Lecture on Common Tumours of Lids For 4th Year MBBS Undergraduate Students By Prof. Dr. Hussain Ahmad Khaqan

1. Common Tumours of Lids
Prof. Dr. Hussain Ahmad Khaqan
 MD
 FRCS(Glasgow)
 FCPS(Ophth.)
 FCPS(Vitreo Retina)
 MHPE (KMU)
 CICO(UK)
 CMT(UOL)
 Fellowship in Medical Retina (LMU, Munich)
 Fellowship in Vitreo Retinal Surgery (LMU, Munich)
 Consultant Ophthalmologist & Retinal Surgeon
Professor of Ophthalmology
Lahore General Hospital, Lahore
Ameer Ud Din Medical College, Lahore
Post Graduate Medical Institute, Lahore
Shaukat Khanum Memorial Cancer Hospital & Research Centre ,Lahore

2. SQUAMOUS PAPILLOMA

3. DEFINITION
• The most common benign lesion of the eyelid is the
squamous papilloma, also known as a fibroepithelial
polyp, acrochordon,or skin tag. These lesions may be
single or multiple and commonly involve the eyelid
margin.

4. CLINICAL FEATURES
• Squamous papillomas characteristically are flesh
colored and may be sessile or pedunculated

5. DIAGNOSIS
• Diagnosis is made by the typical clinical appearance
and histological characteristics.
• Microscopically, the lesion has finger-like projections
(fronds) with a fibrovascular core, and the overlying
epidermis demonstrates acanthosis and
hyperkeratosis.

6. DIFFERENTIAL DIAGNOSIS
• Seborrheic keratosis
• Verruca vulgaris
• Intradermal nevus

7. TREATMENT
• Simple excision at the base of the lesion

8. CUTANEOUS HORN

9. • A cutaneous horn is a projection of packed keratin.
This is a clinically descriptive term, not a diagnostic
one.
DEFINITION

10. CAUSES
• Cutaneous horn is not a distinct pathological entity
but may develop from a variety of underlying lesions,
including seborrheic keratosis, actinic keratosis,
inverted follicular keratosis, verruca vulgaris, basal
cell carcinoma (BCC), squamous cell carcinoma (SCC),
and other epidermal tumors.

11. DIAGNOSIS & TREATMENT
• Biopsy of the cutaneous horn (including the
underlying epidermis) is required to obtain a
histological diagnosis.
• Definitive therapy is dependent on the underlying
cause.

12. SEBORRHEIC KERATOSIS

13. DEFINITION
• Seborrheic keratosis, also known as senile verruca, is
a common benign epithelial neoplasm that may
occur on the face, trunk, and extremities. These
lesions usually affect middle-aged and older adults.

14. CLINICAL FEATURE
• Single or multiple, greasy, stuck-on plaques. Color
varies from tan to brown, and the surface is
frequently papillomatous.

15. DIFFERENTIAL DIAGNOSIS
• Skin tag
• Nevus
• Verruca vulgaris
• Actinic keratosis
• Pigmented Basal cell carcinoma (BCC)

16. TREATMENT
Simple excision may be performed for biopsy or
cosmesis or to prevent irritation.

17. INVERTED FOLLICULAR KERATOSIS
(Basosquamous Cell Acanthoma)

18. CLINICAL FEATURES
• Usually appears as a small, solitary, papillomatous
lesion on the face. It is a well-demarcated, keratotic
mass that may appear as a cutaneous horn. The
lesion may resemble verruca vulgaris and seborrheic
keratosis—many consider it an irritated seborrheic
keratosis.
• Histopathology reveals hyperkeratosis and lobular
acanthosis. Proliferation of basaloid cells occurs with
areas of acantholysis and zones of squamous cells,
often arranged in whorls called squamous eddies.

