PRIMARY CARCINOMA OF T H E MEIBOMIAN GLAND JAMES E. LEBENSOHN, CHICAGO
The case reported of primary carcinoma of the Meibomian gland is quite typical. As usual the nature of the chalazionlike tumor had not been recognized, and it was the re peated recurrence that prompted a histologic examination. The treatment, consisting of wide excision, plastic repair, and radium therapy thereafter, achieved a very satisfactory cosmetic, functional, and therapeutic result. From the Department of Ophthalmology, Northwestern University Medical School. Read before the Chicago Ophthalmological So ciety, October IS, 1934. Tumors of the eyelids, apart from otherwise incompletely operated upon, chalazion, are as rare as chalazia are the course of the lesion changes drama frequent, and consequently it is not sur tically to that of active malignancy, prising that the various neoplasms of marked by quick recurrences, followed the tarsal glands as well as the other — unless adequately controlled — by proliferations in this area—as Jaensch 1 progressive extension through the lid, points out—such as tubercle, gumma, rapid orbital involvement, and death. 3 sarcoma, and nevus carcinoma have Of sixteen cases collected by Riva in The re been generally confused with chalazion 1922, five thus10 ended fatally. ports of Snell , Cavara 5 , and Shoji 11 and so treated. Neoplasms of the Meibomian gland, vividly exemplify the dangerous poten though unusual, still outnumber those tialities of this lesion, and further em arising from the other palpebral glands. phasize the responsibility of the oph Adenoma and carcinoma occur in about thalmologist who happens upon this equal proportions. The total number of condition. In an early case the diagnosis might both reached 30 in 19132, and 40 in 19223. As regards particularly Meibom- be suspected when one notes, in an in ian-gland cancer, there were on record dividual of middle age or over, an indo 8 cases in 19044, 21 cases in 19205, and lent painless chalazionlike tumor of 48 cases in 1930s. Additional reports cartilaginous consistency, with a bossy since 7 ' 8> B together with this presenta appearance on the conjunctival surface, tion bring to a total of 52 the cases and without any present or past inflam matory reaction. With the possibility of listed to date. In accord with the customary inci neoplasm in mind, the tumor should be dence of carcinoma, the patients af enucleated and the tissue submitted to fected have usually been over 40 years histological investigation. The more advanced case presents a of age, though an undoubted case has occurred as early as at 11 years 4 . Before distinctive clinical picture. The firm 40, most neoplasms of the Meibomian mass appears well encapsulated, and gland are adenomata, but after 40 car- moves freely underneath the skin, but cinomata preponderate. Transitional is intimately fused both with the tarsus forms have been noted. Curiously, and the lid margin. The skin at the af though lid cancer has a predilection for fected lid margin is atrophic, and the the lower lid, both forms of Meibomian cilia of the region are scanty or gone. neoplasm are found in the upper lid The lid edge is puffy or protruding, and the adjoining conjunctival surface is twice as frequently as in the lower. Meibomian-gland cancer is a type of thickened, red, irregular, and ulcerated. skin-gland cancer, and shares the gen The lymph glands are only occasionally eral characteristic of being relatively involved. Meibomian-gland cancer is a type of benign in its early evolution. The growth first progresses with extreme adenocarcinoma. Microscopically, the slowness, without local reaction or lym tumor consists of a large epithelial phatic involvement, and does not at mass, surrounded by connective-tissue tain a noticeable size for about a year. lamellae, and separated into lobules by However, once the mass is curetted or connective-tissue septa. About the cen552
CARCINOMA OF THE MEIBOMIAN GLAND tral mass may be found tumor-cell nests, and here and there accumulations of small round cells. The tumor cells are aggregated in alveolar formations which reach twenty to thirty times the size of normal acini. The cells in the alveolar periphery are smaller and more regularly arranged than those in the center. Shoji 11 , point ed out that two types of cells are distinguishable, probably based on a difference of age. The more primitive cells have large nuclei, frequently in mi tosis, and scanty cytoplasm; while the more differentiated cells have small nu clei and an abundant cytoplasm filled with fatty granules. These fatty gran ules are seen as vacuoles in alcoholether preparations, and in frozen sec tions stain, orange-red with sudan I I I and violet-red with Nile blue. W i t h po larized light they can be identified as cholesterin esters. These sebaceous cells tend to undergo fatty degenera tion and form in the center of the alve oli amorphous masses. Capillaries enter the lobules and about them the primi tive cells frequently gather in rosettes. Exceptionally, as in the case of Imatomi 11 , the epithelioma consisted of pavement calls (probably originating from the duct of the gland), while in a case reported by Fuchs 2 prickle-cells were observed. The treatment is essentially surgical, and the intervention indicated depends on the involvement present. Fortu nately, in most patients seen the lesion is confined to the lid and the lymphatic glands are not affected. In such cases a radical excision with a suitable lid plas tic, followed by irradiation, generally assures a favorable prognosis. Case report. A Polish woman, aged 43 years, in excellent general health, vis ited the Illinois Eye and Ear Infirmary May 21, 1932, because of a small lump in the outer third of the left upper eye lid. A year previously the growth, at that time the size of a pea, was cur etted, and recurred two months later. Since then it had been operated on twice, always with recurrence. The vission in each eye was normal. At the Infirmary the growth was conservatively excised by a member of
the staff and sent to Dr. Georgiana Theobald for pathological diagnosis. After receiving a report of malignancy, the surgeon treated the lesion with dia thermy and observed no recurrence
Fig. 1 (Lebensohn). Primary carcinoma of the Meibomian gland. Microphotograph of section (X 465). Numerous mitotic figures are evident.
