Ocular Disease: Lecture 6: Eyelids Flashcards
What are the 7 Malignant Tumors we went over in class?
- Basal Cell Carcinoma
- Squamous Cell Carcinoma
- Keratoacanthoma
- Sebaceous Gland Carcinoma
- Lentingo Maligna
- Merkel Cell Carcinoma
- Kaposi Sarcoma
Eyelids: Malignant Tumors: Basal Cell Carcinoma
- How common of a human malignancy is it?
- How common is it as a Malignant Eyelid Tumor?
- Who does it affect more?
- 3 Major Risk Factors?
- % that are in the head and neck?
- Most common
- Most common (>90%)
- Males
- a. Chronic Sun Exposure
b. Fair Skin
c. Inability to Tan - 90%; (10% are Eyelid)
Eyelids: Malignant Tumors: Basal Cell Carcinoma
Characteristics
- How fast does it grow?
- Is it invasive?
- Metastatic?
- What else?
- Prevalence?
- Slow growing
- Locally
- Rarely (greater risk if LARGER than 5 cm, and make sure to PALPATE LYMPH NODES!!)
- Madarosis
- a. Lower Lid
b. Medial Canthus
c. Upper Lid
d. Lateral Canthus
Eyelids: Malignant Tumors: Basal Cell Carcinoma
Clinical Types
- 4 Major clinical Types?
- Nodular
- Noduloulcerative (rodent Ulcer)
- Sclerosing (Morphoeic)
- Other: (Cystic, Adenoid, Pigmented)
Eyelids: Malignant Tumors: Basal Cell Carcinoma
Nodular
- What does it look like?
- What is seen on it?
- Growth rate?
- May develop what?
- Shiny Firm Pearly Nodule
- Small, dilated surface Vessels
- Initially it’s very slow growing
- May develop an Ulcer
Eyelids: Malignant Tumors: Basal Cell Carcinoma
Noduloulcerative
- AKA?
- What is seen w/in the Nodule?
- What does the border look like?
- What do we see at the margins?
- Rodent Ulcer
- A Central Ulcer
- It will be raised and seem to “Roll Over”
- Dilated Vessels will be seen at the Margin
Eyelids: Malignant Tumors: Basal Cell Carcinoma
Sclerosing
- Form type?
- How common?
- Infiltration occurs how and where?
- What does it form?
- Margins are difficult to what?
- Looks like what condition?
- Morpheaform
- Less Common
- Lateral Infiltration beneath the Epidermis
- A Plaque
- They are difficult to Delineate
- Looks like Blepharitis
Eyelids: Malignant Tumors: Basal Cell Carcinoma
Typical Presentation
- What does it first show up as?
- What will the patient report about it?
- How fast does it increase in size?
- May report what problem?
- A “lump” that doesn’t go away
- That it’s been there a LONG TIME (up to 4 years)
- VERY SLOW INCREASE in size
- A small wound that won’t heal
Eyelids: Malignant Tumors: Basal Cell Carcinoma
Treatment
- What is done first?
- Canthal Tumors require what to be done?
- Finally, what 2 things do we need to tell them/do?
- Complete Excision and Biopsy (Rarely Radiation and Cryotherapy)
- Orbital CT
- Referral to Oncologist for Systemic work up and tell them to AVOID FURTHER SUN DAMAGE!!
Eyelids: Malignant Tumors: Basal Cell Carcinoma
Follow Up
- When after treatment?
- After that?
- Close follow ups for 3-6 months by dermatology
2. Annual Exam to monitor for recurrence
Eyelids: Malignant Tumors: Squamous Cell Carcinoma
- How common is it?
- Where is it most commonly seen?
- Who does it affect the most (3)?
- When is there a HIGHER INCIDENCE of this?
- Possible link to what STD?
- Less common than BCC (less than 10% of eyelid malignancies)
- On Lower lid and Lid Margin
- Elderly Patients w/fair complexion and those with a HIstory of Chronic Sun Exposure
- In patients who are Immune Compromised
- To HPV
Eyelids: Malignant Tumors: Squamous Cell Carcinoma
- More Aggressive than what?
a. Metastatic in what % of cases?
b. Where is it possible for it to metastasize? - Why is diagnosis difficult?
