Ulcerative Squamous Eyelid Papilloma: A Rare Presentation

Abstract Purpose To highlight the importance of histopathological evaluation of a lid mass to prognosticate the disease. We report a case of ulcerative squamous cell papilloma with clinical features suggesting malignancy. Case report A 65-year-old man presented with a rapidly enlarging mass in the left upper eyelid, with clinical features suggesting a squamous cell carcinoma. However, a repeat histopathological examination showed no malignant cells. The patient was diagnosed with squamous cell papilloma. He was followed-up for 30 months and no recurrence was observed. No such case has previously been reported in the literature. Conclusion This report highlights the need for histopathological examination of all eyelid lesions to enable surgeons to prognosticate the disease.


INTRODUCTION
Eyelid papilloma is one of the most common eyelid tumors and typically occurs in middle-aged or elderly patients. [1,2] These tumors are papillomatous and appear as a smooth, rounded, or pedunculated elevation of abnormal tissue.
Squamous papilloma may mimic other benign eyelid lesions with the same appearance, and malignant skin lesions, particularly squamous cell carcinoma. Feeder vessels, hyperkeratosis, leukoplakic plaque, keratinization, scaling, and ulceration are considered as features suggestive of malignancy. Nevertheless, atypical malignant behavior of a benign eyelid lesion is unusual. Herein, we report the case of a lesion presenting with typical malignancy features that was histopathologically found to be benign. To the best of our knowledge and based on a review of the literature, ulcerative squamous papilloma of the eyelid has not been reported thus far.    enlarging for the past seven years. A pedunculated growth measuring 20 × 12 mm was observed involving the medial half of the eyelid. The mass was huge, with superficial ulceration and a red base with sharply defined indurated borders. It was pedunculated, such that the base of the mass was smaller than its superficial appearance. He was diagnosed with papilloulcerative squamous cell carcinoma [ Figure 1]. The mass was excised with a 4-mm free margin, creating a defect measuring 8 × 6 cm, which was reconstructed using a Cutler-Beard flap. The flap was prepared from the inferior eyelid below the tarsus to ensure compatibility with the superior eyelid defect by making a horizontal incision 4 mm below the lid margin. Histopathological examination revealed no atypia; rather, the lesion was composed of papillae with vascularized connective tissue covered by acanthotic epithelium. Hence, it was diagnosed as ulcerative squamous cell papilloma [ Figure 3]. A repeat examination with repeat tissue cuts and histopathology slide preparation performed by another pathologist did not change the diagnosis. The patient was followed-up for 30 months and no recurrence was observed.

DISCUSSION
Ocular papillomas favor sites where the epithelium undergoes transition. They can occur at either the limbus or the eyelid margin. Papillomas typically arise from the basal cells but, rarely, may form through the proliferation of squamous cells. Squamous cell papilloma is the most common benign lesion of the eyelid, constituting 13-19.5% of benign eyelid tumors. [3,4] For squamous cell papilloma, having surface ulceration and indurated margins is not unusual. In the present case, the clinical appearance suggested malignancy, but histopathology changed the diagnosis. Kersten et al reported that the majority of the initially benign lesions were found to be malignant on repeat histopathology. [5] Our case revealed an absence of atypia on repeat examination. Furthermore, the patient was followed-up for two and a half years with no recurrence.
Although rare, case reports of surface pigmentation and hyperkeratosis in squamous papilloma exist. [6,7] This also emphasizes the need for histopathological examination of all eyelid lesions to enable surgeons to prognosticate the disease and advise patients accordingly.
The gold standard treatment for eyelid carcinomas is surgical resection with clear margins followed by reconstructive procedures. Cutler-Beard flap surgery is a successful procedure for superior eyelid tumors with wide tissue loss. [8,9] The long-time closure of the eyelids, and the need for a second surgery are the major disadvantages of this procedure.
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Conflicts of Interest
There is no conflict of interest.