Ординатура / Офтальмология / Английские материалы / Diagnostic Atlas of Common Eyelid Diseases_Dutton, Gayre, Proia_2007
.pdf
Hydropic Degeneration of Basal Layer
Hydropic degeneration of the basal layer, also termed vacuolar degeneration and liquefactive degeneration, refers to degeneration of the basal cell layer characterized by formation of clear spaces (vacuoles) beneath the basal layer. It is a histological feature prominent in lupus erythematosus, erythema multiforme, graft-versus-host disease, as well as other dermatological diseases not common to the eyelids.
Hyperkeratosis
Hyperkeratosis is increased thickness of the stratum corneum (horny layer) of the epidermis. Hyperkeratosis may result from orthokeratosis, parakeratosis, or a combination of these two. Refer to Orthokeratosis and Parakeratosis (below).
Keratohyalin
Keratohyalin is seen as darkly basophilic granules found in keratinocytes of the granular layer (stratum granulosum) of the epidermis. Keratohyaline granules form matrix that cements cytokeratin tonofibrils together resulting in increased strength and stability.
42 ■ CHAPTER 5: HISTOPATHOLOGIC TERMINOLOGY
Koilocyte
Koilocytes are vacuolated keratinocytes with eccentrically placed, basophilic, shrunken nuclei surrounded by clear halos. They are found in the upper spinous and granular cell layers of the epidermis in human papillomavirus infections (verruca vulgaris, in the eyelid).
Langhans’ Giant Cell
Langhans’ giant cells are multinucleated giant cells derived from fusion of epithelioid cells (activated macrophages). They are large cells with their nuclei arranged along the periphery of the cell forming an arc. Langhans’ giant cells are non-specific, and they may be seen in both immune-type granulomas (such as sarcoidosis and tuberculosis) and foreign body granulomas.
Lichenoid Inflammation
Lichenoid inflammation or lichenoid reaction pattern refers to a dense band of lymphocytes clustered around the interface between the epidermis and dermis, often causing it to be obscured. Lichenoid inflammation is common to many dermatological conditions, though only a few, such as erythema multiforme and graft- versus-host disease, are seen in the eyelids.
CHAPTER 5: HISTOPATHOLOGIC TERMINOLOGY ■ 43
Melanophage
A macrophage containing phagocytized melanin is referred to as a melanophage. Melanin granules are dark brown and non-refractile in sections stained with hematoxylin and eosin. Melanophages are seen in the dermis in inflammatory conditions affecting the epidermis, as well as in neoplasms such as seborrheic keratosis, blue nevus, and melanomas.
Necrobiosis
Necrobiosis refers to death of cells or tissue due to aging or overuse. Zones of smudged or homogenized dermal collagen characterize it histologically. Necrobiosis is often seen as the center of a palisading granuloma. In granuloma annulare, the necrobiotic zone contains mucin, while in rheumatoid nodules there is usually fibrin within the necrobiotic area. The photomicrograph shows a zone of necrobiosis at the top left, surrounded by palisading epithelioid cells in a case of granuloma annulare involving the eyelid.
Orthokeratosis
Orthokeratosis is an increased thickness of the horny layer (stratum corneum) by anucleate (i.e., normal appearing) cells. Orthokeratosis my be compact, laminated, or have a basket-weave configuration.
44 ■ CHAPTER 5: HISTOPATHOLOGIC TERMINOLOGY
Papillomatosis
Papillomatosis is characterized histologically by abnormally elongated epidermis and papillary dermis resulting in irregular undulation of the epidermal surface. Papillomatosis is seen most commonly in seborrheic keratosis and verruca vulgaris (shown).
Parakeratosis
Parakeratosis is an increased thickness of the horny layer (stratum corneum) by nucleated cells. Parakeratosis represents a defect in cellular differentiation and is usually associated with a thinned or absent granular layer. An example of parakeratosis in a specimen with actinic keratosis is shown here.
Pigment Incontinence
Pigment incontinence refers to the release of melanin granules from the epidermis and its resulting deposition in the upper dermis either free or within macrophages (melanophages).
