Study of Histomorphological Spectrum of Eyelid Lesions PDF

Journal of Pathology of Nepal (2021) Vol. 11, 1790 - 1802 linic al Pathologi st...

Journal of Pathology of Nepal (2021) Vol. 11, 1790 - 1802 linic al Pathologi st Journal of fC of PAT H O L O G Y no N ti o ep ci a al- Asso 201 of Nepal 0 andu Nepal M athm www.acpnepal.com edi ,K ca As ad soc Ro l iatio i on n Building Exhibit Original Article Study of histomorphological spectrum of eyelid lesions Reshmi Shrestha1, Gita Sayami2 1 Department of Pathology, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal 2 Department of Pathology; Hospital for Advanced Medicine and Surgery, Kathmandu, Nepal ABSTRACT Keywords: Background: Eyelid pathologies are the most common surgical specimens encountered among all of the Benign; ophthalmic lesions and constitute a wide range of diseases by their unique histologic features. This study Eyelid lesions; aims to find out the histopathological spectrum of eyelid lesions, their demographic distribution, and Malignant; preferential location prevalent in our community. Sebaceous carcinoma; Materials and Methods: This is an observational study in which we retrospectively evaluated the data of 692 patients retrieved from the histopathology department of National Reference Laboratory, Kathmandu, from May 2016 to April 2019. Results: A total of 701 histologic diagnoses comprised of benign, precursor, and malignant lesions and accounted for 86.6%, 2.6%, and 10.8% respectively with preponderance in females. The common benign lesions included melanocytic nevus (17.7%), epidermal cyst (11%), hemangioma (8.9%), dermoid cyst (8.2%), chalazion (6.7%), and squamous papilloma (6.4%). Tumour of epidermal origin was the most common neoplastic lesion accounting for 31.2%. Basal cell carcinoma (50%) followed by sebaceous carcinoma (27.6%) and squamous cell carcinoma (14.5%) constituted the majority of malignant lesions prevalent above the age of 60 years with the preferential site of the upper eyelid for basal cell carcinoma and squamous cell carcinoma; and lower eyelid for sebaceous carcinoma. Conclusions: Benign eyelid lesions are more prevalent than malignant ones with overall female preponderance. Epidermal tumours are common among neoplasms. A malignant tumour, a disease of an elderly individual, is predominated by basal cell carcinoma followed by sebaceous carcinoma, an aggressive tumour with a high recurrence rate in our population. INTRODUCTION Correspondence: Dr. Reshmi Shrestha, MD Eyelid lesions are quite common and most of the surgically Associate professor, Department of Pathology excised ophthalmic specimens submitted for histopathologic Nepalese Army Institute of Health Sciences evaluation are obtained from this site. Numerous and ORCID ID: 0000-0002-9914-9213 diverse pathologic lesions in the eyelids are due to their Email: [email protected] unique anatomical features as the whole skin structures Received : 23rd December 2020 ; Accepted : March 7th 2020 with its appendages, skeletal muscle, modified glands, Citation: Shrestha R, Sayami G. Study of histomorphological spectrum of eyelid lesions. J Pathol and conjunctival mucous membrane are represented in Nep. 2021;11:1790-1802 DOI: 10.3126/jpn.v11i1.31244 the eyelid.1,2 Eyelid lesions can be divided into congenital, Copyright: This is an open-access article distributed under the terms of the Creative Commons inflammatory, nonneoplastic masses, and neoplasms (benign Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. or malignant). Neoplastic lesions can be further classified DOI : 10.3126/jpn.v11i1.31244  1791 Shrestha R et al. according to their anatomical origin. 