An Analysis of Conjunctival Map Biopsies in Sebaceous Carcinoma

Adnexal neoplasms of the eye

Adnexal neoplasms of the eyelid encompass a wide variety of benign and malignant tumors of sebaceous, follicular, and sweat gland origin. Due to the specialized structures of the eyelid, these neoplasms present differently when compared with those of other locations. Although most dermatologists and ophthalmologists are familiar with the commonly reported adnexal tumors of the eyelid, such as hidrocystoma, pilomatrixoma, and sebaceous carcinoma, many other adnexal neoplasms have been reported at this unique anatomic site. Accurate and timely identification of these neoplasms is essential, as alterations of eyelid anatomy and function can have a negative impact on eye health, vision, and quality of life. We review the clinical and histopathologic features of common and rare eyelid adnexal neoplasms and discuss proposed treatment options.

Periocular sebaceous carcinoma: updates in the diagnosis, treatment, staging, and management

Periocular sebaceous carcinoma (PSC) is a rare, aggressive, and potentially metastatic adnexal malignancy. Due to the ability of PSC to resemble several benign and malignant conditions, diagnosis is often delayed or mistaken. In addition, even with a known diagnosis, choosing the right treatment is still an open debate. For this reason, we decided to review the most up-to-date literature on PSC and propose a dedicated procedural protocol to help clinicians when dealing with PSC. A PubMed search was carried out using the terms "Sebaceous Carcinoma", "Adnexal Periocular Cancer", "Sebaceous Carcinoma AND eyelid", "Periocular Sebaceous Carcinoma", and "Ocular Adnexa". Pertinent studies published in English from 1997 up to December 2022 were compared to the selection criteria and if suitable, included in this review. Through the initial search, 84 articles were selected. Of these, 36 were included in the final study. Several papers explored different diagnostic and therapeutic strategies regarding PSC diagnosis and management. In light of the current literature review and the multidisciplinary experience of three clinical centers, a dedicated procedural protocol is proposed. PSC diagnosis may be achieved through accurate clinical evaluation, but it requires histopathologic confirmation, which can be challenging. Dermoscopy, in vivo reflectance confocal microscopy, and optical coherence tomography may facilitate PSC clinical examination, while immunohistochemistry stains may support histological diagnosis. Appropriate disease staging is necessary before choosing the treatment, as local disease requires radically different treatment compared to advanced disease. In addition, recent innovations in nonsurgical treatments, including radio-chemotherapy, immunotherapy, and targeted therapy, may be a viable option in the most challenging cases.

Intraepithelial growth pattern for eyelid sebaceous carcinoma: a cohort of 214 patients from a single institution

AIMS

To determine the distribution of three different intraepithelial growth patterns (pagetoid, bowenoid and papillary) in eyelid sebaceous carcinoma (SC) and correlate them with the clinical characteristics and prognosis.

METHODS

A retrospective cohort study. The medical charts and pathological sections were retrospectively reviewed. All eligible patients were followed up for recurrence, metastasis and tumour-related mortality. The clinical significance of each intraepithelial growth pattern was determined by Cox regression.

RESULTS

Of the 214 patients, 67 (31%) presented with intraepithelial invasion, among them, 34 (16%) were pagetoid, 27 (13%) were bowenoid and 6 (2.8%) were papillary. Patients of pagetoid intraepithelial spread showed significantly longer diagnostic delay (p=0.001) and more initial misdiagnoses of blepharitis (p=0.035). After a median follow-up period of 34.0 months, 67 (46%) patients in the non-intraepithelial group, 17 (50%) in the pagetoid group, 8 (30%) in the bowenoid group and 2 (33%) in the papillary group recurred. And 30 (20%) patients in the non-intraepithelial group, 9 (27%) in the pagetoid group and 4 (15%) in the bowenoid group developed metastasis. Moreover, 15 (10%) patients in the non-intraepithelial group, 6 (18%) in the pagetoid group and 1 (3.7%) in the bowenoid group died of SC. Cox regression indicated that pagetoid intraepithelial growth pattern was remarkably associated with increased chances of tumour-related mortality (HR=2.95, 95% CI 1.14 to 7.64, p=0.026).

CONCLUSIONS

Intraepithelial tumour invasion was presented in nearly one third of patients with eyelid SC. Pagetoid intraepithelial neoplasia, the predominant growth pattern, significantly increased the risk of tumour-related mortality. Meticulous histopathological intraepithelial examination is recommended for every patient of eyelid SC. Special attention should be paid to those with pagetoid invasion, who may require more intensive managements.

Pagetoid tumour spread in periocular sebaceous gland carcinoma: a comparative analysis in 130 patients

PURPOSE

To compare the clinical features, histopathology features, treatment, and prognosis of patients with and without pagetoid tumour spread secondary to periocular sebaceous gland carcinoma (SGC).

METHODS

Retrospective study of 130 patients with SGC who underwent conjunctival map biopsy.