CHAPTER 5: HISTOPATHOLOGIC TERMINOLOGY ■ 45
Pseudocarcinomatous (Pseudoepitheliomatous) Hyperplasia
Pseudocarcinomatous hyperplasia is a histopathological reaction pattern manifest as irregular hyperplasia of the epidermis with prominent acanthotic downgrowth of the epidermis. The epidermal proliferation occurs in response to a wide range of stimuli including chronic irritation, trauma, and dermal fungal infections. Pseudocarcinomatous hyperplasia differs from squamous cell carcinoma by having minimal cytological atypia and fewer mitoses.
Psoriasiform Dermatitis
Psoriasiform dermatitis, also known as superficial dermatitis with psoriasiform proliferation, refers to a form of epidermal thickening with uniform elongation of rete ridges that extend downward into the dermis. Parakeratosis is common. The nature of the inflammatory cells in the dermis, the presence and degree of spongiosis, and the presence of exocytosis are features that aid in rendering a more specific diagnosis.
Shadow Cell
Shadow cells, also known as ghost cells, are characteristic of pilomatrixomas. They are pale, eosinophilic cells with a clear area in place of the nucleus.
46 ■ CHAPTER 5: HISTOPATHOLOGIC TERMINOLOGY
Spongiosis
Spongiosis is intercellular edema between squamous cells of the epidermis. It is characteristic of acute dermatitis and may lead to microand macrovesicles (spongiotic blisters). Intracellular edema may accompany severe spongiosis, resulting in bursting of epidermal cells and formation of multilocular bulla.
Squamous Eddies
Squamous eddies are whorled onionskin-like foci of brightly eosinophilic keratinocytes. They are a typical feature of irritated seborrheic keratoses.
Touton Giant Cell
Touton giant cells are multinucleated giant cells derived from fusion of epithelioid cells (activated macrophages). They have a ring of nuclei surrounding eosinophilic non-vacuolated cytoplasm centrally and lipid-filled foamy cytoplasm peripherally. They are characteristic of xanthogranulomas.
CHAPTER 5: HISTOPATHOLOGIC TERMINOLOGY ■ 47
Vesicle
A vesicle is a small blister, generally less than 0.5 cm in diameter. A subepidermal blister is shown.
48 ■ CHAPTER 5: HISTOPATHOLOGIC TERMINOLOGY
Chapter 6
Surgical Management of Eyelid Lesions
Some eyelid lesions can be identified by their history and clinical appearance, and then treated appropriately. However, many benign lesions can be confused with more aggressive malignant tumors from which they must be differentiated. When doubt exists as to a specific diagnosis, a biopsy should be obtained and submitted for histopathologic evaluation. Based on the findings a more directed therapeutic approach can then be planned. In some cases such as inflammatory lesions medical therapy alone might be indicated. But for malignant and premalignant neoplasms or for benign lesions that are of cosmetic or functional concern further surgery is often necessary.
When biopsy is necessary for diagnosis there are several techniques that are useful depending upon the lesion and location. In some cases representative tissue only is obtained with most of the lesion left behind. In other techniques an attempt is made to remove the entire lesion.
BIOPSY TECHNIQUES
Shave Biopsy
For elevated lesions of uncertain etiology, especially those on the lid margin, the shave biopsy is a useful procedure. It provides a representative sample of tissue for the pathologist without risking lash loss, eyelid deformity or other complications. In this procedure a scalpel is used to shave off the elevated portion of the lesion flat with the surrounding eyelid (Fig. 1). Light cautery or pressure is applied, with care taken not to injure eyelash follicles. If the lesions is benign or can be treated medically, then no further surgery is necessary. However, if the results require complete excision then a more definitive wedge resection can be performed, preferably under frozen section control.
Incisional Biopsy
For large lesions that cannot be removed as an initial procedure or for which a simple shave is not appropriate, a small segment of the tumor can be excised and submitted for histopathologic exam. As with the shave biopsy, some tumor is intentionally left behind to be managed by further surgery or ancillary therapy once a definitive diagnosis is available. The incisional biopsy should include a representative portion of the tumor plus a segment of the margin to show some adjacent normal tissue (Fig. 2).
Figure 1 Technique of shave biopsy where a portion of the lesion is shaved flush with the surrounding eyelid skin.
Figure 2 Incisional biopsy with a representative sample of the lesion is excised leaving most of the lesion behind.
