Lid Lesions and Tumor Terminology

Lid Lesions

• Topics covered include benign and malignant eyelid tumors.
• Tumors are categorized as benign or malignant.
• Benign tumors are non-cancerous; composed of cells that do not invade other tissues or body organs. They may grow abnormally but do not spread. Secondary complications are possible.
• Malignant tumors are cancerous; composed of cells that invade the basement membrane and can spread to other tissues and organs. This spread often happens via direct extension or via metastasis (spread through the vascular or lymphatic systems, or via seeding/implantation).
• Medical history and demographic considerations are crucial in evaluating eyelid lesions.

Dermatology Terminology

• Tumors can be classified as benign (non-cancerous) or malignant (cancerous).
• Benign tumors are non-cancerous, unlike malignant tumors which are cancerous.

Derm Terms (Abnormal Cell Growth)

• Neoplasia: A new growth (tissue or cells) that serves no useful function.
• Hyperplasia: An abnormal increase in the number of cells normally present in a tissue.
• Hypertrophy: An abnormal increase in the size of cells already present in the tissue.
• Metaplasia: Replacement of one mature cell type with another mature cell type.
• Dysplasia: Replacement of one mature cell type with a less mature cell type.
• Note: Hyperplasia, metaplasia, and dysplasia are often reversible. Neoplasia is generally irreversible.

Derm Terms (Tumor Types)

• Tumors ending in "oma" are usually benign. Examples of benign tumors are: adenoma (glandular tumor), osteoma (bone tumor).
• Ex: Malignant glandular tumor: adenocarcinoma
• Ex: Malignant bone tumor: osteosarcoma
• Carcinoma: Epithelial tissue cancers.
• Sarcoma: Connective tissue cancers (bones, fat, muscle, lymph, blood vessels)
• Hemangioma: Tumors comprised of blood vessels.
• Lymphoma: Lymphatic system tumors (including leukemia).
• Melanoma: Tumors of pigmented cells.
• Hamartoma: A benign tumor made up of the same cell types found in the surrounding tissue.
• Blastoma: A tumor derived from embryonic cells (retinoblastoma).
• Additional factors (age, ethnicity, prior trauma) can influence the type and presentation of tumors.

Squamous Papilloma

• Aka acrochordon or skin tag
• Most common benign, non-infectious eyelid lesion.
• Caused by overgrowth of squamous epithelium.
• Commonly found in areas where skin layers rub against each other (eye lids, groin, armpits, neck).
• Usually grows slowly.

Clinical Presentation (Squamous Papilloma)

• Can appear as sessile (flattened) or pedunculated (on a stalk).
• Can be same color as skin or pigmented (e.g. cauliflower-shaped).
• Most patients are asymptomatic.

Papilloma

• Images presented as eyelid papilloma examples.

Evaluation (Squamous Papilloma)

• Rule out neoplastic growth.
• Look for rapid growth, color change.
• Bleeding is unlikely unless traumatized.
• Vascularization is not typically present.
• Surface may be roughened, but usually not eroded or ulcerated.
• Consider other possible benign or pre-malignant conditions.

Management (Squamous Papilloma)

• Generally no treatment is necessary.
• Cosmetic excision can be considered.
• Referral to dermatologist/oculoplastics if large, flat, or concerning cases.
• Follow-up necessary for suspicions of new lesions; timing of follow-up depends on size, age, appearance, and personal/medical history.

Ellman Unit

• Uses radiofrequency to cut tissue.
• Probe is not hot.
• Reacts to water molecules in cells.
• Less bleeding compared to traditional methods.
• Useful for precise tissue removal.

Verrucae

• Aka viral wart; caused by HPV.
• Common in children/younger adults.
• Spread via direct/indirect contact, autoinoculation.
• Two forms, filiform (finger-like) and plana (flat).
• Usually start as small papules, slightly lighter than surrounding skin.
• Tend to darken and thicken over time.

