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Well-differentiated squamous cell carcinoma of the eyelid arising during a 20-year period

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Well-differentiated squamous cell carcinoma of the eyelid arising during a 20-year period
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  Well-Differentiated Squamous Cell Carcinomaof the Eyelid Arising During a 20-Year Period  Jane M. Olver, FRCOphth; Mohammed Muhtaseb, MBBS; Devinder Chauhan, FRCOphth; Ethna Mannion, MRCPath A n 81-year-old man had a keratotic eyelid lesions for 20 years. He eventually soughttreatment by ophthalmic plastic surgery. Clinically, the lesion resembled a keratoac-anthoma.Findingsfromhistologicexaminationoftheexcisionbiopsyspecimenshoweda squamous cell carcinoma. The lesion was completely excised. This case demon-strates the difficulty in making a correct clinical diagnosis of a keratotic eyelid lesion. Performinga histologic examination of nonregressed keratotic lesions is essential to exclude a squamous cellcarcinoma. Arch Ophthalmol. 2000;118:422-424 The relationship between keratoacan-thoma and squamous cell carcinoma(SCC) is controversial. We report a caseofanoldermanwithalong-standingkera-toticeyelidlesion,whichprobablyrepre-sented a nonregressed keratoacanthomathatatsomestagehadundergonefocalma-lignant degeneration to a well-differ-entiated SCC. REPORT OF A CASE An 81-year-old man complained that aneyelidlesionthatwaspresentfor20yearswasinterferingwithhisvisionandthathisfamily was embarrassed by his appear-ance.Hehadregularlytrimmedthekera-tinhornsgrowingfromhisrightuppereye-lid,butthesecontinuedtoregrow,andthelesion enlarged steadily during the 20-yearperiod.Hereportednorecentchangein its growth pattern, no pain or bleed-ing, and was systemically well. An inci-sionalbiopsyspecimenwasobtainedfromthe edge of the lesion by dermatologistsand showed actinic keratosis. He was re-ferred to the ophthalmic plastic surgeryclinic for excision of the entire lesion.He had severe right mechanical pto-sis with compensatory bilateral frontalismuscleoveraction( Figure1 ).Therewasa multinodular mass with several kera-totic horns arising from both the pretar-salandpreseptaluppereyelid( Figure2 ).Thetumorwasnottetheredtotheunder-lyingtarsalplateororbitalstructures.Hisvisualacuitywas20/60OU(whentheeye-lidwasliftedoffthevisualaxis),andocu-lar findings were normal.A large and deep incisional biopsyspecimenwasobtainedfromoneofthele-sionsbytheophthalmicplasticsurgeons;findingsfromexaminationconfirmedSCC.The patient declined micrographic sur-gery under local anesthesia. He under-went an excisional biopsy under generalanesthesia,whichincludedpartoftheun-derlyingorbicularisoculimuscleandmostoftheeyelashesbutsparedthetarsalplate.A large anterior lamellar defect requiredreconstruction ( Figure3 ). This necessi-tated repair by the placement of free skingraftsfromtheipsilateralpostauricularareaand from the contralateral upper eyelid.His recovery was satisfactory with no re-sidual ptosis ( Figure 4 ), and he experi-enced only mild lagophthalmos withoutexposure keratitis. There has been no re-currence of the lesion 1 year later.Two specimens were excised for his-topathological examination ( Figure 5 ).The main lesion measured 3.5  2.5 cmin area, extending up to 1 cm in depth.Findings from histologic examinationshowed actinically damaged skin contain-ing an ulcerated hyperkeratotic, well-differentiated, focally keratinizing, inva- From the Eye Department (Drs Olver, Muhtaseb, and Chauhan) and the PathologyDepartment (Dr Mannion), Charing Cross Hospital, London, England. CLINICOPATHOLOGIC REPORT ARCH OPHTHALMOL/VOL 118, MAR 2000 WWW.ARCHOPHTHALMOL.COM 422 ©2000 American Medical Association. All rights reserved.  by DEVINDERCHAUHAN, on July 15, 2010www.archophthalmol.comDownloaded from   sive SCC, which was completelyexcised. There was an associatedmarked inflammatory response anda focal giant-cell reaction in rela-tion to the keratin. The secondsmaller specimen was of aninvolved area superomedial to themain lesion. This measured1.2  0.5 cm in area and 0.2 cmdeep. Results of histologic exami-nation showed prominent actinicdamage with focal severe dysplasiaamounting to the intraepidermalcarcinoma, which was completelyexcised. COMMENT This patient had a long-standingkeratoticeyelidlesion.Clinically,itappeared to be a keratoacanthoma(KA), but findings from histologicexamination revealed SCC. Thechronicity suggested that this le-sion may have initially been a KAthat failed to regress and under-went focal malignant degenerationto a well-differentiated SCC, per-haps many years ago.Periocular SCC is an aggres-sive neoplasm, accounting for be-tween 2.4% and 30.2% of malig-nanteyelidlesionsbutforfewerthan2% of all eyelid lesions. 1 Cutane-ousSCChasseveralhistopathologi-cal subtypes including adenoid/ acantholytic,mucinproducing,andverrucous.Theprognosisisbasedonlocation, histologic characteristics,cause, and clinical features. 