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Periocular Sebaceous Carcinoma Masquerading as an Intratarsal Cyst

Radmall, Bryce R. M.D.*; Sampson, Aron D. M.D.*; Syed, Nasreen A. M.D.*,†; Ko, Audrey C. M.D.*

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Ophthalmic Plastic and Reconstructive Surgery: September/October 2020 - Volume 36 - Issue 5 - p e135
doi: 10.1097/IOP.0000000000001505
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A 60-year-old woman with no significant medical history presented to an outside eye care provider for a persistent right lower eyelid lesion. This lesion was diagnosed as a chalazion, and she underwent incision and drainage. Postoperatively, the lesion did not resolve and maintained the same size and appearance. She was referred 6 months later for tarsal cyst excision. Examination was remarkable for an intratarsal cystic lesion involving the margin of the right lower eyelid (Fig. A, B). There was no associated madarosis, ulceration, bleeding, keratinization, or telangiectasia. A wedge excision and reconstruction were performed. Pathologic examination revealed a poorly differentiated sebaceous carcinoma (Fig. C, D). The patient underwent a second resection and conjunctival map biopsies, which showed negative surgical margins and no conjunctival involvement. She subsequently underwent reconstruction, and there was no evidence of recurrence at 6-month follow-up.

External photograph demonstrating a right lower eyelid sebaceous cell carcinoma and corresponding histological findings. A,B, The cystic lesion involves the posterior aspect of the tarsus and extends to the margin. C, Lower power photomicrograph demonstrating the cystic growth pattern of the lesion (hematoxylin and eosin; original magnification = ×10). D, High magnification photomicrograph demonstrating that the cyst wall is composed of atypical cells with marked nuclear pleomorphism and vacuolated or foamy cytoplasm in many cells (hematoxylin and eosin; original magnification = ×300).

Sebaceous carcinoma is a relatively rare, aggressive malignancy most commonly arising from the periocular tissues including the meibomian glands of the tarsus, and the glands of Zeis of the eyelashes, caruncle, and skin of the eyebrow. Although sebaceous carcinoma accounts for only 0.5% of all eyelid lesions, it is the most concerning because it is associated with increased morbidity and mortality. This periocular malignancy is notoriously difficult to diagnose, masquerading as an assortment of conditions which frequently leads to delays in diagnosis and proper treatment in greater than two thirds of cases. Despite a seemingly benign appearance, any lesion with yellow coloration and thickening of the eyelid or adjacent conjunctiva should cause the clinician to consider sebaceous carcinoma as a possibility with a low threshold for biopsy.

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