Tx/Mx (Verrucae)

• Lesions often regress spontaneously.
• Excision if necessary.
• Chemical cautery (dichloroacetic acid) is an option.
• Cryotherapy can be used as well.
• Consider the patient's age, health, and lesion size/appearance in determining the most appropriate treatment plan.

Molluscum Contagiosum

• Associated with DNA poxvirus.
• Four main types (I, II, III, IV), though type I is most common.
• Highly contagious via skin-to-skin contact.
• More common in children/immunocompromised.
• Can cause follicular conjunctivitis.

Clinical Presentation (Molluscum Contagiosum)

• Small, flesh-colored papules.
• Often with an umbilicated center.
• Elevated, rounded, waxy, pearly appearance.
• Multiple lesions are common.

Management (Molluscum Contagiosum)

• If quiet lesions, leave alone; may spontaneously regress over months.
• If many lesions, or concern re:transmission/recurrence, consider appropriate treatment.
• Increased numbers (100+) should prompt the consideration that the patient may have HIV.
• Patient Education: Hand washing, covering lesions, avoiding scratching, and avoiding physical contact and sharing towels/clothing to limit spread is important.

Topical Treatments (Molluscum Contagiosum)

• Podophyllotoxin Cream: Use cautiously; avoid during pregnancy.
• Iodine
• Salicylic Acid
• Potassium Hydroxide
• Tretinoin Cream
• Cantharidin
• Imiquimod

Seborrheic Keratosis

• Aka "barnacles of old age"
• Hyperkeratinized plaques.
• Most common benign epidermal tumor in middle-aged/elderly individuals.
• Commonly found on trunk and head (may appear on eyebrows and lids).
• Not pre-malignant, unlike actinic keratosis.
• Lesions display a sharply defined, elevated appearance.

Clinical Presentation (Seborrheic Keratosis)

• Sharply defined, slightly elevated, brown, plastered-on appearance.
• Looks like it's stuck to skin, with little epidermal invasion.
• Can appear waxy, greasy, or scaly.

Tx/Mx (Seborrheic Keratosis)

• Monitoring is often sufficient.
• Referral to dermatologist/oculoplastics if removal is desired; removal can be performed for cosmetic reasons.
• Removal must be performed if rapid growth is observed, or change in the lesion's appearance is suspicious, or bleeding or ulceration is present.

Dermoid

• Not neoplasms but tumor-like growths that are not cancerous.
• Associated with development (not a fully formed tumor).
• Look for other congenital anomalies if a dermoid is observed, like Goldenhar's syndrome (associated with dermoids over globe and may present with coloboma lid and facial appendages).

Clinical Presentation (Dermoid)

• Tends to be cystic ("dermoid cyst").
• Usually found superior temporal, located in relation to periosteum of the orbit easily slid over.
• Anterior lesions are often painless, presenting as fullness in the upper lid, typically at the lateral orbital rim.
• Deep lesions may cause painless progressive proptosis (a bulging forward of the eyeball) and diplopia (double vision).
• Consider associated anomalies such as Goldenhar syndrome.

Tx/Mx (Dermoid)

• Rule out other possible differentials.
• Imaging may be necessary (depending on location/size).
• Small, asymptomatic cysts often do not require surgery (may stabilize or even reduce in size over time).
• Surgeons will excise a dermoid cyst early to reduce risk of rupture; this is especially important for deep-seated dermoids.

Xanthelasma

• Cholesterol plaques on eyelids.
• Common, slowly progressive.
• Typically develops in 4th/5th decade.
• Associated with hyperlipidemia, diabetes, or thyroid dysfunction.
• 50% of adults with xanthelasma have abnormal lipid levels.
• Can also occur in younger patients with inherited dyslipidemia (hypercholesteremia, hyperapobetalipoproteinemia).
• Careful consideration of associated systemic issues.

Primary/Secondary Lipid Disorders

• Primary lipid disorders: Type IIa or IIb phenotype hyperlipidemias, Type IV phenotype hyperlipidemia, low levels of high-density lipoprotein (HDL).
• Secondary lipid disorders: Primary biliary cholangitis (PBC), acquired hyperlipoproteinemia from systemic illnesses (like diabetes, hypothyroidism, nephrotic syndrome), sarcoidosis,treatment with retinoids and estrogens.
• Careful examination of medical history and possible connections to secondary lipid disorders.

