RALAT

Pada BAB I halaman 1 (Latar Belakang paragraf terakhir) tertulis “Pasien

biasanya mengeluh timbul benjolan pada 1ating 1 al.”
Seharusnya: “Pasien biasanya mengeluh timbul benjolan pada kelopak mata.”

Pada BAB II halaman 3 (Identifikasi) tertulis “3ating ke poli mata RSUP dr. Moh.
Hoesin Palembang ”
Seharusnya: “Datang ke poli mata RSUP dr. Moh. Hoesin Palembang ”

Pada BAB II halaman 6 (Status Lokalis)

Seharusnya tertulis: Palpebra superior: Tampak massa sebesar kacang merah
pada margo palpebra sentral, warna merah kekuningan, permukaan berdungkul-
dungkul, batas tegas, madarosis (+), ukuran 14x4x0,7 mm, immobile, konsistensi
padat, nyeri (-), mudah berdarah (-).
1
 Case Presentation
March 12th, 2019

Diagnosis and Management of

Sebaceous Gland Carcinoma
Nodular Type

Defayudina Dafilianty Rosataria*

Consultant
dr. H. Ibrahim, SpM(K)

OPHTHALMOLOGY DEPARTMENT OF SRIWIJAYA UNIVERSITY

MOHAMMAD HOESIN HOSPITAL PALEMBANG
2019
Introduction

Sebaceous gland carcinoma 

malignant tumor from sebaceous
gland

Originate from meibom gland of the

tarsus, zeis gland of the eyelid
skin,and sebaceous gland of th
caruncle
 Introduction

Sebaceous Gland Carcinoma

>> Upper eyelid

60 years old

Lesion appears as a
firm with a yellow hue
Asian >
due to the high
Caucasian
concentration of
intracellular lipids
 Introduction

TREATMENT

• Wide excision
• Orbital exenteration
Operative • Lymph node dissection
• Cryotherapy

Post tumor • Reconstruction

excision
AIM

To report a case of Sebaceous

Gland Carcinoma and its
management

6
CASE REPORT
 Identification

Name • Mrs. N

Age • 60 years old

Sex • Female

Address • Out of Town

Date of Visit • January 29th, 2019

Med. Record • 1028906

Occupation • Housewife
 Anamnesis

Chief complain: There is a lump in the inside of

upper right eyelid since 2 years ago.

Since ± 2 years ago, There is a lump in the inside of

upper right eyelid. Initially small lumps, as big as
rice, yellowish white, painful (-), itchy (-), easy to
bleed (-), red eye (-), tearing eye (-), blurred vision
(+), felt slowly, views like smoky (+). The patient is
not treated.

9
 Anamnesis

Since a month ago, the lump is getting bigger.

Pain (-), itching (-), easily bleed (-), red eyes (-),
eye discharge (-), blurred vision (+), felt slowly,
views like smoky (+). The patient went to the
regional eye hospital and incisional biopsy was
performed. After the results of the PA came out,
they were then referred to RSUP Dr. Moh.
Hoesin Palembang.

10
 History of Past Illness

Trauma &
Denied
Allergy

Hypertension
Denied
& DM

Spectacles Denied

11
 History of Past Illness

Eye Surgery:

• Incisional biopsy a month

ago: Sebaceous Gland
Carcinoma of the right eye. Occupation history:

• Farmer

12
 Physical examination

Sensorium: Blood pressure:

compos mentis 130/80 mmHg Pulse: 76/menit

Respiratory rate: Temperature:

18x/minutes afebril

13
 Physical examination

Axila : no enlargement

Supraclavicula : no enlargement

Submandibule : no enlargement

Inguinale : no enlargement

Retroauricular : no enlargement
 Ophthalmology Examination

OD OS
VA 6/15 ph 6/9 6/12 ph 6/9
IOP 15,6 mmHg 15,6 mmHg
Ocular Alignment Orthophoria

