression favours the diagnosis of metastatic renal cell carcinomas.
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Furthermore, the immunoreactivity for adipophilin and EMA is very useful to establish
the diagnosis of sebaceous adenocarcinomas35. However, few studies have focused on
immunohistochemistry of salivary gland origin sebaceous adenocarcinomas.

Other carcinomas or adenocarcinomas of salivary gland origin may present

sebaceous differentiation. Mucoepidermoid carcinomas with sebaceous differentiation
may represent a potential diagnostic pitfall and must be differentiate from a true
sebaceous adenocarcinoma. Therefore, the presence of true holocrine secretion and
positivity for EMA and adipophilin in all cases of the current series favours sebaceous
adenocarcinoma. Furthermore, all cases were consistently negative for PAS after
diastase digestion and mucicarmine. Regarding p63, this marker has been suggested to
be useful to differentiate mucoepidermoid carcinoma from sebaceous adenocarcinoma;
p63 was negative in the latter and expressed in mucoepidermoid carcinomas,
particularly in the epidermoid component36,37. However, in sebaceous carcinoma of the
skin, the p63 expression has been associated with the degree of tumour differentiation,
as it was expressed in immature sebocytes, as well as in poorly differentiated carcinoma
cells38. Interestingly, five of the studied cases was positive for p63, which was mainly
expressed in the most peripheral or basal layers of the tumour nests, when it is expected
to be located the less differentiated cells (see Fig. 2B). Thus, it is possible that the
frequency of p63 expression in salivary sebaceous adenocarcinomas may be variable
and linked to tumour differentiation.

Overall, primary metastatic SC showed higher Ki67-index and higher MVD than
primary non-metastatic cases. Associated with the pattern of expression of adipophilin,
these markers may be useful in the prediction of metastatic potential in salivary gland
SC, but these results need be confirmed in future studies.

The Muir-Torre syndrome (MTS) is a subset of Lynch Syndrome also called

Hereditary Non Polyposis Colorectal Carcinoma7,8. Genetically, microsatellite
instability in the DNA mismatch repair system causes multiple neoplasms, including
sebaceous benign and malignant tumours, and internal malignancies, which may
involve colon, pancreas, endometrium and ovary. Patients with skin sebaceous

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 neoplasms or complex sebaceous lesions should be evaluated to exclude MTS
possibility. One case of sebaceous adenocarcinoma of the parotid gland associated with
Muir-Torre syndrome was previously reported10, in which the patient had
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periampullary/pancreatic adenocarcinoma, colonic carcinoma and gastric carcinoma. In
this series, one patient showed parotid SC, associated with multiple sebaceous
hyperplastic lesions and ovarian carcinoma, characterizing the Muir-Torre syndrome,
with consequent unfavourable outcome, remaining with the disease to date (14 months)
after the initial diagnosis of the sebaceous adenocarcinoma of the parotid gland.
Mutations in the MMR system repair is commonly associated with tumours of patients
with MTS. The MLH1 and MSH2 proteins have been studied in these neoplasms. In the
studied cases, MLH1 was expressed in approximately 63%, while MSH2 in 57% of the
nuclei of tumour cells. One case of sebaceous adenocarcinoma in a patient with MTS
showed loss of MSH2 expression, confirming the MSH2 microsatellite instability,
similar to the findings of Neelakantan et al.10. Our results warrant additional
investigations of MMR proteins in sebaceous adenocarcinomas of the salivary gland
origin.

Occasionally, salivary glands sebaceous adenocarcinomas may recur and

metastasize11,34. Six cases of salivary gland sebaceous adenocarcinomas were reported
as causing metastasis. In two of the studied cases, distant metastasis was detected (on
lungs and mandible). In addition, 4 other patients died due to the disease, with a mean
survival after diagnosis of 12.5 months. In fact, the salivary gland sebaceous
adenocarcinoma 5-year overall survival rate is about 60%, lower than the 75.2%
considered for SC of the skin and orbit39,40. The treatment of the sebaceous
adenocarcinomas of the salivary glands, as well as of other sites, is basically
surgical20,22,41,42. In this study, most patients were treated only with surgery or surgery in
association with other therapies, such as chemotherapy or chemoradiotherapy. Given the
fact that few cases of salivary glands SCs have been reported in the literature, the best
protocol of treatment should yet be better established.

In conclusion, sebaceous adenocarcinomas of salivary gland origin are

uncommon tumours of aggressive behaviour that may cause recurrence, metastasis and
death. Diagnosis of such tumours is mainly based in histopathological features, but
immunohistochemical expression of EMA and adipophilin are useful to confirm

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 diagnosis and to distinguish it from other clear cell adenocarcinomas of salivary gland
origin.
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Conflict of interest

The authors have no conflicts of interest to disclose.

Acknowledgement This work was supported by São Paulo Research Foundation –

FAPESP (Grants #2015/25905-1 and #2017/16102-8).

Author contributions

C.D. Soares, R. Carlos, A.M.M. Altemani and M.G.F. Carvalho conceptualized the
study, reviewed pathological slides, performed morphological analysis, and drafted the
manuscript. T.M.L. Morais performed the immunohistochemical reactions and the
digital analyses. J. Jorge and O.P. Almeida provided cases and clinical information,
analysed data and performed critical revision. All authors have read and approved the
final version to be published and agree to be accountable for all aspects of the work.

