J Cutan Pathol 2016 © 2016 John Wiley & Sons A/S.

doi: 10.1111/cup.12726 Published by John Wiley & Sons Ltd

John Wiley & Sons. Printed in Singapore
Journal of
Cutaneous Pathology

Nuclear factor XIIIa staining (clone

AC-1A1 mouse monoclonal) is a
sensitive and specific marker to
discriminate sebaceous proliferations
from other cutaneous clear cell
neoplasms
Sebaceous carcinoma is a rare but serious malignancy that may be Elizabeth E. Uhlenhake1 ,
difficult to diagnose when poorly differentiated. Other epithelial Lindsey N. Clark1 , Bruce R.
tumors with clear cell change may mimic sebaceous carcinoma. Smoller2 , Sara C. Shalin1 and
Few useful or specific immunohistochemical markers for Jerad M. Gardner1
sebaceous differentiation are available. Nuclear staining with
1
factor XIIIa (clone AC-1A1) was recently found to be a highly Department of Pathology, University of
Arkansas for Medical Sciences, Little Rock,
sensitive marker of sebaceous differentiation. We evaluated AR, USA, and
nuclear factor XIIIa (AC-1A1) staining in sebaceous neoplasms vs. 2
Department of Pathology, University of
other cutaneous clear cell tumors. We stained 27 sebaceous Rochester, Rochester, NY, USA
proliferations: sebaceous hyperplasia (7), sebaceous adenoma
(8), sebaceoma (5), sebaceous carcinoma (7). We also stained 67
tumors with clear cell change: basal cell carcinoma (8), squamous
cell carcinoma (8), hidradenoma (7), desmoplastic
trichilemmoma (2), trichilemmoma (10), trichilemmal
carcinoma (3), clear cell acanthoma (9), atypical fibroxanthoma
(1), syringoma (8), trichoepithelioma (1), metastatic renal cell
carcinoma (2), and nevi with balloon cell change (8). Nuclear
factor XIIIa (AC-1A1) staining was present in 100% of sebaceous
proliferations; 96% displayed strong staining. Non-sebaceous
clear cell tumors were negative or only weakly positive with factor
XIIIa (AC-1A1) in 95.5%; only 4.5% showed strong staining. This
suggests that strong nuclear factor XIIIa (AC-1A1) staining is a
sensitive and specific marker of sebaceous neoplasms vs. other
clear cell tumors.
Keywords: adnexal, clear cell, factor XIIIa, sebaceous, sebaceous
carcinoma Jerad M. Gardner, MD,
Department of Pathology, University of Arkansas
Uhlenhake EE, Clark LN, Smoller BR, Shalin SC, Gardner JM. for Medical Sciences, 4301W. Markham St, #517
Nuclear factor XIIIa staining (clone AC-1A1 mouse monoclonal) Little Rock, AR 72205, USA
is a sensitive and specific marker to discriminate sebaceous Tel: +5015264539
e-mail: JMGardnerMD@gmail.com
proliferations from other cutaneous clear cell neoplasms. Twitter: @JMGardnerMD
J Cutan Pathol 2016. © 2016 John Wiley & Sons A/S. Published by
John Wiley & Sons Ltd Accepted for publication May 3, 2016

