The Practice Patterns in the Management of Sebaceous

Carcinoma of the Eyelid in the Asia Pacific Region

Cheung, J. J. C., Esmaeli, B., Lam, S. C., Kwok, T., & Yuen, H. K. L. (2019). The practice patterns in the management of
sebaceous carcinoma of the eyelid in the Asia Pacific region. Eye (London, England), 33(9), 1433–1442.

Jane Framita
ADVISORS
Dr. dr. Halimah Pagarra, Sp.M(K) COMENTATOR

dr. Suliati P. Amir, Sp.M, M.MedEd dr. Adelina T. Poli, Sp.M, M.Kes

dr. Ahmad Ashraf, MPH, Sp.M(K), M.Kes

MODERATOR

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dr. Andi Pratiwi, Sp.M, M.Kes
dr. Andi Pratiwi, Sp.M, M.Kes
dr. Sukriyah Sofyan, Sp.M
 ABSTRACT
PURPOSE METHODS RESULTS CONCLUSION
• 192 Respondents
To determine An electronic • For initial diagnosis  • SC can have
the Survey  incisional biopsy variable
• Initial workup 
oculoplastic clinical
practice surgical
palpation of lymph
nodes presentations
patterns of colleagues
• Conjunctival map biopsy
was done in selected and may also
the (Asia Pacific) cases behave
• Sentinel lymph node
management  clinical biopsy (SLNB)  tumors differently in
of eyelid information + larger than 10 mm.
• Management  surgical
different
Sebaceous treatment excision combined with ethnicities,
approaches adjuvant therapy. explaining the
Carcinoma to SC
• Margin status  frozen
section as evaluated by variation in

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(SC) the pathologist
practice and
• Surveillance  based
mainly on physical management.
examination alone
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THEORY
JURNAL
 ANATOMY OF THE EYELID
LAYERS
(ANTERIOR TO POSTERIOR)
■ Skin
■ Subcutaneous fat
■ Orbicularis muscle
■ M. Levator palpebrae superioris
■ Tarsal plate
■ Orbital septum
■ Adipose tissue

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■ Conjunctiva and mullers muscle

Atlas of human anatomy, ed 7, Plates 94 and 95. Chapter 8 Head and Neck 4
Sebaceous Gland of The Eyelid
• Glandula Tarsal / Meibomian
• Glandula Moll
• Glandula Zeis
• Lacrimal Caruncle

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 Sebaceous Carcinoma
CLINICAL FEATURES
Approx. 5% cases
a relatively of malignant eyelid
Risk
rare tumor Clinically, SC of the eyelid may manifest as a
tumors in the USA7 painless solitary nodule or diffuse pseudo
of the eyelid and 7.9% in inflammation, may mimic chalazion
Taiwan.

Pagetoid spread  intraepithelial (in situ)

disease in the conjunctiva, even to the
cornea in a noncontiguous fashion. The rates
 26%–51%.

disease of elderly the 3rd most common eyelid

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patients, especially malignancy after basal cell ocular SC  indistinguishable from SCC,
carcinoma (BCC) and BCC, intratarsal keratinous cyst, or other
females squamous cell carcinoma
rare eyelid lesions
(SCC)
Buitrago W, Joseph AK. Sebaceous carcinoma: The great masquerader: Emgerging concepts in diagnosis and treatment. Dermatol
Ther. 2008;21:459–66. 05
Lesion mimics blepharoconjunctivitis Patient with recurrent, advanced
Lesion mimics a chalazion of the
with eyelid erythema, loss of sebaceous carcinoma in the upper
lower eyelid. Focal lash loss is
eyelashes, ulceration and irregular right eyelid that has infiltrated the
present
eye thickening lower lid.