49
Figure 3 In the excisional biopsy the entire lesion is removed with a small zone of normal tissue.
Figure 4 The Mohs microsurgical technique employs a sequential tangential layered excision procedure with histologic examination of all margins.
Excisional Biopsy
When the lesion is small enough so that it can likely be completely removed at an initial procedure the excisional biopsy is best. This is especially true if a benign tumor is suspected so that clear margins are of less concern. A small rim of normal tissue is taken around the margins of the lesion and care is taken to remain deep to the involved tissue (Fig. 3). For suspected malignant tumors or for benign lesions with a high recurrence rate when incompletely removed, excision should be performed under frozen section control.
Mohs Microsurgical Excision
For all malignant tumors around the eyelids the Mohs procedure gives the highest cure rate, generally in the 99.0–99.5% range. Sequential tangential layers are cut and all surfaces are marked for identification. Histologic examination of the entire cut surface is performed by a trained Mohs surgeon and detailed maps are made to note the precise location of any residual tumor. Additional layers are then cut in areas where residual pathology is noted (Fig. 4). The procedure is continued until all margins are free of tumor. In most cases the defect will require reconstruction using local tissue flaps or grafts. For small defects on non-mobile areas such as the nasal bridge, cheek, or temple, it can sometimes be left to granulate spontaneously.
EYELID RECONSTRUCTION TECHNIQUES
Primary Layered Closure
For smaller defects involving the non-marginal skin and muscle, or full-thickness marginal eyelid, repair can be accomplished by directly re-approximating the individual layers. Non-marginal skin defects can be excised with an elliptical incision (Fig. 5). Muscle and skin are then closed in separate layers. Some undermining of edges may be needed for slightly larger defects. For marginal eyelid defects in younger patients where tissues show less laxity, a 25% lid defect can usually be closed without difficulty. In older patients it may be possible to close 40–50% or more. With modification of the basic technique by cutting the lateral canthal tendon, even larger defects can often be closed primarily. It is important to align the lid margin and lash line first, and then the tarsus, orbicularis, and skin in separate layers to avoid any cosmetic deformity (Fig. 6).
50 ■ CHAPTER 6: SURGICAL MANAGEMENT OF EYELID LESIONS
Figure 5 The elliptical excision is used for small lesions where the defect can be closed primarily. Source: From Dutton JJ. Atlas of Ophthalmic Surgery, Volume II. Oculoplastic, Lacrimal, and Orbital Surgery. St. Louis: Mosby Year Book, 1992.
Free Tarsoconjunctival Graft
For full thickness defects that are too large to close primarily, a graft taken from the posterior surface of the ipsilateral or contralateral upper eyelid will provide both conjunctiva and tarsus to reconstruct the posterior lamella. The donor site is left to granulate. The graft is sutured to the residual tarsus or canthal tendons in the recipient site and then covered by a sliding myocutaneous flap to reconstruct the anterior lamella (Fig. 7). This technique works equally well for the lower or upper eyelid.
Rhombic Flap
The rhombic flap is a rotational type flap for repair of small quadrangular defects in the paraorbital region. It can be designed from any of four quadrants around the defect by marking out a V-shaped cut from one of the corners (Fig. 8). When closed, tension is concentrated across the arms of the V so that the flap can be planned to avoid vertical tension that might distort the eyelid. Once the V is closed there is no residual tension on the flap. The procedure yields excellent cosmetic and functional results.
Cutler-Beard Procedure
When a total or near total upper eyelid is missing the Cutler-Beard procedure is one of the major techniques available for reconstruction. A full-thickness horizontal blepharotomy is cut 4 to 5 mm below the lower lid lash line across the entire lid, and the incisions are then extended vertically to the inferior fornix to create a flap (Fig. 9). This leaves a bridge of marginal eyelid supported
Figure 6 Primary layered closure is used for full-thickness marginal defects where all tissues are re-apposed in layers. Source: From Dutton JJ. Atlas of Ophthalmic Surgery, Volume II. Oculoplastic, Lacrimal, and Orbital Surgery. St. Louis: Mosby Year Book, 1992.
CHAPTER 6: SURGICAL MANAGEMENT OF EYELID LESIONS ■ 51