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A few words need to be said regarding fixatives. The majority of conjunctival specimens can be sent in 10% neutral buffered formalin; however, there are a few exceptions. The possibility of pagetoid spread must be considered in cases of possible sebaceous carcinoma of the palpebral or bulbar conjunctiva. In such cases, map biopsies of the conjunctiva (representative conjunctival biopsies from each sector) should be performed and biopsy specimens sent fresh for evaluation of intraepithelial neoplasia with the use of fat stains (such as Oil Red O), if needed [10, 11]. Suspected lymphoproliferative lesions should also be sent fresh for impression cytology and flow cytometry. If electron microscopy may be diagnostically useful (for example, in cases of possible conjunctival Merkel cell carcinoma), a small fragment of the specimen should be sent in glutaraldehyde [12].
11.4 Eyelid Specimens
For pathologic evaluation of eyelid specimens, proper specimen orientation is the key. Specimens being submitted fresh for frozen section evaluation of margins need to be correctly oriented. A drawing of the eye and periocular structures is helpful for this purpose. For full-thickness lesions involving the eyelid margin, the pathologist needs to know which eye the specimen is from and whether the specimen is from the upper or the lower eyelid. With this minimum orientation, the pathologist can determine nasal, temporal, and superior or inferior margins (the eyelid margin itself is not a surgical margin).
For specimens not involving the eyelid margin yet still involving the dermis, a suture must be placed to indicate the orientation; commonly, the 12 o’clock position is tagged. However, the surgeon may choose to mark any clock hour and may choose to mark a clock hour in a segment about which there is most concern. Another method for specimen orientation is to make a drawing of the pertinent facial structures as a reference and then place the specimen in its correct orientation on the drawing (Fig. 11.5). In complex cases or when the pathologist does not frequently handle eyelid specimens, it is recommended that the surgeon hand-carry the specimen to the pathologist so that together the surgeon and the pathologist can ink the margins and discuss any questions or areas of particular concern.
If multiple specimens are being submitted, a preoperative photograph with the biopsy sites labeled is a useful tool in addition to the description of the specimen location on the specimen submission form (Fig. 11.6). Each specimen needs to be submitted in a separate container labeled with the appropriate information about patient identification and biopsy location.
Several of the recommendations for handling conjunctival specimens also apply to eyelid specimens: (1) specimens from tumors suspected of being sebaceous carcinomas or lymphoproliferative lesions need to be sent fresh, (2) frozen section margin control is not recommended for melanoma owing to the unreliability of assessment of melanocytic atypia on frozen sections, and (3) tangential cutting must be avoided in the case of melanomas because tumor thickness is the most
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Fig. 11.5 Surgical eyelid specimen. (a) Preoperative surgical markings. (b) Primary surgical specimen A placed on sketch with sutures marking medial and lateral margins for orientation. (c) Additional surgical specimens B and C, removed to obtain clear margins, placed on sketch for orientation. Photos courtesy of Dr. Bita Esmaeli
important prognostic factor for melanomas. Two other factors also underscore the critical importance of proper specimen handling to enable accurate determination of melanoma tumor thickness. First, a recent study indicated that thin periocular melanomas may be excised with 5-mm margins, which are associated with less morbidity than the previously recommended 1-cm margins, which in any case are often unobtainable in the periocular region [13, 14]. Second, eyelid skin and conjunctival melanomas that are more than 1-mm thick are viewed by many authorities as being appropriate for sentinel lymph node biopsy [14, 15].
11.5 Mohs Micrographic Surgery
Mohs micrographic surgery is a technique for excising cancerous skin lesions. It utilizes microscopic margin control, enabling tumor excision with minimal sacrifice of normal surrounding tissue. This is advantageous in the eyelid, particularly in the
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Fig. 11.6 Preoperative surgical photograph of eyelid primary acquired melanosis suggestive of melanoma. The photograph was submitted to the pathologist to aid with specimen orientation. Photo courtesy of Dr. Bita Esmaeli
medial canthal region and the lacrimal drainage system. Mohs surgery has been proven to be highly successful in the excision of basal cell carcinoma and squamous cell carcinoma [16].
In contrast, the use of Mohs surgery for melanoma, Merkel cell carcinoma, and sebaceous carcinoma is controversial [17–21]. Some investigators recommend a variant coined “slow-Mohs” or “modified Mohs technique” for such tumors [9, 18]. However, most investigators agree that for melanomas, the margins need to be assessed by permanent section technique. The tumor is excised, and the pathologist performs a 24-hour expedited assessment of the margins. Additional tissue is excised daily until the margins are clear or until both the patient and the surgeon agree to stop—for example, if the tumor has become inoperable or if other nonsurgical modalities, such as radiation therapy, or topical medications, such as imiquimod, are to be used to address microscopic residual in situ melanoma at margins.
11.6 Summary
Proper surgical specimen handling of conjunctival and eyelid tumors is not difficult, but it is a critical component of a successful surgical ablation of periocular and ocular adnexal tumors. The basic concepts of specimen orientation and effective
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communication between the surgeon and the pathologist will enable the ophthalmologist to provide optimal patient care.
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