Therapie bei malignen Lidtumoren

Surgical excision of eyelid tumors and subsequent ophthalmoplastic reconstruction

In recent years new modern therapeutic concepts have been developed in the treatment of malignant eyelid tumors; however, surgical restoration remains an important component of the therapeutic options addressed, which include microsurgical tumor excision into healthy tissue and subsequent coverage of the defects. An ophthalmic surgeon experienced in oculoplastic surgery is responsible for the recognition and evaluation of the existing alterations and planning a procedure together with the patient that meets the patient's expectations. The planning of surgery must always be individualized and fit the initial findings. Depending on the defect size and localization, different coverage strategies are available to the surgeon. To ensure successful reconstruction, every surgeon should master a wide range of reconstructive techniques.

Diagnosis and treatment of malignant eyelid tumors

BACKGROUND

Malignant tumors of the eyelid are much less frequent than benign eyelid alterations. These are frequently incidental findings without symptoms which are often overlooked or misinterpreted by patients.

OBJECTIVE

This article gives an overview of clinical aspects, diagnostics and treatment of the five most common malignant eyelid tumors and exemplarily explains the essential principles of evidence-based treatment of malignant eyelid tumors.

METHODS

This narrative review was prepared based on a selective literature search. The depiction of the treatment of eyelid tumors is supported by illustrations of clinical cases.

RESULTS

The medical history and inspection provide initial indications of malignancy. Every eyelid change suspected of being malignant should be examined histologically to confirm a diagnosis. By far the most common malignant eyelid tumor in Europe is basal cell carcinoma, which metastasizes only in exceptional cases. Squamous cell carcinomas, sebaceous adenocarcinomas, melanomas and Merkel cell carcinomas occur much less frequently. In these cases, potential metastasis in particular must be considered when making the diagnosis and staging has to be initiated. Surgical excision into healthy tissue with tumor-free margins is the gold standard for malignant eyelid tumors. Non-surgical adjuvant or neoadjuvant forms of evidence-based treatment can be initiated based on the individual case to minimize the risk of recurrence and metastasis.

CONCLUSION

It is essential to recognize eyelid changes at an early stage, to classify them correctly and to initiate the appropriate treatment. The interaction between the general condition and the personal needs of a patient as well as state of the art medicine are the keys to a good personalized treatment.

[Diagnosis and treatment of malignant eyelid tumors]

BACKGROUND

Malignant tumors of the eyelid are much less frequent than benign eyelid alterations. These are frequently incidental findings without symptoms which are often overlooked or misinterpreted by patients.

OBJECTIVE

This article gives an overview of clinical aspects, diagnostics and treatment of the five most common malignant eyelid tumors and exemplarily explains the essential principles of evidence-based treatment of malignant eyelid tumors.

METHODS

This narrative review was prepared based on a selective literature search. The depiction of the treatment of eyelid tumors is supported by illustrations of clinical cases.

RESULTS

The medical history and inspection provide initial indications of malignancy. Every eyelid change suspected of being malignant should be examined histologically to confirm a diagnosis. By far the most common malignant eyelid tumor in Europe is basal cell carcinoma, which metastasizes only in exceptional cases. Squamous cell carcinomas, sebaceous adenocarcinomas, melanomas and Merkel cell carcinomas occur much less frequently. In these cases, potential metastasis in particular must be considered when making the diagnosis and staging has to be initiated. Surgical excision into healthy tissue with tumor-free margins is the gold standard for malignant eyelid tumors. Non-surgical adjuvant or neoadjuvant forms of evidence-based treatment can be initiated based on the individual case to minimize the risk of recurrence and metastasis.

CONCLUSION

It is essential to recognize eyelid changes at an early stage, to classify them correctly and to initiate the appropriate treatment. The interaction between the general condition and the personal needs of a patient as well as state of the art medicine are the keys to a good personalized treatment.

[Surgical excision of eyelid tumors and subsequent ophthalmoplastic reconstruction]

In recent years new modern therapeutic concepts have been developed in the treatment of malignant eyelid tumors; however, surgical restoration remains an important component of the therapeutic options addressed, which include microsurgical tumor excision into healthy tissue and subsequent coverage of the defects. An ophthalmic surgeon experienced in oculoplastic surgery is responsible for the recognition and evaluation of the existing alterations and planning a procedure together with the patient that meets the patient's expectations. The planning of surgery must always be individualized and fit the initial findings. Depending on the defect size and localization, different coverage strategies are available to the surgeon. To ensure successful reconstruction, every surgeon should master a wide range of reconstructive techniques.

[Hordeolum and chalazion : (Differential) diagnosis and treatment]

Hordeolum and chalazion are the most frequent inflammatory eyelid tumors. They can occur in association with underlying diseases causing Meibomian gland dysfunction and/or chronic blepharitis. Due to the typical morphological features and clinical course, the diagnosis can mostly be clinically established. The majority of these lesions resolve spontaneously over time. In some instances, surgical intervention is unavoidable. In persistent, recurrent or clinically atypical cases malignant tumors must be excluded as a differential diagnosis by excisional biopsy and histopathological assessment.