Ocular Movement
15
 Ophthalmology Examination
Palpebra Localized status Normal
Conjunctiva Normal Normal
Cornea Clear Clear
COA Normal depth Normal depth
Iris Good feature Good feature
Pupil Round, central, LR(+), ϴ 3 mm Round, central, LR(+), ϴ 3 mm
Cloudy, shadow test (+), Cloudy, shadow test (+),
Lens nuclearis cataract grade II, nuclearis cataract grade II,
LOCS NO2NC2C0P0 LOCS NO2NC2C0P0
Fundus Reflex (+) Fundus Reflex (+)
Papil : Round, defined margin, Papil : Round, defined margin,
Posterior normal color, c/d 0,3, a:v 2:3, normal color, c/d 0,3, a:v 2:3,
segment Macula : RF (+) Macula : RF (+)
Retina : Good blood vessel Retina : Good blood vessel
contour contour
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 Ophthalmology Examination

Superior:
A mass with red bean size on the
central palpebral margin, yellowish red
color, multinodular, firm boundary,
Localized Status 14x4x0.7 mm in size, immobile, dense
consistency, madarosis (+), no
bleeding and painless.

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 Diagnosis

Sebaceous Gland Carcinoma Nodular Type OD

Grade II Nuclearis Cataract OD

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 Management

• Informed consent

• Pro laboratory check, chest xray

• Pro wide excision + VC + palpebral reconstruction

• Pro consult to internal department and anesthesiology department

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Prognosis

Quo ad vitam: Dubia ad bonam

Quo ad
Dubia ad bonam
functionam:

20
 Laboratory Result

Hb : 12 g/dL SGOT : 19
Leucocyte : 7.040/mm3 SGPT : 10
Thrombocyte : 180.000/µL Ureum : 26 mg/dL
Hematocrit : 34 % Creatinine : 0,60 mg/dL
Diff count : 0/5/52/35/8 Natrium : 146 mg/dL
BT : 1 minutes Calium : 3,9 mg/dL
CT : 8 minutes HBsAg : non-
Plasma blood : 123 mg/dl reactive
sugar

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 Consultation Report

Internist
Department
Chest xray, ECG : normal Anesthesia
Laboratory : normal Department
USG abdoment : normal
Bone survey : on schedule Assessment:
ASA II, geriatric
Assessment:
• Cor and pulmo functional
compensate
• No metastase
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Intraoperative Photograph

23
 Ophthalmology Examination
Follow Up Day-1

OD OS
VA 1/ PSB 6/12 ph 6/9
IOP P=N+0 14,3 mmHg
Ocular Alignment Can’t be explained

Ocular Movement Can’t be explained

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 Ophthalmology Examination
Follow Up Day-1

Palpebra Localized status Normal

Conjunctiva Can’t be explained Normal
Cornea Can’t be explained Clear
COA Can’t be explained Normal depth
Iris Can’t be explained Good feature
Pupil Can’t be explained Round, central, LR(+), ϴ 3 mm
Cloudy, shadow test (+),
Lens Can’t be explained nuclearis cataract grade II,
LOCS NO2NC2C0P0
Fundus Reflex (+)
Papil : Round, defined margin,
Posterior normal color, c/d 0,3, a:v 2:3,
Can’t be explained
segment Macula : RF (+)
Retina : Good blood vessel
contour 25
 Diagnosis

• Post wide excision + VC + palpebral reconstruction

a.i. Sebaceous Gland Carcinoma Nodular Type OD
• Grade II Nuclearis Cataract OD

26
 Management

• Mefenamic acid 3x500 mg tab per oral

• Cefixime 2x100 mg tab per oral

• Chloramphenicol EO 3x1 OD

• Unhospitalized, out patient control in a week

27
 Ophthalmology Examination
Follow Up Week-1

OD OS
VA 1/ PSB 6/12 ph 6/9
IOP P=N+0 16,4 mmHg
Ocular Alignment Can’t be explained

