MALIGNANT EYELID TUMOURS 1. Basal cell carcinoma 2. Squamous cell carcinoma 3. Meibomian gland carcinoma 4. Melanoma 5. Kaposi sarcoma 6. Merkel cell carcinoma 7. Treatment

Basal Cell Carcinoma - Important Facts 1. Most common human malignancy 2. Usually affects the elderly 3. Slow-growing, locally invasive 4. Does not metastasize 5. 90% occur on head and neck 6. Of these 10% involve eyelids 7. Accounts for 90% of eyelid malignancies

Frequency of location of basal cell carcinoma Lower lid - 70% Medial canthus - 15% Upper lid - 10% Lateral canthus - 5%

Nodular basal cell carcinoma Early Advanced Slow progression Shiny, indurated nodule Surface vascularization May destroy large portion of eyelid

Ulcerative basal cell carcinoma (rodent ulcer) Early Advanced Chronic ulceration Raised rolled edges and bleeding

Sclerosing basal cell carcinoma Early Advanced Spreads radially beneath normal epidermis Indurated plaque with loss of lashes May mimic chronic blepharitis Margins impossible to delineate

Histology of basal cell carcinoma Cell nests in fibrous stroma Downgrowth from epidermis of small, dark atypical basal cells Peripheral palisading

Squamous cell carcinoma Less common but more aggressive than BCC May arise de novo or from actinic keratosis Predilection for lower lid Nodular Ulcerative Hard, hyperkeratotic nodule Red base May develop crusting fissures Borders sharply defined, indurated and elevated No surface vascularization

Histology of squamous cell carcinoma Prominent nuclei and abundant acidophilic cytoplasm Variable sized groups of atypical epithelial cells within dermis Keratin ‘pearl’

Meibomian gland carcinoma Very rare aggressive tumour with 10% mortality Predilection for upper lid Nodular Hard nodule; may mimic a chalazion Very large tumour Spreading Diffuse thickening of lid margin and loss of lashes Conjunctival invasion; may mimic chronic conjunctivitis

Histology of meibomian gland carcinoma Cells contain foamy vacuolated cytoplasm and large hyperchromatic nuclei Cells stain positive for fat

Melanoma Nodular Superficial spreading From lentigo maligna (Hutchinson freckle) Plaque with irregular outline Blue-black nodule with normal surrounding skin Affects elderly Slowly expanding pigmented macule May be non-pigmented Variable pigmentation

Kaposi sarcoma Vascular tumour occurring in patients with AIDS Usually associated with advanced disease Very sensitive to radiotherapy Early Advanced Pink, red-violet lesion May ulcerate and bleed

Merkel cell carcinoma Highly malignant with frequent metastases at presentation Fast-growing, violaceous, well-demarcated nodule Intact overlying skin Predilection for upper eyelid

Treatment Options 1. Surgical excision 2. Radiotherapy 3. Cryotherapy Method of choice 2. Radiotherapy Small BCC not involving medial canthus Kaposi sarcoma 3. Cryotherapy Small and superficial BCC irrespective of location Adjunct to surgery in selected cases

Lower eyelid reconstruction following tumour excision a b Direct closure of small defect a b b Tenzel flap for moderate defect Mustarde cheek rotation flap for large defect

Eyelid-sharing procedure Extensive sclerosing BCC Total excision of lower lid Tarsoconjunctival flap Appearance after healing Reconstruction of posterior lamella Reconstruction of anterior lamella with skin graft