Microcystic Adnexal Carcinoma Involving a Large Portion of the Face: When Is Surgery Not Reasonable? DANIEL BRIAN EISEN, MD, ✽ AND DAVID ZLOTY , MD † ✽ Department of Dermatology, University of California, Davis Medical Center, Sacramento, California; † Division of Dermatology, University of British Columbia, Vancouver, British Columbia BACKGROUND. We report a case of microcystic adnexal carcinoma (MAC) involving a large portion of the face, one of the largest of any MAC reported thus far in this area, and review the literature regarding the nature of the tumor and available treatments. We also review all of the reported cases of metastases and the possi- ble role of radiation in the etiopathogenesis of this tumor. OBJECTIVE. To review the literature about what is known about therapy for MAC and what options are available to patients who have this disease. MATERIALS AND METHODS. Case report and review of the litera- ture. RESULTS. Of the 274 cases of MAC thus far reported, there are 6 cases of metastases, only 1 of which resulted in death. CONCLUSION. Mohs surgery should be the treatment of choice for this tumor; however, when extirpation entails sufficiently large morbidity, given the low rate of metastases and mortality, obser- vation is a reasonable alternative. © 2005 by the American Society for Dermatologic Surgery, Inc. • Published by BC Decker Inc ISSN: 1076–0512 • Dermatol Surg 2005;31:1472–1478. DANIEL BRIAN EISEN, MD, AND DAVID ZLOTY, MD, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. Case Report A 58-year-old female presented to the Dermatologic Surgery Center for Mohs micrographic surgery of a biopsy-proven microcystic adnexal carcinoma (MAC) of the midforehead (Figures 1 and 2). She stated that she had had an inflamed papule at that location for approximately 1 year. There were no noted sensory changes. Her medical history was significant for asthma requiring albuterol and beclometasone dipropionate inhalers. She had no history of radiotherapy. The size of the initial lesion was 0.5  0.5 cm. Local anesthesia was completed, and Mohs surgery was then performed. Four Mohs levels were removed, with extensive tumor still present in every specimen. Further evaluation of the patient revealed diffuse thickening and textural changes in the skin of the patient’s forehead, cheeks, and upper lip areas (Figure 3). More detailed his- tory taking revealed that the patient had first noted changes in the skin of her glabellar area 20 to 25 years pre- viously, which had slowly spread over the rest of her face. She thought that the skin changes were due to aging. Surgery was then aborted, and mapping biopsies from the patient’s right and left lateral eyebrows, nasal root, cheek, and upper lip were performed (Figure 4). The 4.6  4.2 cm midforehead defect was then repaired using bilat- eral O to T rotation flaps. The results of the biopsies (Figure 5) indicated MAC of the left and right nasal roots, cheek, and upper lip areas, encompassing an area approximately 12  12 cm. The patient was sent to the plastic surgery service to evaluate the possibility of resection. The plastic surgery service Address correspondence and reprint requests to: Daniel Brian Eisen, MD, Department of Dermatology, University of California, Davis Medical Center, 4860 Y Street, Suite 3400, Sacramento, CA 95818 or e-mail: dbeisen@ucdavis.edu. Figure 1. Initial biopsy from patient’s forehead (hematoxylin-eosin stain; 20 original magnification)