- Than BCC
a. 20%
b. To Intracranial Space Via Orbit is Possible. - May underlie a Benign Lesion (Actinic Keratosis and Cutaneous HORN)
Eyelids: Malignant Tumors: Squamous Cell Carcinoma
Clinical Variation
- Varies: 3 points to think about?
- 3 Clinical Types?
- a. Flat or Slightly Elevated Plaque
b. May be Scaly or Ulcerated
c. Often Arises from Actinic KERATOSIS - a. Nodular
b. Ulcerating
c. Cutaneous Horn
Eyelids: Malignant Tumors: Squamous Cell Carcinoma
Clinical Types
- Nodular
a. What does it look like?
b. Type of Nodule? - Ulcerating
a. Base looks like what?
b. What about the borders? - Cutaneous Horn
a. What may be present underneath it?
- a. Crusting erosions and cracks/fissures
b. Hyperkeratotic Nodule - a. Red
b. Sharply defined borders - a. Invasive SCC may be present
Eyelids: Malignant Tumors: Squamous Cell Carcinoma
Treatment
- First thing to do?
- 2 other possible things that can be done?
- What else?
- Excision and Biopsy (wider surgical margin than BCC)
- Adjunctive radiation, cryo or chemo therapy (or combo of them)
- Post-septal involvement (exenteration)
* Referral to oncologist for a systemic work up
* Avoid further sun damage
Eyelids: Malignant Tumors: Keratoacanthoma
- How common is it?
- How fast does it grow?
- Seen in whom?
- Where do we normally see it on the body?
- Who is affected more?
- Rare
- Rapidly growing lesion
- Elderly Adults (fair skinned; chronic sun exposure)
- Sun exposed areas
- Immune compromised = higher prevalence. Possibly a spectrum of SCC
Eyelids: Malignant Tumors: Keratoacanthoma
Clinical Presentation
- What does it look like
a. Normally see where on the eye? - How fast will it increase in size?
- When does growth normally stop?
- Spontaneous what?
- What happens in about 1 year?
- Pink, rapidly growing, hyperkerototic lesions
a. Lower Lid frequently - Double or triple size in a few weeks
- in about 2-3 months
- Spontaneous involution (keratin fille Crater)
- Complete Involution (significant scar)
Eyelids: Malignant Tumors: Keratoacanthoma
Treatment
- What is normally done?
- Complete surgical excision
* hard to differentiate from SCC dictates that surgical intervention should be considered
* Tx may improve cosmetic outcome
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
- How common is it?
- Growth rate?
- Generally looks like what?
- Seen in whom?
- Who does it affect more?
- More common location on the eye?
- Very RARE
- Slow Growing
- Hard Yellowish Lesion (No characteristic Clinical appearance)
- Elderly Patients (5th to 7th decade)
- Females
- on the UPPER Lid. (simultaneously upper and lower lid 5% of the time)
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
- What does it arise from?
a. So why is it found more often on the upper lid? - Occasionally it comes from what 2 things?
- Meibomian Glands
a. Cuz there are more glands there - a. Glands of Zeis
b. Sebaceous Glands of Caruncle
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
- Diagnosis is hard. Early stage resembles what 2 things?
- Cardinal Clinical Signs? (4)
- a. Chronic Blepharitis
b. Recurrent Chalazion - a. Madarosis
b. Marginal Inflammation
c. Poliosis
d. Thickened Red Lid Margin
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
- What type of metastasis is possible? (2)
- What can happen to the Orbit?
- Regional or Systemic Metastasis is possible. (Lymphadenopathy)
- Orbital Extension is possible.
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
- Prognosis is worse if the following 3 things are seen:
- Prognosis is better if…? (1)
- a. On both lids (>80% mortality)
b. Size of lesion 10mm or greater
* >20mm = 60% mortality
c. Symptoms >6months –> 35% mortality
2. if it Arises from Glands of Zeis..MAYBE??
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
- 3 Clinical Types
- Nodular
- Spreading
- Pagetoid
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
Nodular
- What is it?
- May be YELLOWISH. Why?
- What does it look like?
- Hard Nodule w/in Upper Tarsal Plate
- Due to lipids w/in the Lesion
- Like a Chalazion
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
Spreading
- What does it infiltrate?
- What happens to the Lid Margin?
- What 2 things are possible?
- What does it resemble?
- May be what?
- The Dermis
- Thickens
- Madarosis and Poliosis
- Chronic Blepharitis
- non-contiguous
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
Pagetoid
- May resemble what condition?
