| Abstract|| |
Aims : The purpose of the study was to evaluate different eyelid lesions appearing as a swelling or mass, using fine needle aspiration cytology (FNAC), to conduct a cytological diagnosis of these lesions with subsequent histopathological correlation, and to identify the problems faced during microscopical examination of the smears.
Materials and Methods : Fine needle aspirates from 80 eyelid swellings and histopathological correlation in 62 cases were studied.
Results: Forty eight cases of benign and 32 cases of malignant lesions were diagnosed by FNAC. The five leading benign lesions were chalazions (12 cases, 15%), epithelial cysts (eight cases, 10%), chronic nonspecific inflammation (six cases, 7.5%), seborrheic keratosis (five cases, 6.25%) and benign adnexal adenoma (four cases, 5%). The most common malignant lesion was basal cell carcinoma (12 cases, 15%) followed by sebaceous gland carcinoma (nine cases, 11.25%) and squamous cell carcinoma (eight cases, 10%).
Conclusions: Histopathological correlation showed that the accuracy of fine needle aspiration cytology in making diagnosis was 83.87%. Incidence of basal cell carcinoma in the study was lower, compared to most western studies. Therefore, there may be a racial and geographical variation.
Keywords: Fine needle aspiration cytology; eyelid lesions; histopathology.
|How to cite this article:|
Mondal SK, Dutta TK. Cytohistological study of eyelid lesions and pitfalls in fine needle aspiration cytology. J Cytol 2008;25:133-7
|How to cite this URL:|
Mondal SK, Dutta TK. Cytohistological study of eyelid lesions and pitfalls in fine needle aspiration cytology. J Cytol [serial online] 2008 [cited 2020 May 28];25:133-7. Available from: http://www.jcytol.org/text.asp?2008/25/4/133/50798
| Introduction|| |
Many of the surgical specimens provided by the ophthalmologist were lesions from the eyelid and periocular skin. Eyelids are divided into conjunctival and cutaneous portions. Skin appendages of eyelids comprise sebaceous glands (Mebomian glands and glands of Zeis), aporcine glands (glands of Moll) and eccrine sweat glands. Most of the pathologic processes that involve the eyelids are those that involve the skin as well. Any pathologic condition affecting the eyelid, whether a benign, vascular, inflammatory or malignant lesion, may appear as a nodule. , At times, it is difficult to decide clinically whether it is a true neoplasm or an inflammatory lesion. In all such cases, FNAC has proved to be very useful in quickly determining the nature of the lesion and also in deciding the mode of treatment.
FNAC has a high diagnostic accuracy rate, if the aspirated material is sufficient for microscopical examination and if it is properly interpreted. , Aspiration cytology is cost effective and offers rapid diagnosis, with minimal discomfort to the patient. 
| Materials and Methods|| |
The present study, conducted in our institute, included 80 patients (46 males and 34 females), with complaints of eyelid swelling over a period of five years, from March 2003 to February 2008. The male-female ratio was 1.35 : 1. The cases selected were from those referred to us by the Ophthalmology and Surgery Out Patient Department (OPD).
Aspiration was done in every patient, as requisitioned by the clinicians. Each patient was thoroughly evaluated at an initial assessment to determine the exact nature of the mass or swelling. Relevant clinical data and routine hematological investigations were noted in all cases.
Consent was taken prior to FNAC. The site was not routinely anaesthetized before FNAC. The overlying skin over the lesion was disinfected with an alcohol swab and FNA was carried out using a 20-ml syringe attached to a 23-27 gauge needle fitted into a Camco pistol type holder. An average of 4-6 needle passes were made. The aspirated material was evenly spread on glass slides. Half of the smears were fixed by alcohol and subsequently stained by Hematoxylin and Eosin (H and E) or Papanicolaou (Pap) stain. Other slides were air dried and stained by May-Grunwald-Giemsa (MGG) stain.
Six cases, especially hemangiomas and large malignant tumors, had bleeding from the aspiration site, which was controlled by local compression. In addition, three patients with local infection were managed by proper antibiotic therapy. Seven cases yielded inadequate material and were subjected to repeated attempts. The smears were interpreted by cytopathologists and cytological diagnosis was made in conjunction with clinical findings and clinical diagnosis.
