- Email: [email protected]
1. Masquerade Syndrome
Ocular Pathology for Clinicians Edited by Frederick A. Jakobiec, MD
1. Masquerade Syndrome SEYMOUR BROWNSTEIN, MD,*t FRANCOIS CODERE, MD,*t W. BRUCE JACKSON, MD* Abstract: A 52-year-old man experienced chronic blepharoconjunctivitis of the right eye of the three years' duration that was unresponsive to medications. Conjunctival cytologic examinations suggested carcinoma and this was confirmed by biopsy specimens of the conjunctiva. However, only a full-thickness eyelid biopsy established that the tumor was a sebaceous carcinoma. We discuss the importance of considering this condition in all cases of unilateral, persistent, or recurrent eye I id inflammation resistant to the usual therapy; the diagnostic value of conjunctival scrapings and full-thickness lid biopsy; and the necessity of interpretation of the biopsy material by a pathologist experienced with, and alerted to look for, this neoplasm. Early recognition of sebaceous carcinoma followed by prompt adequate therapy should improve the survival of patients with this rare but malignant tumor. [Key words: blepharoconjunctivitis, masquerade syndrome, sebaceous carcinoma.] Ophthalmology 87:259-262, 1980
The masquerade syndrome was first described in 1967 by Theodore 1 and Irvine 2 as chronic blepharoconjunctivitis due to an underlying conjunctival carcinoma. While the originally described neoplasms were squamous cell carcinomas, many of the tumors producing this clinical picture are believed to be sebaceous in origin. 3 Sebaceous carcinoma clinically also mimics chalazion and a variety of benign and malignant eyelid and orbital neoplasms. 4 - 9 Even pathologists have noted difficulty in arriving at a correct histologic diagnosis of this condition. 4 •9 •10 We describe a case of sebaceous carcinoma that had been treated for over three years as a chronic blepharoconjunctivitis. We demonstrate some of the pitfalls that led From the Departments of Ophthalmology* and Pathology,t McGill University, Royal Victoria Hospital. Montreal. Reprint requests to Seymour Brownstein, MD, Department of Ophthalmology, Royal Victoria Hospital, 687 Pine Avenue W, Room E4.61, Montreal, Quebec, Canada H3A 1A1.
to the incorrect clinical and pathologic diagnoses and we recommend some measures to avoid these misinterpretations which often result in a delay in definitive therapy.
CASE REPORT A 52-year-old man presented in April 1978 with a three-year history of redness of the inferior bulbar conjunctiva of the right eye associated with itching, burning, tearing, crusting. and some morning discharge. He had been treated by three physicians with a variety of topical medications containing antibiotics and corticosteroids without much improvement. He was otherwise in good health. Ocular examination revealed a correctable visual acuity of 20/20 in each eye. Examination of the right eye revealed slight thickening of the lower lid with marginal crusting and missing eyelashes (Fig I). The inferior tarsal conjunctiva was hyperemic with a mild papillary reaction while the superior tarsal conjunctiva appeared normal. A diffuse injection of the bulbar conjunctiva and a micropannus with epithelial erosions were noted inferiorly. The left eye showed only mild marginal crusting of the eyelids. The initial diagnosis was severe chronic marginal blepharitis with an associated keratoconjunctivitis. Cultures from the right eyelids and conjunctiva revealed a light growth of Staphylococcus epidermidis. Cytologic examination of a scraping from the right inferior tarsal conjunctiva showed many poorly differentiated, pleomorphic epithelial cells (Fig 2) and some acute and chronic inflammatory cells. Multiple conjunctival biopsies showed carcinoma in situ in the right inferior tarsal, forniceal and bulbar conjunctiva (Fig 3) and chronic conjunctivitis in the right superior bulbar and tarsal conjunctiva while a full-thickness right lower lid biopsy was interpreted as invasive squamous cell carcinoma (Figs 4, 5). This diagnosis was revised when the sections were re-examined in June 1978 and were noted to show features of a sebaceous carcinoma arising from the glands of Zeis and the meibomian glands with the presence of some foamy, well-differentiated sebaceous carcinoma cells surrounded by many vacuolated, more basophilic, anaplastic cells and with pagetoid invasion of the epithelium of the lid margin (Figs 4-6). The right lower lid was irradiated between May 19 and June 6, 1978 with a total dosage of
(f)
z
<{
0
z
::J
u
0::
0
lL
>-
<.9 0 _j
0 I
f-
<{
0.. 0::
:5:::J
u 0
•
z
w z
f-
(f)
s0
0::
(!)
259
C')
a: w
Cil
::'j!
=>
z
•
r--ro
w
::'j!
=> _j
0
>
•
0
ro
0)
I
0
a:
::'j!
•
>-
(9
0 _j 0
::'j! _j
I-
I
()_
0
260
Figs 1- 5 left column: Figs 6 - 9 right column . Fig I. Hype re mia of inferior bulbar and palpebral conjuncti va a nd thi cke ning of right lower lid with cru~ting a nd lo ss of lashe s (April 1978) . Fig 2. Co njun cti va l scraping (April 1978) . An
4,500 roentgens and a right inferior bulbar conjunctivectomy was performed on June 7, 1978. Sections of the excised bulbar conjunctiva revealed carcinoma extending to the margins of the specimen. Subsequent bulbar conjunctival biopsies taken in July and August 1978 showed only mild inflammation. In November 1978, a moderate papillary reaction was evident in the right superior tarsal conjunctiva (Fig 7). Scrapings and a biopsy from this region and from the inferior tarsus revealed carcinoma (Fig 8). The right orbital contents were exenterated. The lower lid showed findings similar to those noted in the full-thickness lid biopsy of June 1978. Tumor cells were present in the superficial bulbar and superior and inferior forniceal conjunctiva and were noted to replace the superior corneal epithelium (Fig 9). There was no evidence of recurrent or metastatic tumor during the following six months.