RESULTS

Of the 130 patients with SGC, 30 (23%) patients had histopathology proven pagetoid tumour spread. On multivariate analysis, increasing tumour basal diameter (p < 0.001) was predictive of pagetoid tumour spread. The odds ratio for tumour basal diameter in prediction of map biopsy positivity for pagetoid tumour spread was 1.13 (95% CI, 1.07-1.19). The sensitivity and specificity of clinicopathological correlation of pagetoid tumour spread was 57 and 90%. Overall, globe salvage was better in those without pagetoid tumour spread compared to those with pagetoid tumour spread (95% vs 33%; p < 0.0001). Comparing those with pagetoid tumour spread vs those without, the 5-year Kaplan-Meier estimate of systemic metastasis was 21% vs 4% (p = 0.15) and death was 28% vs 4% (p = 0.21), respectively.

CONCLUSION

Increasing tumour basal diameter can predict the risk of pagetoid tumour spread. Every mm increase in tumour basal diameter increases the risk of pagetoid tumour spread by 13%. Map biopsy is recommended for all patients with periocular SGC's. Though the globe salvage rates are poor in those with pagetoid tumour spread, the occurrence of systemic metastasis and death are not significantly higher compared to those without pagetoid tumour spread.

Sebaceous carcinoma of the eyelid: 21-year experience in a Nordic country

PURPOSE

To evaluate the clinical features, diagnostic challenges, management, and prognosis of sebaceous carcinoma (SC) of the eyelids and periocular region in a Nordic country.

METHODS

Patients were identified from the Finnish Cancer Registry and the Helsinki University Hospital databases during the 21-year period 1998-2018. Age, sex, location, clinical and histopathologic diagnosis, treatment and outcome were registered.

RESULTS

Sebaceous carcinoma (SC) was diagnosed in 32 patients. The incidence was 0.6 per million. Median age at the time of histopathologic diagnosis was 74 years, and 72% of patients were women. Diagnostic delay was often long, median 12 months. The most common cause for delay was misdiagnosis (72%): a chalazion in 34% and a benign tumour in 22%. The most common location was the upper eyelid (53%) and tumour type a solitary nodule (94%). The SC was not correctly diagnosed in 12 (40%) of 30 preoperative biopsies. The treatment for 31 (97%) patients was complete surgical removal with reconstruction. Conjunctival intraepithelial growth was found in 50%. The leading postoperative problem was ocular irritation (30%). During a median follow-up of 58 months, two patients (6%) experienced a local recurrence and one patient died from metastatic SC.

CONCLUSIONS

The estimated incidence of SC in Finland was somewhat higher than in other Western countries. The diagnosis was often markedly delayed. Especially differentiation from chalazion continues to be essential. To improve outcomes, it is essential to inform the pathologist about the possibility of SC in eyelid biopsies and specimens and ideally submit them to an ophthalmic pathology service.

Nordic treatment practices survey and consensus for treatment of eyelid sebaceous carcinoma

Background

The purpose was to describe the Nordic treatment practices and to reach a Nordic consensus for the treatment of sebaceous eyelid carcinoma.

Methods

The treatment practices data was collected by a questionnaire with 37 questions to the Nordic oculoplastic surgeons and analyzed. A PubMed MEDLINE database search was done to gather data on the published treatment practices and recommendations. A working group that consisted of in minimum one senior consultant from each leading Nordic University Eye Hospital was assigned. A structured interactive method was used to establish the consensus.

Results

Twenty-four doctors responded to the questionnaire. 23/24 (96%) of the respondents took a biopsy before surgery. Regional lymph node scanning was routinely done by 14/23 (61%) and a systemic screening of a metastatic disease by 13/23 (57%). 6/22 (27%) never took conjunctival mapping biopsies and 12/23 (52%) never screened for Muir- Torre. Respondents used Mohs surgery, frozen section or multi-stage excision with delayed closure, and 5–6 mm was the mostly preferred margin. Sentinel lymph node biopsy was a possible option for 9/22 (41%) and cryotherapy and Mitomycin C for 6/22 (27%) respondents. 50% of respondents considered radiation as a treatment option. 15/16 (94%) respondents always followed-up their patients, most for 5 years. Two thirds scanned regional lymph nodes during the follow-up. Consensus was reached for 18 statements representing three domains: preoperative work-up, treatment and follow-up.

Conclusion

Treatment practices differ in between the five Nordic countries which have similar public health care systems. In the article the authors present a Nordic consensus for the treatment of eyelid sebaceous carcinoma.

Cutaneous sebaceous carcinoma

Cutaneous sebaceous carcinoma occurs almost exclusively on the head and neck and has a significant propensity for recurrence and metastasis. It is easily mistaken for benign conditions, resulting in inappropriate management. Thus, it is important to maintain a high index of suspicion. Despite previous reports, sebaceous carcinoma may occur with similar frequency in Asians and whites. Recent genetic data suggest there are multiple mutational groups of sebaceous carcinoma, paving the way for targeted treatment. After a diagnosis, investigations for staging and for Muir-Torre syndrome should be considered. The available evidence on the treatment options for sebaceous carcinoma is discussed, and specific recommendations for management are made.

The practice patterns in the management of sebaceous carcinoma of the eyelid in the Asia Pacific region

PURPOSE

To determine the practice patterns of ophthalmic plastic surgeons regarding the management of eyelid sebaceous carcinoma (SC).