Clinical Presentation (Xanthelasma)

• Elevated yellowish discoloration of skin (often found bilaterally on medial aspect of the upper eyelid).
• Plaque-like with slightly granular surface.
• Patients are typically asymptomatic.

Eval/Tx/Mx (Xanthelasma)

• Rule out other causes of hyperlipidemia (corneal arcus, cholesterol emboli in retina).
• Rule out concomitant vascular disease (HTN, DM).
• Order blood tests (lipid panel, glucose, CBC).
• Referral for removal if cosmetic concerns only; surgery, electrocoagulation, chemical cauterization are used.
• Remove if growing rapidly, causing symptoms, or for cosmetic reasons.

Capillary Hemangioma

• Aka strawberry mark.
• Congenital (present shortly after birth) or develops shortly after.
• Usually regress completely by age 5.
• Can increase in size temporarily.
• Often presents as a brightly colored lesion.

Clinical Presentation (Capillary Hemangioma)

• Flat reddish, pink, lobulated lesions.
• Color can vary with venous return (straining, crying, lifting may cause redder appearance).
• Important to document size, location, and changes over time.

Nevus Flammeus

• Aka port-wine stain.
• Congenital or present shortly after birth; usually unilateral.
• Can develop anywhere; most common on face.
• Strong correlation with Sturge-Weber Syndrome.
• Presence of leptomeningeal angiomas – abnormal blood vessels often found in brain.
• Thoroughly document the location and characteristics of the lesion

Clinical Presentation (Nevus Flammeus)

• Pink/red homogenous patch on face (variable size).
• Size increases with physical growth.
• Can darken over time.

Tx/Mx (Nevus Flammeus)

• Slight pressure will often blanch.
• Rule out other congenital anomalies; r/o nevi/melanomas.
• Photodocumentation.
• Capillary hemangiomas usually spontaneously regress.
• Laser therapies are effective for port-wine stains.
• Referral after adolescence if cosmetics concerns persist.
• Treat any associated glaucoma.
• Monitor for changes & symptoms (including pain, bleeding, ulceration)

Benign Melanotic Lesions

• Ephelides
• Solar Lentigines
• Nevi
• Additional important considerations for individuals with a family history of skin cancer.

Ephelides

• Aka freckle; plural: ephelides
• Larger sized melanocytes (number is normal).
• Autosomal dominant inheritance pattern.
• Intensified in sunlight; may fade in winter.
• Common in those with fair skin.
• Document and monitor any changes in appearance.

Solar Lentigines

• Aka liver spots/sunspots/age spots.
• Occur in response to sunlight..
• Persist in absence of sunlight.
• Typically seen in middle-aged and older patients.
• Expanding macules (flat patches).
• Normal amount of melanocytes.

Nevi

• Aka mole; plural: nevi.
• Benign neoplasms/melanocytes showing overgrowth of melanin-containing cells in skin.
• Congenital or early onset.
• Occasional changes in size/pigmentation may suggest malignancy.
• Three main types: dermal, junctional, compound.

Dermal Nevus

• Most common type.
• Located in the dermis.
• Raised, dome-shaped.
• Becomes browner/darker with age.
• Smooth/warty surfaces; potentially with telangiectatic vessels on surface.
• Exposed to trauma from clothing; monitor for changes in appearance.

Junctional Nevus

• Located at dermoepidermal junction.
• Flat; potentially only slightly elevated.
• Uniform light to medium brown in color.
• Symmetrical borders.
• Rare chance of becoming malignant.

Compound Nevus

• Transitional type: dermoepidermal junction and dermis.
• Elevated, more so as age increases.
• Flesh/brown colored.
• Smooth or warty surfaces.
• Symmetric; round/oval.
• Monitor for changes in appearance.