Ocular Movement Can’t be explained

28
 Ophthalmology Examination
Follow Up Week-1
Superior: good suture in 3mm above
the superior palpebral margin, outer
knot, blood (-), pus (-)
Palpebra Normal
Inferior: good suture in 3mm below
the inferior palpebral margin, outer
knot, blood (-), pus (-)
Conjunctiva Can’t be explained Normal
Cornea Can’t be explained Clear
COA Can’t be explained Normal depth
Iris Can’t be explained Good feature
Pupil Can’t be explained Round, central, LR(+), ϴ 3 mm
Cloudy, shadow test (+), nuclearis
Lens Can’t be explained cataract grade II, LOCS
NO2NC2C0P0
Fundus Reflex (+)
Papil : Round, defined margin,
Posterior
Can’t be explained normal color, c/d 0,3, a:v 2:3, Macula
segment
: RF (+)
Retina : Good blood vessel contour 29
 Diagnosis

• Post wide excision + VC + palpebral reconstruction

a.i. Sebaceous Gland Carcinoma Nodular Type OD
• Grade II Nuclearis Cataract OD

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 Management

• Chloramphenicol EO 3x1 OD

• Out patient control in 2 weeks

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 Pathology Anatomy

Impression: Well differentiated

sebaceous gland
carcinoma of the
palpebra superior
oculi dextra.
DISCUSSION
 DISCUSSION

60 yo female with a
lump in upper eyelid of
right eye since 2 years
ago, painless, not
easily bleed .
Occupation history:
farmer.
Getting bigger since a Long ultraviolet
month exposure was one of
predisposition factor Biopsy result:
Sebaceous gland
carcinoma

34
DISCUSSION
VOD: 6/15 ph 6/9
VOS: 6/12 ph 6/9
Lens ODS : cloudy,
shadow test (+), nuclearis
cataract grade II
Palpebra superior OD:
A mass with yellowish red
color, multinodular, firm
boundary, 14x4x0.7 mm in
size, immobile, dense
consistency, madarosis (+).
Characteristic SGC:
firm, painless, indurated
thickening of the eyelid,
with a yellow hue
Yellowish color due to the
high concentration of
intracellular lipids
Madarosis  sign of
malignancy
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 DISCUSSION

Sebaceous Gland Carcinoma

Nodular Type OD

Wide excision + frozen section Quo ad vitam and

+ reconstruction functionam:
Dubia ad bonam

Histology result:
Well differentiated sebaceous
gland carcinoma

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 CONCLUSION

• Reported a case sebaceous gland carcinoma upper eyelid

in the right eye. Diagnosis based on anamnesis and
ophthalmolgy examination
• Sebaceous Gland Carcinoma (SGC) is a malignant tumor
that originates from sebaceous gland adnexa. The
principal management is to remove malignant lesions to
prevent local or systemic spread. Periodic follow-up is
needed as an observation of the success of the flap,
recurrence, invasion of the orbit and distant metastases.

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42
43
44
NODULAR SPREADING

PAGETOID 45
46
LOBULAR

47
PAPILLARY

48
COMEDOCARCINOMA

49
well-differentiated • readily identified by the
sebaceous microvesicular foamy nature of the
carcinomas tumor cell cytoplasm.

Moderately
• may exhibit some degree of
differentiated sebaceous differentiation.
tumors

Poorly • may be difficult to distinguish from

differentiated the other, more common epithelial
tumors, malignancies

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53
glandula meibom seperti glandula sebaseus lainnya, merupakan target
organ androgen. Androgen meregulasi perkembangan, diferensiasi dan
produksi lipid dari glandula sebaseus pada tubuh. Hal yang sama,
androgen mengontrol fungsi glandula meibom, meningkatkan kualitas
dan/ atau kuantitas lipid yang diproduksi oleh jaringan ini dan
meningkatkan pembentukan lapisan lipid air mata. Pada keadaan
dimana terdapat defisiensi androgen, seperti pada kondisi menopause,
penuaan berhubungan dengan disfungsi glandula meibom
defisiensi androgen menyebabkan kehilangan lapisan lipid, secara
spesifik adalah trigliserida, kolesterol, monounsaturated essential fatty
acids (misalnya : asam oleik), dan lipid polar (misalnya :
fosfatidiletanolamin, sfingomielin). Kehilangan lipid polar (yang terdapat
Universitas Sumatera Utara 25 pada bidang pemisah lapisan akuos
airmata) memperburuk kehilangan evaporatif airmata, dan penurunan
asam lemak tidak tersaturasi meningkatkan titik lebur meibum,
menghasilkan sekresi yang lebih tebal dan lebih kental yang
mengobstruksi duktulusduktulus dan menyebabkan hambatan sekresi
59
 Treatment