METHODS

An electronic survey was distributed to oculoplastic surgical colleagues in the Asia Pacific region requesting clinical information and treatment approaches to SC.

RESULTS

The responses from 192 respondents from the Asia Pacific region was included and analyzed in this study. For initial diagnosis, most surgeons selected incisional biopsy (55%), followed by complete excision (35%). Initial workup was mainly by palpation of lymph nodes, chest X-ray, and computerized tomography scan (CT-scan) of the orbit. Conjunctival map biopsy was done in selected cases. Sentinel lymph node biopsy (SLNB) was done mainly for tumors larger than 10 mm. Management was mainly by surgical excision (5 mm margin) combined with adjuvant therapy in some cases, with radiotherapy being the most common. Margin status was determined most frequently by frozen section as evaluated by the pathologist (57%) followed by Mohs micrographic surgery (18%). Surveillance was based mainly on physical examination alone.

CONCLUSION

The Asia Pacific oculoplastic surgeons prefer incisional biopsy for lesions suspicious of SC prior to definitive surgery. This is in contrast to survey results previously reported in other populations. Frozen section control (done by an oculoplastic surgeon with pathology support) is most commonly used for margin control and conjunctival map biopsies are done only in selected cases. Despite the potential benefits of SLNB, access and expertise in this area is currently lacking in the Asia Pacific region.

Current review of sebaceous cell carcinoma

PURPOSE OF REVIEW

Periocular sebaceous cell carcinoma is a rare malignancy that is often misdiagnosed leading to increased morbidity and mortality. This review aims to describe current knowledge on the disease to aid clinicians in timely diagnosis and treatment.

RECENT FINDINGS

New research has shown that the diagnosis of sebaceous cell carcinoma can be aided with immunohistochemical stains. A revision in the American Joint Committee on Cancer staging system incorporates new tumor size classifications in the staging of eyelid carcinomas. Wide local excision and Mohs micrographic surgery continue to represent the standard of care for initial treatment of localized disease.

SUMMARY

The current review highlights diagnostic and treatment modalities to allow clinicians to make timely diagnosis and tailor treatment plans for individual patient presentations.

Surgical Management of Periocular Cancers: High- and Low-Risk Features Drive Treatment

PURPOSE OF REVIEW

Recent advances in the treatment of eyelid tumors have centered on the excision, evaluation of margins, role of sentinel lymph node biopsy, and adjunctive/adjuvant systemic and radiation therapy. The purpose of this review is to elaborate on these advances.

RECENT FINDINGS

Mohs excision of basal cell carcinoma and squamous cell carcinoma continues to provide the greatest success in complete excision of the cancer, especially in those cases of high-risk disease including medial canthal location and recurrent disease. Sentinel lymph node biopsy has proven useful in the assessment of early regional metastasis in sebaceous cell carcinoma, melanoma, and Merkel cell carcinoma. The pathologic finding of perineural invasion is a high-risk feature in all periocular cancers, and adjuvant therapy should be considered. Targeted therapy shows great potential in situations that are not amenable to complete excision without sacrificing the globe. Identification of high- and low-risk features in eyelid cancers allows a stratified approach to treatment. While high-risk features may require adjuvant therapy, larger margins, and sentinel lymph node biopsy, low-risk features may allow topical therapy to adequately address the condition. Monoclonal antibodies and small molecule inhibitors show great promise in the treatment of extensive disease.

Risk Factors for Local Recurrence or Metastasis of Eyelid Sebaceous Gland Carcinoma After Wide Excision With Paraffin Section Control

PURPOSE

To identify risk factors for local recurrence and metastasis of sebaceous gland carcinoma (SGC) after wide excision with paraffin section control.

DESIGN

Retrospective, observational case-control study.

METHODS

Setting: Single institution.

PATIENT POPULATION

Thirty-four patients with SGC who had undergone excision with 5-mm surgical margins and paraffin section pathologic analysis. Observational Procedures: The following were considered potential risk factors for local recurrence/metastasis of SGC: patient's sex, patient's age, initial diagnosis at other clinics, topical treatments at other clinics, interval between appearance of symptoms and referral to our institution, tumor location, tumor origin, tumor presentation pattern, T category, tumor size, presence/or absence of pagetoid spread, tumor differentiation, mitosis grade, growth pattern. Logistic regression analysis was performed to identify the actual risk factors.

MAIN OUTCOME MEASURES

Risk factors for local recurrence or metastasis of SGC after wide excision with paraffin section control.

RESULTS

Involvement of both upper and lower eyelids, topical treatments at other clinics, multicentric origin, diffuse pattern, stage T3a, large tumor size, and a nonlobular pattern significantly influenced local recurrence/metastasis (P < .050). Pagetoid spread tended to affect local recurrence/metastasis (P = .052). The other items did not significantly influence local recurrence/metastasis (P > .050).

CONCLUSIONS

This study identified risk factors for local recurrence or metastasis of SGC after wide excision with paraffin section pathologic analysis. The results of this study will be helpful to surgeons when planning additional management, such as map biopsy or adjuvant treatment.