Dysplastic Nevus

• Atypical nevus, "fried-egg" appearance.
• Pigmented or amelanotic.
• Diameter typically larger than 5mm with irregular margins, lesional color variations.
• Commonly found at lid margin; diameter is typically less than 8-10mm.
• Increased risk of melanoma if multiple, and in those with a family history of melanoma..
• Monitor for any changes in appearance, size, and/or color.

Tx/Mx (Benign Melanotic Lesions)

• Careful history & photodocumentation (follow-up).
• Re-evaluate lesions with concerns/changes based on degree of suspicion (q3-6 months; q1 year).
• Any concerns must be referred out for biopsy.

Nevus of Ota

• Aka oculodermal melanosis.
• Benign melanosis; typically involving the region of trigeminal nerve distribution (V1 & V2).
• Typically unilateral.
• Gray/blue hyperpigmentation from entrapped melanocytes.
• Increased risk of uveal melanoma and glaucoma in affected patients; refer for further evaluation.

Premalignant Lesions

• Actinic Keratosis (also called solar keratosis).
• Caused by UV exposure or damage to the skin.
• Squamous cell dysplasia; may lead to squamous cell cancer.

Clinical Presentation (Actinic Keratosis)

• Can range from mm-1cm in size.
• Erythematous/scaly macules/papules.
• Potentially elevated, with flaky crust.

Tx/Mx (Actinic Keratosis)

• Rule out neoplasia (keratoacanthoma, melanoma).
• Dermatology consult.
• Cryotherapy
• Curettage
• Topical anti-cancer creams (e.g. imiquimod).
• PDT.
• Educate patient on UV exposure risks; avoid sun exposure or use proper sun protection.

Keratoacanthoma

• Benign growth; pseudocarcinomatous hyperplasia.
• Usually develops on head/face.
• Common in middle-aged/older fair-skinned people.
• Grows rapidly (2-6 weeks).

Clinical Presentation (Keratoacanthoma)

• Raised lesion; initially dome-shaped nodule.
• Central core resembling a molluscum or crater-like excavation.
• Elevated rolled borders (mimics SCC/molluscum).
• Grows rapidly to 1-2cm; displays keratin-filled crater.
• Growth stops; keratin plug is discharged, leaving a pit; spontaneously regresses by involution.
• Carefully scrutinize the lesion's appearance; monitor for changes.

Tx/Mx (Keratoacanthoma)

• Rule out SCC (refer out for biopsy); biopsy may be necessary if growth is rapid or concerning changes appear.
• Reassure patient.
• Photodocument and monitor closely.
• Consider dermatology consult for evaluation/biopsy.
• Removal if necessary.

Malignant Neoplasms of the Lid

• Basal Cell Carcinoma (BCC)
• Squamous Cell Carcinoma (SCC)
• Malignant Melanoma

Basal Cell Carcinoma (BCC)

• Most common malignant eyelid neoplasm (~90% on lids).
• Slow-growing lesion (months to double in size).
• Usually in areas of chronic UV exposure but less common on lids in relation to other exposed areas of the skin.
• More common in older adults (especially Caucasian males).
• Higher incidence in areas with a history of trauma, burns, or X-ray exposure.

Clinical Presentation (BCC)

• Starts as translucent/waxy/greyish-white nodule.
• Center often slowly ulcerates/darkens (increasing size).
• Smooth/pearly white borders with fine telangiectatic vessels.
• Multiple variants (nodular, superficial, sclerosing-morpheaform).
• Lower lid most common (~60%).
• Symptoms include a "lump or growth that doesn't go away or heal".
• History of previous damage/trauma to area is a crucial factor to consider.
• A thorough examination of the medical history and physical characteristics of the lesion is necessary.

Tx/Mx (BCC)

• Rule out other lesions; refer out for biopsy when needed.
• Dermatology consultation.
• Biopsy; excision (by Mohs, radiation, cryo, conventional surgery).
• Early intervention is key.

Squamous Cell Carcinoma (SCC)

• Less common than BCC (5-9% on lids).
• Rapid growth; ability to metastasize (local invasion, extension to regional nodes).
• Elderly, fair-skinned individuals are more at-risk.
• Exposure to irritants, chemicals, trauma (sun, thermal burns) is also a factor.
• Usually develops in areas with significant UV exposure; less prevalent on eyelids in relation to other exposed skin areas.