Wide surgical excision

Mohs micrographic surgery
Map biopsies of the conjunctiva
Cryotherapy
Orbital exenteration
Sentinel lymph node (SLN) biopsy
61
CUTTLER BEARD

62
 CUTTLER BEARD

Flap jembatan Cutler-Beard merupakan flap komposit full-thickness

dari kelopak mata bawah.7 Insisi transversum full-thickness dibuat 5
mm di inferior margo palpebra inferior, sehingga memungkinkan elevasi
flap tanpa mengganggu vaskularisasi palpebra inferior yang tersisa.
Lebar flap horizontal harus sesuai dengan lebar defek di palpebra
superior, dan insisi full-thickness flap vertikal harus sesuai dengan
lebar defek di palpebra superior dan insisi dilakukan di fornix inferior.
Flap lalu dilanjutkan ke margo palpebra yang masih ada lalu difiksasi
pada defek palpebra superior dengan dijahit lapis demi lapis.
Konjungtiva dipisahkan dari flap musculocutaneous dan graft kartilago
dapat dilakukan untuk menyokong flap yang telah dibuat karena flap ini
biasanya hanya menyisakan sedikit atau tidak terdapat tarsus
didalamnya.2
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 INDIKASI

CUTTLER BEARD
Melakukan penanaman sebagian palpebra superior untuk menutupi defek pada
palpebra inferior.
• Fullthickness
• Jika defek palpebra horizontal > 50% dan defek vertikal sedang (10–15 mm)
• Mengenai daerah sentral

Keunggulan tehnik ini dibanding metode lainnya lebih sederhana dan dapat
menutupi defek yang lebar.
Kelemahan dari teknik ini yaitu (1) rekonstruksi dilakukan dalam 2 tahap dan
antar tahapan tersebut menganggu visus pasien, (2) gangguan kelopak mata
bawah yang kemungkinan memerlukan revisi dan/atau prosedur
pengencangan kelopak mata, dan (3) kekurangan bulu mata diregio yang
dilakukan rekonstruksi.

64
 Survival rate

Survival rates for sebaceous carcinoma are worse than

those for squamous cell carcinoma, but they have
improved in recent years as a result of increased
awareness, earlier detection, more accurate diagnosis, and
appropriate treatment.
Metastases first involve regional lymph node
The majority of recurrences in SGC appear within the first 4
years of treatment
5-year mortality in patients with metastatic disease has
been estimated at 50 – 67%
 Follow up

short intervals post-operatively as the tumor has a fast

growth potential. Adequate follow-up
includes meticulous inspection of the local site. Palpation of
the pre auricular, submandibular and other neck lymph
node chains is mandatory.
The approximate guidelines are 3 monthly interval during
the first year, 6 monthly during the second year and then on
a yearly basis for life
Prognosis
1. Keterlibatan kelopak
mata atas terutama
dengan keterlibatan 5.
simultan dari kedua 6.
kelopak atas dan
bawah.
7.
2. Durasi gejala lebih dari
6 bulan.
8.
3. Bentuk pertumbuhan
yang infiltratif. 9.
4. Diferensiasi sebasea
sedang sampai buruk
(diferensiasi sebasea
yang kecil).
Asal multisentrik.
Karsinoma intraepitel
(penyebaran pagetoid).
Invasi vaskular dan
saluran limfatik.
Invasi ke orbit.
Ukuran lebih dari 10
mm