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Pleomorphic adenoma is a neoplasm named for its mixture of disparate tissue elements, including branching double-layered ductules within a fibroid, myxoid, cartilaginoid, and (rarely) adipocytic stroma.
A rare cutaneous tumour presumably arising from apocrine or eccrine sweat ducts, it has been described in the eyelid, where it may occupy various locations, including the sub-brow region.
in: Silverberg S. Sobin L.H. Tumors of the eye and ocular adnexa, AFIP atlas of tumor pathology. American Registry of Pathology,
Washington, DC2006: 223-246
We report a pleomorphic adenoma of the brow that presented with the unusual symptom of focal brow loss.
A healthy 77-year-old male complained of hair loss on the temporal third of the left eyebrow. Examination disclosed a subtly elevated, nontender, faintly erythematous subcutaneous mass in that location (Fig. 1). Excisional biopsy including overlying skin yielded a mass measuring 0.7 cm × 0.2 cm × 0.3 cm. Histology showed a well-circumscribed, nonencapsulated intradermal tumour consisting of branching and nonbranching strands of tubuloalveolar structures arranged among chondroid and adipocytic zones (Fig. 2A). The tubules were composed of a double layer of epithelial cells, the inner layer of which stained positively with epithelial immunostains AE1/AE3, EMA, and CAM5.2 (spotty) as well as gross cystic fluid disease protein (GCDFP-15), an apocrine marker. The outer layer was positive for S100 and NSE but not SMA or GFAP. Ki67 showed a low proliferative rate (<5%).
Fig. 1Hair loss and tumour of the temporal portion of the left brow (arrow). The pigmented eyelid lesion is a seborrheic keratosis.
Formerly designated “chondroid syringoma” and “cutaneous benign mixed tumour,” the current preferred terminology of this rare cutaneous neoplasm is “pleomorphic adenoma” implying morphologic variety that includes epithelial and mesenchymal portions.
Histology shows a biphasic, variable architecture containing epithelial tubules set in a fibrous, myxoid, cartilaginoid, and even an unusual adipocytic stroma as in the current case. Immunohistochemisty shows a different staining pattern for the inner tubular cells compared with the outer layer. As there are no characteristic clinical features, diagnosis relies upon excisional biopsy. Malignant transformation has been described, especially after incomplete excision, paralleling the experience in the lacrimal and salivary glands.
The differential diagnosis of eyebrow madarosis is extensive, including common localized disorders such as seborrheic dermatitis, malignancies (basal and squamous cell carcinoma), or components of systemic diseases (alopecia areata, discoid lupus erythematosis, Vogt–Koyanagi–Harada syndrome, sarcoidosis, leprosy, syphilis, cutaneous T-cell lymphoma).
Focal brow infarction may provide a clue to the diagnosis of giant cell arteritis. Drugs such as retinoids, heparin, anticonvulsants, angiotensin-converting enzyme (ACE) inhibitors, and androgens may trigger telogen hair shedding and madarosis.
The approach to brow loss may be challenging and should involve consideration of the systemic medical status, including medication usage, and possible psychiatric evaluation. Focal and asymmetric brow loss merits suspicion for an underlying tumour
in: Silverberg S. Sobin L.H. Tumors of the eye and ocular adnexa, AFIP atlas of tumor pathology. American Registry of Pathology,
Washington, DC2006: 223-246
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