Clinical presentation of SCC, BCC and SGC.

1. Squamous cell carcinoma,
basal cell carcinoma &
sebaceous gland carcinoma
Epidemiology, classification & histology
Noor Aniah Azmi
MBBCh (Cairo University, Egypt)

2. Objectives of this presentation
① To understand the difference between SCC, BCC and
SGC
a. Better diagnosis
b. Better management
② To understand which is the local and metastasizing
tumour
③ Be able to identify the histological slides
a. OSCE exam for part I

3. Normal Layers of the Skin

4. Normal Histology of the Eyelid

5. Basal Cell Carcinoma
Squamous Cell
Carcinoma
Sebaceous Gland
Carcinoma

6. Basal Cell Carcinoma
Most common eyelid tumor

7.  90% of all
eyelid tumour
 Arises from
 Stratum basale
 Outer root sheath of the hair follicle
 Only in hair-bearing tissue
 Commonly at lower eyelid

8.  Slowly-growing tumour, locally invasive
 Non-metastasizing
 Can recur if incompletely treated – more difficult to treat

10. Common sites
(1) Inferior 50-60%
(2) Medial 25-30%
- Most dangerous
- Spread via lacrimal
system and spread
(4) Lateral 5%
(3) Superior 15%

11. Risk Factors
 Prolonged exposure to sunlight
 Fair-skinned
 Blue-eyed, red-haired
 English, Irish or Scottish ancestry
 Male, > 50 years old
 History of cigarette-smoking
 Prior basal cell carcinomas
 Family history of skin cancer

12. Young patients or positive family history –
look for possible system associations
Basal Cell Nevus syndrome
(Gorlin’s syndrome)
- Multiple nevoid
- Skeletal anomaly
Xeroderma pigmentosa
- Excessive sensitivity to sun
- Defect in repair mechanism for
UV-induced DNA damaged-cells

13. Clinical Types
1. Nodular BCC
2. Noduloulcerative BCC (Rodent Ulcer)
3. Sclerosing BCC (morphoeic)

14. 1. Nodular BCC
• Slowly-growing
• 1-2 years to reach 0.5 mm
diameter
• Shiny and firm
• Pearly nodule
• With dilated surface vessels

15. 2. Rodent Ulcer
• Central ulceration
• Pearly raised rolled edges
• Dilated vessels over its margins
• Telangectasis

16. 3. Sclerosing BCC
• Less common and difficult to
diagnose – beneath the epidermis
• Indurated plaque
• Loss of lashes
 Mistaken diagnosis: Chronic
blepharitis

17. Histological Features
epithelial proliferation arising from the basal layer of the epidermis
Normal dermis Desmoplastic stroma – pale-pink
stroma supporting neoplastic cells

18. Histological Features
Peripheral
palisades
Mitotic
figures

19. Histological Features
Higher magnification
Atypical cells
- High nuclear-cytoplasmic
ratio
- Hyperchromatic nuclei
- Pleomorphic

20. Histological Features
Sclerosing BCC
Thin cords
radiate
peripherally

21. Basal Cell Carcinoma
Squamous Cell
Carcinoma
Sebaceous Gland
Carcinoma

22. Squamous Cell Carcinoma

23.  40 times less than BCC
 Arises from the squamous layer
 May arise
 De novo
 From pre-existing actinic keratosis
 From carcinoma in-situ
SPREAD
 Regional LN 20% of cases
 Lymphatics and perineural invasion

25. Common sites
(1) Lower eyelid 49%
(2) Medial canthus 36%
(3) Upper eyelid 23%

26. Risk Factors
 Elderly
 Fair skin
 History of chronic sun exposure
 Immunocompromised
 AIDS
 Renal transplant

27. Clinical Types
1. Nodular SCC
2. Ulcerating SCC
3. Cutaneous horn

28. 1. Nodular SCC
• Hyperkeratotic nodule
• Crusting erosions and fissures

29. 2. Ulcerating SCC
• Red base
• Sharply defined
• Indurated and everted borders

30. Ulcerating SCC vs Rodent Ulcer
Ulcerating SCC
- Everted borders
- Pearly margin
- No telangectasia
Rodent Ulcer
- Pearly margins with rolled edges
- Telangectasia present

