eyelid: malignant tumours

Basal cell carcinoma

Most common malignant tumour, frequently in elderly px

• risk factors: fair skin, inability to tan, chronic sun exposure

• 90% occur in head and neck, 10% involves the eyelid

• slow growing but locally invasive - if in medial aspect will invade orbit and sinuses

• Recurrent tumours following incomplete tx becomes more aggressive and harder to manage.

What is the most to least frequent area of the eye for basal cell carcinoma to be located?

Most is lower eyelid, medial canthus, upper lid then temporal canthus being the least.

What are the subtypes of basal cell carcinoma?

1. Nodule-ulcerative basal cell carcinoma

2. Sclerosis basal cell carcinoma

What is Nodulo-ulcerative basal cell carcinoma?

Has shiny firm pearly nodule with dilated BVs on surface.

• initially slow growing

• If untreated growth becomes rapid and BCC develops central ulceration

• Overtime may erode large portion of lid

What is sclerosing basal cell carcinoma?

Infiltrates laterally beneath the skin as a plaque which can distort lid and cause area of madarosis.

• can be difficult to define margins clinically

• Resemble localised area of chronic blepharitis - need to differentiate.

Squamous cell carcinoma

Less common but more aggressive as metastasises to regional lymph nodes, may also spread to intracranial cavity via orbit.

• 5-10% eyelid malignancies

• May arise from pre-existing actinic keratosis

• Predilection for lower and lid margin

• Keratocanthoma may show squamous cell changes at deeper layers

What are the risk factors of SCC and which type of px is commonly affected.

Risk factors = fair skinned, history of chronic sun exposure and skin damage

Common in elderly px.

Is SCC difficult to diagnose, why?

SCC is difficult to diagnose as other benign or malignant lesions may resemble SCC such as basal cell carcinoma.

• usually has no surface vascularisation and a more rapid growth.

What are the 3 types of squamous cell carcinoma?

1. Plaque like squamous cell carcinoma

2. Nodular squamous cell carcinoma

3. Ulcerating squamous cell carcinoma

What is plaque like SCC?

roughened scaly reddened hyperkeratotic plaque.

• may arise due to pre-existing actinic keratosis

What is nodular squamous cell carcinoma?

Hyperkeratotic nodule - crusty erosions and fissures may develop

What is ulcerating squamous cell carcinoma?

Red base and sharply defined infuriated and everted borders.

What is sebaceous gland carcinoma?

Very rare, but most dangerous. Occurs more on upper lid as more lashes there.

Arises from meibomian glands, occasionally glands of zeiss or sebaceous glands.

• Can have simultaneous involvement of both lids (very rare) = intraepithelial spread or multiple primaries

• Early tumours may mimic less aggressive lesions (beware of chalazion that doesn’t resolve)

What are the two types of sebaceous glands carcinomas?

1. Nodular meibomian gland carcinoma

2. Spreading meibomian gland carcinoma

What is nodular meibomian gland carcinoma?

• Discrete hard nodules in upper tarsal plate

• NB: recurrent or non-resolving chalazion

What is spreading meibomian gland carcinoma?

• diffuse thickening of lid margin

• Similar to sclerosing BCC, but usually no madarosis

• Pagetoid spread: if invades palpebral, fornix or bulbar conjunctiva

• Misdiagnosis for chronic conjunctiva

list to be suspicious of malignant tumours

1. Ulceration (red but not sore)

2. Lack of tenderness

3. Induration (dome/volcano appearance)

4. Irregular borders

5. Destruction of lid margin (notching)

6. Madarosis

7. Loss of skin pres

What is karposi sarcoma?

Vascular tumour affecting AIDs px.

• small tumours that are pink, red-violet or brown resembling maemartoma or naevus

• Larger tumours can ulcerate and bleed

What is Merkel cell carcinoma?

Fast growing tumour arising from Merkel cells in dermis.

Common in elderly px.

• highly malignant and potentially lethal

• Frequent metastatic spread at diagnosis.

What are intradermal naevi?

Most common naevi that is usually elevated and papillomatous in appearance.

• maybe non-pigmented (pale) or brown-black

• Lashes may grow through if on margin, no madarosis

• “Kissing” naevi

• Naevus cells are in dermis and have no malignant potential

What are ‘kissing” naevi which are seen in intradermal naevi?

Symmetrical lesions on upper and lower lids.

Are uncommon and usually congenital.

What are the types of intradermal naevi?

1. Junctional naevi

2. Compound naevi

What are junctional naevi?

Flat, well circumscribed and uniform in colour.

• cells located at junction of epidermis and dermis

• Low potential for malignancy

What are compound naevi?

Have intradermal and junctional components

• usually brownish

• Low malignant potential

Actions for naevi

1. Document size, location and appearance of naevi

2. Take photograph

3. Educate px

4. Refer if unsure or nervous

What is melanoma?

Rarely on eyelids but potentially lethal.

• skin melanomas are pigmented but lid melanomas may be non-pigmented

What are the subtypes of melanoma?

1. Superficial spreading melanoma

2. Nodular melanoma

3. Lenticonus maligna

What is spreading melanoma?

1. plaque with irregular outline and variable pigmentation

What is nodular melanoma?

Blue-black nodule surrounded by normal skin

What is lentico maligna?

Slowly expanding pigmented macule which commonly affects the elderly px.

Hutchinson freckle - sometimes associated with melanoma development

How to differentiate between naevi and melanoma?

ABCDE:

A = asymmetrical

B = border irregularity

C = colour

D = diameter greater than 6 mm

E = evolving