1
Uhlenhake et al.
Sebaceous carcinoma is a relatively
uncommon tumor comprising 0.05% of all cuta-
neous malignancies, but it is the second most
common malignant eyelid tumor (2–4% of eye-
lid tumors) after basal cell carcinoma (BCC).1
It can be very aggressive with local recurrences
in up to 29% and regional or distant metastases
affecting 14–25% of patients.2,3 Reported 5-year
mortality rates range from 30 to 67%, and thus
timely and accurate diagnosis is essential.3,4
Sebaceous carcinoma may be a difficult diag-
nosis to make, not only histologically but also
clinically, as it can mimic benign processes such
as chalazion or other malignancies such as BCC.
Clinical misdiagnosis has been estimated to
occur in 23–77% of cases, potentially result-
ing in delayed or inadequate treatment.5 – 7
Well-differentiated sebaceous carcinoma is
usually readily recognized by lobules com-
posed of cells with multivacuolated, lipid-filled
cytoplasm and crenulated nuclei. However,
poorly differentiated sebaceous carcinomas
are predominantly composed of basaloid cells
and often have a paucity of tumor cells with
obvious, well-developed cytoplasmic lipid vesi-
cles; these tumors pose a particular diagnostic
challenge as they can resemble BCC, poorly
differentiated squamous cell carcinoma (SCC),
or other malignancies with basaloid features.
The converse is also true: that distinguish-
ing non-sebaceous epithelial neoplasms with
clear cell features from sebaceous carcinoma
on histopathologic grounds alone can some-
times be challenging.8 As the prognosis of
sebaceous carcinoma improves considerably
with early diagnosis and definitive surgery,
this remains an important diagnostic pitfall in
dermatopathology.9
Currently, few useful or specific immunohisto-
chemical markers for sebaceous differentiation
are readily available. Ancillary histochemical
stains such as Oil Red O and Sudan Black IV
have been used to detect cytoplasmic lipid vesi-
cles but require fresh, frozen tissue and often
non-specifically highlight macrophages and stro-
mal non-lipid laden cells.8,10 And while studies
have shown that epithelial membrane anti-
gen (EMA), cytokeratin 7, CAM 5.2, Ber-EP4,
and androgen receptor can be used to suggest
sebaceous differentiation, the relatively low
specificity of these antibodies limits their prac-
tical utility in the immunohistochemical workup
of sebaceous carcinoma.11 – 14
A few recent studies investigated the util-
ity of antibodies against the PAT family of
lipid droplet-associated proteins: perilipin,
2
adipophilin and TIP47/PP17 in identifying
sebaceous differentiation.3,15,16 Adipophilin was
expressed in sebaceous tumors in a membranous
vesicular pattern and in some non-sebaceous
clear cell tumors in a granular cytoplasmic pat-
tern, but it also showed non-specific highlighting
of macrophage cytoplasm and keratohyaline
granules.3,11 Other investigators have recently
used antibodies against proteins involved in
lipid synthesis and/or processing, namely
alpha/beta hydrolase domain-containing
protein 5 (ABHD5), progesterone receptor
membrane component-1 (PGRMC1) and squa-
lene synthase (SQS) as markers of sebaceous
differentiation. These markers showed punctate
vesicular cytoplasmic and membranous stain-
ing in sebaceous tumor cells with non-specific
cytoplasmic blush in some cases of BCC.8 While
these antibodies may have increased specificity
for sebaceous differentiation, their clinical util-
ity is diminished by limited availability and/or
difficulty of interpretation. At this time, there is
a practical need to identify a novel immunohis-
tochemical marker that is widely available, easily
interpretable, and sensitive and specific for
sebaceous differentiation to improve diagnostic
accuracy in distinguishing sebaceous tumors
from their histological mimics.
We previously reported that strong nuclear
factor XIIIa (AC-1A1) staining is a sensitive
marker for sebaceous differentiation in benign
and malignant proliferations, showing strong
nuclear staining in normal and neoplastic sebo-
cytes in a clone-specific manner.17 In this current
study, we sought to further define the diagnos-
tic utility of this antibody by comparing factor
XIIIa (AC-1A1) staining in sebaceous neoplasms
and their potential histologic mimics (cutaneous
tumors with focal clear cell change).
Methods
Case selection
The University of Arkansas for Medical Sci-
ences (UAMS) Dermatopathology database was
searched for tumors with clear cell features
from 2009 to 2013. The archival pathology
materials (formalin-fixed, paraffin-embedded
tissue blocks and glass slides) were retrieved
after Institutional Review Board approval was
obtained. All cases were independently reviewed
by three study dermatopathologists (EEU, SCS
and JMG) for diagnosis confirmation. A total
of 67 non-sebaceous neoplasms with at least