Fig. 2 (Lebensohn). Patient in whom the outer third of the left upper lid was removed for primary carcinoma of the Meibomian gland, showing the result of the lid plastic, and subsequent interstitial irradiation, four months after operation. during the following month of observa tion. On March 20, 1934, the patient re ported again at the Infirmary, this time with the growth occupying the outer third of the lid. The mass appeared well circumscribed, but intimately attached to the lid edge and the underlying tar sus. The overlying, skin was freely movable, but the conjunctival surface was ulcerated and presented fungoid excrescences, especially at the palpebral border. The lymphatic glands were uninvolved. The diagnosis of carcin oma of the Meibomian gland was made
JAMES E. L E B E N S O H N
on the basis of these findings, the pre vious history, and the pathological re port. Before attempting excision of the growth, the healthy inner half of the lid was prepared for a sliding plastic, as described by J. E. Sheehan 12 . Through a vertical incision near the nasal attach ment of the lid, the tarsus was sepa rated from the overlying tissue. Into this cleft was inserted a stent covered on both sides by a Thiersch graft with its raw surface outward. A thin slice of cartilage obtained from the ear was then placed over the distal end of the stent, and the wound sutured. Two weeks later the involved area with a margin of apparently healthy tissue was excised. The stent was removed, and the healthy portion of the lid divided into two halves through the gray line at the lid edge. The upper half, having normal skin for covering, the cartilage implant for support, and the Thiersch graft for lining, was swung over to take the place of the excised tissue. That portion of the Thiersch graft which covered the area of overlapping was
removed from both upper and lower halves. Healing progressed unevent fully at first, but a month later an ex crescence at the lid margin was noted. The patient was thereupon referred to Dr. Max Cutler of the Tumor Clinic, Michael Reese Hospital, for radium therapy, and I want to take this oppor tunity to thank him for his kind coop eration. Interstitial radiation was given for forty-eight hours through two needles each containing one milligram of radium, filtered through one-half millimeter of platinum. W i t h this single treatment, the tendency to recurrence completely regressed, and, except for a slight shortening in width, the lid re gained a fairly normal appearance and function. Four months later, September 15,1934, Dr. Cutler treated the lid again with interstitial radiation as a means of further prophylaxis. The pathologic picture presented es sentially the characteristics already de scribed. A noteworthy feature was the extraordinary number of mitotic cells. 310 S. Michigan Avenue.
References 'Jaensch, P. A. Bosartige Geschwiilste unter dem Bilde von Hagelkornern. Klin. Monatsbl. f. Augenh., 1933, v. 90, p. 598. * Scheerer, R. Ein Beitrag zur Kenntnis der Geschwiilste der Meibomschen Driisen. Klin. Monatsbl. f. Augenh., 1914, v. 52, p. 86. 8 Riva, G. Epitelioma delle ghiandole Meibomiane. Arch, di ottal., 1922, v. 29, p. 261. * Lagrange, F. Traite des tumeurs de l'oeil. Paris, Steinheil, 1904, v. 2, p. 733. * Cavara, V. L'epitelioma primitivo delle ghiandole di Meibomio. Arch, per le sci. med., 1920, v. 43, p. 1. 6 Lazarescu, D., Lazarescu, E., and Ionescu, E. A case of epithelioma of the Meibomian glands. Brit. Jour. Ophth., 1930, v. 14, p. 588. 7 Chaillous, J., and Kalt, M. Tumeur meibomienne recedivante. Bull. Soc. Opht, Paris, 1931, p. 771. 8 Nastri F. Epitelioma meibomiano diffuso. Zentralbl. f. ges. Ophth., 1931, v. 28, p. 647. ' Hughes, C. A. Multiple chalazia showing malignancy. Trans. Ophth. Soc. U. King dom, 1932, v. 52, p. 557. 10 Snell, S. Carcinoma of the orbit, originating in a Meibomian gland. Ophth. Rec, 1908, v. 27, p. 94. " Shoji, Y. Un cas d'epitheliome primitif de la glande de Meibomius, envahissent la cavite orbitaire avec atrophie du globe oculaire. Arch. d'Opht, 1929, v. 46, p. 144. " Sheehan, J. E. Plastic surgery of the orbit. New York, Macmillan Co., 1927, pp. 200203.