A 69-year-old man comes to the office due to a skin lesion near the medial left eye. The lesion does not itch or hurt. There have been no visual changes or eye discharge. Medical history is notable for hypothyroidism treated with levothyroxine. Examination of the lesion is shown in the exhibit. Extraocular movements are intact. Visual acuity is 20/20 bilaterally. Conjunctivae are clear. If left untreated, what is the most likely prognosis of this lesion?

Question

A 69-year-old man comes to the office due to a skin lesion near the medial left eye.  The lesion does not itch or hurt.  There have been no visual changes or eye discharge.  Medical history is notable for hypothyroidism treated with levothyroxine.  Examination of the lesion is shown in the exhibit.  Extraocular movements are intact.  Visual acuity is 20/20 bilaterally.  Conjunctivae are clear.  If left untreated, what is the most likely prognosis of this lesion?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be7d_ab44_8f63_7353552a1199_MD0005_00 This patient has a pearly, skin-colored nodule with telangiectasia concerning for basal cell carcinoma (BCC), the most common cancer of the eyelid. BCC is thought to originate from the basal keratinocytes of the hair follicles and the interfollicular epidermis. Perhaps because of its dependence on the dermal stroma, BCC rarely metastasizes (ie, <1% of the cases, in contrast to cutaneous squamous cell carcinoma, which has a higher rate) (Choice D). nodule However, BCC can invade local structures (eg, cartilage, bone, nerve). At the eyelid, BCC can invade the orbit, and delayed diagnosis can result in blindness and exenteration (Choice B). Risk factors for invasion include large tumor size, location at the medial canthus, and aggressive histologic type. Treatment typically involves Mohs micrographic surgery to ensure complete tumor removal and maximal preservation of normal tissue. (Choice A) Seborrheic keratosis is a common skin lesion characterized by a benign course with slow growth. It typically presents as a stuck-on papule with a rough, not smooth, surface; colors may range from skin-colored to dark brown. Intralesional telangiectasia is not present. stuck-on papule (Choice C) Molluscum contagiosum presents as a skin-colored papule with central umbilication and typically self-resolves within 6-12 months. Intralesional telangiectasia is not present. central umbilication Educational objective: Basal cell carcinoma is the most common malignancy of the eyelid. It characteristically presents as a pearly, skin-colored nodule with telangiectasia. Although metastasis is rare, local invasion of the orbit can result in blindness and exenteration. Treatment typically involves Mohs micrographic surgery. References: Basal cell carcinoma: from pathophysiology to novel therapeutic approaches. (http://www.ncbi.nlm.nih.gov/pubmed/33113965) Periocular basal cell carcinoma-clinical perspectives. (http://www.ncbi.nlm.nih.gov/pubmed/32395200)

A 69-Year-Old Man Comes to the Office Due to a Skin