OPT 221 Eyelids: Malignant

For the ABCDE rule, what is "A"?

asymmetry; one half does not match the other half

For the ABCDE rule, what is "B"?

borders; indistinct borders (uneven, scalloped, notching)

For the ABCDE rule, what is "C"?

color; various colors within the lesion (tan, brown, dark brown, red, blue, black)

*can also be amelanotic

For the ABCDE rule, what is "D"?

diameter/disruption; 6 mm or larger, disruption of normal eyelid architecture (madarosis, poliosis, swelling or thickening of the eyelid)

For the ABCDE rule, what is "E"?

evolving; any change in size, shape, color, or elevation; bleeding, itching or crusting

*new mole after age 40

What is a basal cell carcinoma (BCC)?

malignant tumor of the skin

What is the etiology of BCC?

-proliferation of atypical basal epithelial cells

-associated with UV exposure

What demographics are generally more affected by BCC?

-typically develops after age 50

-more common in caucasians

Is BCC commonly bilateral or unilateral?

unilateral

What are symptoms of BCC?

-asymptomatic

-bump or mole, scab or sore on eyelid

What are signs of BCC?

variable appearance

-pink, shiny, firm, or pearly nodule with small overlying blood vessels

-centrally ulcerated with pearly raised rolled edges

-firm, waxy yellow plaque with indistinct borders

-open sore

-most frequently involves the LL and medial canthus

What are complications associated with BCC?

-orbital extension: <5% invade the orbit

-metastasis: extremely rare: <0.1% metastatic potential

How is BCC managed?

-refer for biopsy and surgical excision

-Moh's surgery: 98% curative of BCC

-if suspect orbital involvement, need CT or MRI

What is true if a BCC extends beyond eyelid septum?

will need more aggressive surgical procedures including external beam radiation or orbital exenteration

What are clinical pearls of BCC?

-most common skin cancer (90% of cases involve head and neck, 10% involve the eyelid)

-most common eyelid cancer/malignant tumor (accounts for 90% of all malignant cases)

What is squamous cell carcinoma?

malignant tumor of the skin

What is the etiology of SCC?

-proliferation of atypical squamous epithelial cells

-associated with UV exposure

-associated with pre malignant lesions: actinic keratosis, keratoacanthoma

What demographics are usually more affected by SCC?

-typically develops after the age of 50

-more common in caucasians

Is SCC typically bilateral or unilateral?

unilateral

What are symptoms of SCC?

-asymptomatic

-bump or scab/sore on eyelid

What are signs of SCC?

-variable appearance

-scaly red patch (crusting, scabbing, slight bleeding to margins)

-rough, thickened or wart like skin

-raised growths with central depression

-open sore

-most frequently involved the LL

What are complications associated with SCC?

-orbital extension

-metastasis

How is SCC managed?

-referral for biopsy and surgical excision

-Moh's surgery (curative if localized)

-need CT or MRI if orbital involvement is suspected

What are clinical pearls of SCC?

-most variable in presentation of all eyelid cancers

-2nd most common skin cancer

-2nd most common eyelid cancer (5-10% of all cases)

-two pre malignant associated diagnoses

What are the two pre malignant associated diagnoses that are connected to SCC?

-actinic keratosis (majority SCC arise from this)

-keratoacanthoma

What is actinic keratosis?

pre malignant small dry, scaly, or crusty patches of skin that can feel dry or rough to touch (can also be painful, itchy, or burning)

What percent of actinic keratosis can transform into SCC?

5-10%

What is keratoacanthoma?

pre malignant variant of SCC that is characterized by rapid growth over a few weeks to months followed by slow regression and even spontaneous resolution in 4-6 months (refer for biopsy and excision)

What is a sebaceous gland carcinoma?

malignant tumor of a sebaceous gland (usually a meibomian gland)

What is the etiology of SGC?

proliferation of atypical epithelial cells lining sebaceous glands

What demographics are mostly affected by SGC?

typically develops after age of 50

Is SGC typically unilateral or bilateral?

unilateral

What are symptoms of SGC?

-asymptomatic

-bump in or on eyelid, stye the comes back

What are signs of SGC?

-variable appearance (hard nodule, yellow discoloration (lipid), can resemble benign lesions like chalazion or hordeolum)

-tends to spread along conjunctival surface

-most frequently involved the UL (since this is where more sebaceous glands are located)

What complications are associated with SGC?

-orbital extension

-metastasis (higher risk)

How are SGC managed?

referral for biopsy and surgical excision

What are clinical pearls of SGC?

-can develop in any sebaceous gland (most often meibomian)

-represents < 1% of all eyelid tumors

-overall mortality is 5-10% due to metastasis (and delayed diagnosis)

What is a melanoma?

malignant tumor of the skin

What is the etiology of melanomas?

-proliferation of atypical melanocytes

-develop from nevus

-associated with UV exposure

What demographics are mostly affected by melanomas?

more common in caucasians

Are melanomas typically unilateral or bilateral?

unilateral

What are symptoms of melanomas?

-asymptomatic

-bump on eyelid

-quick development

-Hx of nevus or mole, noticed change vs unaware

What are signs of melanomas?

-variable appearance

-flat or slightly raised and discolored, asymmetric patch with uneven borders

-variable size but greater concern if> 6 mm

-madarosis

What are complications associated with melanomas?

-metastasis

-orbital extension (can rapidly involve other ocular structures)

-strong propensity with lymphatic invasion (may involve other organs)

How are melanomas managed?

referral for biopsy and surgical excision

What are clinical pearls of melanomas?

-can occur anywhere on the skin

-least common eyelid malignancy

-most fatal eyelid malignancy due to metastasis (accounts for majority of skin cancer deaths)

What is the 5 year survival rate of melanomas?

99% if treated prior to metastasis (62% if spreads to lymph nodes, 20% if spreads to distant body sites like organs)

What is Kaposi's sarcoma?

malignant tumor that usually appears on the skin or mucosal surfaces

What is the etiology of KS?

proliferation of endothelial cells that line lymph or blood vessels in response to human herpesvirus 8 (HHV-8)

What are the 4 populations/ types of KS?

1. AIDS associated

2. Mediterranean

3. African

4. transplant related

Is KS typically bilateral or unilateral?

can be either

What are symptoms of KS?

-asymptomatic

-bump or plaque on the eyelid, may be multiple

What are signs of KS?

painless purple, red, or brown nodules or papules

can occur on eyelid and/or conjunctiva

How is KS managed?

-refer out for biopsy

-lesions are treated with surgical excision (radiotherapy, cryotherapy, intralesional chemotherapy)

-refer out for PCP or oncology Tx (HAART)

What are clinical pearls associated with KS?

-infection with HHV-8 does not always lead to KS

-can occur anywhere on the skin or mucosal surface (skin lesions most often affect legs and face)

-no treatment available to eradicate HHV-8 infection (purpose of therapy is improving cosmesis and slowing progression)

T or F: KS is not considered an AIDS defining illness.

False. When KS occurs in someone infected with HIV, they are officially diagnosed as having AIDS