LUMPS AND BUMPS: AN ORGANIZED APPROACH TO DIAGNOSIS AND MANAGEMENT Tammy P. Than, M.S., O.D., F.A.A.O. The University of Alabama at Birmingham / School of Optometry 1716 University Blvd. Birmingham, AL 35294-0010 Phone: 205-975-5235 / Fax: 205-934-6758 / email: [email protected]

This course will include practical information regarding the identification of benign, premalignant, and malignant lesions of the eyelid and conjunctiva. Emphasis is on differential diagnosis, therapeutic management, and in-office minor surgical treatments for each lesion.

INTRODUCTION A. Terminology 1. Macule – non-palpable color change (< 1.0 cm) 2. Patch – large non-palpable color change 3. Papule – small, firm raised area (< 1.0 cm) 4. Nodule – large papule; deeper 5. Plaque – elevated lesion with flat top 6. Scale – flattened keratinized cells; flakes

PART I. BENIGN TUMORS I. EPITHELIAL TUMORS A. Papillomas 1. Squamous Papilloma a. skin tags, acrochordons – epidermal hyperplasia b. neck, axilla, eyelids c. F > M 2. Verrucae a. “warts” - verrucae vulgaris, verrucae plana, filiform b. etiology is human papilloma viruses c. 2/3 spontaneously resolve within 2 years d. treatment: · electrocautery · chemical cautery · surgical excision · argon laser B. Molluscum Contagiosum 1. caused by poxvirus 2. umbilicated papules 3. if located on eyelid, may have conjunctivitis and SPK 4. treatment: · surgical excision (recommended) · liquid nitrogen · light electrocautery

C. Sebaceous Cyst 1. retained sebum - yellowish 2. moveable capsule 3. remove for cosmetic reasons (make sure to remove capsule) D. Cutaneous Horn 1. hyperkeratotic growth 2. often associated with actinic keratosis, verruca, or basal cell carcinoma E. Millium 1. epidermal cyst in pilosebaceous follicles 2. 1-2 mm 3. sites: eyelids, cheeks, forehead F. Xanthoma 1. yellow bilateral plaques (dermal) 2. 40% recur G. Pyogenic Granuloma 1. soft, fragile, red nodule that arises after trauma H. Seborrheic Keratosis 1. located on sun-exposed surfaces 2. "stuck-on" appearance – tan, brown, or black 3. differential diagnosis: · actinic keratosis · basal cell carcinoma · malignant melanoma 4. treatment: · excision · CO2 laser · electrocautery · cryotherapy 5. variant – Dermatosis Papulosa Nigra 6. CO2 Laser Skin Resurfacing · 10,600 nm · photovaporization · penetration is only 0.02 mm · indications include rhytids, scars, lesion removal, rhinophyma, tattoo removal · candidates should have healthy skin, fair complexion, and realistic expectations I. Keratoacanthoma 1. begins as smooth, dome-shaped papule 2. rapidly grows for short time then stabilizes 3. isolated lesion 4. must differentiate from squamous cell carcinoma 5. treatment: · excision · cryosurgery · 5-fluorouracil injections J. Syringoma 1. sweat gland tumor 2. firm skin-colored papules

2 II. VASCULAR TUMORS A. Strawberry Nevus 1. capillary hemangioma – bright red 2. often present at birth 3. some resolve on own 4. potential for permanent, residual skin changes 5. consider cyrotherapy B. Cherry Angioma 1. most common vascular malformation C. Cavernous Hemangioma 1. involves dermis and subcutaneous tissue 2. does not spontaneously resolve 3. if lid involvement, may cause ptosis D. Port Wine Stain

III. COMMON ACQUIRED NEVUS A. The Basics 1. mole 2. benign neoplasm of melanocytes 3. appear during childhood through young adulthood then most disappear by 60s 4. may have coarse hairs associated with nevus 5. minimal risk of malignancy B. Classification according to site of pigment: 1. junctional · flat / cells at epidermal-dermal junction 2. compound · somewhat elevated / cells in both epidermis and dermis 3. intradermal · elevated, dome-shaped / cells only in dermis C. Conjunctival Nevus 1. often near limbus 2. associated with retention cysts 3. may occur later in life D. Melanosis 1. concern if unilateral acquired E. Management 1. Document size, color, and other characteristics 2. Photograph 3. Monitor for change (use H-ABC'S as guideline) · H – history, hair · A – asymmetry, avascular · B – borders, bleeding · C – color, change · S – size