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BCSC 2022-2023 : Ophthalmic Pathology and Intraocular Tumors
 SEBACEOUS CARCINOMA
HISTOLOGY
AND PROGNOSIS
MANAGEMENT
PATOLOGY

- the mortality has decreased to

3% – 7.3% due to
can be recognized by the dependent on its comprehensive therapy
following 4 patterns: histopathologic type and - Worse prog. metastasis, orbital
lobular, disease staging guidelines invasion, involvement of
comedocarcinoma, for eyelid carcinomas after upper/lower eyelids or

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papillary, and mixed complete clinical multicentric origin, poor
evaluation differentiation, tumor dm > 10
mm, and pagetoid invasion

BCSC 2022-2023 : Ophthalmic Pathology and Intraocular Tumors

06
 HISTOPATHOLOGY

Sebaceous Malignant
Carcinoma and Cells with frothy sebaceous cells
normal sebaceous are organized
sebaceous cytoplasm around a central
glands-Low area of necrosis

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power

BCSC 2022-2023 : Ophthalmic Pathology and Intraocular Tumors

BACK TO THE
JOURNAL

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INTRODUCTION
SEBACEOUS
CARCINOMA
Asian population  2nd most common
malignant eyelid tumor (BCC) Difficulties in early recognition
Incidence male : female ratio  0.32 :
combined with its potentially aggressive
Caucasian population  3rd most 0.1 per 100.000 persons-years in the US
behavior can lead to poor prognosis.
common (BCC and SCC)

The tumor-related mortality rate  6% Treatment  surgical excision

Mean follow-up  39.2 months Adjuvant treatment  External beam
5-year disease-specific survival rate  radiotherapy, cryotherapy, and topical
92% chemotherapy

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This study aims to identify difference of management and explore the current practice patterns amongst oculoplastic surgeons in
the Asia Pacific region in the management of eyelid SC
METHODS

A survey containing 40 MCQ with the option of The survey was The responses were
questions regarding the selecting one-best answer, electronically distributed via extracted from the online
demographics, training multiple answers, or to e-mail to members of the platform and analyzed.
background, and practice specify their answer in free- Asia Pacific Society of
patterns for management of text format. Oculoplastic and
SC of eyelid. Reconstructive Surgery
(APSOPRS), Hong Kong
Society of Oculoplastic and

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Reconstructive Surgery
(HKSOPRS), and individual
oculoplastic society
directories of the
corresponding author
RESULT

Geographic distribution,
training, and experience
Outcomes (Q32-34)
with SC of survey
respondents (Q1-7)

Reported practice patterns

Follow-up (Q35-37)
(Q8-31)

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RESULT
S The Country of respondents come from : Hongkong (23%)

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Most respondents practice in Academic
Institution and
have been practicing as Oculoplastic

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surgeon for 10-20 years
Most respondents received oculoplatic training in
United States

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Most respondents manage < 5 cases per year and

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have managed > 40 cases in their career so far
Most respondents experienced Painless Eyelid Mass as the most common presentation of
SC

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Most respondents preferred Incisional Biopsy

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for initial biopsy and do Lymph Node
Palpation for workup for localized SC
INITIAL
DIAGNOSIS

- Chest Xray on
initial diagnosis
of localized SC <
10 mm

- CT Orbit on
initial diagnosis
of localized SC >

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10 mm
 Most respondents perform
Conjunctival Map Biopsy 

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Suspicious pagetoid involvement of conjunctiva
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Most respondents usually excise for SC According to Frozen Section Finding and also
preferred Send specimen for frozen section by pathologist to asses margin involvement
after excision
After Wide Excision, for
Posterior Lamellar
Reconstruction,
most choice :
- Lid Sharing Procedure
(Upper and lower Eyelid
reconstruction)

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Most respondents use
Adjuvant Treatment
in Positive Margins
after surgery and use
Radiotherapy

Most respondents use

Radiotherapy as
Adjuvant Treatment

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For mitomycin C, most respondents do not apply mitomycin, but for whom they
use 0.04% Mitomycin-C four times daily for a week followed by one week off
in 4 cycles
In cases with Pagetoid Spread without metastasis, most respondents prefer Wide

