A 76 year-old man presented to his ophthalmologist with a 4 week history of mild erythema and edema of the left upper eyelid. The patient was initially treated conservatively for a chalazion with topical antibiotic/steroid ointment and asked to return in 3 weeks. On his follow up visit, a marked increase in the size of the lesion and features suspicious for a malignancy were noted. An incisional biopsy at the time yielded a preliminary diagnosis of SebCCa, prompting a referral for further management. A week later at oculoplastics consultation, the patient reported a 4 week history of a rapidly enlarging lesion with yellowish discharge, episodes of hemorrhage, and decreased vision of the left eye due to mechanical obstruction ().
Figure 1 A. Clinical photograph of patient showing yellowish ulcerated mass of the posterior lamella of the left upper eyelid. B. PET/CT of the region showing hypermetabolic left upper eyelid mass that had a maximum standard uptake value (SUV) of 10.6 abutting (more ...)
Examination showed visual acuity of 20/40 OD and 20/60 OS. A very aggressive appearing 20mm × 14mm × 6mm pedunculated, multilobulated, yellowish, and ulcerated mass with areas of necrosis and telangeictasia protruded from the posterior lamella of the left upper eyelid. The rest of the ophthalmic exam was normal except for moderate bilateral nuclear sclerosis, and no palpable lymph nodes were present in the head and neck. Subsequent PET/CT showed the hypermetabolic left upper eyelid mass (). No regional or distant metastatic disease was identified. Conjunctival map biopsies were deferred owing to the normal clinical appearance of the bulbar conjunctiva, the inferior fornix, and the inferior palpebral conjunctiva.
The patient was promptly referred for resection of the tumor with a modified Mohs technique with additional margins using frozen and paraffin embedded sections. The histopathology showed a tumor with papillomatous epithelium that was infiltrated by malignant cells with abundant vacuolated cytoplasm and small nuclei, thereby confirming SebCCa with pagetoid spread () and mitotic figures (). However, the peripheral margins of the tumor showed widespread xanthogranulomatous reaction without any evidence of SebCCa (). Further evaluation of the center of the tumor by immunocytochemistry showed cytokeratin positive SebCCa infiltrating the mass and small foci in the subepithelial stroma (). These tumor cells were surrounded by a much larger dense collection of CD 68 positive foamy histiocytes () that composed the bulk of the tumor.
Figure 2 A. H & E stained section of the lesion showing papillomatous conjunctival epithelium infiltrated by SebCCa cells with cytoplasmic vacuolations. B. Enlarged view of malignant SebCCa cells with mitotic figures (arrows)(400X) C. Enlarged view of (more ...)