Sebaceous carcinoma of the eyelid diagnosed on fine needle aspiration cytology.

Sebaceous carcinoma of the ocular adnexa is a malignant neoplasm which has aggressive local behavior and can metastasize to regional lymph nodes and distant organs. It is a malignant neoplasm known to masquerade as other benign and less malignant lesions, resulting in delay in diagnosis and relatively high morbidity and mortality. Aspiration cytological features of this neoplasm have not been well characterized in the literature. We report a case of this tumor diagnosed on fine needle aspiration. Clinically, a diagnosis of chalazion was made and fine needle aspiration cytology (FNAC) was performed. Cytological diagnosis of a malignant tumor with closest resemblance to sebaceous carcinoma was suggested which was confirmed on histopathology. Eyelid reconstruction was done after histopathological confirmation of tumor-free margins. The article highlights the role of FNAC in early diagnosis and subsequent appropriate surgical management of eyelid sebaceous gland carcinoma to prevent recurrence and metastasis.

Introduction

Sebaceous carcinoma of the eyelid may arise from the diverse sebaceous glands of the ocular adnexa.[1] The tumor can arise from the meibomian glands in the tarsus, zeis glands at the eyelid margin or sebaceous glands in the caruncle or eyebrow.[2] It simulates a number of pathological conditions affecting the lids. Among these papillomas, keratoacanthoma, chalazion, seborrheic keratosis, benign calcifying epithelioma, and inverted follicular keratotis need to be differentiated.[3] Owing to its rarity and ability to masquerade as other periocular lesions; diagnosis of the disease might be difficult. Prognosis is still regarded as being poor compared to most other malignant eyelid tumors, with a mortality second only to malignant melanoma.[1] In this article, we highlight the role of fine needle aspiration cytology (FNAC) in early diagnosis and appropriate surgical management of sebaceous gland carcinoma.

Case Report

We report a case of a 68-year-old female who presented with loss of eyelashes and nodule over right lower eyelid for last 2 years. On local examination, the nodule was 1.5 × 1 cm in size, firm in consistency, nontender and nonmobile. Overlying skin was intact [Figure 1]. Vision was 6/18 in that eye. There was no lymphadenopathy. General physical examination, systemic examination and other laboratory investigations did not reveal any abnormality. Clinically, a diagnosis of chalazion was made and FNAC was advised.

Figure 1

Photograph showing a nodular swelling over right lower eyelid

FNA performed using 22-gauge needle yielded blood mixed aspirate. The smears were cellular with cells arranged in loose groups, clusters as well as dispersed singly in a background of red blood cells. The cells were pleomorphic with moderate to scanty amount of clear vacuolated cytoplasm, round to oval large hyperchromatic nuclei and conspicuous nucleoli. Mitotic figures were also seen [Figure 2]. Cytological diagnosis of a malignant tumor with closest resemblance to sebaceous carcinoma was given which was confirmed on histopathology. Eyelid reconstruction was done after histopathological confirmation of tumor-free margins.

Figure 2

(a) Photomicrograph showing cellular smear with tumor cells arranged in groups as well as singly scattered (MGG, ×100); (b) pleomorphic tumor cells with vacuolated cytoplasm (MGG, ×400)

Discussion

Sebaceous carcinoma is a very rare malignant tumor primarily found in the area of the eyelid.[4] It accounts for 1–5.5% of all eyelid malignancies. It occurs more commonly in women, in the elderly and has a predilection for the upper lid. Its occurrence in the western literature is reported to be less than 1% of all eyelid tumors and accounts for 1–5% of all malignant eyelid tumors. Recent studies from India and China have shown that sebaceous carcinoma accounts for 33–60% of malignant eyelid tumors.[1] The periorbital primaries are reported to behave aggressively with the tendency to metastasize early with a significant mortality in most series. In many cases, correct diagnosis of a sebaceous carcinoma of the eyelid is delayed not only as a result of the rarity of this tumor but also because of its ability to masquerade as a variety of other eye conditions such as chalazion or chronic blepharoconjunctivitis.[4]

Historically, biopsy has been reported as the preferred mode for establishing correct diagnosis of such lid nodules. FNAC has been employed only rarely in the diagnosis of periocular sebaceous carcinoma. However, now FNAC can be helpful in making the correct diagnosis by a careful study of the smear. Early diagnosis of this growth by FNAC increases the cure and survival rate.[1]

Cytologically, the differential diagnosis includes blepharitis, chalazion, pilomatricoma, squamous cell carcinoma and basal cell carcinoma. The fatty contents liberated from sebaceous glands due to ductal obstruction evoke a granulomatous response accompanied by neutrophils, plasma cells, lymphocytes, occasional multinucleated giant cells, suggesting the diagnosis of chalazion, and the presence of non-granulomatous inflammation, often containing neutrophils, suggest the possibility of blepharoconjunctivitis.[5] Cytologically, pilomatrixoma shows bland sheets of basaloid cells, nucleated basophilic cells and “ghost” cells. Basal cell carcinoma shows less cellular smears and tightly cohesive small clusters of monomorphic basaloid cells without vacuolation.[6] The cytoplasm of the cells conveys useful information for cytological interpretation. In squamous cells, the cytoplasm undergoes keratinization as the cells mature, and cytoplasmic vacuolization suggests sebaceous carcinoma.[1]

Hence, a painless growth in the lid in an aged person, persisting in spite of medication and operations should be viewed with suspicion. The preoperative diagnosis of sebaceous carcinoma by simple FNAC in the outpatient department itself avoids one additional surgical procedure, i.e. tissue biopsy. It is also time-saving for the surgeon and cost-effective to the patient.