A Novel Approach to Handling Eyelid Biopsies of Low Malignancy Suspicion

Abstract

Purpose :

It is the standard of care to submit for pathological evaluation any eyelid lesions that are considered suspicious or likely to show malignancy. There is less clarity on how to handle lesions felt to be of low malignancy risk. Many ophthalmologists feel comfortable discarding certain lesions without pathologic evaluation based on a convincingly non-malignant appearance. However, there are always some lesions that are not clearly malignant or benign, and therefore are typically submitted.
In general, the estimated malignancy rate of eyelid lesions is 10-20 percent.^1,2 However, in biopsied eyelid lesions thought to be benign by the clinician, the rate of malignancy drops to between 2-4.6 percent.¹ As a result, a large number of pathologic evaluations are performed with the result being a benign diagnosis in up to 80-90 percent of all lesions and up to 97 percent of lesions thought to be benign clinically.^1,2
A significant downside of pathologic evaluation is cost, with uninsured patients at our institution paying 75 dollars out of pocket. Therefore, a way to substantially reduce or eliminate this expense without compromising risk to the patient would be desirable.

Methods :

We propose therefore a new paradigm of the management of eyelid biopsy specimens (Figure 1).

Results :

This protocol allows subsequent submission of pathology specimens if regrowth appears to be occurring, while substantially reducing unnecessary pathology submissions and cost to patients.
One possible downside to our approach is that malignancies such as sebaceous carcinoma (SC) traditionally require a fixation method other than formalin for histological analysis.⁴ However, IHC staining has emerged as a helpful tool in differentiating SC from other common eyelid malignancies like BC and remains an option for even formalin fixed samples.⁵ In addition, basal cell carcinoma (BC)—by far the most common eyelid malignancy—has low propensity to spread metastatically, reducing the risk of any delayed diagnosis that may result from the use of this paradigm.³

Conclusions :

In order to assess the safety and efficacy of this new treatment paradigm, we hope to perform a controlled study comparing it to the current standard of practice. Given the common nature of eyelid lesions, the cost savings could potentially be in the millions of dollars for the medical system.

This is a 2021 ARVO Annual Meeting abstract.

 

Figure 1: Flowchart of proposed clinical decision making in the approach of eyelid lesions