Eye lid tumors
Eyelid tumors are abnormal growths around the eyes that may be either benign or malignant. Basal cell carcinoma is the most common malignant tumor. Squamous cell carcinoma, meibomian gland carcinoma, and malignant melanoma also occur. Surgery for any lesion involving the lid margin should be performed by an ophthalmologist or suitably trained plastic surgeon to avoid deformity of the lid.
Histopathologic examination of eyelid tumors should be routine, since 2% of lesions thought to be benign clinically are found to be malignant. The Mohs technique of intraoperative examination of excised tissue is particularly valuable in ensuring complete excision so that the risk of recurrence is reduced.
Medications such as vismodegib (an oral inhibitor of the hedgehog pathway), imiquimod (an immunomodulator), and 5-fluorouracil occasionally are used instead of or as an adjunct to surgery.
Most patients with eyelid tumors will notice a nodular growth on their eyelid. This growth can be skin colored, red, brown or black. Malignant tumors may cause loss of eyelashes or distort the position of the eyelid. All patients with eyelid tumors should be evaluated by an eye care specialist with experience in the care of eyelid tumors.
Benign melanocytic eyelid tumors
Melanocytic lesions of the skin are common and may arise from nevus cells, melanocytes of the epidermis, and melanocytes of the dermis; all derive embryologically from the neural crest. The location of the melanocytic cells affects the clinical appearance of the various types of the melanocytic lesions.
Freckles are small, flat brown skin spots scattered over sun-exposed areas, including the eyelids that characteristically darken with sunlight exposure and fade in the absence of sunlight. Histologically, there is hyperpigmentation of the basal cell layer but no elongation of the rete ridges.
These lesions are small, flat brown-to-black lesions that clinically are indistinguishable from junctional nevi. They are not affected by exposure to light. Histologically they show an increase in number of basal melanocytes with elongation of the rete ridges and scattered melanophages in the upper dermis.
These lesions are light to dark brown in color and develop in chronically sun-exposed areas of the skin, such as the back of the hand, in over 90% of elderly Caucasians. They may appear on the eyelids. As lentigo simplex, they show histologically an increase in the number of melanocytes in the basal cell layers and elongation of the rete ridges which are club-shaped and exhibit irregular tortuosity.
Eyelid nevi are common benign melanocytic lesions that show clinical and histological varieties.
Congenital nevi are common, present in the skin in about 1% of newborns. They may vary in size from small to giant and have a small lifetime risk for malignant transformation. Histopathologically, nevus cells usually involve the deep dermis and subcutaneous tissue with perifollicular and perivascular distribution.
Common malignant eyelid tumors
Sebaceous carcinoma: Mostly occurring in middle age to older adults, sebaceous carcinoma is the second most common eyelid cancer. It may start from meibomian glands, which are glands of the eyelids that discharge a fatty secretion that lubricates the eyelids. Less frequently, it starts from glands of Zeis, the sebaceous glands at the base of the eyelashes. Sebaceous carcinoma is an aggressive cancer that normally occurs on the upper eyelid and is associated with radiation exposure, Bowen’s disease, and Muir-Torre syndrome
Squamous cell carcinoma: Squamous cells make up most of the top layer of the epidermis. Approximately 10% to 30% of skin cancers begin in this layer. These skin cancers usually arise from sun exposure. They may also appear on skin that has been burned, damaged by chemicals, or exposed to x-rays. Squamous cell carcinoma is much less common than basal cell carcinoma, but it behaves more aggressively and can more easily spread to nearby tissues.
Basal cell carcinoma: Under the squamous cells (flat, scale-like cells) in the lower epidermis are round cells known as basal cells. About 80% of skin cancers arise from this layer in skin, and they are directly related to exposure to the sun. Basal cell carcinoma is the most common type of eyelid cancer. It usually appears in the lower lid and occurs most often in individuals with fair or pale skin.
Melanoma: The deepest layer of the epidermis contains scattered cells called melanocytes, which produce the melanin that gives skin color. Melanoma starts in melanocytes, and it is the most serious of the three skin cancer types.
Benign epithelial tumors
Squamous papilloma is the most common benign epithelial tumor of eyelid and is often sessile or pedunculated with papillary shape and keratinized surface. Squamous papillomata may be multiple. It typically occurs in middle-aged or older adults
Histopathologically, the papilloma consists of papillomatous structures of benign squamous epithelium showing variable levels of acanthosis and hyperkeratosis, and sometimes focal parakeratosis, overlying a fibrovascular core, and may show some chronic inflammation
Seborrheic keratosis is a common benign skin lesion that affects middle-aged and older individuals. They are well-demarcated warty plaques that may vary in size, degree of pigmentation, and shape of surface which may be greasy
Inverted follicular keratosis
This is a benign, solitary nodular or papillary keratotic mass that may be pigmented and most frequently occurs at the eyelid margin. In general, the lesion is of recent onset and has a tendency to recur if incompletely excised and can easily be mistaken for SCC.
Pseudoepitheliomatous (pseudocarcinomatous) hyperplasia
This is a reactive process that may clinically and histopathologically be confused with basal cell or SCC. These lesions are usually elevated with an irregular surface, sometimes with ulceration or crust, and may occur anywhere in the eyelid and typically are of short duration. It is usually associated with chronic inflammation and occurs as a reaction to trauma, surgical wound, burns, radiotherapy, cryotherapy, mycotic infections, insect bites, or topical drugs. It may be evoked by certain tumors such as lymphoma.
This lesion is typically a dome-shaped nodule with a central keratin-filled crater and elevated, rolled margins. It usually develops over a short period of weeks to a few months and may regress spontaneously. There is a long-standing debate as to whether those lesions are benign reactive lesions or a variant of SCC.
Cutaneous horn (nonspecific keratosis)
These are hyperkeratotic lesions that may be associated with a variety of benign or malignant lesions. There are no specific histopathologic findings other than hyperkeratosis.