Rare Skin Cancer Syndromes
Brooke-Spiegler Syndrome, Multiple Familial Trichoepithelioma, and Familial Cylindromatosis
Brooke-Spiegler Syndrome (BSS), familial cylindromatosis, and multiple familial trichoepithelioma (MFT) are all autosomal dominant syndromes with overlapping clinical characteristics with allelic variance. Features of BSS include multiple skin appendage tumors such as cylindromas (tumors arising in the hair follicle stem cells), trichoepitheliomas (tumors arising in the hair follicle), and spiradenomas (benign tumors arising in the sweat gland). MFT is characterized by nonmalignant skin tumors, primarily trichoepitheliomas, and familial cylindromatosis manifests predominantly as cutaneous cylindromas. Onset of tumors for these syndromes is typically in late childhood or early adolescence, suggesting a hormonal influence. There is some evidence of greater severity in females than in males. UV radiation appears to be a major initiating factor for cylindromas. Typical tumor sites for cylindromas in familial cylindromatosis are the scalp (81% of carriers), the trunk (69% of carriers), and the pubic area (42% of carriers). Other tumors that can be associated with these syndromes include parotid gland tumors, basal cell adenomas, and basal cell carcinomas. Refer to Table 2, Basal Cell Carcinoma (BCC) Syndromes, for more information about BSS.
Because mutations in CYLD on16q12-q13 have been identified in individuals with each of these disorders, these syndromes are thought to represent different phenotypic manifestations of the same disease. Penetrance for mutations in CYLD is reported to be 60% to 100%.[3,5] In one study, 85% of the BSS families, 100% of familial cylindromatosis families, and only 44% of MFT families were found to have mutations in CYLD. A second locus for MFT maps to 9p21, but the gene for this locus remains unknown.
Given the potential for progressive enlargement, the preferred approach for cylindromas is ablation while the tumors are small and easily managed. Electrosurgery or Mohs micrographic surgery may be utilized for therapy, although excision of large lesions may require skin grafting for closure. Trichoepitheliomas and spiradenomas typically remain smaller in size; thus, after the diagnosis is confirmed by skin biopsy, unless there is impingement on critical structures, further intervention is not required. If therapy is deemed necessary and appropriate, either electrosurgery or ablative laser therapy is a valid option. Radiotherapy is not recommended for treatment of any of these tumors because a potential for increased tumor induction.
Cutaneous sebaceous neoplasms may be associated with Muir-Torre syndrome (MTS). Multiple types of sebaceous tumors including sebaceous adenomas, epitheliomas, carcinomas, and keratoacanthomas or BCCs with sebaceous differentiation have been described. A variant of Lynch syndrome/hereditary non-polyposis colorectal cancer syndrome, the MTS phenotype involves the synchronous or metachronous development of at least one cutaneous sebaceous neoplasm and at least one visceral malignancy. The visceral malignancies may be of gastrointestinal (colorectal, stomach, small bowel, liver, and bile duct) and/or genitourinary (endometrial and bladder) origin and typically demonstrate a less aggressive phenotype than non-MTS equivalent tumors.[9,10] MTS, inherited in an autosomal dominant fashion with high penetrance and variable expressivity, is associated with mutations in the mismatch repair genes MLH1, MSH2, and less commonly, MSH6.[11-16] In a study of 36 sebaceous lesions that included sebaceous carcinomas, sebaceous adenomas, and sebaceomas, 38.9% of lesions were missing one or more mismatch repair proteins by immunohistochemistry (IHC). Of the ten individuals with absent staining of one or more proteins, five had gene testing that confirmed a diagnosis of Lynch syndrome. This result suggests that routine screening of sebaceous lesions by IHC may be useful in identification of individuals with Lynch syndrome.
While the commonly noted sebaceous hyperplasia has not been associated with MTS, any sebaceous lesion with atypical or difficult to classify histologic features should prompt further exploration of the patient’s family and personal medical history. Consideration should be given to referring patients with sebaceous neoplasms to medical geneticists or gastroenterologists to evaluate further for Lynch syndrome. While the diagnosis of visceral malignancy precedes that of cutaneous sebaceous neoplasms in the majority of patients, 22% of patients develop cutaneous sebaceous neoplasms first, offering an opportunity for visceral malignancy screening. Current diagnosis of MTS is based upon clinical criteria but may be supported by immunohistochemical staining for MSH2, MLH1, and MSH6 as a screening mechanism before molecular genetic analysis.[12,14-16,19] Genetic counseling and testing for the patient and family members, with appropriate visceral malignancy screening regimens, should be pursued.