19. TREATMENT
• Complete excision, because recurrence is common
after incomplete removal.

20. KERATOACANTHOMA

21. CLINICAL FEATURES
• Keratoacanthoma most commonly appears as a
solitary, rapidly growing nodule on sun-exposed
areas of middle-aged and older individuals. The
nodule is usually umbilicated, with a distinctive
central crater filled with a keratin plug. The lesion
develops rapidly over weeks and typically undergoes
spontaneous involution within 6 months to leave an
atrophic scar. Lesions that occur on the eyelids may
produce mechanical abnormalities such as ectropion
or ptosis and occasionally may cause destructive
changes.

22. HISTOLOGY
• Microscopically, there is cup-shaped elevation of
acanthotic squamous epithelium that surrounds a
central mass of keratin. Microabscesses, which
contain necrotic keratinocytes and neutrophils,
may be found within the proliferative epithelium.
Cellular atypia may be present, making
differentiation from squamous cell carcinoma
(SCC) difficult. Many pathologists consider
keratoacanthoma a type of low-grade squamous
cell carcinoma (SCC).

23. DIFFERENTIAL DIAGNOSIS
• Squamous cell carcinoma (SCC)
• Basal cell carcinoma (BCC)
• Verruca vulgaris
• Molluscum contagiosum (MC)

24. TREATMENT
• Complete excision is recommended because an
invasive variant exists, with the potential for
perineural and intramuscular spread.
• Additional treatment modalities including
intralesional chemotherapy, topical agents, lasers,
cryotherapy, and photodynamic therapy have also
been described.

25. ACTINIC KERATOSIS

26. DEFINITION
• Actinic keratosis, also known as solar or senile
keratosis, is the most common premalignant skin
lesion. The lesions develop on sun-exposed areas
and commonly affect the face, hands, and scalp and,
less commonly, the eyelid.

27. CLINICAL FEATURES
• They usually appear as multiple, flat-topped papules
with an adherent white scale.
• Microscopically, actinic keratoses display
hyperkeratosis, parakeratosis, and dyskeratosis.
Atypical keratinocytes in the deep epidermal layers
often form buds that extend into the papillary
dermis.

28. TREATMENT
• Surgical excision or cryotherapy (following biopsy).

29. SEBACEOUS ADENOMA

30. CLINICAL FEATURES
• This uncommon lesion usually appears in the elderly
as a solitary, yellow papule, with a predilection for
the eyelid and brow. It is associated with internal
malignancy, known as the Muir–Torre syndrome.
Patients with this syndrome also may develop
multiple keratoacanthomas.
• Microscopically, the sebaceous adenoma is a well-
circumscribed lesion with lobules containing an outer
layer of basal germinal cells that become lipidized
centrally.

31. TREATMENT
• Complete surgical excision, because incompletely
excised lesions commonly recur.

32. VASCULAR TUMORS

33. TYPES
• Capillary hemangioma
• Lymphangioma
• Pyogenic granuloma

34. CAPILLARY HEMANGIOMA

35. DEFINITION
The capillary hemangioma, also known as a benign
hemangioendothelioma, is the most common orbital
tumor found in children.

36. TYPES
A periorbital hemangioma may appear as:
• Superficial cutaneous lesion
• Subcutaneous lesion
• Deep orbital tumor
• Combination of these types.

37. CLINICAL FEATURES
• The classic superficial lesion, the strawberry
nevus, appears as a red, raised, nodular mass
that blanches with pressure. It may first be
seen as a flat lesion with telangiectatic surface
vessels.
• A subcutaneous lesion appears as a bluish
purple, spongy mass.
• Deep orbital lesions may cause proptosis and
globe displacement with no associated
cutaneous findings.

38. HISTOLOGY
• Microscopically, the early proliferative phase of the
lesion contains lobules of plump endothelial cells
separated by fibrous septa, with frequent mitotic
figures and small, irregular vascular lumina. Mature
lesions contain more prominent vascular structures
and flatter endothelial cells diminished in number.

39. COMPLICATIONS
• Amblyopia, which may result from occlusion of the
visual axis, or from anisometropia due to induced
astigmatism.
• Strabismus may occur secondary to the amblyopia or
be caused by orbital involvement with restriction of
ocular motility.

