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Stoplights in lid malignancy

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✅ Basal cell carcinoma

✅ Squamous cell carcinoma

✅ Sebaceous gland carcinoma

✅ Malignant melanoma

✅ Kaposi's sarcoma

✅ Merkel cell carcinoma

🇪🇬🇪🇬🇪🇬🇪🇬🇪🇬🇪🇬🇪🇬🇪🇬

✅ Basal cell carcinoma

✍️ Most common 90%

✍️ Locally invasive ( rarely metastatic)

✍️ Nodular ( with smooth rounded pearly edges with surface telangectasia and necrosis)

✍️ sclerotic type ( resembling chronic marginal blepharitis )

✍️ Common sites in sequence

• Lower Lid
• Inner canthus
• Upper lid
• lateral canthus

✍️ Risk factors
• basal cell naveus syndrome
• Xeroderma pigmentosa
• old age
• white skin
• sun exposure

✍️ Histology
• nests of basaloid tumour cells
• hyperchromatic nuclei
• sparse cytoplasm
• peripheral palisading of nuclei
• cleft artefacts, and variable inflammation and necrosis

✍️ TTT
• wide local excision with safety margins 2 -4 mm by Mohs technique or frozen sections

• A 2–4mm margin is recommended.

• Lesions incompletely excised at the deep margins are at greatest risk of recurrence.

• Recurrent tumours are more difficult to treat.

• When non-surgical treatments are used, diagnosis should be confirmed by incisional biopsy.

• Cryotherapy

👌 double or triple freeze-thaw technique (–50 to –60ฐ C for 30s ื3)
👌 useful for low-risk BCCs (small nodular BCCs or multiple lesions).

• topical imiquimod 5% cream

👌 an immune response modifier that stimulates apoptosis
👌 indicated for small superficial BCC.
👌 Applied 5 ื weekly for 6–12wk
👌 82–90% response rate with estimated 2y recurrence of 20.6%

• Photodynamic therapy (PDT)
👌 for super cial BCC, average clearance 85%.

• Vismodegib

👌 approved in the USA, Jan 2012
👌 for recurrent or metastatic BCC not amenable to surgery or irradiation.

✅ Squamous cell carcinomas

✍️ Less common 5%

✍️ Highly malignant with metastatic risk

• perineural
• lymphatic spread

✍️ Nodular resembling BCC with leukoplakia

✍️ sclerotic forms ( chronic blepharitis)

✍️ Common sites (Lower Lid )

✍️ Histology

• Epidermal cell proliferation
• Dermis invasion by atypical keratinocytes and epithelial or keratinous pearls or squamous eddies.

✍️ Risk factors

• xeroderma pigmentosa
• cutaneous horn
• OSSN
• old age
• white skin
• sun exposure

✍️ TTT

• Wide local excision with Mohs technique or frozen sections with wide safety margins

• Exenteration( orbital involvement)

• Chemotherapy in metastasis

• SCC in situ may be treated

👌surgically
👌 cryotherapy
👌 imiquimod cream
👌 5- fluorouracil (5-FU)
👌 mitomycin
👌 PDT

✅ Sebaceous glands carcinoma

✍️ From meibomian gland or ziess gland

✍️ Very rare 2%

✍️ Highly fatal 10% , with metastatic 67% fatal

✍️ Common sites UL

✍️ Risk factors

• old age
• female

✍️ May occur as part of the Muir–torre (sebaceous neoplasia-visceral carcinoma) syndrome

✍️ Nodular resembling recurring chalazion

✍️ sclerotic resembling chronic blepharoconjunctivitis

✍️ Pagetoid spread (skip lesions) so mapping biopsy required

✍️ Histology

• cytoplasmic lipid vacuolization

✍️ TTT

• wide local excision with regional lymphadenectomy

• Exenteration ( orbit involved)

🛑😢I have seen it once in my practical life 3 months ago ( am the one to diagnose and excise with lid reconstruction by tenzel flap , mapping conjunctival biopsy) and I sent him for further systemic assessment and management and F/up)

✅ Malignant melanoma

✍️ Very rare 1%

✍️ Highly fatal 50% if >1.5 mm thick in 5 yrs

✍️ Risk factors

• dysplastic naveus syndrome
• xeroderma pigmentosa
• old white skin
• chronic sun exposure

✍️ ABCD rule:
• Asymmetry
• Border irregularities
• Colour heterogeneity
• Dynamics (evolution in colour, elevation or size)

✍️ histology

• Melanocytic differentiation
• Pigmentation (melanin).
• Nuclear pseudoinclusion.
• Gray cytoplasm.
• Clear (artefactual) halo around cells
• Cell Sheeting - diagnostic.
• Asymmetry of architecture
• Lack of maturation
• Nuclear atypia - esp. nucleoli
• Upward scatter of melanocytes
• intraepidermal ascent cannonball appearance

✍️ Local spread

• horizontal
• vertical

✍️ Metastatic

• hematological
• lymphatic

✍️ TTT

• wide local excision with 10 mm safety margin

• Regional lymahadenectomy if 1.5 mm thick

• Chemotherapy if metastasis

• for unresectable tumours (vemurafenib ) FDA approved for late-stage melanoma. It is a kinase inhibitor with specific activity against malignant melanoma

✅ Kaposi's sarcoma

✍️ Caused by HHV8
✍️ Very rare
✍️ Related to immunodeficiency
✍️ Purple red nodular lesion

✍️ TTT
• radiotherapy but not curative

✅ Merkel cell carcinoma

✍️ Highly malignant
✍️ Extremely rare
✍️ Rapidly growing purple nodular lesion
✍️ Common on UL