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Role of fine needle aspiration cytology in diagnosis of eyelid sebaceous carcinoma

Maheshwari, Rajat MS; Maheshwari, Sejal MS; Shekde, Satish MD

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Indian Journal of Ophthalmology: May–Jun 2007 - Volume 55 - Issue 3 - p 217-219
doi: 10.4103/0301-4738.31944
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Abstract

Sebaceous gland carcinoma is a malignant tumor occurring in the periorbital area, usually in the eyelid.123 The tumors can arise from the meibomian glands in the tarsus, Zeis glands at the eyelid margin or sebaceous glands in the caruncle or eyebrow.3 The recognition of sebaceous gland carcinoma is often delayed because of its variable clinical presentation.456 The authors highlight the role of fine needle aspiration cytology (FNAC) in early diagnosis and appropriate surgical management of sebaceous gland carcinoma.

Case Reports

Case 1

An 83-year-old male presented with a recurrent nodule over the right upper eyelid since three years [Fig. 1]. He had a history of undergoing incision and curettage twice by two local ophthalmologist on different occasions for a suspected diagnosis of chalazion. FNAC from the nodule was done to confirm the diagnosis to help in appropriate surgical planning. The slide showed a good cellular aspirate with a moderately cellular smear. The background was clear with cells seen in loose groups, these cells were less cohesive and few were seen in isolation. The nuclei were round to oval, large, hyperchromatic and showed pleomorphism. Nucleoli were prominent and the cytoplasm appeared clear and scanty. Cytological features were suggestive of malignancy [Fig. 2]. Subsequently surgical excision was done with wide tumor-free margins. Histopathology of the lesion showed neoplastic cells with basophilic cytoplasm, hyperchromatic nuclei and prominent nucleoli. The lobules of cells were separated by thick fibrous septa. There were small areas of sebaceous differentiation having cells with vacuolated or foamy cytoplasm. Histopathology report confirmed the diagnosis of sebaceous gland carcinoma [Fig. 3]. Eyelid reconstruction was done after histopathologically confirmed tumor-free margins.

Figure 1
Figure 1:
Recurrent nodule on the right upper eyelid for 3 years in an 83 year old male twice operated for chalazion elsewhere
Figure 2
Figure 2:
Cytology smear showing a group of cells with round to oval large hyperchromatic nuclei. The cells as well the nuclei show pleomorphism (dark arrow) (H&E, 40x)
Figure 3
Figure 3:
Histopathology showing a moderately differentiated sebaceous carcinoma, showing neoplastic cells with basophilic cytoplasm, hyperchromatic nuclei and prominent nucleoli. The lobules of cells are separated by fibrous septa (big arrow). Small area of sebaceous differentiation having cells with vacuolated or foamy cytoplasm also seen (arrow head). (H&E, 40x)

Case 2

A 35-year-old lady was seen with complaints of swelling on the right upper eyelid since three months [Fig. 4]. She was diagnosed elsewhere as meibomitis and treated for the same. FNAC from the nodule was done, which showed presence of malignant cells. The smear showed loosely arranged cells with few cells lying in isolation. The cytoplasm was scanty with an altered nuclear cytoplasm ratio. Nuclei were large, round to oval in shape and showed pleomorphism, all features suggestive of malignancy. Excision with histopathologically tumor-free margin was done. Histopathology report confirmed the diagnosis of sebaceous gland carcinoma.

Figure 4
Figure 4:
35 year old lady with swelling on the right upper eyelid of 3 months duration

Case 3

A 60-year-old lady was seen with recurrent nodule over the right upper eyelid since three and a half years [Fig. 5]. FNAC of the nodule showed characteristic malignant cells in the cytology smear. The patient underwent excision with histopathologically tumor-free margins followed by reconstruction. Histopathology of the lesions showed it to be a poorly differentiated sebaceous gland malignancy.

Figure 5
Figure 5:
Recurrent nodule on the right upper eyelid in a 65 year old lady since 3.5 years

Discussion

Sebaceous gland carcinoma is a malignant neoplasm that originates from cells that comprise sebaceous glands.5 There is an unusual abundance of sebaceous glands in the ocular region, particularly in the tarsus (meibomian glands), cilia (Zeis glands) and caruncle.

Historically, sebaceous gland carcinoma of the eyelid is notorious for masquerading as a more common benign condition, often resulting in a long delay before the correct diagnosis is made. Such a delay in diagnosis can increase the chance of local recurrence, metastasis and death.5 Its occurrence in the western literature is reported to be less than 1% of all eyelid tumors and accounts for 1- 5% of all malignant eyelid tumors.123 Recent studies from India and China have shown that sebaceous carcinoma accounts for 33-60% of malignant eyelid tumors.57 It thus seems that the incidence of sebaceous gland carcinoma has a geographic variation and is more common in Asians. Though there have been numerous publications that stress the clinical features of sebaceous carcinoma and its tendency to masquerade as chalazion or chronic blepharo-conjunctivitis,12356 studies show that delay in diagnosis is still common.

Biopsy has been reported as the preferred mode for establishing correct diagnosis of such lid nodules. FNAC has been employed only rarely in the diagnosis of periocular sebaceous carcinoma possibly because of the limited tissue availability. However, FNAC can be helpful in differentiating benign from malignant condition by a careful study of the smear.8 The important components of any cytology smear are the nucleus, cytoplasm, cellular arrangement and the slide background. Nuclear characteristics are important criteria in diagnostic cytopathology. As a rule, benign cells have smooth contours and are similar to one another. Malignant cells show alterations in size and shape with irregular nuclear folding, indentation and outward irregularities, all in haphazard arrangement. Malignant cells usually have large nucleoli with prominent polymorphism and greater variation in the number of nucleoli per nucleus.9

The cytoplasm of the cells conveys useful information for cytological interpretation. In squamous cells the cytoplasm undergoes keratinization as the cells mature, in mesothelial cells the cytoplasm shows microvilli and in glandular cells the cytoplasm forms intracytoplasm lumina. Other characteristics of the cytoplasm which play a role in identifying malignant cells include cytoplasm volume, ratio between nucleus and cytoplasm and cytoplasm content. Malignant cells have decreased cytoplasm size and increased nuclear cytoplasm ratio. Once interpretation about individual cells is completed, careful attention should be given to the intercellular relations. As a general rule, benign cells tend to cluster together so that few individual cells are present in background. On the other hand malignant cells are loosely arranged and show absence of cohesion.

In contrast, smears of chalazion display inflammatory cells without any malignant cells. Microscopy shows a lipogranulomatous reaction caused by liberated globules of fat, surrounded by epithelial cells and multinucleated giant cells intermixed with neutrophils, lymphocytes and plasma cells. In all three of our cases we could establish the diagnosis of carcinoma on routine cytological examination. The main treatment of sebaceous carcinoma is surgical excision with adequate margins. The preoperative diagnosis of sebaceous carcinoma by simple FNAC in the outpatient department itself avoids one additional surgical procedure for the patient and surgeon. It is also time-saving for the surgeon and cost-effective to the patient. The report is ready within a few minutes and helps in appropriate surgical planning for best surgical results.

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9. Fernando UGAtkinson BF, Silverman JF. General cytologic pitfalls Atlas of difficult diagnosis in cytopathology. 19981st ed Philadelphia WB Saunders:1–27
Keywords:

Eyelid sebaceous gland carcinoma; fine needle aspiration cytology; surgical management

© 2007 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow