Meibomian Gland Carcinoma in a 20-year-old Patient

Meibomian Gland Carcinoma in a 20-year-old Patient

114 January, 1991 AMERICAN JOURNAL OF OPHTHALMOLOGY kia. T h e c o e x i s t e n c e o f r u b e o s i s a n d p r o g r e s ­ sive g l a u c o m a...

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114

January, 1991

AMERICAN JOURNAL OF OPHTHALMOLOGY

kia. T h e c o e x i s t e n c e o f r u b e o s i s a n d p r o g r e s ­ sive g l a u c o m a s u g g e s t e d t h e t r u e n a t u r e o f t h e lesion.

References

Fig. 2 (Portnoy and associates). Light microscopic appearance of iris tumor, displaying sheets of poly­ hedral-shaped cells with clear cytoplasm infiltrating the iris stroma. Remnants of iris pigment epithelium are seen on the left (hematoxylin and eosin, x 250).

1. Ferry, A. P., and Font, R. L.: Carcinoma meta­ static to the eye and orbit. II. A clinicopathological study of 26 patients with carcinoma metastatic to the anterior segment of the eye. Arch. Ophthalmol. 93:472, 1 9 7 5 . 2. Chance, B. K.: A case of secondary hyperne­ phroma of the iris and ciliary body. Trans. Am. Ophthalmol. Soc. 11:178, 1906. 3. Hudson, A. C , and Lister, W.: Metastatic hyper­ nephroma of the iris. Proc. R. Soc. Med. 27:1613, 1934. 4. Wyzinski, P., Rootman, J., and Wood, W.: Simul­ taneous bilateral iris metastases from renal cell carci­ noma. Am. J. Ophthalmol. 92:206, 1 9 8 1 .

M e i b o m i a n G l a n d C a r c i n o m a in a c o n t r o l , a n d the l e s i o n w a s e x c i s e d b y m e a n s of a superior sector iridectomy. Pathologic exami­ n a t i o n d i s c l o s e d a finely v a s c u l a r i z e d g l o b u l a r gelatinous mass measuring 6 x 5 x 4 mm. M i c r o s c o p i c a l l y , the m a s s c o n s i s t e d o f s h e e t s o f l a r g e r o u n d e d or p o l y g o n a l - s h a p e d c e l l s h a v i n g a b u n d a n t c l e a r c y t o p l a s m rich in g l y c o g e n a n d l a c k i n g m u c u s (Fig. 2 ) . T h e h i s t o l o g i c a p p e a r ­ a n c e was c o n s i s t e n t with a m e t a s t a t i c r e n a l c l e a r cell c a r c i n o m a . A c o m p u t e d a x i a l t o m o ­ g r a p h i c s c a n s h o w e d a l a r g e t u m o r o f the left k i d n e y with p r o b a b l e l y t i c l e s i o n s o f t h e r i g h t pelvis. M e t a s t a t i c c a r c i n o m a is t h e m o s t c o m m o n i n t r a o c u l a r m a l i g n a n t n e o p l a s m in a d u l t s a n d m a y b e the first m a n i f e s t a t i o n o f s y s t e m i c c a n ­ cer. M e t a s t a s e s to the a n t e r i o r s e g m e n t o c c u r m u c h l e s s f r e q u e n t l y t h a n to t h e c h o r o i d . M e ­ t a s t a s e s to the iris h a v e m a n i f e s t e d a s fleshy p i n k n o d u l e s , iris s u r f a c e p l a q u e s , or i r i d o c y c l i ­ tis.' R e n a l cell c a r c i n o m a is a r e l a t i v e l y r a r e c a u s e of m e t a s t a s e s to the iris, a n d h a s m a n i ­ fested as a gray- or y e l l o w - w h i t e m a s s w i t h p r o m i n e n t fine v a s c u l a r i z a t i o n l o c a t e d o n t h e i n n e r p o r t i o n of the iris s u r f a c e . ' "* T h e findings in our c a s e are u n u s u a l b e c a u s e o f the m a n i f e s ­ t a t i o n o f a m e t a s t a t i c iris t u m o r as a s m o o t h d o m e d , c y s t i c - a p p e a r i n g m a s s , s i m u l a t i n g an e p i t h e l i a l i n c l u s i o n cyst, in a p a t i e n t w i t h a p h a -

2 0 - y e a r - o l d Patient Jatinder S. Bhalla, M.S., S. Vashisht, M.S., Vijay K. Gupta, M.S., and A. K. Sen, M.D. De;partments of Ophthalmology (J.S.B., S.V., V.K.G.) an d Pathology (A.K.S.), Deen Dayal Upadhyaya Hospital. Inquiries to jatinder S. Bhalla, M.S., D-1 /4, Deen Dayal Upadhyaya Hospital Residential Complex, Hari Nagar, New Delhi 110064, India. In J a n u a r y 1 9 8 9 , a 2 0 - y e a r - o l d w o m a n h a d a r a p i d l y g r o w i n g s w e l l i n g o n h e r left u p p e r e y e l i d for six m o n t h s ( F i g . 1 ) . T h e p a t i e n t h a d undergone incision and curettage o f this swell­ ing t h r e e m o n t h s p r e v i o u s l y . S h e h a d n o t r e ­ ceived radiotherapy. On examination, a small s w e l l i n g o f 5 x 3 m m w a s n o t e d o n the e y e l i d

Fig. 1 (Bhalla and associates). Growth on the left upper eyelid.