2-4 inflammatory lesion, cyst/congenital lesion, infectious lesion, and cutaneous deposit.3,14 The relative frequencies of different eyelid lesions are variable from different locations in the world as reported The classification of tumours used in this study is based on in the literature.5 Benign lesions are more common than the WHO Classification of Skin Tumours (2018) 15 along malignant lesions.6,7 Basal cell carcinoma has been shown with the revised 2006 edition of the AFIP atlas of tumour to have the highest incidence among malignancies in the pathology 1 and Mckee et al16. West but a higher incidence of sebaceous carcinoma is documented in Asian countries.7-11 Geographic variation, The retrieved data from the pathology department of genetic factors, socioeconomic status, easy access to health this referral laboratory showed that the patients were care facilities has been attributed to the variations seen in the predominantly from Central (Kathmandu, Lalitpur, frequency of various tumour subtypes in different studies.11 Bhaktapur, Makwanpur, Chitwan) and Eastern region (Jhapa) of Nepal. These major cities have a diverse Malignant eyelid lesions may masquerade as both benign population in terms of race and ethnicity with good health and histologically different types of malignant lesions, care facilities. The geographic altitude varies and the climate often resulting in delayed diagnosis.6,12 Histopathological zone ranges from temperate to tropical climate. Literacy evaluation is important in early detection, prompt treatment, rate, socioeconomic status, and disease awareness are also and further management of malignant tumours.6,13 considered better amongst different regions of Nepal based on the National Population and Housing Census 2011, There has been a limited number of studies on eyelid lesions national report.17 in Nepal which mostly include a very less number of cases. We aimed to evaluate the histomorphological spectrum of RESULTS eyelid lesions and their frequency and demographic and topographic distribution from the data of 692 patients at the A total of 692 patients with eyelid lesions were studied Kathmandu-based referral laboratory. during the period of three years from May 2016 to April 2019, of which 400 (57.8%) were females and 292 (42.2%) MATERIALS AND METHODS were males with a female to male ratio of 1.3:1. This was a retrospective observational study conducted Total histologic diagnoses were found to be 701 in these 692 during the period of three years from May 2016 to April 2019. patients as some of the patients had more than one diagnosis A total of 692 patients with eyelid lesions were included in the biopsied specimen. Of these 701 diagnoses, benign who submitted their biopsy specimens in the histopathology lesions were the most common eyelid lesions (n= 607; department of National Reference Laboratory, Baneshwor, 86.6%) which included nonneoplastic lesions (n=242; Kathmandu for histopathological examination. 34.5%) and benign neoplastic lesions (n=365; 52.1%) followed by malignant lesions (n=76; 10.8%) and precursor This study received the approval of the Institutional lesions were found to be 18 (2.6%). Eyelid neoplasms Review Committee of the Nepalese Army Institute of accounted for 459 lesions. Females predominated in benign Health Sciences. Clinical data, demographic characteristics, and malignant tumours with a female to male ratio of 1.6:1 location of the lesions, gross features, and histopathologic and 1.9:1. Equal distribution was noted in nonneoplastic diagnoses with detailed histologic findings, marginal tissue lesions with a female to male ratio of 1.07:1. In precursor involvement in malignant lesions were retrieved from the lesions, males predominated (1:1.6). histopathology record database. Haematoxylin and eosin- stained slides were also retrieved and reviewed wherever The mean age of