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Unusual eyelid lesion causes concern
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An 85-year-old white male was referred from his optometrist for evaluation of a suspicious lesion on the right upper eyelid margin. The patient thought that the lesion started growing several months earlier but had not changed in size or shape over the past 3 weeks. It was not tender to touch. The patient had tried to remove it himself by pulling on it. This was not successful and resulted in the lesion bleeding temporarily.
The patient was interested in having the lesion removed because other people were talking about it and he was uncomfortable with the attention it drew from his family and friends. The patient had no other ocular concerns. He felt his vision was adequate for what he needed to do.
The patient’s medical history was significant for hypertension and hyperlipidemia. He denied any history of skin cancer. His medication included low-dose aspirin (81 mg daily), diltiazem (120 mg daily), furosemide (40 mg daily) and simvastatin (40 mg daily). He was allergic to influenza virus vaccines.
Hornlike projection from the upper eyelid margin. Eyelid margin deformity with notching. Eyelash irregularity and madarosis.
Images: Skorin L
The patient’s entering visual acuities with his habitual glasses were 20/40 OD, 20/50- OS. Pinhole improved his vision to 20/30- OD, 20/50 OS. He refused refraction since he was just seen by his optometrist a few weeks earlier. Pupils were equal, round and reactive without afferent pupillary defect. Motilities were full and smooth, and confrontation visual fields were full in both eyes. He had moderate nuclear sclerotic cataracts. IOPs were 12 mm Hg OD and 14 mm Hg OS via applanation tonometry. A dilated fundus exam revealed bilateral posterior vitreous detachments and healthy optic nerves with .30/.30 cupping in both eyes. The rest of the fundus examination was unremarkable.
Slit lamp evaluation of the nasal aspect of the right upper eyelid revealed a solid-appearing protruding lesion from the eyelid margin. The lesion also had a thickened elevated base. Immediately adjacent to the lesion was an area of eyelid margin distortion and notching. A small crusted scab was also present. The adjacent eyelashes appeared irregular, but, overall, the involved aspect of the eyelid margin was devoid of eyelashes. The area of involvement measured a total of 1 cm along the eyelid margin. The eyelid margin distortion did not appear to extend as far as the puncta.
What’s your diagnosis?
Eyelid lesion
Eyelid margin deformity, lash irregularity, madarosis and friability are all signs of possible underlying malignancy. Of additional concern are the changes seen in the adjacent eyelid margin. This patient has a cutaneous horn.
I performed a shave biopsy of the cutaneous horn and the adjacent eyelid margin tissue. The eyelid was first injected with lidocaine 2% with 1:100,000 epinephrine. The area was then sterilely prepped and draped. I used a surgical blade to do a shave biopsy incorporating the complete cutaneous horn and its base with a small area of adjacent eyelid margin tissue. I then cauterized any bleeding blood vessels. The specimen was sent to pathology in formalin for histopathologic examination.
Leonid Skorin
A shave biopsy is the preferred procedure for unknown lesions that involve the eyelid margin. This type of biopsy collects enough tissue for an accurate histopathologic diagnosis and yet does not distort the normal eyelid margin contour. I try to approximate the depth of the lesion and remove it as completely as possible. Sometimes eyelash follicles are spared and other times they are sacrificed.
If the suspicious lesion is benign, often no further surgery is necessary. If the specimen is found to be malignant, further surgery would need to be performed if it is found that the tumor extends to the surgical margins of the excised specimen.
Histopathologic evaluation of the biopsy specimen confirmed marked hyperkeratosis consistent with a cutaneous horn and a grade 2 (out of 3 grades) squamous cell carcinoma involving the underlying dermal tissue. The tumor extended to all the margins.
The patient was referred to oculoplastics for Mohs excision of remaining tumor and eyelid reconstruction.
Description, epidemiology
A cutaneous horn (cornu cutaneum) is a protrusion from the skin of compacted keratin organized in a shape that resembles an animal horn in miniature. The term cutaneous horn is a descriptive one and is not a true diagnosis. Cutaneous horn is not a distinct pathological entity, but is derived from a variety of underlying benign, premalignant and malignant epidermal lesions.