After FNA, patients were followed up and a histological examination was done, in available cases, on the surgical biopsies. No cell block was prepared in this study. Histopathological diagnosis was made from formalin fixed, paraffin embedded, 4-5 µm thick cut tissue sections stained with H and E stain.
| Results|| |
Benign lesions constituted the majority and accounted for 48 cases (60%) while 32 cases (40%) were malignant lesions [Table 1]. A majority of the patients were in the 31-40 age group, as compared to those above 60 years [Table 2].
Chalazions were characterized by histiocytes, foamy cells and neutrophils with few granulomas. Spores of rhinosporidium were better seen after Periodic Acid Schiff (PAS) stain. Aspirates from eight cases of epithelial cysts yielded foul smelling, thick, greasy material. Smears showed high cellularity with numerous nucleated squamous cells and anucleated squames in a background of keratinous debris. Most of the hemangiomas yielded peripheral blood, with a few cases showing an occasional cluster of endothelial cells.
Aspirates from neurofibroma (n=2) showed cohesive spindle-shaped cells within fibrillary mesenchymal background material. Smears from benign adnexal adenomas aspirates ( n = 4) showed groups or sheets of basaloid cells. In nevi, the aspirates were composed of nevoid or fusiform cells, devoid of the nuclear and cytological features of malignant melanoma. In seborrheic keratosis, occasional degenerated squamous epithelial cells, along with mature superficial squamous cells, were seen. The cytological findings were similar in squamous papilloma and it was very difficult to distinguish them cytologically. The clinical appearance of these lesions, along with the history and clinical diagnoses, was correlated to give a cytological diagnosis.
Evenly distributed cohesive basaloid cells with monomorphic nuclei and a little cytoplasm were noted in the smears of basal cell carcinoma (12 cases). Hyperchromasia of nuclei and basophilia of cytoplasm were best seen in Papanicolaou stain. Nucleoli were indistinct. Peripheral palisading was found in some cases.
In sebaceous gland carcinoma (nine cases), smears showed loose clusters of pleomorphic cells with focal acinar or glandular pattern. Numerous lipid vacuoles with inequality in size were found in cytoplasm or in the background [Figure 1]. Most aspirates were hemorrhagic in cases of squamous cell carcinoma. The aspirates showed sheets, clusters and individual atypical squamous cells [Figure 2]. Necrosis was also present in most of the cases. Nuclear atypia and nucleoli were seen. Orangiophilia in Pap stain helped to identify cytoplasmic keratin and to differentiate it from necrotic cells which impart the same eosinophilia in H and E stain.
The retinoblastoma cells were hyperchromatic small round cells with high N:C ratio. Sometimes the cells formed rosettes. The smears of malignant melanoma were usually highly cellular. Cells were mostly dispersed and noncohesive. The cells had dense hyperchromatic nuclei, a coarse chromatin pattern, a large eosinophilic nucleolus in H and E smears and indefinite cell borders with slightly raised nucleocytoplasmic ratio. The cytoplasm was abundant and dense with fine dust like pigment granules. Uniform nuclear hyperchromasia, a unique feature of melanoma cells was noted in MGG smears.
Surgical specimens for histopathological correlation were available in 62 cases [Table 3]. Histology of different lesions was similar to the features found in skin or elsewhere. In sebaceous gland carcinoma, histology showed lobules of cells with abundant, foamy, lipid-laden cytoplasm and well defined borders. Larger islands of tumor exhibited a comedocarcinoma pattern with central necrosis [Figure 3].
| Discussion|| |
Both benign and malignant lesions of the eyelid were most commonly seen in patients in their forties and fifties. Malignancy was rare in children and young adults, barring a case of retinoblastoma that invaded the eyelid. Though elderly people rarely had eyelid lesions, the risk of malignancy remained higher.