focal clear cell change were obtained: BCC (8),
squamous cell carcinoma (8), hidradenoma
 Nuclear factor XIIIa is sensitive and specific for sebaceous proliferations
(7), desmoplastic trichilemmoma (2), trichilem-
moma (10), trichilemmal carcinoma (3), clear
cell acanthoma (9), atypical fibroxanthoma
(AFX) (1), syringoma (8), trichoepithelioma
(1), metastatic renal cell carcinoma (2) and
melanocytic nevi with balloon cell change (8).
The 27 sebaceous proliferations were taken from
our previously characterized cohort as reported
by Clark et al. and included sebaceous hyperpla-
sia (7), sebaceous adenoma (8), sebaceoma (5)
and sebaceous carcinoma (7).17
Immunohistochemical staining
Histologic sections were placed on positively
charged glass slides (Thermo Shandon; Thermo
Fisher Scientific, Pittsburgh, PA, USA). Stain-
ing was performed in a Ventana Benchmark
Ultra automated immunostainer (Ventana Med-
ical Systems, Tucson, AZ, USA) with factor
XIIIa antibody according to standard protocols
(prediluted to 0.05 μg/ml, AC-1A1 monoclonal
mouse; Ventana Medical Systems, Inc.). Appro-
priate positive controls were included for each
run of immunostaining and cases were stained
in batches to minimize the number of runs.
Non-neoplastic sebaceous glands and dermal
dendritic cells within background skin on the
sections also served as internal positive controls.
Scoring
Nuclear factor XIIIa (AC-1A1) staining intensity
was graded by four separate dermatopathologists
(EEU, BRS, SCS and JMG) as strong, weak or
negative and distribution was scored as diffuse
(the majority of tumor cells) or focal (a minor-
ity of tumor cells). Pure cytoplasmic staining
only was regarded as negative. This tier system
was chosen for clinical ease and more practical
applicability than a 0–4+ grading system. The
nuclear factor XIIIa (AC-1A1) staining results of
the 67 clear cell tumors were tabulated and were
then compared with the dataset of nuclear factor
XIIIa (AC-1A1) staining results for the 27 seba-
ceous proliferations from our previous study.17
Statistical analysis
The statistical association between the factor
XIIIa (AC-1A1) staining and the tumors tested
was analyzed using Fisher’s exact test with a
p value <0.05 considered to be statistically
significant (conducted via http://graphpad.
com/quickcalcs/contingency1.cfm; accessed
on 7 February 2016). The sensitivity and speci-
ficity were manually calculated with factor
XIIIa (AC-1A1) staining in sebaceous prolifer-
ations and in non-sebaceous clear cell tumors.
Only strong nuclear staining was considered
a positive result for purposes of statistical
calculation; negative and weak staining both
were considered as negative. Sensitivity was
calculated as (strong staining of sebaceous
proliferations)/[(strong staining of sebaceous
proliferations) + (negative or weak staining
of sebaceous proliferations)]. Specificity was
calculated as (negative or weak staining of
non-sebaceous clear cell tumors)/[(negative
or weak staining of non-sebaceous clear cell
tumors) + (strong staining of non-sebaceous
clear cell tumors)].
Results
Nuclear factor XIIIa (AC-1A1) staining was
present in 100% (27/27) of sebaceous prolifer-
ations, of which 96% (26/27) displayed strong
staining (23 diffuse strong, 3 focal strong)
(Figs. 1A,B and 2A,B); these are the same data
we presented in Clark et al.17 Non-sebaceous
clear cell tumors were negative or focal weak pos-
itive in 70% (47/67) or diffuse weak positive in
25.5% (17/67). Only 4.5% (3/67) of the entire
non-sebaceous clear cell tumor group showed
strong staining with factor XIIIa (AC-1A1), and
these three cases with strong staining were all
different tumor types: one clear cell hidrade-
noma (diffuse strong), one trichilemmoma
(diffuse strong) and one clear cell BCC (focal
strong) (Figs. 3–6). Detailed data are presented
in Tables 1 and 2.
When the group of sebaceous proliferations
was compared with the group of clear cell
tumors, strong nuclear staining of factor XIIIa
(AC-1A1) was more frequently seen in the seba-
ceous lesions than in the non-sebaceous clear
cell tumors (p < 0.0001). Strong nuclear stain-
ing of factor XIIIa (AC-1A1) had a sensitivity of
96% for sebaceous proliferations and a speci-
ficity of 96% for sebaceous proliferations vs. the
non-sebaceous clear cell tumor group.
As we noted in our previous study, factor XIIIa
(AC-1A1) again displayed a gradient staining
pattern within the nuclei of normal squamous
epithelium, hair follicular epithelium, and sweat
ducts and glands.17 This staining was accentu-
ated toward the terminally differentiated epithe-
lial and follicular cells and secretory units of
eccrine glands and diminished toward the less
differentiated basaloid cells and periphery of
eccrine ducts/glands (Figs. 7–9). Nuclear fac-
tor XIIIa (AC-1A1) staining in these normal
3
Uhlenhake et al.