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Local Excision combined with Adjuvant Therapy as Primary Therapy. And they
use Radiotherapy as a palliative treatment in advanced disease
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Most respondents never Perform SLNB, and in cases with regional nodal
metastasis without distant metastasis they use Lymph node dissection with
chemotherapy
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Most respondents do surgical excision combined with adjuvant treatment in
locally advanced non metastatic SC, and they do not use any neo-adjuvant agent
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The technique they use for exenteration Depends on Extent of Disease, and for
wound closure they prefer Healing by Granulation
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In cases with widespread non metastatic disease requiring exenteration, they prefer wait
for specimen finding after exenteration and in patients with recurrent disease they prefer
surgical excision with adjuvant treatment
In patient with localized SC who are not fit or refuse for surgery,
most respondent choose Radiotherapy as Primary Management

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According to the respondents, most experienced about < 10% recurrence rate of localized
SC, and about < 5% mortality rate from SC
 According to the respondents,
most experienced the main
caused of death in patient with
SC is Distant metastatic disease

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RESULT
SFollow-Up
Most respondents refer
patients with SC for
oncologist assessment,
and perform physical
examination alone after
surgery during
surveillance, and for the
majority of stable cases,
the longterm surveillance
is done by Oculoplastic
Surgeon

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DISCUSSION

Main presenting symptom of SC  solitary

Respondent of this study  more
eyelid nodule (36%)  in keeping with
experienced in managing SC (up to 24%
Watanabe et al (2013), Lam SC et al (2018),
have managed more than 40 cases)
Yoon JS et al (2007)

Incisional biopsy + incision curettage is commonly performed,

different from a recently published British cohort 
Primary Excisional Biopsy was the most commonly performed diagnostic

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intervention (42%)
DISCUSSION
More respondents chose CT orbit over MRI orbit for investigative
modality  due to the availability and affordability of CT over MRI.

This study  performed conjunctival map biopsy in selected

cases,

Shields et al., (2015)  perform map biopsy only if there is

clinical suspicion of diffuse palpebral and bulbar conjunctival
involvement
McConnell et al., (2017)  map biopsies for all cases because

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even in solitary nodular SC with no conjunctival involvement
clinically, half had biopsy-proven conjunctival involvement
DISCUSSION
Respondents of this study rely on physical examination as
the main method for the detection of lymph node
metastasis
Since SC metastasize to regional and systemic lymph nodes,
USG of parotid, submandibular and cervical lymph nodes, and
SLNB  to evaluate regional lymph nodes to rule out
metastasis.

This study  24% of respondents would perform

SLNB for lesion >10mm
This low percentage of SLNB performed in may be
related to the lack of technical expertise and time

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consuming to set up
DISCUSSION
The majority of responders (32%) utilized
frozen section to determine the size of
excision margin with 27% using a 5 mm This study  To assess for margin
clinical excision margin. involvement , frozen section is the most
commonly employed technique (57%)

While et al., (2014)  local

Snow et al., (2002)  resection with rapid paraffin section
frozen section control using analysis offered low recurrence
en-face margins can yield rates with good cosmetic outcome
comparable results to Mohs and more reliable for detection of

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intraepithelial pagetoid spread and
surgery margin evaluation
DISCUSSION

This study 
Shields et al., (2004)  use cryotherapy after local excision in 68%
adjuvant
This
Kyllo study
et al.,
of therapy

(2015)
their 46%
  of
radiotherapy
respondents
Chemotherapy
patients and (42%),
combined
report nottopical
dowith
a recurrence use MMC
surgical 18%(38%),
rateneo-adjuvant
excision
of may be
chemotherapy
used in cases withfor and cryotherapy
extensive disease, nodal(14%)
globe-preservation in locally advanced
involvement, metastasisSC.
and
occasionally in recurrent cases

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CONCLUSION
This survey
highlights some This study also This study
Initial diagnostic
differences in found that SLNB is suggests that most
intervention and
practice patterns in less commonly practitioners prefer
approach to
the Asia Pacific. In performed, a multidisciplinary
conjunctival map
particular, SC possibly due to approach in
biopsy may be
favors a nodular lack of access and managing patients
different.
presentation in the expertise with SC
Asia Pacific region.

SC can have variable clinical presentations

and may also behave differently in different
ethnicities, explaining the variation in practice

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and management.
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