patients with benign eyelid lesions was necessary. Eyelid tissue with histologically nonspecific 33.7±19.2 years (median age, 31years) ranging from 1 to 84 descriptive findings, such as consisting of only normal years. Among the patients with benign lesions, the average tissue was excluded. The recurrent tumour was not repeated age for nonneoplastic lesions and benign tumours was 28 as a separate case in this study. Laterality of the eyelid years and 37.5 years respectively. The mean age of patients lesions was not found in the record in most of the cases, with malignant tumour was 60.3±17.8 years (median age, 65 therefore it could not be determined. Statistical analysis years) with ages ranging from 5-97 years. Precursor lesions of the frequency of eyelid diseases, their demographic and were seen in the patients with a mean age of 48.2±20.2years topographic distribution, and clinical characteristics were (median age, 50.5years) and age ranging from 9-84 years. done by using SPSS 20 software. Preferential locations for the eyelid lesions are presented in Table 1. Eyelid lesions were grouped into four categories i.e., non-neoplastic lesion, benign tumour, precursor lesion, Non-neoplastic lesions were predominantly cysts followed and malignant tumour. Nonneoplastic lesions and benign by inflammatory lesions in the eyelid (Table 2). Among tumours were together considered as benign eyelid lesions. the non-neoplastic lesions, epidermal cyst was the most Nonneoplastic lesions were further categorized into the common finding (n=65; 26.9%) followed by dermoid cyst DOI : 10.3126/jpn.v11i1.31244 Histomorpholgical spectrum of eyelid lesions 1792 Table 1: Topographic distribution of different categories of eyelid lesions Both upper and Location Upper eyelid Lower eyelid Medial Canthus Lateral Canthus lower eyelids Benign Lesions 352 176 43 26 10 Precursor lesions 11 5 1 1 0 Malignant Lesions 32 37 3 1 3 Total 395 218 47 28 13 Table 2: Frequency, demography and topographic distribution of various non-neoplastic lesions, (n=242) All lesions Mean age Peak age Sex ratio Location (UL/ Type of non-neoplastic lesions No. cases (%) (range years) interval years (F:M) LL) Inflammatory lesions (n=82) Chalazion 41 5.8 24.8 (4-70) 21-30 1.4:1 1.7:1 Inflammatory granulation tissue 28 4 23.9 (2-74) 60 1.3:1 4:1 Granulomatous inflammation 4 0.6 35.3 (22-62) 21-30 3:1 3:1 Pemphigus vulgaris 1 0.1 8 60 1:0 0:1 Verrucae vulgaris 5 1.1 0.7 42.2 (20-75) 21-30;>60 4:1 4:1 Precursor lesions (n=18) Actinic keratosis 10 2.2 1.4 45.7 (9-84) 41-50 1:1.5 4:1 SCC in situ‡ 6 1.3 0.9 53.2 (27-74) >50 1:1 1:1 S. papilloma with dysplasia§ 1 0.2 0.1 35 31-40 0:1 LC S. keratosis with dysplasia¶ 1 0.2 0.1 58 51-60 0:1 0:1 Malignant epidermal tumour (n=49) BCC 38 8.3 5.4 66.1 (25-97) >60 1.7:1 0.4:1 SCC 11 2.4 1.6 48.7 (27-74) >60 2.7:1 0.6:1 *female:male; †upper eyelid/lower eyelid; ‡squamous cell carcinoma in situ; §squamous papilloma with dysplasia; ||lower canthus; ¶seborrheic keratosis with dysplasia; **basal cell carcinoma; ††squamous cell carcinoma developed dysplasia and thus was categorized under precursor and lower eyelids. No single junctional nevus or other lesion. Another common epidermal tumour, i.e., seborrheic specific variants of melanocytic nevus was found in the keratosis, was composed of acanthotic papillomatous eyelid. lesion lined by basaloid keratinocytes along with multiple pseudo-horn cysts formation. Keratotic, pigmented, and Frequently seen hemangioma was mainly found to be of irritated (inverted follicular keratosis) variants were also capillary type (n=29, 7.9% of benign tumours). Pyogenic seen showing histologic features of marked hyperkeratosis, granuloma, a variant of capillary hemangioma was increased keratinocytes pigmentation with