PART II. PREMALIGNANT AND MALIGNANT TUMORS 3

I. PREMALIGNANT LESIONS A. Dysplastic Nevus 1. larger in size than common acquired nevus (usually >6 mm) 2. different histologically than a mole 3. usually appears later than a mole 4. contour and shape often asymmetric 5. significant potential for malignant transformation (MM) B. Actinic keratosis = Senile keratosis = Solar keratosis 1. sun-induced lesion 2. sites: face, neck, scalp, arms 3. "felt before seen" 4. red macule with rough surface --> plaque with thick yellow scale 5. significant malignancy potential (SCC) a. rename to solar keratotic intra-epidermal squamous cell carcinoma 6. treatment: - sunscreen - 5% Efudex cream (5-fluorouracil) - cryosurgery - surgical excision - Solaraze - Aldara (5% imiguimod) - 5-aminolevulinic acid C. Lentigo Maligna = Hutchinson's Freckle 1. sun-induced lesion 2. older; fair-complexioned patients 3. dark macular lesion with irregular pigment and irregular borders 4. significant malignancy potential D. Congenital Nevus 1. plaque with course hair 2. usually born with it 3. isolated lesion 4. life-long follow up

II. MALIGNANT LESIONS A. Basal Cell Carcinoma 1. most common skin cancer – 900,000 / year 2. slowly growing 3. areas of chronic sun exposure 4. 80-90% of all malignant lid tumors 5. most common site on eyelid - medial aspect of lower lid 6. metastasis is VERY unlikely 7. no precursors 8. four main types: a. Nodular type b. Nodular Ulcerative type c. Superficial type d. Sclerosing (Morpheaform) type - “more than meets the eye”; invasive

9. treatment: 4 a. excision b. cryotherapy c. electrocautery d. Mohs' procedure - recommended for BCC near nose, ears, eyelids - gold standard e. monitor every 3 months

B. Squamous Cell Carcinoma 1. atypical squamous cells in epidermis 2. predisposing factors: · sun exposure · ionizing radiation · carcinogens · chronic skin lesions 3. usually >55 4. sites: scalp, back of hands, lower lip, ear, upper eyelid 5. scaly lesion --> indurated --> proliferate into dermis 6. from premalignant lesion or de novo 7. may metastasize 8. compared to BCC: faster growing, more inflammation, firmer 9. DDX: keratoacanthoma, BCC 10. treatment: · protection: sun, carcinogens · surgical excision · cryotherapy · Mohs' 11. prognosis: · good

C. Malignant Melanoma · radial and vertical growth phases · early diagnosis is the key · ? relationship to sun exposure

1. Lentigo Maligna Melanoma (5%) - definite relationship to sun exposure - slowly arises from lentigo maligna - papules in middle of macule - irregular borders, notching - long radial growth phase - ± vertical growth phase - less aggressive than other MM

2. Superficial Spreading Malignant (70%) - 30-50 years - back and legs - flattened papule --> plaque --> nodule(s) - isolated lesion - dark brown or black with mix of pink, gray blue-gray - hallmark is haphazard colors 5 - unpredictable radial and vertical growth phases

3. Nodular Malignant Melanoma (15-20%) - average age: 50 - F = M - head, neck, trunk - can arise form pre-existing nevus - "blueberry-like" nodule - black, blue, red, or amelanotic - no radial growth phase; immediate vertical phase - pedunculated variant – most aggressive

4. Acral Lentiginous Melanoma - rare but most common melanoma in African Americans and Asian Americans - involved soles, palms, fingers, and toes

5. Malignant Melanoma Analysis - thickness - staging · I, II, III – local disease · IV – enlarged local lymph nodes · V – clinical evidence of dissemination

6. Management - biopsy - excision / reconstruction - irradiation - prognosis varies on staging - life-long, frequent follow up

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