31. 3. Cutaneous Horn
• With underlying invasive SCC

32. Histological Features
Ulcerated region
overlying
Infilrates the
dermis deeply

33. Histological Features
Keratin
pearls
Mitotic
figures
Pseudosarcomatous change

34. Basal Cell Carcinoma
Squamous Cell
Carcinoma
Sebaceous Gland
Carcinoma

35. Sebaceous Gland Carcinoma

37.  Highly-malignant
 Arises from
 Meibomian glands
 Glands of Zeis
 Sebaceous gland of the caruncle, eyebrow or face
 Commonly at upper eyelid
 Multifocal origin, spread superficially

38. Epidemiology
 Females, > 50 years old
 Most common eyelid tumour after BCC
 1.5-5% of all eyelid tumour
Adverse Prognostic Factor
 Upperlid involvement
 Tumour size > 10mm
 Duration of symptoms > 6 months
 Mortality rate 22%

39. Spread
 Via lymph node
 Perineural to intracranial via orbit

40. Clinical Types
1. Nodular SGC
2. Spreading SGC
3. Pagetoid SGC

41. 1. Nodular SGC
• Discrete hard nodule
• Yellowish discolouration – lipid
• Commonly at upper tarsal plate
 Mistaken diagnosis: chalazion

42. How to differentiate between
nodular SGC and chalazion?
Nodular SGC Chalazion
Nodule at tarsal plate
Maybe tender if inflammed

43. 2. Spreading SGC
• Diffuse thickening of lid margin
• Infiltrates into dermis
• Loss of lashes
• Multifocal non-contiguous origin
 Mistaken diagnosis: chronic
blepharitis

44. How to differentiate between SGC
and chronic blepharitis?
Spreading SGC Chronic Blepharitis

45. 3. Pagetoid Spread
• Extension of tumour within
epithelium
• Including palpebral, forniceal and
bulbar conjunctiva
 Mistaken diagnosis: inflammatory
condition

46. Normal Histology

47. Histological Features
Large tumour nodules in the dermis,
Irregular lobular mass of cells resembling
adenoma but more aggressive
Central necrosis

48. Histological Features
Hyperchromatic atypical nuclei Scanty cytoplasm

49. Histological Features
Pagetoid Spread
Spread through epidermis
Dermis layer

50. Histological Features
Oil red-O fat stain
Cytoplasm of abnormal cells

51. Please remember…
 Any chronic unilateral blepharitis should raise the
possibility of sebaceous gland carcinoma.
 Any case of recurrent chalazion, think of malignancy!

52. In summary

53. SCC BCC SGC
Epidemiology 5-10% of eyelid
malignancy
90% of eyelid
tumour
1.5 – 5% of eyelid
tumour
Origin Epidermis,
extending beyond
stratum basale
Stratum basale of
epidermis
Meibomian gland,
sebaceous gland
Common sites Lower eyelid Lower eyelid Upper eyelid
Behaviour Very aggressive Not very
aggressive
Highly-malignant
Spread Lymphatic
transmission,
perineural spread
Locally invasive,
does not spread
Via lymph node
Clinical types Nodular, ulcerating,
cutaneous
Nodular,
noduloulcerative,
sclerosing
Nodular, spreading,
pagetoid
Pathognomonic
histological feature
Keratin pearls Palisading
peripheral cells
Foamy cytoplasm

54. Let’s try to identify the slides

57. Choose one answer
Squamous cell carcinoma in situ is defined as a
pathologic anatomic limitation by which one of the
following:
a) Superficial epithelium
b) Stromal keratocytes
c) Basal epithelium
d) Basement membrane

58. Choose one answer
Appropriate management of multiple or recurrent chalazia
includes:
a) Needle biopsy
b) Local antibiotics
c) Full-thickness biopsy
d) Shave biopsy

59. Reference
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992157/
 Jack J Kanski, Clinical Ophthalmology 6th Edition
 Jack J Kanski, Clinical Ophthalmology Systemic Approach
7th Edition
 Myron Yanoff, Ocular Pathology 6th Edition
 AAO, Ophthalmic Pathology and Intraocular Tumours
 AAO, Orbit, Eyelid and Lacrimal System