|ONE MINUTE OPHTHALMOLOGY
|Year : 2019 | Volume
| Issue : 10 | Page : 1519
Eyelid chalazion or not?
Jerry A Shields, Sara E Lally, Tatyana Milman, Carol L Shields
Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
|Date of Web Publication||23-Sep-2019|
Dr. Carol L Shields
Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, Suite 1440, Philadelphia, PA 19107-5109
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shields JA, Lally SE, Milman T, Shields CL. Eyelid chalazion or not?. Indian J Ophthalmol 2019;67:1519
| Case|| |
A 56-year-old male noted swelling of his right lower eyelid (RLL) in January 2017. This was initially diagnosed as a stye and treatment with warm compresses was advised. In February 2017, the stye was unchanged and antibiotic–steroid combination ointment was added. In March 2017, the lesion became firm and nodular. Biopsy elsewhere revealed eyelid squamous cell carcinoma (SCC), well-differentiated. The patient was referred for our management. On examination, his visual acuity was 20/40 OD and 20/20 OS. There was a firm, painless mass in the RLL [Figure 1]a, measuring 20 mm in diameter and involving full-thickness eyelid. There was no orbital invasion on magnetic resonance imaging [Figure 1]b.
|Figure 1: Firm mass in the right lower eyelid (a), measuring 20 mm in diameter and involving full-thickness eyelid. There was no orbital invasion on magnetic resonance imaging (b). Histopathology showed moderately differentiated invasive carcinoma (c) with predominant squamous differentiation and keratinization. Glandular areas with goblet cells (d, arrows) were identified within the tumor|
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| What is Your Next Step?|| |
- Posterior lamellar resection of the eyelid
- Full-thickness resection of the eyelid with frozen section control
- Orbital exenteration
- Stereotactic radiotherapy.
Correct Answer: D.
Full-thickness resection of the eyelid with frozen section control of margins.
| Findings|| |
Following resection, histopathology revealed a mass arising from the conjunctiva with a moderately differentiated invasive carcinoma showing predominant squamous differentiation and keratinization [Figure 1]c. Glandular areas with goblet cells [[Figure 1]d, arrows] were identified within the tumor nests and were highlighted with PAS and Alcian blue stains. The squamous component of the lesion strongly expressed cytokeratin 17 (CK17), while the goblet cells and glandular component of the lesion expressed CK7. These findings were compatible with mucoepidermoid carcinoma, now referred to as adenosquamous carcinoma by the World Health Organization.
| Diagnosis|| |
Conjunctival adenosquamous carcinoma
| Discussion|| |
This malignancy demonstrated full-thickness eyelid invasion, so choice B, and not A, would be most appropriate. There was no evidence of orbital invasion, so choice C is not correct, and this mass was surgically resectable so choice D is not considered.
Conjunctival adenosquamous carcinoma is rare, accounting for <1% of all conjunctival tumors. This malignancy develops in the conjunctiva as a gray-white mass, typically in older patients and with an aggressive course. Histopathologically, this tumor is characterized by epidermoid and mucin-producing malignant (goblet) cells. This carcinoma can demonstrate CK7 positivity (CK7+), typically lost in conventional conjunctival SCC that usually expresses only CK17. Rankin et al. emphasized that CK7+ staining in an epibulbar squamous dysplasia/carcinoma and coexistent intracellular mucin (highlighted with Alcian blue or mucicarmine stains) should raise consideration for adenosquamous carcinoma. Wide surgical resection is advocated for management of this malignancy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mudhar HS, Edward DP, Chan ASY. Adenosquamous carcinoma of the conjunctiva and caruncle. In: Grossniklaus HE, Eberhart CG, Kivela TT, editors. WHO Classification of Tumours of the Eye. 4th
ed. Lyon: IARC; 2018, p. 20-1.
Shields CL, Alset AE, Boal NS, Casey MG, Knapp AN, Sugarman JA, et al
. Conjunctival tumors in 5002 cases. Comparative analysis of benign versus malignant counterparts. The 2016 James D. Allen lecture. Am J Ophthalmol 2016;173:106-33.
Rankin JK, Jakobiec FA, Zakka FR, Foster CS. An improved approach to diagnosing and treating conjunctival mucoepidermoid carcinoma. Surv Ophthalmol 2012;57:337-46.