|Year : 2021 | Volume
| Issue : 3 | Page : 292-294
Thinking beyond chalazion!!!
Harikrishnan Marappan, P Deepika Makam, Dhatri Himanshu Karanam
Lotus Eye Hospital and Institute, Coimbatore, Tamil Nadu, India
|Date of Submission||22-Oct-2020|
|Date of Decision||28-Apr-2021|
|Date of Acceptance||02-Jun-2021|
|Date of Web Publication||09-Sep-2021|
Dr. Harikrishnan Marappan
60/46, Sri Lakshmi Nagar, Thanneerpandhal Road, Peelamedu, Coimbatore - 641 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
A 57-year-old male complained of painless swelling in the left eye upper lid for 5 months and increasing in size for 2 months. On examination, a round well-defined, firm swelling, nontender measuring 5 mm horizontally and 7 mm vertically above the lid margin in lateral part of the upper eyelid with small yellowish pustule at the lid margin corresponding to the site of lesion. The architecture of the lid and lid margin was maintained, no telangiectasia and there were no loss of eyelashes. A provisional diagnosis of marginal chalazion was made. Then incision and curettage were done. Biopsy showed invasive meibomian gland carcinoma with malignant sebocytes, numerous mitoses, and necrosis. Later, wide excision with reconstruction by tenzels flap done after edge clearance. Sebaceous gland carcinoma though rare is an aggressive tumor, and is a great mimicker of many benign conditions leading to diagnostic difficulty. Hence thinking beyond chalazion is necessary in old age, recurrent chalazion, unilateral blepharitis, keratoconjunctivitis should arise suspicion to decease the morbidity and mortality associated with the tumor.
Keywords: Chalazion, eyelid tumor, meibomian gland carcinoma
|How to cite this article:|
Marappan H, Makam P D, Karanam DH. Thinking beyond chalazion!!!. TNOA J Ophthalmic Sci Res 2021;59:292-4
| Introduction|| |
Sebaceous gland carcinoma (SGC) is considered to be the third most common eyelid carcinoma after basal and squamous cell carcinoma and accounts for 1%–1.5% of the eyelid malignancies. SGC arises the most commonly from meibomian glands anterior to the gray line and occasionally from glands of zeis or moll or from sebaceous glands in caruncle. The most common site of occurrence is in the upper eyelid (65% of cases) because of the presence of more number of meibomian glands and in the lower eyelid in 27% cases and in 5% it can be seen in both lids. Tumor usually presents in the sixth or seventh decade and is more common in women.
SGC is a masquerader and mimicks many benign and inflammatory conditions. Hence there is a delay in diagnosis and treatment of the disease which attributes to increased morbidity and mortality in these tumors.
| Case Report|| |
A 57-year-old male presented to us with complaints of swelling in the left eye upper lid for 5 months which was increasing in size for 2 months. Swelling was painless in nature and not associated with any itching or discharge from the lesion. External examination revealed a round well-defined swelling, nontender, firm in consistency measuring 5 mm horizontally and 7 mm vertically above the lid margin and was seen in lateral part of the upper lid with a small yellowish pustule at the lid margin corresponding to the site of lesion. The architecture of the lid and lid margin was maintained, no telangiectasia and there were no loss of eyelashes [Figure 1]. On Systemic examination, there was no regional or systemic lymphadenopathy. Hence a provisional diagnosis of chalazion was made and incision and curettage were performed. Biopsy material had usual putty-like consistency, but there was suspicion of malignancy because of the presence of small yellow pustule at the lid margin and the age of the patient to consider chalazion. Hence the curetted material was sent for histopathological examination and borders of chalazion were marked with cautery.
|Figure 1: Well-defined chalazion, preserved eye lashes and lid architecture|
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On histopathology, sections showed invasive meibomian gland carcinoma consists of a typical keratinocytes, admixed with malignant sebocytes with scalloped malignant nuclei. Numerous mitosis and necrosis were noted [Figure 2]. Hence the diagnosis of the left eye upper eyelid nodular variant of SGC without orbital involvement was made and planned for surgical intervention.
|Figure 2: (a) Malignant cells with foamy cytoplasm. (b) Sebaceous glands showing malignant cells. (c) Malignant cells with vacuolated cytoplasm, vesicular nucleus and prominent nucleoli|
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The patient underwent wide excision including 4 mm of healthy margins in pentagonal manner and the margins were sent for frozen section to see for edge clearance. After obtaining margin clearance, reconstruction of the upper lid was made by tenzels flap advancement for the closure of primary defect [Figure 3]a and [Figure 3]b.
|Figure 3: (a) After excision of the lesion (b) reconstruction by tenzel flap advancement with 6-0 silk sutures in lid, 6-0 vicryl sutures in lateral canthus|
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On postoperative day 1, the wound was healthy with good margin alignment and at 6-month follow-up, the patient was doing fine with no recurrence.
| Discussion|| |
Although sebaceous glands are seen throughout the body, the occurrence of SGC in periocular region is the most common and accounts for 75% of cases. SGC is most frequently seen in women than men and the elderly age group usually in the sixth or seventh decade. Presentation in the younger age group is secondary to radiation exposure.
SGC is one of the most dangerous tumors because of its notorious characteristics such as (a) masquerading as other benign conditions such as chalazion (like in our case) most commonly or as chronic blepharitis and superior limbic keratoconjunctivitis leading to delay in diagnosis and treatment,, (b) high incidence of metastasis (41%) and (c) difficulty in delineating tumor margins even with best paraffin-embedded sections because of their intraepithelial/pagetoid spread.
The importance of this case report is the need to have a high index of suspicion for SGC in any elderly patient with chalazion with no or minimal signs suggesting of malignancy like in our case where the lid architecture, lashes were maintained and no telangiectasia. Hence the importance would be to send all curetted material even if it appears to be a chalazion for histopathological evaluation.
A chalazion that presents in the elderly age group without a prior history or a recurrent chalazion and other inflammatory conditions such as unilateral blepharitis or keratoconjunctivitis which are partially responding to the therapy should arise suspicion. On physical examination, diffuse thickening of the lid and the presence of madarosis should also warrant further investigation. Histopathologically, special stains such as oil red O are helpful in the diagnosis. However, this requires fresh or wet tissue as paraffin processing washes out lipid.
The primary modality of treatment for SGC remains surgical. Treatment varies from wide excision to orbital exenteration depending on the stage of the disease at presentation. Surgical excision with wide margins even wider than that which is usually taken for other carcinomas because of multicentricity and pagetoid spread.
Mohs microscopic surgery carries advantages such as definite margin excision and minimal loss of surrounding normal tissues. Radical neck dissection is performed for lymph node disease. Other treatment modalities such as topical mitomycin c for pagetoid spread and cryotherapy can be done as an adjunct to surgery, and sparing exenteration.
The mortality rate of the disease is 5%–10% and can go up to 25% if metastasis has occurred. These tumors can have widespread local spread to lacrimal sac, nasolacrimal duct, regional lymph nodes, and rarely fatal distant metastasis. SGC arising from glands of zeis is more favorable.
| Conclusion|| |
Sebaceous gland tumor though rare is an aggressive tumor and is a great mimicker of many benign conditions leading to diagnostic difficulty. Hence, thinking beyond chalazion or other benign conditions is necessary to arrive at a prompt diagnosis as early detection and the treatment of SGC decreases the morbidity and mortality associated with this tumor.
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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]