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A Black-Pigmented Eyelid Nodule in an African American Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 73-year-old African American woman was referred for the evaluation of a pigmented lesion on her left upper eyelid margin of 6 weeks’ duration. The patient first noted an erythematous, tender swelling with yellow discharge, which later evolved to the pigmented mass. Her ocular history was unremarkable. Her medical history revealed hypertension, type 2 diabetes mellitus, and hyperlipidemia.

On examination, her visual acuity was 20/40 OD and 20/30 OS. There was a sausage-shaped, darkly pigmented (black), focally ulcerated nodule involving the medial upper eyelid margin and measuring 8 × 6 × 4 mm. Associated madarosis, eyelid margin notching, and telangiectasia were noted (Figure 1). The remainder of the anterior segment and a dilated fundus examination were unremarkable.

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Pigmented basal cell carcinoma

D. Perform a full-thickness eyelid resection with intraoperative control of margins

The differential diagnosis of a pigmented eyelid lesion includes a broad spectrum of benign and malignant tumors.1,2 Diagnostic considerations include benign tumors, such as nevi, blue nevi, seborrheic keratosis, apocrine hidrocystomas, vascular malformations, and inflammatory processes (eg, a chalazion). Malignant considerations include melanoma, metastasis, pigmented squamous cell carcinoma, and pigmented basal cell carcinoma (BCC).

The original symptoms of a tender, erythematous swelling with discharge raised initial concern for an inflammatory process, such as a chalazion; however, the large, firm, pretarsal nodule with a focal madarosis suggested a neoplastic process. Thus, hot compresses and an antibiotic-steroid ointment (choice A), an incision and drainage (choice B), and a corticosteroid injection (choice C), all of which treat inflammatory chalazia, would not be appropriate management options. Surgical excision is the mainstay of treatment for most primary eyelid malignant conditions. An anterior lamellar resection is a reasonable option for anteriorly situated tumors that do not involve the tarsus or posterior lamella of the eyelid. However, in this case, the tumor was associated with madarosis, which is indicative of tarsal involvement, leading to the decision to perform a full-thickness eyelid resection with intraoperative control of margins (choice D) and a subsequent reconstruction.1 At the time of surgery, the mass was found to be temporally invasive, and final margins were clear. Pathological testing confirmed pigmented BCC of the nodular and infiltrative types, involving the anterior and posterior lamellae of the eyelid (Figure 2).

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Article Information

Corresponding Author: Carol L. Shields, MD, Ocular Oncology Service, 840 Walnut St, Ste 1440, Philadelphia, PA 19107 (carolshields@gmail.com).

Published Online: November 21, 2019. doi:10.1001/jamaophthalmol.2019.4591

Conflict of Interest Disclosures: None reported.

Funding/Support: Support was provided by the Eye Tumor Research Foundation (Dr Shields).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study, in the collection, analysis and interpretation of the data, and in the preparation, review or approval of the manuscript.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Shields  JA, Shields  CL.  Eyelid, Conjunctival, and Orbital Tumors. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2016.
2.
Eagle  RC.  Eye Pathology: An Atlas and Textbook. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2017:279-282.
3.
Matsuoka  LY, Schauer  PK, Sordillo  PP.  Basal cell carcinoma in black patients.  J Am Acad Dermatol. 1981;4(6):670-672. doi:10.1016/S0190-9622(81)70067-7PubMedGoogle ScholarCrossref
4.
Abreo  F, Sanusi  ID.  Basal cell carcinoma in North American blacks: clinical and histopathologic study of 26 patients.  J Am Acad Dermatol. 1991;25(6 pt 1):1005-1011. doi:10.1016/0190-9622(91)70298-GPubMedGoogle ScholarCrossref
5.
Kikuchi  A, Shimizu  H, Nishikawa  T.  Clinical histopathological characteristics of basal cell carcinoma in Japanese patients.  Arch Dermatol. 1996;132(3):320-324. doi:10.1001/archderm.1996.03890270096014PubMedGoogle ScholarCrossref
6.
Maloney  ME, Jones  DB, Sexton  FM.  Pigmented basal cell carcinoma: investigation of 70 cases.  J Am Acad Dermatol. 1992;27(1):74-78. doi:10.1016/0190-9622(92)70160-HPubMedGoogle ScholarCrossref
7.
Hornblass  A, Stefano  JA.  Pigmented basal cell carcinoma of the eyelids.  Am J Ophthalmol. 1981;92(2):193-197. doi:10.1016/0002-9394(81)90769-8PubMedGoogle ScholarCrossref
8.
Kirzhner  M, Jakobiec  FA.  Clinicopathologic and immunohistochemical features of pigmented basal cell carcinomas of the eyelids.  Am J Ophthalmol. 2012;153(2):242-252.e2. doi:10.1016/j.ajo.2011.07.008PubMedGoogle ScholarCrossref
9.
Tan  WP, Tan  AW, Ee  HL, Kumarasinghe  P, Tan  SH.  Melanization in basal cell carcinomas: microscopic characterization of clinically pigmented and non-pigmented tumours.  Australas J Dermatol. 2008;49(4):202-206. doi:10.1111/j.1440-0960.2008.00469.xPubMedGoogle ScholarCrossref
10.
Bigler  C, Feldman  J, Hall  E, Padilla  RS.  Pigmented basal cell carcinoma in Hispanics.  J Am Acad Dermatol. 1996;34(5 pt 1):751-752. doi:10.1016/S0190-9622(96)90007-9PubMedGoogle ScholarCrossref
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