2 Periocular SCC commonlyarisesincasesofsolarkeratoses.Kera-toacanthoma is an epithelial tumorbearingacloseclinicalandhistologi-cal resemblance to SCC but has thepotential to regress spontaneously.Both KA and SCC appear in fair-skinnedindividualswhohaveahis-toryofchronicsunexposure.Theex-actrelationshipbetweenKAandSCCis controversial. Some authors con-siderKAtobeavariantofSCC,bothfalling within a spectrum of varyingmalignancy. 3-5 Thelackofnotablydif-ferent immunohistochemical find-ings between KA and well-differen-tiated SCC supports this. 6 The treatment of keratotic le-sionsiscontroversialbecauseofthedifficulty in making a precise clini-cal diagnosis. Options include ob-servation, surgical excision withhistologic control of the excision Figure 1. Right mechanical ptosis caused by large keratotic eyelid tumor. Figure 2. Keratotic tumor; right upper eyelid. Figure 3. Extent of perioperative defect after excision biopsy. Figure 4. Appearance 6 months after excision of tumor and reconstruction. Figure 5. Low-power photomicrograph showing hyperkeratotic dysplastic squamous epithelium and islands of invasive focally keratinizing squamous cell carcinoma (hematoxylin-eosin,srcinal magnification   4). ARCH OPHTHALMOL/VOL 118, MAR 2000 WWW.ARCHOPHTHALMOL.COM 423 ©2000 American Medical Association. All rights reserved.  by DEVINDERCHAUHAN, on July 15, 2010www.archophthalmol.comDownloaded from   margins, radiotherapy, and cryo-therapy. 7  Whereas KA is capable of spontaneous regression, periocularSCChasanaggressivemalignantpo-tential, with prognosis correlatingwith local recurrence and metasta-sis rate. These are influenced bytreatmentmodality,location,depthof tumor, histological differentia-tion, perineural involvement, pre-cipitatingfactorsotherthanUVlight,host immunosuppression, and des-moplastic changes. 8 Excisional biopsy of keratoticeyelidlesionsisrecommendedratherthan observation to see if the le-sions regress. In this case, the le-sion was large; therefore, the phy-sician removed a large incisionalbiopsy specimen from the center of the lesion for histologic examina-tion prior to an intended micro-graphicexcision.Ifanincisionalbi-opsyspecimenisobtained,thismustincludeboththeedgeandbaseofthetumor and be large enough for thephysician to detect focal invasion. 9 Frozen section control, such as mi-crographic surgery, is preferred forthecontrolofthemarginswherethetumor has not extended to bone ororbital fat. 1 Our case highlights the diffi-cultyinmakingapreciseclinicaldi-agnosisofSCCandsupportsthecasefor definitive treatment by surgicalexcision of all suspected KA andSCC. Nonregressed keratotic le-sionsshouldberegardedasSCCun-til proven otherwise. An incisionalbiopsyspecimenfromtheedgeofthelesion may not correctly representthemaindiagnosiswhenthereisfo-cally invasive carcinoma, as in ourcase.  AcceptedforpublicationNovember7,1999.Reprints: Jane M. Olver,FRCOphth, Eye Department, Char-ing Cross Hospital, Fulham PalaceRoad, London W6 8RF, England. REFERENCES 1. Reifler DM, Hornblass A. Squamous cell carci-noma of the eyelid. Surv Ophthalmol  . 1986;30:349-365.2. Bernstein SC, Lim KK, Brodland DG, HeidelbergKA. The many faces of squamous cell carci-noma. Dermatol Surg  . 1996;22:243-254.3. Grossniklaus HE, Wojno TH, Yanoff M, Font RL.Invasive keratoacanthoma of the eyelid andocular adnexa. Ophthalmology  . 1996;103:937-941.4. Beham A, Regauer S, Soyer HP, Beham-SchmidC. Keratoacanthoma: a clinically distinct variantof well differentiated squamous cell carcinoma. Adv Anat Pathol  . 1998;5:269-280.5. Manstein CH, Frauenhoffer CJ, Besden JE. Kera-toacanthoma: is it a real entity ? Ann Plast Surg  .1998;40:469-472.6. Cain CT, Niemann TH, Argeyi ZB. Keratoacan-thoma versus squamous cell carcinoma: an im-munohistochemicalreappraisalpfp53proteinandproliferating cell nuclear antigen expression inkeratoacanthoma-like tumors. Am J Dermatopa- thol  . 1995;17:324-331.7. Rowe DE, Carroll RJ, Day CL. Prognostic fac-tors for local recurrence, metastasis, and sur-vival rates in squamous cell carcinoma of theskin, ear, and lip. J Am Acad Dermatol  . 1992;26:976-990.8. Breuninger H, Schamburg-Lever G, HolzschuhJ, Horny HP. Desmoplastic squamous cell car-cinoma of skin and vermilion surface: a highlymalignant subtype of skin cancer. Cancer  .1997;79:915-919.9. NetscherDT,WigodaP,GreenLK,SpiraM.Kera-toacanthoma: when to observe and when to op-erate and the importance of an accurate diagno-sis. South Med J  . 1994;87:1272-1276. 100 Years Ago in the A RCHIVES  A look at the past . . . T he number of microscopical examinations of eyes with syphilitic dis-ease is not large. Besides some short reports by J. Hutchinson, Bader,Klebs, Furstner, and Pagenstecher, I have found the following ac-countsintheliterature:EdmundsandBraileymakethefollowingsummarystate-ment as to syphilis of the interior of the eye: The choroidal vessels seem not tobe altered, while those of the retina, both in acquired and congenital syphilis,are thickened, probably from inflammatory processes. Reference: Nagel G. The examination of two cases of old specific chorio-retinitis. Arch Ophthalmol . 1900;29:514. ARCH OPHTHALMOL/VOL 118, MAR 2000 WWW.ARCHOPHTHALMOL.COM 424 ©2000 American Medical Association. All rights reserved.  by DEVINDERCHAUHAN, on July 15, 2010www.archophthalmol.comDownloaded from 
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