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 Figure legends

Figure 1. Sebaceous adenocarcinomas of the salivary glands were relatively well

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delimited (A) and consisted of islands and nests of neoplastic cells surrounded by basal
cells with scarce cytoplasm. Focally, central areas of degeneration, corresponding to
holocrine secretion were present (B). The solid pattern (C) consisted of nests with cells
demonstrating a granular, clear and vacuolated cytoplasm with central and conspicuous
nuclei (D).

Figure 2. Immunohistochemical findings in sebaceous adenocarcinomas of the salivary

glands. EMA was expressed mainly in the well-differentiated sebocytes in the central
areas of nests (A). Nuclei of cells located at the periphery of solid cell nests were
positive for p63 (B). Adipophilin expression was evident in the sebocytes and in the
holocrine secretion areas (C and D). Nuclear expression of MLH1 (E) and MSH2 (F) in
most of the tumour cells. Moderately MHL1 expression (G) and weakly MSH2
expression (H) in a case of sebaceous adenocarcinoma with Muir-Torre syndrome. In
detail, normal striated ducts and acinar cells showing nuclear expression for MLH1 and
MSH2 served as internal controls.

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 Table 1. Antibodies used in 10 cases of sebaceous adenocarcinomas of the salivary
glands.
Antibody Clone Dilution Source
Accepted Article
Ki-67 MIB-1 1:100 Dakoa
Pan-cytokeratin AE1AE3 1:400 Dakoa
Cytokeratin 5 XM 26 1:400 Novocastrab
Cytokeratin 7 OV-TL 12/30 1:300 Dakoa
Cytokeratin 14 LL 002 1:200 Novocastrab
Epithelial membrane antigen (EMA) E 29 1:400 Dakoa
Vimentin Vim 3B4 1:400 Dakoa
Smooth muscle actin 1A4 1:400 Dakoa
Factor XIIIa E980.1 1:100 Novocastrab
Androgen receptor (AR) AR 441 1:50 Dakoa
Adipophilin (ADP) AP125 Prediluted Fitzgeraldc
P63 4A4 1:300 Dakoa
Estrogen receptor 1D5 1:100 Dakoa
Progesterone receptor PgR 636 1:100 Dakoa
S100 Policlonal 1:10000 Dakoa
CEA II-7 1:500 Dakoa
CD34 QBEnd-10 1:50 Dakoa
hMLH1 EPR3893 1:100 Abcamd
hMSH2 polyclonal 1:100 Abcamd
a
Dako (Carpinteria, CA, USA), bNovocastra (Newcastle, UK), cFitzgerald (Acton, MA,
USA), dAbcam (Cambridge, UK).

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 Table 2. Demographical characteristics of 10 cases of salivary glands sebaceous
adenocarcinomas.
Cas Age Localization Tumour Stag Metastas Treatme Follow Muir-
Accepted Article
e and size e es nt -up Torre
gend (greatest (month syndro
er dimensi s) me
on –
cm)
1 56yof Parotid 2.7 II No SX AWO No
D, 48
2 71yo Parotid 4.2 III No SX + DOD, No
m CX 21
3 63yof Parotid 6.0 IVc Mandibl No DOD, No
e and treatme 8
cervical nt
LN
4 55yof Parotid 3.1 III No SX + AWD, Yes
CRTX 14
5 73yo Parotid 5.2 IVc Lung CRTX DOD, No
m 6
6 60yof Parotid N/A N/A No N/A N/A No
7 57yo Parotid N/A N/A N/A N/A N/A N/A
m
8 90yof Parotid N/A N/A N/A N/A N/A N/A
9 65yof Submandibu 5.5 IVa No SX + DOD, No
lar CX 15
10 31yo Submandibu 1.4 II No SX AWD, No
m lar 9
AWD alive with disease, AWOD alive without disease, DOD dead of disease, LN
lymph node, SX – Surgery, CX – Chemotherapy, CRTX – Chemoradiotherapy, N/A not
available

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ccepted Articl

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination
and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:
10.1111/his.13664
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ccepted Articl
Table 3. Histological and immunohistochemical features of sebaceous adenocarcinomas.

Case Necrosis Vascular Neural Holocrine CK5 CK7 CK14 EMA p63 ADP MVD CPI MLH1 MSH2
invasion invasion secretion
1 A A A A + + +, focal + 74% + 55 13% 54% 61%
2 A A A A + – – + 77% + 70 16% 72% 80%
3 P P P P + +, focal – + 91% +, granular 109 82% 65% 63%
4 P P A A + + + + 80% + 46 64% 28% 2%
5 P A A A + – +, focal + 65% +, granular 92 77% 50% 66%
6 A A A A + +, focal + + 79% + 75 11% 83% 79%
7 A A A P + + + + 82% + 44 8% 63% 72%
8 P A A P + – – + 73% + 53 16% 59% 45%
9 A A A A + +, focal – + 44% + 66 24% 81% 56%
10 A A P A + + – + 31% + 50 11% 70% 41%

P – Present, A – Absent, CK – Cytokeratin, EMA – Epithelial Membrane Antigen, ADP – Adipophilin, Microvessel density (MVD) was
expressed by [number of vessels] per mm², CPI – Cellular Proliferative Index by percentage of Ki67-positive nuclei, MutL Homolog 1 – MLH1
and MutS Homolog 2 – MSH2.

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ccepted Articl

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ccepted Articl

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