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Slow-growing lesion on eyebrow
A 51-year-old woman presented to the family medicine clinic for evaluation of a slightly tender skin lesion on her left eyebrow. The lesion had been slowly growing for a year.
The patient’s family history included multiple family members with colon or breast cancer and other relatives with pancreatic and prostate cancer. A colonoscopy performed a year earlier on the patient was negative. The patient’s past medical history included hypertension, major depressive disorder, hyperlipidemia, and venous insufficiency. She also had a colon polyp history.
Physical examination of the eyebrow showed a 3-mm papule that was firm on palpation. Dermoscopy of the lesion revealed a yellow papule with
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Sebaceous carcinoma
A rapid teledermatology consultation helped us to determine that this was a sebaceous lesion, but its location and the overlying telangiectasia raised concerns for malignancy. After shared decision-making with the patient, she agreed to proceed with a biopsy. We first made an incision into the lesion, which was hard, demonstrating that it was not cystic. A shave biopsy was then completed. The dermatopathology findings showed clear-cell change consisting of bubbly or foamy cytoplasm, with scalloping of the nuclei, which is characteristic of a sebaceous origin. There were tumor cells that were enlarged with pleomorphism, multiple nucleoli, and scattered mitotic figures. These findings pointed to a diagnosis of sebaceous carcinoma.
Sebaceous carcinomas most commonly manifest on the eyelids. They can originate from the Meibomian glands as well as from pilosebaceous glands at other sites on the body.1 They are rare, accounting for only 1% to 5% of eyelid malignancies, and occur in approximately 2 per 1 million people.1 Tumors can invade locally and metastasize, particularly to surrounding lymph nodes. Periocular pathology may sometimes lead to misdiagnosis, which contributes to a mortality rate that has been reported as high as 20%.1 Suspicion for malignancy may arise due to ulceration, bleeding, pain, or rapid growth.
A lesson in considering the full differential
While sebaceous lesions on the eyelid and eyebrow are often benign, this case underscored the importance of considering the more worrisome elements in the differential. The differential diagnosis for lesions in the area of the eye include the following:
Sebaceous hyperplasia is a common condition (typically among older patients) in which sebaceous glands increase in size and number.2 The classic clinical feature is yellow or skin-colored papules. The lesions typically manifest on the face—particularly on the forehead. They are benign and often have a central umbilication.2
Sebaceous adenomas are benign tumors that may manifest as tan, skin-colored, pink, or yellow papules or nodules.2 The lesions are usually asymptomatic, small, and slow growing.2
Continue to: Basal and squamous cell carcinomas
Basal and squamous cell carcinomas. Basal cell carcinomas often feature translucent lesions on areas of the skin that are exposed to sunlight. These lesions often have slightly rolled border edges or overlying branching telangiectasia and may be nodular.3 Squamous cell carcinomas often feature scaled, reddened patches that may become tender and ulcerate.4
Hordeolums and chalazions. A hordeolum (or stye) is a painful, acute, localized swelling of the eyelid.5 These often develop externally at the lid margin from infection of the follicle. A chalazion is characterized by a persistent, nontender mass that results from small, noninfectious obstruction of the Meibomian glands with secondary granulomatous inflammation.5
Dermoscopy can (and did) help with the Dx
Dermoscopy can help confirm whether a lesion has a sebaceous origin because it would show yellow globules with “crown vessel” telangiectasias that classically do not cross midline.6 Unfortunately, the findings of yellow globules and dermal vessels do not adequately differentiate benign from malignant lesions.6 Carcinomas can manifest in an undifferentiated way early in their course.
Sebaceous carcinomas can be associated with the autosomal dominant Muir-Torre syndrome, a subset of the Lynch syndrome.7,8 Colorectal and genitourinary carcinomas are the most common internal malignancies seen in patients with Muir-Torre syndrome.9
Patients benefit from Mohs surgery
Treatment outcomes for sebaceous carcinoma appear to be improved by Mohs surgery. In a recent review of 1265 patients with early-stage sebaceous carcinomas, Su et al found that 234 patients who were treated with Mohs surgery had improved overall survival, compared with 1031 who were treated with surgical excision.10
Continue to: Our patient
Our patient was referred to a Mohs surgeon who removed the lesion (FIGURES 2 and 3). Given the overall small tumor size, a sentinel lymph node biopsy was not necessary. Because of the patient’s family history, which was suggestive of a genetic predisposition to cancer, she requested a clinical genetics consultation for definitive testing. She went on to pursue genetic testing, which came back negative for Lynch syndrome genes.
The dermatologist recommended yearly skin examination for 5 years for the patient.
1. Kahana A, Pribila HT, Nelson CC, et al. Sebaceous cell carcinoma. In: Levin LA, Albert DM, eds. Ocular Disease: Mechanisms and Management. Saunders/Elsevier; 2010:396-407.
2. Iacobelli J, Harvey NT, Wood BA. Sebaceous lesions of the skin. Pathology. 2017;49:688-697.
3. Marzuka AG, Book SE. Basal cell carcinoma: pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med. 2015;88:167-179.
4. Smith H, Patel A. When to suspect a non-melanoma skin cancer. BMJ. 2020;368:m692.
5. Sun MT, Huang S, Huilgol SC, et al. Eyelid lesions in general practice. Aust J Gen Pract. 2019;48:509-514.
6. Kim NH, Zell DS, Kolm I, et al. The dermoscopic differential diagnosis of yellow lobularlike structures. Arch Dermatol. 2008;144:962.
7. EG, Bell AJY, Barlow KA. Multiple primary carcinomata of the colon, duodenum, and larynx associated with kerato-acanthomata of the face. Br J Surg. 1967;54:191-195.
8. Torre D. Multiple sebaceous tumors. Arch Dermatol. 1968;98:549-55.
9. Cohen PR, Kohn SR, Kurzrock R. Association of sebaceous gland tumors and internal malignancy: the Muir-Torre syndrome. Am J Med. 1991;90:606-613.
10. Su C, Nguyen KA, Bai HX, et al. Comparison of Mohs surgery and surgical excision in the treatment of localized sebaceous carcinoma. Dermatol Surg. 2019;45:1125-1135.
A 51-year-old woman presented to the family medicine clinic for evaluation of a slightly tender skin lesion on her left eyebrow. The lesion had been slowly growing for a year.
The patient’s family history included multiple family members with colon or breast cancer and other relatives with pancreatic and prostate cancer. A colonoscopy performed a year earlier on the patient was negative. The patient’s past medical history included hypertension, major depressive disorder, hyperlipidemia, and venous insufficiency. She also had a colon polyp history.
Physical examination of the eyebrow showed a 3-mm papule that was firm on palpation. Dermoscopy of the lesion revealed a yellow papule with
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Sebaceous carcinoma
A rapid teledermatology consultation helped us to determine that this was a sebaceous lesion, but its location and the overlying telangiectasia raised concerns for malignancy. After shared decision-making with the patient, she agreed to proceed with a biopsy. We first made an incision into the lesion, which was hard, demonstrating that it was not cystic. A shave biopsy was then completed. The dermatopathology findings showed clear-cell change consisting of bubbly or foamy cytoplasm, with scalloping of the nuclei, which is characteristic of a sebaceous origin. There were tumor cells that were enlarged with pleomorphism, multiple nucleoli, and scattered mitotic figures. These findings pointed to a diagnosis of sebaceous carcinoma.
Sebaceous carcinomas most commonly manifest on the eyelids. They can originate from the Meibomian glands as well as from pilosebaceous glands at other sites on the body.1 They are rare, accounting for only 1% to 5% of eyelid malignancies, and occur in approximately 2 per 1 million people.1 Tumors can invade locally and metastasize, particularly to surrounding lymph nodes. Periocular pathology may sometimes lead to misdiagnosis, which contributes to a mortality rate that has been reported as high as 20%.1 Suspicion for malignancy may arise due to ulceration, bleeding, pain, or rapid growth.
A lesson in considering the full differential
While sebaceous lesions on the eyelid and eyebrow are often benign, this case underscored the importance of considering the more worrisome elements in the differential. The differential diagnosis for lesions in the area of the eye include the following:
Sebaceous hyperplasia is a common condition (typically among older patients) in which sebaceous glands increase in size and number.2 The classic clinical feature is yellow or skin-colored papules. The lesions typically manifest on the face—particularly on the forehead. They are benign and often have a central umbilication.2
Sebaceous adenomas are benign tumors that may manifest as tan, skin-colored, pink, or yellow papules or nodules.2 The lesions are usually asymptomatic, small, and slow growing.2
Continue to: Basal and squamous cell carcinomas
Basal and squamous cell carcinomas. Basal cell carcinomas often feature translucent lesions on areas of the skin that are exposed to sunlight. These lesions often have slightly rolled border edges or overlying branching telangiectasia and may be nodular.3 Squamous cell carcinomas often feature scaled, reddened patches that may become tender and ulcerate.4
Hordeolums and chalazions. A hordeolum (or stye) is a painful, acute, localized swelling of the eyelid.5 These often develop externally at the lid margin from infection of the follicle. A chalazion is characterized by a persistent, nontender mass that results from small, noninfectious obstruction of the Meibomian glands with secondary granulomatous inflammation.5
Dermoscopy can (and did) help with the Dx
Dermoscopy can help confirm whether a lesion has a sebaceous origin because it would show yellow globules with “crown vessel” telangiectasias that classically do not cross midline.6 Unfortunately, the findings of yellow globules and dermal vessels do not adequately differentiate benign from malignant lesions.6 Carcinomas can manifest in an undifferentiated way early in their course.
Sebaceous carcinomas can be associated with the autosomal dominant Muir-Torre syndrome, a subset of the Lynch syndrome.7,8 Colorectal and genitourinary carcinomas are the most common internal malignancies seen in patients with Muir-Torre syndrome.9
Patients benefit from Mohs surgery
Treatment outcomes for sebaceous carcinoma appear to be improved by Mohs surgery. In a recent review of 1265 patients with early-stage sebaceous carcinomas, Su et al found that 234 patients who were treated with Mohs surgery had improved overall survival, compared with 1031 who were treated with surgical excision.10
Continue to: Our patient
Our patient was referred to a Mohs surgeon who removed the lesion (FIGURES 2 and 3). Given the overall small tumor size, a sentinel lymph node biopsy was not necessary. Because of the patient’s family history, which was suggestive of a genetic predisposition to cancer, she requested a clinical genetics consultation for definitive testing. She went on to pursue genetic testing, which came back negative for Lynch syndrome genes.
The dermatologist recommended yearly skin examination for 5 years for the patient.
A 51-year-old woman presented to the family medicine clinic for evaluation of a slightly tender skin lesion on her left eyebrow. The lesion had been slowly growing for a year.
The patient’s family history included multiple family members with colon or breast cancer and other relatives with pancreatic and prostate cancer. A colonoscopy performed a year earlier on the patient was negative. The patient’s past medical history included hypertension, major depressive disorder, hyperlipidemia, and venous insufficiency. She also had a colon polyp history.
Physical examination of the eyebrow showed a 3-mm papule that was firm on palpation. Dermoscopy of the lesion revealed a yellow papule with
WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Sebaceous carcinoma
A rapid teledermatology consultation helped us to determine that this was a sebaceous lesion, but its location and the overlying telangiectasia raised concerns for malignancy. After shared decision-making with the patient, she agreed to proceed with a biopsy. We first made an incision into the lesion, which was hard, demonstrating that it was not cystic. A shave biopsy was then completed. The dermatopathology findings showed clear-cell change consisting of bubbly or foamy cytoplasm, with scalloping of the nuclei, which is characteristic of a sebaceous origin. There were tumor cells that were enlarged with pleomorphism, multiple nucleoli, and scattered mitotic figures. These findings pointed to a diagnosis of sebaceous carcinoma.
Sebaceous carcinomas most commonly manifest on the eyelids. They can originate from the Meibomian glands as well as from pilosebaceous glands at other sites on the body.1 They are rare, accounting for only 1% to 5% of eyelid malignancies, and occur in approximately 2 per 1 million people.1 Tumors can invade locally and metastasize, particularly to surrounding lymph nodes. Periocular pathology may sometimes lead to misdiagnosis, which contributes to a mortality rate that has been reported as high as 20%.1 Suspicion for malignancy may arise due to ulceration, bleeding, pain, or rapid growth.
A lesson in considering the full differential
While sebaceous lesions on the eyelid and eyebrow are often benign, this case underscored the importance of considering the more worrisome elements in the differential. The differential diagnosis for lesions in the area of the eye include the following:
Sebaceous hyperplasia is a common condition (typically among older patients) in which sebaceous glands increase in size and number.2 The classic clinical feature is yellow or skin-colored papules. The lesions typically manifest on the face—particularly on the forehead. They are benign and often have a central umbilication.2
Sebaceous adenomas are benign tumors that may manifest as tan, skin-colored, pink, or yellow papules or nodules.2 The lesions are usually asymptomatic, small, and slow growing.2
Continue to: Basal and squamous cell carcinomas
Basal and squamous cell carcinomas. Basal cell carcinomas often feature translucent lesions on areas of the skin that are exposed to sunlight. These lesions often have slightly rolled border edges or overlying branching telangiectasia and may be nodular.3 Squamous cell carcinomas often feature scaled, reddened patches that may become tender and ulcerate.4
Hordeolums and chalazions. A hordeolum (or stye) is a painful, acute, localized swelling of the eyelid.5 These often develop externally at the lid margin from infection of the follicle. A chalazion is characterized by a persistent, nontender mass that results from small, noninfectious obstruction of the Meibomian glands with secondary granulomatous inflammation.5
Dermoscopy can (and did) help with the Dx
Dermoscopy can help confirm whether a lesion has a sebaceous origin because it would show yellow globules with “crown vessel” telangiectasias that classically do not cross midline.6 Unfortunately, the findings of yellow globules and dermal vessels do not adequately differentiate benign from malignant lesions.6 Carcinomas can manifest in an undifferentiated way early in their course.
Sebaceous carcinomas can be associated with the autosomal dominant Muir-Torre syndrome, a subset of the Lynch syndrome.7,8 Colorectal and genitourinary carcinomas are the most common internal malignancies seen in patients with Muir-Torre syndrome.9
Patients benefit from Mohs surgery
Treatment outcomes for sebaceous carcinoma appear to be improved by Mohs surgery. In a recent review of 1265 patients with early-stage sebaceous carcinomas, Su et al found that 234 patients who were treated with Mohs surgery had improved overall survival, compared with 1031 who were treated with surgical excision.10
Continue to: Our patient
Our patient was referred to a Mohs surgeon who removed the lesion (FIGURES 2 and 3). Given the overall small tumor size, a sentinel lymph node biopsy was not necessary. Because of the patient’s family history, which was suggestive of a genetic predisposition to cancer, she requested a clinical genetics consultation for definitive testing. She went on to pursue genetic testing, which came back negative for Lynch syndrome genes.
The dermatologist recommended yearly skin examination for 5 years for the patient.
1. Kahana A, Pribila HT, Nelson CC, et al. Sebaceous cell carcinoma. In: Levin LA, Albert DM, eds. Ocular Disease: Mechanisms and Management. Saunders/Elsevier; 2010:396-407.
2. Iacobelli J, Harvey NT, Wood BA. Sebaceous lesions of the skin. Pathology. 2017;49:688-697.
3. Marzuka AG, Book SE. Basal cell carcinoma: pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med. 2015;88:167-179.
4. Smith H, Patel A. When to suspect a non-melanoma skin cancer. BMJ. 2020;368:m692.
5. Sun MT, Huang S, Huilgol SC, et al. Eyelid lesions in general practice. Aust J Gen Pract. 2019;48:509-514.
6. Kim NH, Zell DS, Kolm I, et al. The dermoscopic differential diagnosis of yellow lobularlike structures. Arch Dermatol. 2008;144:962.
7. EG, Bell AJY, Barlow KA. Multiple primary carcinomata of the colon, duodenum, and larynx associated with kerato-acanthomata of the face. Br J Surg. 1967;54:191-195.
8. Torre D. Multiple sebaceous tumors. Arch Dermatol. 1968;98:549-55.
9. Cohen PR, Kohn SR, Kurzrock R. Association of sebaceous gland tumors and internal malignancy: the Muir-Torre syndrome. Am J Med. 1991;90:606-613.
10. Su C, Nguyen KA, Bai HX, et al. Comparison of Mohs surgery and surgical excision in the treatment of localized sebaceous carcinoma. Dermatol Surg. 2019;45:1125-1135.
1. Kahana A, Pribila HT, Nelson CC, et al. Sebaceous cell carcinoma. In: Levin LA, Albert DM, eds. Ocular Disease: Mechanisms and Management. Saunders/Elsevier; 2010:396-407.
2. Iacobelli J, Harvey NT, Wood BA. Sebaceous lesions of the skin. Pathology. 2017;49:688-697.
3. Marzuka AG, Book SE. Basal cell carcinoma: pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med. 2015;88:167-179.
4. Smith H, Patel A. When to suspect a non-melanoma skin cancer. BMJ. 2020;368:m692.
5. Sun MT, Huang S, Huilgol SC, et al. Eyelid lesions in general practice. Aust J Gen Pract. 2019;48:509-514.
6. Kim NH, Zell DS, Kolm I, et al. The dermoscopic differential diagnosis of yellow lobularlike structures. Arch Dermatol. 2008;144:962.
7. EG, Bell AJY, Barlow KA. Multiple primary carcinomata of the colon, duodenum, and larynx associated with kerato-acanthomata of the face. Br J Surg. 1967;54:191-195.
8. Torre D. Multiple sebaceous tumors. Arch Dermatol. 1968;98:549-55.
9. Cohen PR, Kohn SR, Kurzrock R. Association of sebaceous gland tumors and internal malignancy: the Muir-Torre syndrome. Am J Med. 1991;90:606-613.
10. Su C, Nguyen KA, Bai HX, et al. Comparison of Mohs surgery and surgical excision in the treatment of localized sebaceous carcinoma. Dermatol Surg. 2019;45:1125-1135.