[Personalized medicine in the treatment of periocular tumors : Targeted treatment and use of immune checkpoint inhibitors]

The aim of this article is to provide an overview on the current state of personalized medicine in the systemic treatment of selected periocular tumors, such as basal cell carcinoma, Merkel cell carcinoma and conjunctival melanoma. This article therefore provides an extensive current literature review from PubMed including the current guidelines and standard operating procedures (SOP). As 90% of basal cell carcinomas have a pathologic activation of the sonic hedgehog pathway, vismodegib is a new treatment option for inoperable or metastatic basal cell carcinoma and for patients with Gorlin-Goltz syndrome. A novel approach of systemic medicine for the treatment of metastatic Merkel cell carcinoma is immunotherapy using the immune checkpoint inhibitor avelumab. Other personalized immunotherapies, such as the checkpoint inhibitors pembrolizumab and nivolumab, the tyrosine kinase inhibitor pazopanib and the role of the hedgehog pathway in Merkel cell carcinomas are the subject of current research and will certainly play an important role in future treatment. In the narrow sense personalized medicine has only come true for metastatic conjunctival melanomas: systemic treatment with BRAF, MEK and/or checkpoint inhibitors is initiated only when a BRAF mutation is detected in the tumor or metastatic tissue. Systemic immunotherapy with the checkpoint inhibitors pembrolizumab and nivolumab can also be used as a treatment option in metastatic conjunctival melanomas. In summary, personalized medicine is a subject of current research and provides many new targeted treatment options especially for periocular malignancies; however, it also involves many great challenges in the development and implementation of new techniques and therapies.

[Surgical resection with ophthalmoplastic reconstruction : Gold standard in periocular basal cell carcinoma]

The gold standard for the treatment of periocular basal cell carcinoma is surgical resection followed by ophthalmoplastic reconstruction. The highest priority in most cases is the complete histopathologically controlled tumor excision. The histopathological preparation can be carried out in two stages by rapid overnight embedding or intraoperatively by a rapid frozen section procedure. A variety of reconstruction methods enable a customized and in most cases also a cosmetically and functionally attractive defect coverage. Postoperatively, a regularly performed tumor aftercare is essential.

[Young male patient with unusual space-occupying lesion of the lower eyelid]

BACKGROUND

A space-occupying lesion of the eyelid in young adults is often a sign of an inflammation, a trauma or a benign neoplasm. The aim of this case report is to demonstrate a rare basal cell carcinoma, which presumably already arose in adolescence without further high-risk factors.

METHODS

A 28-year-old male patient presented for a second opinion on a painless swelling of the right lower eyelid. According to the patient's history the swelling had been present since the age of 16 years and originally resembled a molluscum contagiosum. An ophthalmologist in private practice made the diagnosis of a suspected trichoepithelioma. The extended patient history revealed a blood coagulation disorder. The clinical ophthalmological examination revealed a nodular space-occupying lesion with a border wall and telangiectasia. The further ophthalmological examination was bilaterally inconspicuous. Due to the suspicion of a malignant process, an operation was promptly carried out using local anesthesia with complete tumor excision and pedicled flap plasty as well as a histopathological investigation to confirm the diagnosis.

RESULTS

The histopathological investigation revealed underlying infiltrates of a basaloid tumor with bale-shaped trabecular growth, sometimes with peripheral palisading of the cells. The cells were predominantly monomorphic with isolated pleomorphic nuclei and sometimes enclosed mitoses. Immunohistochemically the cells were strongly positive for BerEP4 and negative for epithelial membrane antigen (EMA). The diagnosis of a nodular basal cell carcinoma of the right lower eyelid was made. All incision margins were free of tumor cells (R0 resection). In the dermatological screening no further manifestations were detected.

CONCLUSION

Despite the occurrence of a space-occupying lesion of the eyelid in a young adult patient and also with no further risk factors, in addition to an inflammatory event and a benign tumor, a malignant disease, such as a basal cell carcinoma should also be taken into consideration. A tissue biopsy or complete excision with subsequent histological examination including an immunohistochemical analysis are essential for differentiation from other tumor entities.

Case report repairing orbital skin defects using composite flaps after giant eyelid-derived tumor excision and orbital exenteration

RATIONALE

Though giant malignant tumors arising in the eyelid are rare, they often require extensive surgery for removal along with orbital exenteration. Because of this, repairing orbital defects is an important factor in the surgical strategy.

PATIENT CONCERNS

Case 1 was a 78-year-old nomad man who presented in the Department of Ophthalmology with a giant tumor in his right eyelid, which had developed over three years. Clinical examination revealed a huge pigmented, nonhealing ulcerated lesion, approximately 52×44×40 mm in size. Case 2 was a 52-year old rural male complaining of a huge tumor in the right eyelid. Patient medical history revealed that the mass was initially the size of a soybean and gradually grew over 3 years to the size of a fist.

DIAGNOSES

Histopathological examination of the tumors revealed that one was a basal cell carcinoma and the other a sebaceous gland carcinoma.

INTERVENTIONS

The two cases of giant malignant eyelid tumors were surgically excised using rapid frozen section margin control. Different pedicle myocutaneous flaps were used to repair the orbital skin defects.

OUTCOMES

Postoperative follow-up showed perfect healing of the pedicle flaps and good patient compliance. The results of these cases indicate that covering exposed orbital cavities with composite pedicle mycuaneous flaps is a simple and practical strategy for orbital reconstruction. Not only does this help maintain orbital stability, but it also provides opportunities for patients to return to normal lives.

LESSONS

Although surgical management is often the first option for treatment of giant eyelid tumors, recurrence and mortality due to the tumors is still high after long-term follow-up. Therefore, early discovery and treatment is the best way to control the progression of giant eyelid tumors and enhance survivability.