40. DIAGNOSIS
• Lesions that involve the eyelid and anterior orbit
usually can be diagnosed by clinical findings.
• Imaging: Ultrasonography, computed tomography,
and magnetic resonance imaging may aid in
diagnosis and in determining the extent of
involvement.

41. DIFFERENTIAL DIAGNOSIS
• Rhabdomyosarcoma
• Neuroblastoma
• Encephalocele
• Lymphangioma
• Inflammatory masses

42. • Because most capillary hemangioma undergo
spontaneous regression to some extent, treatment
generally is reserved for patients who have specific
ocular, dermatological, or systemic indications for
intervention.
• Ocular indications: amblyopia, compressive optic
neuropathy, and proptosis with globe exposure.
TREATMENT CONTINUE

43. TREATMENT CONTINUE
• Previous treatment modalities have included
intralesional corticosteroid injection, systemic
corticosteroids, radiotherapy, laser therapy, systemic
interferon, and surgery.
• More recently, however, systemic propranolol has
emerged as the treatment of choice as a relatively
safe and effective agent in inducing lesion regression.

44. • Surgery should be considered for localized,
noninfiltrative lesions, or for those that fail to
respond medically.
• Amblyopia should be treated with appropriate
patching and spectacle correction, as indicated.
TREATMENT

45. LYMPHANGIOMA

46. DEFINITION
Lymphangiomas may involve the eyelid, conjunctiva, or
orbit. Lesions often appear at birth or early in
childhood and only occasionally in adulthood.

47. CLINICAL FEATURES
• They often are poorly circumscribed, with an
infiltrative growth pattern. Eyelid involvement may
occur as a superficial lesion with multiple cyst like
excrescences or as a complex of channels that cause
lid thickening and distortion. Hemorrhage into the
lesion may occur to produce a hematoma when the
eyelid is involved or proptosis when orbital lesions
are present.

48. DIAGNOSIS
• Biopsy may be needed for definitive diagnosis.
• Microscopically, dilated, thin-walled vascular spaces
lined by endothelial cells are present.

49. TREATMENT
• Surgical excision is indicated for cosmesis or eyelid
malposition.
• Intralesional sclerosing agents, oral sildenafil, and
subtotal surgical resection has been recently
described as effective treatment modalities.

50. PYOGENIC GRANULOMA

51. Pyogenic granuloma is the most common acquired
vascular lesion to involve the eyelids.
DEFINITION

52. CAUSES
• It usually occurs after trauma or surgery

53. CLINICAL FEATURES
• It presents as a fast-growing, fleshy, red-to-pink
mass, which readily bleeds with minor contact.
Lesions also may develop in association with
inflammatory processes, including chalazia.
• Microscopically: there is granulation tissue consisting
of fibroblasts and blood vessels, with acute and
chronic nongranulomatous inflammatory cells.

54. DIFFERENTIAL DIAGNOSIS
• Kaposi’s sarcoma
• Intravascular papillary endothelial hyperplasia.

55. TREATMENT
• Surgical excision at the base of the lesion

56. TUMORS OF NEURAL ORIGIN

57. NEUROFIBROMA

58. • Neurofibromas most commonly are considered in
the context of neurofibromatosis, in which patients
often develop multiple cutaneous lesions in
association with other stigmata of the disease,
usually apparent by adolescence.
• The neurofibromas may occur on any cutaneous
surface, including the eyelid, and typically enlarge
slowly over many years.
INTRODUCTION

59. CLINICAL FEATURES
• They appear as soft, fleshy, often pedunculated
masses.
• Isolated cutaneous neurofibromas, often resembling
intradermal nevi, may occur in individuals with no
other associated abnormality.
• Plexiform neurofibroma, characteristic of type 1
neurofibromatosis, often occurs as a diffuse
infiltration of the eyelid and orbit. The upper eyelid is
usually ptotic, with an S-shaped curvature. On
palpation, the lesion feels like a “bag of worms.”