Fig. 1. A) Sebaceous hyperplasia stained with factor XIIIa (AC-1A1). There is strong diffuse nuclear staining of mature sebocytes,
×100 magnification. B) Differential staining of more mature sebocytes. Nuclei of mature sebocytes stain strongly with factor XIIIa
(AC-1A1), but less mature peripheral basaloid cells (right and bottom left) are negative, ×400 magnification.

Fig. 2. A) Sebaceous carcinoma. Hematoxylin & eosin stain, 200× magnification. B) Sebaceous carcinoma showing strong diffuse
nuclear staining with factor XIIIa (AC-1A1). The strong staining is particularly prominent in the more mature vacuolated sebocytes.
The basaloid cells are weakly staining or negative, ×200 magnification.

epithelia was usually much weaker than the
nuclear staining seen in normal and neoplastic
sebocytes.
Discussion
Sebaceous carcinoma is an uncommon but
aggressive, potentially fatal malignancy that
may mimic other benign or malignant tumors
histologically when not well differentiated. Oil
red O and Sudan black IV are histochemical
stains for lipid; they are the classically described
ancillary tests for the diagnosis of sebaceous
carcinoma, but their utility is limited due to
suboptimal specificity and the requirement
for fresh or frozen tissue.8 Other investigators
have attempted to find a specific and reliable
immunohistochemical marker that can detect
sebaceous differentiation on formalin-fixed
paraffin-embedded tissue sections. A variety

4
 Nuclear factor XIIIa is sensitive and specific for sebaceous proliferations
Fig. 3. Clear cell hidradenoma showing strong diffuse nuclear
staining with factor XIIIa (AC-1A1), ×200 magnification.
Fig. 4. Basal cell carcinoma with clear cell change showing
strong focal nuclear staining with factor XIIIa (AC-1A1), ×200
magnification.
of antibodies have been advocated, includ-
ing EMA, cytokeratin 7, CAM 5.2, Ber-EP4,
androgen receptor, perilipin, adipophilin,
TIP47/PP17, ABHD5, PGRMC1 and SQS.3,10 – 16
These markers suffer from a variety of issues,
including lack of specificity, difficult interpre-
tation, and/or limited availability. In addition,
some of these have limited utility outside the
setting of evaluating sebaceous differentiation
Fig. 5. Clear cell hidradenoma showing weak diffuse nuclear
staining with factor XIIIa (AC-1A1), ×100 magnification.
Fig. 6. Clear cell trichoepithelioma showing weak focal nuclear
staining with factor XIIIa (AC-1A1). There is also nuclear
staining in the overlying epidermal keratinocytes. Background
dermal dendritic cells serve as a strong internal positive control,
×100 magnification.
making them impractical to validate and main-
tain on the test menu in most laboratories. The
dermatopathology community still lacks a widely
available, easily interpretable, and sensitive and
specific marker of sebaceous differentiation.
In our study, we examine nuclear factor
XIIIa (AC-1A1) staining in a series of cuta-
neous clear cell tumors, some of which could
5
Uhlenhake et al.