Clinical Presentation (SCC)

• No typical location but often appears on lips (~30%).
• Possibly arises from existing actinic keratosis or cutaneous horn.
• Can appear as a raised nodule, flat crusty area, or flat scaly area, ulcerated with bleeding/thickened margins, possibly even very keratotic.
• Difficult to differentiate from benign growths; a proper evaluation is paramount.
• Document the lesion's features.

Tx/Mx (SCC)

• Refer for excisional biopsy if suspicious.
• Surgery (Mohs technique) if positive for SCC.
• Discuss recurrence rates and potential risks.
• Early intervention is key; thorough patient education is crucial.

Malignant Melanoma

• Most malignant skin tumor; derived from melanocytes.
• Comprises ~3% of primary skin cancers; however ~ 70% of deaths are caused by this tumor type (related to skin cancer).
• High rates of metastasis (can metastasize in early stages).
• Profile of likely susceptible patients is similar to BCC and SCC.
• Incidence increasing; most important to get this diagnosis and treatment correct.

Clinical Presentation (Malignant Melanoma)

• Asymmetric, pigmented lesion with irregular borders; variable coloration.
• Variable diameter.
• Types: superficial spreading, nodular, acral lentiginous, lentigo malignant.
• Assess the entire lesion carefully when evaluating.

Tx/Mx (Malignant Melanoma)

• Refer out for biopsy.
• Surgery is the primary form of treatment
• Shave biopsies are not recommended; all skin layers need to be removed.
• Careful evaluation of regional lymph nodes.
• Considerations to remove lymph nodes might be necessary in melanomas greater than 1mm depth.
• Thoroughly document all features.

Optometrist Role

• Skin cancer can present in the eyes, which should prompt immediate referrals. (10% of skin cancers are located in or around the eyes).
• Madarosis, lid notching, loss of meibomian gland orifices, surface telangiectasia, and ulceration are classic signs of lid carcinoma.
• Opthalmologic or dermatologic referrals are necessary.

ABCDEs of Lesions

• Asymmetry: if any two halves of a lesion are not symmetric
• Borders: irregular, developing satellite pigmentation
• Color: uneven color or changes
• Diameter: enlarging size or >6mm
• Elevation/Evolving: changes in appearance (ulceration, scaling/discharge/bleeding)
• Document and monitor for changes!

Neoplastic Considerations

• Patient history (other skin/systemic issues, excessive UV exposure, pre-existing lesions).
• Lesion characteristics: chronic/acute onset, duration, irregular growth patterns, pain/irritation.
• Presentation differs from typical for age/sex/race.

Other Considerations (BCC, Melanoma, and SCC)

• BCC: Metastasis unlikely(rare); but if metastasis do occur, regional lymph nodes affected.
• Melanoma: High rate of metastasis; early staging necessary.
• SCC: Rapid growth; local invasion and extension to regional nodes possible.
• Assess the risk!

Stages of Melanoma & Survival Risks

• Stage 0 (in situ), Stage I, II, III, IV.
• Survival rates vary by stage. Important to assess and document the stage correctly.

Mohs Surgery

• Aka Mohs micrographic surgery
• Removal of visible tumor plus a small layer of tissue surrounding the tumor.
• Tissue sections examined for cancer cells; crucial for accurate diagnosis.
• Process repeats until no cancerous cells remain
• Aims to remove as little tissue as possible.
• May be indicated for high-risk/aggressive lesions.

Patient Education & Information

• Educate patient on sun protection/habits.
• Document all conversations and information provided to the patient.
• Make sure that all individuals dealing with possible skin cancers are evaluated properly.

This quiz explores the classification of eyelid tumors, focusing on the distinctions between benign and malignant types. It also covers important dermatology terms related to abnormal cell growth, including neoplasia, hyperplasia, and hypertrophy. Test your knowledge on these critical dermatological concepts!