- Bowen S, Gill M, Lee DA, et al.: Mutations in the CYLD gene in Brooke-Spiegler syndrome, familial cylindromatosis, and multiple familial trichoepithelioma: lack of genotype-phenotype correlation. J Invest Dermatol 124 (5): 919-20, 2005. [PUBMED Abstract]
- Burrows NP, Jones RR, Smith NP: The clinicopathological features of familial cylindromas and trichoepitheliomas (Brooke-Spiegler syndrome): a report of two families. Clin Exp Dermatol 17 (5): 332-6, 1992. [PUBMED Abstract]
- Rajan N, Langtry JA, Ashworth A, et al.: Tumor mapping in 2 large multigenerational families with CYLD mutations: implications for disease management and tumor induction. Arch Dermatol 145 (11): 1277-84, 2009. [PUBMED Abstract]
- Young AL, Kellermayer R, Szigeti R, et al.: CYLD mutations underlie Brooke-Spiegler, familial cylindromatosis, and multiple familial trichoepithelioma syndromes. Clin Genet 70 (3): 246-9, 2006. [PUBMED Abstract]
- Welch JP, Wells RS, Kerr CB: Ancell-Spiegler cylindromas (turban tumours) and Brooke-Fordyce Trichoepitheliomas: evidence for a single genetic entity. J Med Genet 5 (1): 29-35, 1968. [PUBMED Abstract]
- Saggar S, Chernoff KA, Lodha S, et al.: CYLD mutations in familial skin appendage tumours. J Med Genet 45 (5): 298-302, 2008. [PUBMED Abstract]
- Harada H, Hashimoto K, Ko MS: The gene for multiple familial trichoepithelioma maps to chromosome 9p21. J Invest Dermatol 107 (1): 41-3, 1996. [PUBMED Abstract]
- Rajan N, Trainer AH, Burn J, et al.: Familial cylindromatosis and brooke-spiegler syndrome: a review of current therapeutic approaches and the surgical challenges posed by two affected families. Dermatol Surg 35 (5): 845-52, 2009. [PUBMED Abstract]
- Schwartz RA, Torre DP: The Muir-Torre syndrome: a 25-year retrospect. J Am Acad Dermatol 33 (1): 90-104, 1995. [PUBMED Abstract]
- Cohen PR, Kohn SR, Kurzrock R: Association of sebaceous gland tumors and internal malignancy: the Muir-Torre syndrome. Am J Med 90 (5): 606-13, 1991. [PUBMED Abstract]
- Cerosaletti KM, Lange E, Stringham HM, et al.: Fine localization of the Nijmegen breakage syndrome gene to 8q21: evidence for a common founder haplotype. Am J Hum Genet 63 (1): 125-34, 1998. [PUBMED Abstract]
- Mangold E, Pagenstecher C, Leister M, et al.: A genotype-phenotype correlation in HNPCC: strong predominance of msh2 mutations in 41 patients with Muir-Torre syndrome. J Med Genet 41 (7): 567-72, 2004. [PUBMED Abstract]
- Mathiak M, Rütten A, Mangold E, et al.: Loss of DNA mismatch repair proteins in skin tumors from patients with Muir-Torre syndrome and MSH2 or MLH1 germline mutations: establishment of immunohistochemical analysis as a screening test. Am J Surg Pathol 26 (3): 338-43, 2002. [PUBMED Abstract]
- Mangold E, Rahner N, Friedrichs N, et al.: MSH6 mutation in Muir-Torre syndrome: could this be a rare finding? Br J Dermatol 156 (1): 158-62, 2007. [PUBMED Abstract]
- Arnold A, Payne S, Fisher S, et al.: An individual with Muir-Torre syndrome found to have a pathogenic MSH6 gene mutation. Fam Cancer 6 (3): 317-21, 2007. [PUBMED Abstract]
- Murphy HR, Armstrong R, Cairns D, et al.: Muir-Torre Syndrome: expanding the genotype and phenotype--a further family with a MSH6 mutation. Fam Cancer 7 (3): 255-7, 2008. [PUBMED Abstract]
- Plocharczyk EF, Frankel WL, Hampel H, et al.: Mismatch repair protein deficiency is common in sebaceous neoplasms and suggests the importance of screening for Lynch syndrome. Am J Dermatopathol 35 (2): 191-5, 2013. [PUBMED Abstract]
- Akhtar S, Oza KK, Khan SA, et al.: Muir-Torre syndrome: case report of a patient with concurrent jejunal and ureteral cancer and a review of the literature. J Am Acad Dermatol 41 (5 Pt 1): 681-6, 1999. [PUBMED Abstract]
- Entius MM, Keller JJ, Drillenburg P, et al.: Microsatellite instability and expression of hMLH-1 and hMSH-2 in sebaceous gland carcinomas as markers for Muir-Torre syndrome. Clin Cancer Res 6 (5): 1784-9, 2000. [PUBMED Abstract]