Table 1. Nuclear factor XIIIa (AC-1A1) staining in sebaceous proliferations

Strong diffuse Strong focal Weak diffuse Weak focal Negative

Sebaceous hyperplasia (7) 7 0 0 0 0

Sebaceous adenoma (8) 8 0 0 0 0
Sebaceoma (5) 3 1 1 0 0
Sebaceous Carcinoma (7) 5 2 0 0 0

Numbers represent the number of cases for a given staining intensity and distribution pattern. The most common staining pattern for each tumor
is presented in bold. Adapted from Table 1 in our previous study of nuclear factor XIIIa (AC-1A1) staining in sebaceous proliferations.17

Table 2. Nuclear factor XIIIa (AC-1A1) staining of non-sebaceous tumors with clear cell features

Strong diffuse Strong focal Weak diffuse Weak focal Negative

BCC (8) 0 1 0 3 4
SCC (8) 0 0 2 1 5
Trichilemmal carcinoma (3) 0 0 2 1 0
Clear cell AFX (1) 0 0 0 0 1
Metastatic RCC (2) 0 0 0 0 2
Clear cell acanthoma (9) 0 0 2 5 2
Clear cell trichoepithelioma (1) 0 0 0 1 0
Trichilemmoma (10) 1 0 2 5 2
Desmoplastic trichilemmoma (2) 0 0 0 1 1
Clear cell hidradenoma (7) 1 0 5 0 1
Clear cell syringoma (8) 0 0 0 6 2
Balloon cell nevi (8) 0 0 4 1 3

AFX, atypical fibroxanthoma; BCC, basal cell carcinoma; RCC, renal cell carcinoma; SCC, squamous cell carcinoma.
Numbers in brackets represent the number of cases for a given staining intensity and distribution pattern. The most common staining pattern for
each tumor is presented in bold.

potentially enter the differential diagnosis with xanthogranulomas, xanthomas, hepatocellu-

sebaceous neoplasia. We found strong, crisp
nuclear staining with factor XIIIa (AC-1A1) in
96% (26/27) of sebaceous proliferations and
negative or only weak positive staining in 95.5%
(64/67) of non-sebaceous clear call tumors.
When the group of sebaceous proliferations
was compared with tumors with clear cell fea-
tures, the strong nuclear staining with factor
XIIIa (AC-1A1) was a statistically significant
discriminator (p < 0.0001).
Factor XIIIa is a blood pro-enzyme that has
been identified in platelets, megakaryocytes, and
fibroblast-like mesenchymal or histiocytic cells
present in the placenta, uterus, and prostate
and in macrophages and dermal dendritic cells
in the skin. Presently, more than a dozen pro-
tein substrates with factor XIIIa are known,
including proteins of the coagulation and
fibrinolytic systems, adhesive proteins (intra-
cellular transglutaminases) and cytoskeletal
proteins. Factor XIIIa immunohistochemical
stain has a cytoplasmic localization pattern
in many entities including dermatofibromas,
fibrous papules, undifferentiated pleomorphic
sarcomas, capillary hemangioblastoma, heman-
gioendotheliomas, ‘hemangiopericytomas’,
lar carcinomas and neurofibromas.18 Nuclear
immunoreactivity is not widely commented
upon in the literature, although accumulation
of factor XIIIa in the nuclei of macrophages
has been observed in the early stages of their
differentiation.19,20 Recently, we reported that
strong nuclear staining with factor XIIIa
(AC-1A1) is seen in sebaceous proliferations
including sebaceous carcinomas, and we pro-
posed that this marker could serve as a sensitive
indicator of sebaceous differentiation.17 This
current study expands on our previous work
and suggests that strong staining with factor
XIIIa (AC-1A1) is also highly specific for seba-
ceous differentiation, as the great majority
of morphologically similar tumors (including
melanocytic tumors, squamous cell carcinomas,
sweat duct-derived tumors and hair follicle
tumors with clear cell changes) have only focal
weak or completely absent nuclear staining.
It is worth highlighting once again that the
phenomenon we described of strong nuclear fac-
tor XIIIa (AC-1A1) staining is only seen with
the mouse monoclonal AC-1A1 antibody. In
our previous study, we evaluated a subset of
the sebaceous proliferations with two additional

