Squamous cell carcinoma, basal cell carcinoma &

sebaceous gland carcinoma

Epidemiology, classification & histologyNoor Aniah Azmi

MBBCh (Cairo University, Egypt)

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 slidesa. OSCE exam for part I

Normal Layers of the Skin

Normal Histology of the Eyelid

Basal Cell CarcinomaSquamous Cell Carcinoma

Sebaceous Gland Carcinoma

Basal Cell CarcinomaMost common eyelid tumor

90% of all

eyelid tumour

Arises fromStratum basale Outer root sheath of the hair follicle

Only in hair-bearing tissue

Commonly at lower eyelid

Slowly-growing tumour, locally invasive

Non-metastasizing

Can recur if incompletely treated – more difficult to treat

Common sites

(1) Inferior 50-60%

(2) Medial 25-30%- Most dangerous- Spread via lacrimal

system and spread

(4) Lateral 5%

(3) Superior 15%

Risk FactorsProlonged 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

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

Clinical Types

1. Nodular BCC

2. Noduloulcerative BCC (Rodent Ulcer)

3. Sclerosing BCC (morphoeic)

1. Nodular BCC• Slowly-growing

• 1-2 years to reach 0.5 mm diameter

• Shiny and firm

• Pearly nodule

• With dilated surface vessels

2. Rodent Ulcer• Central ulceration

• Pearly raised rolled edges

• Dilated vessels over its margins

• Telangectasis

3. Sclerosing BCC

• Less common and difficult to diagnose – beneath the epidermis

• Indurated plaque

• Loss of lashes

Mistaken diagnosis: Chronic blepharitis

Histological Featuresepithelial proliferation arising from the basal layer of the epidermis

Normal dermis Desmoplastic stroma – pale-pink stroma supporting neoplastic cells

Histological Features

Peripheral palisades

Mitotic figures

Histological Features

Higher magnification

Atypical cells- High nuclear-

cytoplasmic ratio- Hyperchromatic nuclei- Pleomorphic

Histological Features

Sclerosing BCC

Thin cords radiate

peripherally

Basal Cell CarcinomaSquamous Cell Carcinoma

Sebaceous Gland Carcinoma

Squamous Cell Carcinoma

40 times less than BCC

Arises from the squamous layer

May ariseDe novoFrom pre-existing actinic keratosisFrom carcinoma in-situ

SPREAD

Regional LN 20% of cases

Lymphatics and perineural invasion

Common sites

(1) Lower eyelid 49%

(2) Medial canthus 36%

(3) Upper eyelid 23%

Risk FactorsElderly

Fair skin

History of chronic sun exposure

ImmunocompromisedAIDSRenal transplant

Clinical Types

1. Nodular SCC

2. Ulcerating SCC

3. Cutaneous horn

1. Nodular SCC• Hyperkeratotic nodule

• Crusting erosions and fissures

2. Ulcerating SCC

• Red base

• Sharply defined

• Indurated and everted borders

Ulcerating SCC vs Rodent Ulcer

Ulcerating SCC- Everted borders- Pearly margin- No telangectasia

Rodent Ulcer- Pearly margins with rolled

edges- Telangectasia present

3. Cutaneous Horn

• With underlying invasive SCC

Histological FeaturesUlcerated region overlying

Infilrates the dermis deeply

Histological Features

Keratin pearls

Mitotic figures

Pseudosarcomatous change

Basal Cell CarcinomaSquamous Cell Carcinoma

Sebaceous Gland Carcinoma

Sebaceous Gland Carcinoma

Highly-malignant

Arises fromMeibomian glandsGlands of ZeisSebaceous gland of the caruncle, eyebrow or face

Commonly at upper eyelid

Multifocal origin, spread superficially

EpidemiologyFemales, > 50 years old

Most common eyelid tumour after BCC

1.5-5% of all eyelid tumour

Adverse Prognostic FactorUpperlid involvement

Tumour size > 10mm

Duration of symptoms > 6 months

Mortality rate 22%

SpreadVia lymph node

Perineural to intracranial via orbit

Clinical Types

1. Nodular SGC

2. Spreading SGC

3. Pagetoid SGC

1. Nodular SGC• Discrete hard nodule

• Yellowish discolouration – lipid

• Commonly at upper tarsal plate

Mistaken diagnosis: chalazion

How to differentiate between nodular SGC and chalazion?

Nodular SGC Chalazion

Nodule at tarsal plateMaybe tender if inflammed

2. Spreading SGC

• Diffuse thickening of lid margin

• Infiltrates into dermis

• Loss of lashes

• Multifocal non-contiguous origin

Mistaken diagnosis: chronic blepharitis

How to differentiate between SGC and chronic blepharitis?

Spreading SGC Chronic Blepharitis

3. Pagetoid Spread

• Extension of tumour within epithelium

• Including palpebral, forniceal and bulbar conjunctiva

Mistaken diagnosis: inflammatory condition

Normal Histology

Histological FeaturesLarge tumour nodules in the dermis,Irregular lobular mass of cells resembling adenoma but more aggressive

Central necrosis

Histological Features

Hyperchromatic atypical nuclei Scanty cytoplasm

Histological FeaturesPagetoid Spread

Spread through epidermis

Dermis layer

Histological FeaturesOil red-O fat stain

Cytoplasm of abnormal cells

Please remember…Any chronic unilateral blepharitis should raise

the possibility of sebaceous gland carcinoma.

Any case of recurrent chalazion, think of malignancy!

In summary

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

Let’s try to identify the slides

Choose one answerSquamous 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

Choose one answerAppropriate management of multiple or recurrent chalazia includes:

a) Needle biopsy

b) Local antibiotics

c) Full-thickness biopsy

d) Shave biopsy

Referencehttp://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