scattered predominantly seen (n=26, 7.1%), which showed surface melanophages, and presence of squamatization, squamous ulceration and lobules of capillaries in the dermis. About 36% eddies with a band of superficial lymphocyte infiltrate in of these lesions were clinically diagnosed as hemangioma the dermis respectively. One case of seborrheic keratosis and the remaining were variably diagnosed as granuloma, was also found to be associated with dysplasia, which was, chalazion, papilloma, or cyst. Tumours of neural origin therefore, considered a precursor lesion. were less common accounting for only 3.9% (n=18) of all neoplasms. Among these, neurofibroma (n=12, 3.3% of Among the appendageal neoplasms, tumours with eccrine benign tumours) was the frequently seen benign peripheral and apocrine differentiation were the most frequent ones nerve sheath tumour which was composed of spindled cells accounting for 10% (n=46) of all tumours. Hidrocystoma with wavy nuclei in a collagenous stroma. Myxoid changes was the most common type of benign adnexal tumour and mast cell infiltration were also common findings. Two and was predominantly of eccrine type. Only one case of them were of plexiform variant which showed tortuous of apocrine hydrocystoma was detected consisting of a and swollen neural bundles in the background of myxoid cyst lined by apocrine cells. Secondly, pilomatrixoma, an to collagenous stroma. Less common were schwannoma adnexal tumour with follicular differentiation was seen (n=4) and solitary circumscribed neuroma (n=2). Other with a frequency of 3.8 % (n=14) of all benign tumours. common soft tissue tumours included fibroepithelial polyp The frequency of other less common adnexal tumours is (n=8, 2.2% of benign tumours) and lipoma (n=6, 1.6% of provided in Table 4. benign tumours). One case of fibrolipoma was identified as a variant of lipoma. Dermatofibroma and solitary fibrous The commonest melanocytic nevus which is intradermal tumour were only one each accounting for 60 0:1 0:1 Syringocystadenoma 1 0.2 0.1 78 >60 0:1 MC papilliferum Syringoma 1 0.2 0.1 56 51-60 1:0 1:0 Appendageal tumour with follicular differentiation (n=16) Pilomatrixoma 14 3 2 22.8 (4-53) 11-20 3.7:1 6:1 Dilated pore of Winer 1 0.2 0.1 24 21-30 0:1 1:0 Basaloid follicular 1 0.2 0.1 26 21-30 0:1 1:0 harmartoma Appendageal tumour with sebaceous differentiation (n=38) Sebaceous hyperplasia 9 2 1.3 47.8 (25-72) 21-30;41-50;>60 1:1.3 3.5:1 Steatocystoma 6 1.3 0.9 23.6 (18-27) 21-30 1:5 1:1 Nevus sebaceous 1 0.2 0.1 42 41-50 1:0 1:0 Sebaceous adenoma 1 0.2 0.1 55 51-60 0:1 MC Sebaceous carcinoma 21 4.6 3 61.2 (30-82) >60 2.5:1 3:1 *female:male; †upper eyelid/lower eyelid; ‡medial canthus(location) keratoses (n=10) followed by squamous cell carcinoma in situ tumour cells in the lobules and melanophages in the dermis (n=6). Cases with actinic keratoses had histological features (fig. 2A). Basosquamous carcinoma showed composite showing acanthosis, hyperkeratosis, and papillomatosis histologic features of BCC and squamoid differentiation with mild to moderate dysplastic features. Squamous cell (fig. 2B). Keratotic BCC showed nests of basaloid tumour carcinoma in situ, histologically comprised of atypical cells with abrupt central keratinization. The common gross squamous cells involving the full thickness of epidermis feature of BCC was predominantly ulcerated nodule (n=17) with or without keratin pearl formation and cytoplasmic with an average maximum dimension of 1.5cm (range, 0.3- keratinization. Two cases of seborrheic keratosis and 3.8cm). Pigmented variants were mostly blackish or partly squamous papilloma, one each, were considered precursor showed black colouration. The patients with basosquamous lesions as they developed moderate