Human cutaneous horns can arise from any epidermal covered region of the body. Overall, this lesion is a relatively rare tumor; however, it appears to occur more frequently in sites that are exposed to actinic radiation or burns, according to Mencia-Gutierrez and colleagues and Copcu and colleagues. Although a specific sex predilection has not been found, they appear to be seen more frequently in elderly men with a history of extensive sun-exposed skin. It has also been shown that the possibility of harboring an underlying malignancy at the base of the cutaneous horn is increased in men when compared with age-matched women (Copcu et al.).
Approximately 30% of cutaneous horns arise on the face and scalp, Bondeson reported. They have been estimated to make up only 4% of eyelid tumors (Mencia-Gutierrez et al.). The tumor originates on the upper eyelid more often than on the lower and is also found more frequently in the lateral canthal region or the lid margin (Duke-Elder and MacFaul). The size of these tumors may vary from a few millimeters to several centimeters (Korkut et al.). Large cutaneous horns are considered to be derived from a malignant base, often squamous cell carcinoma (Bondeson).
Left image: Histopathology with 40x magnification. Hyperkeratosis (stained red) can be seen on the left side of the image. The right side of the image shows nests of malignant squamous cells extending to the deep margin. Right image: Histopathology with 400x magnification. Malignant squamous cells with hyperchromatic nuclei, abnormal mitotic figures, loss of polarity and macronucleoli. .
Source:
Histopathological examination of the base of the cutaneous horn is necessary to rule out malignancy. Benign lesions that can form a cutaneous horn include seborrheic keratosis, viral warts, histiocytoma, inverted follicular keratosis, verrucous epidermal nevus, molluscum contagiosum and inclusion epidermal cyst (Mencia-Gutierrez et al., Thappa and Laxmisha, Copcu et al.). Premalignant lesions include solar keratosis, arsenical keratosis and Bowen’s disease. Malignant lesions include squamous cell carcinoma, basal cell carcinoma (as the present case demonstrates), metastatic renal carcinoma, granular cell tumor, sebaceous carcinoma and Kaposi’s sarcoma.
In a large study of cutaneous horns by Yu and colleagues, 65% were found to be of a benign nature, 20% were premalignant and 15% arose from malignant skin tumors, with squamous cell carcinoma being the most frequent-presenting malignancy. The co-existence of other premalignant or malignant skin lesions increase the likelihood of finding a cutaneous horn with a premalignant or malignant base pathology.
Treatment
Because definitive therapy depends on the underlying cause, biopsy of the cutaneous horn and a portion of the underlying epidermis is required to obtain a histologic diagnosis. Adequate therapy requires wide excision of the lesion with a tumor-free margin of at least 3 mm.
References:
Copcu E, Sivrioglu N, Culhaci N. Cutaneous horns: Are these lesions as innocent as they seem to be? World J Surg Oncology. 2004;2:18. http://www.wjso.com/contact/2/1/18. Accessed November 23, 2012.
Duke-Elder S, MacFaul PA. The ocular adnexa: Diseases of the eyelids. In: Duke-Elder S, ed. System of Ophthalmology. Vol. 13, Part I. St. Louis: CV Mosby;1974:418-420.
Korkut T, Tan NB, Oztan Y: Giant cutaneous horn: A patient report. Ann Plast Surg. 1997;39:654-655.
Mencia-Gutierrez E, Gutierrez-Diaz E, Redondo-Marcos I, Ricoy JR, Garcia-Torre JP. Cutaneous horns of the eyelids: A clinicopathological study of 48 cases. J Cutan Path. 2004;31:539-543.
Neff AG, Carter KD: Benign eyelid lesions. In: Yanoff M, Duker JS (eds): Ophthalmology. 3rd ed. Mosby Elsevier; 2009:1422-1433.
For more information:
Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, a Primary Care Optometry News Editorial Board member, practices in Albert Lea, Minn., and writes and lectures on ocular disease and neuro-ophthalmic disorders. He underwent fellowship training in neuro-ophthalmology. He may be contacted at the Mayo Clinic Health System, 404 West Fountain St., Albert Lea, MN 56007; (507) 373-8214; fax: (507) 377-4117; skorin.leonid@mayo.edu.Edited by Leo P. Semes, OD, FAAO, a professor of optometry, University of Alabama at Birmingham and a member of the Primary Care Optometry News Editorial Board. He may be contacted at 1716 University Blvd., Birmingham, AL 35294-0010; (205) 934-6773; fax: (205) 934-6758; lsemes@uab.edu.
Disclosure: Skorin has no relevant financial interests to disclose.