SEBACEOUS CARCINOMA OF THE EYELID: A CASE REPORT OF A MULTIDISCIPLINARY APPROACH
Clinical Radiology , 56(11), 877–886. https://doi.org/10.1053/ crad.2001.0795 ACKNOWLEDGEMENTS Tiffany Shick is a 2nd year Medical Student at Tulane University School of Medicine in New Orleans, La. Neel Dewan Gupta MD is a clinical and academic musculoskeletal radiologist in New Orleans and serves as a clinical assistant professor within the Department of Radiology at the Tulane University Medical Center. Jeremy Nguyen MD, FACR is clinical radiology professor within the Department of Radiology at the Tulane University Medical Center. Donald Olivares, Digital Imaging Specialist and Graphic Designer. ■
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Author: Robert P. VanHoy, Edward Via College of Osteopathic Medicine
tumor that was immunohistochemically BerEp4 positive, and it was diagnosed as a “basal cell carcinoma(BCC), incompletely excised.” The patient was referred for pre-op consultation and decided to proceed with excisional surgery, with intraoperative frozen section controls to optimize chances for clear margins. The surgery was more extensive than planned, with the surgeon removing essentially 100% of her lower eyelid to gain negative margins, a significant deviation from the projected 40%. A Hughs Tarsoconjunctival flap stage I from the right upper lid was performed, as well as a free skin graft from the retroauricular area to repair the excised area(Figure 1B). The excision specimen with frozen sections were sent to the pathology department and assessed by a dermatopathology subspecialist. The tumor demonstrated intraepidermal pagetoid tumor spread in addition to invasion, the former being a key difference between SC and BCC. Further, the tumor showed positivity for epithelial membrane antigen(EMA), Androgen receptor(AR) and adipophilin through immunohistochemical staining. This constellation of features, along with recognition of scattered atypical sebocytes amid intraepidermal and an invasive tumor, allowed reliable histologic diagnosis of poorly differentiated sebaceous carcinoma in this case. The patient was counseled on the updated diagnosis and future treatment included performing further excision of the medial and lateral canthal margins during the second stage of the lid sharing procedure. The lid sharing procedure achieved good eyelid function and cosmetic results(Figure 1C) and the re- excisional biopsy yielded negative margins. The patient was followed postoperatively and it was decided that she would receive conjunctive radiation treatment. Radiation oncology was consulted and the patient was treated with 5000 cGy in 200cGy fraction energy with six MV electrons for 25 treatments over 36 days. Radiation treatment was targeted to the eyelid with minimal orbit involvement. Over a year later the patient, unfortunately, had a recurrence. A positive conjunctival biopsy and staging was conducted by MRI and showed isolation to the same lower lid. Patient was offered exenteration but she declined. It was then planned to place the patient on mitomycin C drops 0.04% four times daily (.04mg/cc) one week on and one week off for a total of four weeks. After completion of the mitomycin C, the patient had a clinically successful cure. Two years later, the patient presented with a suspicious skin lesion on the lower right eyelid. Biopsy was taken and it was confirmed a local skin recurrence of SC. The patient was treated with 5-fluorouracil (5-FU) 1% twice daily for two weeks. Regular follow ups and treatment over the past three years have successfully retained her bilateral sight and preserved her cosmetic appearance(Figure 1D). Coauthors: Dr Michael A. Redmond at Louisiana Eye and Laser and Dr. George R. Collins at Delta Pathology group Alexandria LA
ABSTRACT Sebaceous carcinoma (SC) is a rare malignancy that can arise from the sebaceous glands in the skin. The case presented below is of an 87-year-old caucasian woman who originally presented with a nodular growth on the lower eyelid, which was initially diagnosed on biopsy as basal cell carcinoma. Only after additional staining was the final diagnosis of SC made. Incorrect pathological diagnoses have been reported in 45-75% of SC cases 1 , most commonly being mistaken for squamous and basal cell carcinoma. Clinical recognition of SC of the eyelid is also challenging due to its resemblance to common eye pathologies such as blepharitis and chalazion. Treatment of SC can vary depending on location of the tumor and metastasis but involves surgical removal, radiation, and chemotherapy 1,2 . This case report aims to add to the current literature by highlighting the difficulty in diagnosing SC and offering options for conservative treatment plans. INTRODUCTION Sebaceous carcinoma (SC) is an aggressive tumor that can form anywhere there are sebaceous glands on the skin. Approximately 80% of SC present in the head and neck region and 40% on the eyelid, with a two to three times higher prevalence on the upper eyelid due to the higher number of sebaceous glands 2 . Diagnosis is difficult because the malignancy resembles many pathologies on appearance and is even difficult to distinguish on histology without close attention to subtle morphologic features and characteristic ancillary staining methods 3 . Treatment is surgical excision and is, many times, combined with chemotherapy and/ or radiation 2 . This case report demonstrates that SC is a rare and difficult diagnosis to make, requiring a multidisciplinary approach. CASE REPORT An 87-year-old white woman presented to the ophthalmologist with irritation and lid lesion on her lower right eyelid(Figure 1A). The lesion had been present for two weeks and was described as enlarging and itchy; an earlier visit for the same complaint resulted in antibiotic treatment, giving the patient temporary relief. Upon ophthalmic exam, a lesion was identified on the medial lower right eyelid and meibomian gland dysfunction bilaterally. Previous ocular history only involved cataract removal OU. The differential diagnosis was originally between blepharitis and unknown neoplasm of the skin. The plan was to treat the patient with bacitracin 500unit/gram ointment and erythromycin 5mg/gram ointment applied to the right eyelid and bilateral warm compresses with lid scrubs. Follow up was scheduled in two weeks to remove the lesion if the patient showed no improvement. The patient presented to two week follow up with no reduced symptoms so the lesion was biopsied and sent to pathology. Four days later, pathology results revealed a basaloid
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