dysplasia. variant were both below the age of 60 years (47 and 55 years) presenting with gross finding as an ulcerated mass The received specimen of the histologically proven and lobulated mass respectively. One BCC was a recurrent malignant tumours were mainly excisional biopsy [basal tumour. Of 35 cases, marginal tissue assessment showed 19 cell carcinoma (BCC; n=34), sebaceous carcinoma (n= 19), cases (18 cases of excisional biopsy and one exenterated squamous cell carcinoma (SCC; n= 8), lymphoma (n=2), specimen) with free margins. melanoma (n=2), rhabdomyosarcoma (n=1)]. Exenteration of the eyeball was done for each case of BCC, sebaceous Sebaceous carcinoma was the second most common carcinoma, and SCC. The remaining seven cases of malignant tumour (n=21; 27.6%) with a predilection malignant tumours were received as incisional biopsy for the upper eyelid (n=16). It ranged from well to specimens. poorly differentiated. Moderately differentiated tumours predominated (n=12) having few foci of areas which Malignant tumours of epidermal origin were the most showed differentiated sebaceous carcinoma cells. common malignant neoplasms which accounted for 63.2% Histologic patterns comprised predominantly variable-sized (n=48) of malignant lesions; BCC being the commonest lobules followed by mixed lobular and comedocarcinoma. histologic type (n=38; 50% of malignant tumours) were Well-differentiated tumours (n=4) show well-demarcated predominantly found on the lower eyelid. Histologically, lobules with frequently recognizable atypical sebaceous the common architecture was mostly islands, solid nests, cells consisting of bubbly or vacuolated cytoplasm (Fig. lobules, and sheets with an adenoid pattern comprising 3A). Poorly differentiated tumours (n=5) had marked basaloid cells. Histologic variants included pigmented pleomorphism, high mitotic count up to 28/HPF including (n=8), basosquamous carcinoma (n=2) and keratotic (n=1). atypical mitoses and infiltrative pattern. Intraepithelial Pigmented variants had foci of areas with heavily laden spread to conjunctiva or epidermis or both were frequently DOI : 10.3126/jpn.v11i1.31244 1795 Shrestha R et al. Table 5: Histological classification of neoplasms: Melanocytic tumours, soft tissue tumours and others All Tumors All lesions Mean age Peak age Sex ratio Location Type of non-neoplastic lesions No. cases (%) (%) (range years) interval years (F:M) (UL/LL) Melanocytic tumour (n=110, 24%) Melanocytic nevi (n=108) Intradermal nevi 96 21 13.7 41.3 (16-83) 31-40 3:1 1.4:1 Compound nevi 12 3 1.7 26.7 (6-74) 21-30 2:1 1.2:1 Melanoma 2 0.4 0.3 44.5 (5-84) 60 2:0 2:0 Vascular tumor (n=56, 2.7%) Haemangioma (n=54) Capillary haemangioma 29 6.3 4.1 32.1 (6-70) 11-20;31-40 1:1.6 2.1:1 Cavernous haemangioma 4 0.9 0.6 38.8 (17-58) 11-20 1:3 4:0 Intramuscular haemangioma 1 0.2 0.1 37 - 0:1 0:1 Spindle cell haemangioma 1 0.2 0.1 30 21-30 1:0 MC Others 19 4.1 2.7 31 (6-700 11-20 1.7:1 1.3:1 Lymphangioma 2 0.4 0.3 19 (19-19) 11-20 1:1 1:1 Neural tumour (n=18, 2.7%) Neurofibroma 12 2.6 1.7 33.2 (9-740 21-30 1:1 5:1 Schwannoma 4 0.9 0.6 35 (7-65) - 1:1 1:3 Solitary circumscribed neuroma 2 0.4 0.3 49 (45-53) - 1:1 2:0 Fibroblastic, fibrohistiocytic tumour (n=10, 2.2%) Fibroepithelial polyp 8 1.7 1.1 38.9 (23-59) 21-30 1.7:1 2.5:1 Dermatofibroma 1 0.2 0.1 45 41-50 1:0 1:0 Solitary fibrous tumour 1 0.2 0.1 45 41-50 0:1 1:0 Miscellaneous (n=7, 1.5%) Rhabdomyosarcoma 1 0.2 0.1 14 11-20 0:1 MC Lipoma 6 1.3 0.8 33.6 (14-72) 21-30 5:1 1:1 Lymphoid tumour/Tumour like lesions (n=6, 1.3%) Reactive lymphoid hyperplasia 3 0.7 0.4 33.7 (14-72) 11-20 2:1 2:1 Non-Hodgkin Lymphoma 3 0.7 0.4 50 (34-72) >30 1:2 2:1 Histiocytic lesions (n=9, 2%) Xanthelasma 6 1.3 0.9 44.2 (27-52) 41-60 6:0 5:1 Xanthogranuloma 2 0.4 0.3 16 (2-30)