Case 20 - Cornea, external disease, and anterior segment
62-year-old farmer - Non-healing 'sore' below lower right lid - Sun- exposed occupation
This 62-year-old farmer complains of a non-healing 'sore' below his lower right lid, as depicted in the photograph.
PEARLY, TRANSLUCENT NODULE with RAISED ROLLED BORDERS, CENTRAL ULCERATION/CRATER ('rodent ulcer'), and TELANGIECTASIA (dilated surface vessels). Located on the lower eyelid (70% of periocular BCC). The classic triad: pearly nodule + rolled borders + central ulceration + telangiectasia.
Basal Cell Carcinoma (BCC) - nodular type. Most common malignant eyelid tumor (~90%). Arises from basal cell layer of epidermis. RARELY metastasizes (<0.1%) but locally destructive - can invade orbit requiring exenteration if neglected. Risk factors: cumulative UV exposure (farmer), fair skin, advanced age, immunosuppression, Gorlin syndrome.
BCC (most likely - 90% of malignant eyelid tumors), SCC (harder, more inflammatory, can metastasize, arises from actinic keratosis, grows rapidly), Keratoacanthoma (rapid growth, central keratin plug, may resolve spontaneously - classified as SCC variant), Sebaceous Gland Carcinoma (rare but HIGH MORTALITY - masquerades as recurrent chalazion; pagetoid spread), Merkel cell carcinoma (rare, violaceous, aggressive).
MOHS MICROGRAPHIC SURGERY - gold standard for periocular BCC; 100% margin control via real-time frozen section -> ~99% cure rate + maximal tissue conservation. Eyelid reconstruction after clear margins: direct closure (small), Hughes procedure (large lower lid), rotational flaps, skin grafts. Radiation for poor surgical candidates. Vismodegib (hedgehog inhibitor) for locally advanced/metastatic BCC.
BCC is the most common malignant eyelid tumor (~90%). Three BCC subtypes: nodular (most common, best prognosis), morpheaform/sclerosing (flat, scar-like, highest recurrence - widest margins needed), superficial. Mohs surgery = gold standard for periocular BCC. NEVER miss sebaceous gland carcinoma masquerading as a recurrent chalazion in the upper lid of an elderly patient - it kills via pagetoid spread.
Findings Diagnosis
PEARLY, TRANSLUCENT NODULE with RAISED ROLLED BORDERS, CENTRAL Basal Cell Carcinoma (BCC) - nodular type. Most common malignant eyelid tumor (~90%).
ULCERATION/CRATER ('rodent ulcer'), and TELANGIECTASIA (dilated surface vessels). Arises from basal cell layer of epidermis. RARELY metastasizes (<0.1%) but locally
Located on the lower eyelid (70% of periocular BCC). The classic triad: pearly nodule + destructive - can invade orbit requiring exenteration if neglected. Risk factors: cumulative
rolled borders + central ulceration + telangiectasia. UV exposure (farmer), fair skin, advanced age, immunosuppression, Gorlin syndrome.
DDx Treatment
BCC (most likely - 90% of malignant eyelid tumors), SCC (harder, more inflammatory, can MOHS MICROGRAPHIC SURGERY - gold standard for periocular BCC; 100% margin control
2 metastasize, arises from actinic keratosis, grows rapidly), Keratoacanthoma (rapid growth, 4 via real-time frozen section -> ~99% cure rate + maximal tissue conservation. Eyelid
central keratin plug, may resolve spontaneously - classified as SCC variant), Sebaceous reconstruction after clear margins: direct closure (small), Hughes procedure (large lower
Gland Carcinoma (rare but HIGH MORTALITY - masquerades as recurrent chalazion; lid), rotational flaps, skin grafts. Radiation for poor surgical candidates. Vismodegib
pagetoid spread), Merkel cell carcinoma (rare, violaceous, aggressive). (hedgehog inhibitor) for locally advanced/metastatic BCC.
TEACHING PEARL
BCC is the most common malignant eyelid tumor (~90%). Three BCC subtypes: nodular (most common, best prognosis), morpheaform/sclerosing (flat, scar-like, highest
recurrence - widest margins needed), superficial. Mohs surgery = gold standard for periocular BCC. NEVER miss sebaceous gland carcinoma masquerading as a recurrent
chalazion in the upper lid of an elderly patient - it kills via pagetoid spread.