In our study, chalazion was the single most common benign lesion (25%), followed by epithelial cyst (16.66%), chronic nonspecific inflammation (12.5%) and seborrheic keratosis (10.42%). Histopathological correlation was available in nine out of the 12 cases of chalazions and revealed that diagnoses of two cases were incorrect and turned out to be suppurative inflammation.  On FNA smears, no definite granuloma was present in these two cases and occasional spindle shaped cells (fibroblasts) were misinterpreted as epithelioid cells. Moreover, clinical diagnosis of chalazion created a wrong impression during the evaluation of FNA smears. The three types of epithelial cysts viz. epidermoid, dermoid or trichilemmal could not be separated on cytomorphology though the presence of benign sebaceous cells in a few cases enabled them to be diagnosed as dermoid cysts. Clinically the cystic feel rather than solid appearance of other tumors (except hemangioma) also helped to arrive at a cytological diagnosis in these cases. Histopathological correlation was available in six out of 8 cases of epithelial cysts and confirmed no wrong diagnosis was made on smear examination.
Patients of seborrheic keratosis were usually aged. The lesions were sharply demarcated, flat to raised papules or plaques, often with a fish-colored appearance. Two cases were available for histopathological examination and one case did not correlate and turned out to be a case of melanocytic nevi. That lesion presented as hyperpigmented mass and was diagnosed cytologically as a pigmented variant of seborrheic keratosis. Failure to find out melanin pigment in the nevus cells on smear examination led to misdiagnosis. The other differential diagnosis of seborrheic keratosis was warts. Patients of squamous papilloma presented with finger like projections and showed mature squamous epithelial cells on smear examination. Koilocytic and dysplastic cells were present in warts but absent in seborrheic keratosis and squamous papilloma.
Cytohistological correlation was available in five cases of chronic nonspecific inflammation. Among these, only one case had inaccurate diagnosis and turned out to be chalazion, histologically. The polymorphic picture and granuloma were missing on stained smears. One case which was labeled as benign adnexal tumor on cytology was later diagnosed as basal cell carcinoma on biopsy. The case showed scanty cellularity with a few groups of basaloid cells and, hence, the confusion. One misdiagnosis of hemangioma was given on cytology that later on proved to be a pyogenic granuloma after histopathological examination. Smears predominantly composed of blood cells and occasional endothelial cells lead to misdiagnosis.
Sebaceous carcinoma of the eyelid might arise from Mebomian glands located in the tarsus, the glands of Zeis at the lid margin and sebaceous glands associated with caruncle and eyebrow. , In this study, eight cases were available for histological correlation and two wrong diagnoses were found after biopsy. One case turned out to be blepharitis and the other chalazion. On smears, some sebaceous cells had atypical features along with granulomas or acute inflammatory cells and we thought of well-differentiated sebaceous carcinoma, as fatty contents liberated from sebaceous glands due to ductal obstruction in a few cases of sebaceous carcinoma, might evoke a granulomatous response accompanied by neutrophils, creating confusion with blepharitis and chalazion. 
A case of keratoacanthoma was wrongly diagnosed as squamous cell carcinoma on cytology. Presence of dyskeratotic and dyskaryotic squamous cells led to misdiagnosis. Gordon Canti had pointed out that well-differentiated squamous cell carcinoma could not always be precluded from keratoacanthoma and a biopsy was required to confirm the case. A wrong diagnosis of retinoblastoma was given on cytology. Histopathological examination revealed the case was chronic nonspecific inflammation. The patient underwent enucleation for retinoblastoma and subsequently developed a diffused swelling of the eyelid. Cytomorphology showed paucicellular smear comprising of mononuclear small round cells (lymphocytes), which were misinterpreted as malignant retinoblastoma cells. The possible explanation might be secondary infection following enucleation.
Of the malignant lesions, basal cell carcinomas was the commonest malignant lesion (12 out of 32 malignant cases, 37.5%) followed by sebaceous gland carcinoma (28.12%) and squamous cell carcinoma (25%). In most western studies, incidence of basal cell carcinoma was much higher, as compared to sebaceous gland carcinoma or squamous cell carcinoma, and constituted about 80-90% of the malignant eyelid tumors.
In a study that was conducted in Japan, the findings regarding the incidence of malignant eyelid tumors corroborated our observations.  So, a racial difference in basal cell carcinoma, sebaceous gland carcinoma and squamous cell carcinoma might be considered when making a diagnosis.
To conclude, a combination of a study of the history, clinical diagnosis, smear examination and observation of the gross appearance of the lesion was employed to provide a cytological diagnosis of eyelid lesions.
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Santosh Kumar Mondal
"Teenkanya Complex", Flat 1B, Block B, 204 R N Guha Road, Dumdum, Kolkata - 700 028
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]