60. HISTOLOGY
• Histopathology reveals units of proliferating axons,
Schwann cells, and fibroblasts, with each unit
surrounded by a perineural sheath.

61. TREATMENT
• It depends on the site and extent of disease. Isolated
cutaneous lesions, unrelated to neurofibromatosis,
may be excised surgically. Surgical debulking may be
performed for plexiform neurofibromas that produce
mechanical ptosis or cosmetic deformity.

62. Fig. Neurofibroma. Note the fleshy mass on the Fig. Plexiform Neurofibroma
eyelid of this patient with disseminated cutaneous
neurofibromas.

63. MALIGNANT TUMORS

64. TYPES
• Basal cell carcinoma
• Sebaceous carcinoma
• Squamous cell carcinoma

65. BASAL CELL CARCINOMA

66. INTRODUCTION
Most common malignant eyelid tumor, usually on the
lower eyelid or medial canthus of middle-aged or
elderly patients. Rarely metastasizes but may be locally
invasive, particularly when it is present in the medial
canthal region.

67. TYPES
• Nodular: Indurated, firm mass, commonly with
telangiectases over the tumor margins. Sometimes
the center of the lesion is ulcerated. On rare
occasions, a cystic variant is seen.
• Morpheaform: Firm, flat, subcutaneous lesion with
indistinct borders. More difficult to excise and may
result in a large eyelid defect.

68. TREATMENT
• Surgical excision with histologic evaluation of the
tumor margins either by frozen sections or by Moh's
techniques.
• Cryotherapy and radiation are used rarely.
• Topical imiquimod, an immune modulator.
• Use of protective sunscreens.

69. SEBACEOUS CARCINOMA

70. INTRODUCTION
• More common in middle-aged or elderly patients,
usually elderly women. Most common on the upper
eyelid but may be multifocal, involving both the
upper and the lower eyelids. Often confused with
recurrent chalazia or intractable blepharitis. Loss of
eyelashes and destruction of the meibomian gland
orifices in the region of the tumor may occur.
Regional and systemic metastasis or orbital extension
is possible. Can occur many decades after prior
radiation exposure to the eyelids.

71. The approach is two-staged:
• Stage 1 using map biopsies on the entire surface of
the eye to ascertain the extent of Pagetoid spread or
deep tumor.
• Stage 2 is performed after all biopsies are reviewed
TREATMENT CONTINUE

72. TREATMENT
• Pagetoid spread is treated with cryotherapy.
• Deep tumor requires excision.
• Exenteration is often required when orbital invasion
is present.
• Referral to an oncologist or internist for systemic
work-up and surveillance is important with attention
to the lymph nodes, lungs, brain, liver, and bone.

73. SQUAMOUS CELL CARCINOMA

74. INTRODUCTION
• Variable presentation, often appearing similar to a basal cell
carcinoma. Regional metastasis may occur and can be
extensive with a propensity for perineural invasion. A
premalignant lesion, actinic keratosis, may appear either as a
scaly, erythematous flat lesion or as a cutaneous horn.

75. WORK-UP CONTINUE
• History: Duration? Rapid or slow growth? Previous
malignant skin lesion or other malignancies? Previous
treatment of inflammatory or allergic condition?
Previous radiation therapy? Associated pain?
• External examination: Check the skin for additional
lesions, palpate the preauricular, submaxillary and
cervical nodes to evaluate for metastasis.

76. WORK UP
• Slit lamp examination: Look for telangiectases on
nodular tumors, loss of eyelashes in the region of
the tumor, meibomian orifice destruction. Evert
eyelids of all patients with eyelid complaints.
• Photograph or draw the lesion and its location for
documentation.
• Biopsy of the lesion.
– Incisional biopsy.
– Sentinel node biopsy

77. • Same as for basal cell carcinoma.
• Radiation therapy is the second best treatment after
surgical excision.
• Topical imiquimod and topical or injectable
interferon.
• Referral to an oncologist or internist for regional
and/or systemic work-up and surveillance is
important
TREATMENT