Vol. I l l , No. 1

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Letters to the Journal

M e i b o m i a n c a r c i n o m a is a r a r e b u t h i g h l y l e t h a l t u m o r . A l t h o u g h it c o m p r i s e s o n l y 0 . 2 % to 1 . 3 % o f all e y e l i d t u m o r s , it is t h e m o s t malignant tumor of the eyelid, with mortality e s t i m a t e d from 6 % to 3 0 % . ' ' 2 T h e t u m o r c h a r a c ­ t e r i s t i c a l l y d e v e l o p s l a t e in life, a n d t h e a v e r a g e a g e o f p a t i e n t s at d i a g n o s i s is 6 1 years.^ In patients with m e i b o m i a n c a r c i n o m a before the age of 4 0 years, the tumor usually has occurred after r a d i a t i o n t h e r a p y e i t h e r for r e t i n o b l a s t o ­ ma^ or c a v e r n o u s h e m a n g i o m a . ^ O u r p a t i e n t d e v e l o p e d c a r c i n o m a at a y o u n g a g e w i t h o u t a p p a r e n t e x p o s u r e to a n y k n o w n c a r c i n o g e n or r a d i a t i o n . In f e m a l e s , t h e t u m o r i n c i d e n c e is 1.5 to 2 . 7 5 t i m e s g r e a t e r t h a n in m a l e s . *

Fig. 2 (Bhalla and associates). Moderately differen­ tiated meibomian cell carcinoma of the eyelid show­ ing cells arranged in acinar formation around a central fibrovascular tissue {hematoxylin and eosin, X440).

m a r g i n at t h e j u n c t i o n o f t h e m e d i a l t w o t h i r d s a n d l a t e r a l o n e third o f t h e e y e l i d . T h e s w e l l i n g o r i g i n a t e d from t h e t a r s u s . It w a s firm, n o n mobile, and nontender. The upper eyelid also showed congestion. Excision of the growth was performed. M e i ­ b o m i a n g l a n d c a r c i n o m a w a s d i a g n o s e d on h i s ­ topathologic examination of the biopsy speci­ m e n (Fig. 2 ) . T h e p a t i e n t w a s a g a i n e x a m i n e d for any e v i d e n c e o f s y s t e m i c i n v o l v e m e n t . E x ­ a m i n a t i o n s h o w e d n o l y m p h a d e n o p a t h y or o r ­ g a n o m e g a l y . R e s u l t s o f x-rays o f t h e o r b i t , chest, and long b o n e s were normal. In April 1 9 9 0 , the p a t i e n t a g a i n h a d s e v e r e s w e l l i n g o n t h e left u p p e r e y e l i d , m e a s u r i n g 1 0 X 13 m m . T h e s w e l l i n g i n v o l v e d m o s t o f t h e eyelid, e x c e p t for t h e m e d i a l 2 m m , a n d w a s f o u n d to b e e x t e n d i n g o n t o t a r s a l c o n j u n c t i v a as a p o l y p o i d m a s s . T h e m a s s s h o w e d a r e a s o f u l c e r a t i o n a n d w a s friable a n d t e n d e r . R e s u l t s of s y s t e m i c e x a m i n a t i o n w e r e n o r m a l . A c o m ­ plete excision of the growth was performed and the u p p e r e y e l i d w a s r e c o n s t r u c t e d . On histopathologic examination, the tumor w a s f o u n d to b e a m o d e r a t e l y d i f f e r e n t i a t e d s e b a c e o u s a d e n o c a r c i n o m a . O i l - r e d - O stain for i n t r a c y t o p l a s m i c fat w a s p r e s e n t . T h e c e l l s w e r e m o s t l y a r r a n g e d in a c i n a r f o r m a t i o n a r o u n d a c e n t r a l fibrovascular t i s s u e . T h e c e l l s s h o w e d vesicular nuclei containing basophilic material and prominent nucleoli.

This lesion clinically r e s e m b l e s other less a g g r e s s i v e e y e l i d l e s i o n s . It is o f t e n m i s t a k e n for c h a l a z i o n , w h i c h it m a y s i m u l a t e or c a u s e . T h e r a t e o f g r o w t h is s l o w , o f t e n r e q u i r i n g o n e y e a r to r e a c h a n o t i c e a b l e s i z e . T h e d e l a y b e ­ t w e e n o n s e t of s y m p t o m s a n d d i a g n o s i s r a n g e s from o n e to t h r e e y e a r s .

References 1. Cavanagh, H. D., Green, W. R., and Goldberg, H. K.: Multicentric sebaceous adenocarcinoma of meibomian gland. Am. J. Ophthalmol. 77:326, 1 9 7 4 . 2. Wagener, Μ. D., Beyer, C. K., Gonder, J. R., and Albert, D. M.: Common presentations of sebaceous gland carcinoma of the eyelid. Ann. Ophthalmol. 14:159, 1982. 3. Forest, A. W.: Tumors following radiation about eyes. Trans. Am. Acad. Ophthalmol. Otolaryngol. 65:694, 1 9 6 1 . 4. Schlernitzauer, D. Α., and Font, R. L.: Seba­ ceous gland carcinoma of eyelid following radiation therapy for cavernous hemangioma of face. Arch. Ophthalmol. 9 4 : 1 5 2 3 , 1 9 7 6 . 5. Older, J. J . : Eyelid Tumors. Clinical Diagnosis and Surgical Treatment. New York, Raven Press, 1987, pp. 1 7 - 2 1 .

A N e w I n s t r u m e n t for U s e in Evisceration William L. White, M.D., and Donald A. Hellsten, M.D. Ophthalmology Service, Department of Surgery, Brooke Army Medical Center. The opinions or asser­ tions contained herein are the private views of the authors and are not to be construed as reflecting the