6
 Nuclear factor XIIIa is sensitive and specific for sebaceous proliferations
Fig. 7. Differential staining of normal epidermal keratinocytes.
Nuclei show stronger staining with factor XIIIa (AC-1A1)
towards the mid to upper levels of the epidermis. The basal
layer is negative, ×400 magnification.
Fig. 8. Differential staining of normal hair follicle. The inner
more differentiated layers of the follicular epithelium of nor-
mal hair follicles sometimes showed nuclear staining with factor
XIIIa (AC-1A1); the outer root sheath was typically negative,
×100 magnification.
factor XIIIa clones: EP3372 rabbit monoclonal
(Abcam; Cambridge, MA) and E980.1 mouse
monoclonal (Vector Laboratories; Burlingame,
CA, USA). Neither of those clones showed any
significant nuclear staining in sebaceous cells or
any other cells in the cases we evaluated. This
Fig. 9. Differential staining of eccrine sweat glands and ducts.
Nuclei of apical cells in normal eccrine sweat ducts and
coils were sometimes positive with factor XIIIa (AC-1A1), but
the peripheral basal/myoepithelial layer of cells were usually
negative, ×200 magnification.
led us to suggest that the nuclear staining in our
previous series may represent a clone specific
cross-reactivity to an unidentified nuclear anti-
gen in sebocytes rather to the factor XIIIa pro-
tein itself; regardless, the data still support this
phenomenon as being sensitive and specific for
sebaceous differentiation.17
Incidentally, in some cases we noted that
mature keratinocytes (mid-level and higher in
the normal epidermis) stained with nuclear
factor XIIIa (AC-1A1) (Fig. 7). Staining of
keratinocytes with mouse monoclonal AC-1A1
factor XIIIa has been briefly described [local-
ization of staining (e.g. cytoplasmic vs. nuclear)
was not mentioned], but it was noted that this
phenomenon does not occur with the rab-
bit monoclonal factor XIIIa antibody EP3372
(see below).21 We also observed in some cases
nuclear staining with factor XIIIa (AC-1A1)
in the inner more differentiated layers of the
follicular epithelium of normal hair follicles and
in the apical cells of normal eccrine sweat ducts
and coils (Figs. 8, 9). This raises the possibility
that the factor XIIIa (AC-1A1) nuclear staining
is serving as a surrogate for terminal epithelial
differentiation rather than strictly highlighting
sebaceous differentiation, which is an interesting
finding but a potential limitation of factor XIIIa
(AC-1A1) as a pure sebaceous marker. While the
significance of this differential staining pattern
is uncertain at this point, we suggest that perhaps
7
Uhlenhake et al.

nuclear factor XIIIa (AC-1A1) staining may also
have utility in evaluating cutaneous epithelial
maturation in general. Further investigation of
this is needed.
In conclusion, strong nuclear factor XIIIa
(AC-1A1) staining is highly sensitive and specific
in differentiating sebaceous carcinoma and
other sebaceous neoplasms from their mimics.
It is readily available in most laboratories and
its nuclear staining pattern makes for easy inter-
pretation. As such, it may be a useful adjunct
to the histologic evaluation of poorly differ-
entiated neoplasms with suspected sebaceous
differentiation.

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