- What does it spread to?
- an Inflammatory Condition
2. Bulbar Conj, Fornix, or Palpebral
Eyelids: Malignant Tumors: Sebaceous Gland Carcinoma
Treatment
- Type of biopsy?
- What other biopsy can be done?
- Finally, what 3 treatments are possible?
- Full thickness Biopsy
- Map Biopsies (Determine FULL EXTENT of LESION)
- a. Exenteration may be necessary
b. Palliative Radiation
c. Total Resection
Eyelids: Malignant Tumors: Melanoma
- Type of tumor?
- How common is it?
- Type of Lesion?
- Is it Metastatic?
- Most LETHAL PRIMARY SKIN TUMOR
- RARE (<1% of all eyelid malignancies)
- Pigmented Plaque or Lesion (may be non-pigmented…50%)
- Highly. Early detection and treatment is critical.
Eyelids: Malignant Tumors: Melanoma
- Suspicious Findings? (ABCDEFG)
Assymmetry
Border (Irregular)
Color (Inconsistent)
Diameter (> 6mm)
Evolving or changing
Elevated
Firm
Growth
Eyelids: Malignant Tumors: Melanoma
Suspicious Findings
- Other? (4)
- Itching
- Oozing
- Pain
- Scaliness
Eyelids: Malignant Tumors: Melanoma
- Three Histological Types (NSL)
- Nodular
- Superficial Spreading
- Lentigo Maligna
Eyelids: Malignant Tumors: Melanoma
Nodular
- How common on eyelids?
- Nodule color?
- Surrounded by what?
- How aggressive is it?
- VERY RARE
- Bluish Black Nodule
- Surrounded by Normal Skin
- VERY AGGRESSIVE (Worst Prognosis)
Eyelids: Malignant Tumors: Melanoma
Superficial Spreading
- How common is this form?
- Onset time?
- What does it look like?
- Pigment color normally?
- Quickly develops into what?
- Most COMMON Form (80%)
- 20-60 years of age
- Plaque w/an Irregular Border
- Often Variable and Inconsistent
- into a Raised Nodule
Eyelids: Malignant Tumors: Melanoma
Lentigo Maligna
- AKA?
- % of melanoma cases?
- Associated with what?
- Seen in whom?
- What is it?
- How does it enlarge?
- Hutchinsons Freckle
- 10%
- Sun damaged Skin
- Elderly Patients
- Flat tan-brown plaque w/irregular borders
- Enlarges Radially!
Eyelids: Malignant Tumors: Melanoma
Treatment
- What is it?
a. May include what?
- Wide Excision
a. May include Local Lymph Node Removal
Eyelids: Malignant Tumors: Merkel Cell Carcinoma
- How common is it?
- Growth rate of lesion?
- Where is it usually found?
- Seen in whom?
- How malignant are they?
- RARE
- Rapidly growing solitary lesion
- On Head and Neck. (20 cases of eyelid tumor Since 1983); Upper Lid Predilection
- Elderly Patients
- Highly; 50% of patients have metastatic spread at diagnosis
Eyelids: Malignant Tumors: Merkel Cell Carcinoma
Presentation
- Type of Nodule?
- May have what on the surface of it?
- Who is it usually seen in? (race)
- Metastasis?
- Prognosis?
- Non Tender Violaceous Nodule
- Telangiectatic Vessels on the Surface
- Caucasians
- to Local and Distal Lymph Nodes is Common
- Poor. >65% mortality if local spread.
Eyelids: Malignant Tumors: Merkel Cell Carcinoma
Treatment
- What do they tend to do? (3)
- Complete Excision
- Lymph Node Resection
- Chemo/Radiation Therapy Likely.
Eyelids: Malignant Tumors: Kaposi Sarcoma
- What is it?
- What’s it normally associated with?
- Who does it occur in independently?
- Malignancy?
- Vascular Tumor
- AIDS
- In African and Mediterranean Descent (Rarely)
- Very malignant. esp when associate w/immunocompromised conditions
Eyelids: Malignant Tumors: Kaposi Sarcoma
Presentation
- What does it look like?
- May be found in what 4 places?
- Treatment? (2)
- Pink or Red to Violet Lesion
- Conjunctive, Eyelids, Face, Mouth
- a. Excision
b. Cryo/Radio/Chemo/Immuno therapy