DISCUSSION Sebaceous carcinoma of the eyelid is a relatively rare condition comprising about 1% of all malignant tumors of the lid. 4 It is an important lesion, however, since it is one of the most malignant primary tumors of the lid with 5-year and 10-year actuarial tumor death rates of 15% and 28% respectively. 9 A delay in establishing a correct diagnosis is a key factor for this high mortality and may necessitate radical surgery. It has been shown that the four-year death rate increased from 13% to 43% when the duration of symptoms before excision of the tumor was greater than six months. 9 Factors that contribute to this delay include the rarity of the lesion, its resemblance to a variety of benign conditions, and the inexperience of many clinicians and pathologists with this entity. All cases of persistent or recurrent unilateral external ocular inflammation should be viewed with a high index of suspicion for a possible underlying malignancy. The differential diagnosis would include an infective agent, chronic lacrimal obstruction (dacryostenosis or canaliculitis), a foreign body, and other inflammatory conditions. Since the conjunctival and corneal changes are frequently due to carcinoma in situ or pagetoid involvement of the affected epithelium in the masquerade syndrome, early cytologic examinations should be performed on all cases of chronic conjunctivitis that are unresponsive to the usual medications. This is a relatively simple technique that can be repeated readily. 11 Conjunctival biopsies are indicated in resistant cases especially if there is thickening of the eyelid and loss of lashes; these specimens usually demonstrate carcinoma in situ which cannot be differentiated from squamous cell carcinoma or from other ad-
nexal neoplasms with similar superficial spread. Therefore it is imperative to perform a full-thickness biopsy of the clinically more involved area of the eyelid in order to demonstrate the sebaceous origin of the surface carcinoma. 10 Sebaceous carcinomas are uncommon tumors and are rarely encountered in other parts of the body. The general pathologist usually lacks experience with this condition which most commonly occurs in the eyelid. Of 95 cases of sebaceous carcinoma of the eyelid that were referred to the Armed Forces Institute of Pathology, the correct diagnosis was made by the contributing pathologist in only 47 cases with the most frequent misdiagnoses being squamous cell, basal cell, and adnexal carcinomas and adenocarcinoma not further specified. 9 Even many ophthalmic pathology laboratories encounter this lesion infrequently and may arrive at a similar misdiagnosis. The clinician may help to prevent this problem by alerting the pathologist of his suspicion of sebaceous carcinoma. The criteria for the histopathologic diagnosis include the demonstration of the origin of the tumor from the meibomian glands and/or glands of Zeis, and showing within the neoplasm varying degrees of sebaceous differentiation (Fig 5). It is best to conserve some of the submitted tissue in formalin so that fat stains prepared from frozen sections may demonstrate the sebaceous material of the tumor cells in specimens with less obvious sebaceous differentiation. In cases when there is any doubt of the diagnosis, it is advisable to refer the material to a major center of ophthalmic pathology where there is greater expertise with this condition. Because of difficulty in identifying the margins of sebaceous carcinoma of the eyelid clinically and even histologically and because of the multicentric origin of some of these tumors, the management is prompt wide excision of the involved tissues. 3 •6 •7 •9 • 12 Histologic monitoring of the surgical margins is mandatory. 6 • 12 Exenteration of the orbital contents may be deemed necessary in extensive cases especially if there is orbital invasion. 6 •8 · 9 • 13 The regional lymph nodes may be excised, when they are involved, with good results. 4 •6 •9 •13 Another surgical approach for diffuse cases may be wide excision of nodular lesions of the eyelid combined with total conjunctivectomy and, if indicated, superficial keratectomy in order to eradicate the areas of intraepithelial involvement (personal communication, Dr. F. A. Jakobiec); this procedure may have been beneficial in the preservation of the globe and orbital structures of our patient. Radiotherapy, either alone or combined with surgery, is
(f)
z
<{
0
z
_J
u
n:
0
LL
>-
(_')
0
_J
0 I
1--
<{ D..
n:
:5::::J
u 0
•
ro
Q)
zw
1--
(f)
z
:5:
0
n:
aJ
261
controversial in the management of this disease. 3 • 9 • 14 Although sebaceous carcinoma is generally believed to be radioresistant and this therapy was ineffective in our patient, it has been shown that tumor regression is possible and that there may be indications for this modality in selected cases. 14 A long-term follow-up of many patients is necessary in order to assess the efficacy of radiotherapy and of newer surgical approaches for this condition.
5.
6.
7.
8.
9.
ACKNOWLEDGMENTS
C')
Drs. David Samsome, Ross Harris, and Robert Orton provided clinical and pathologic material. Drs. Lorenz E. Zimmerman and M. Nisar Ahmed reviewed the pathologic and cytologic findings respectively.
0:
LlJ
10.
11.
CD
~
::J
z
,._•
REFERENCES
12.
ro
LlJ
~
::J
_J
0
>
•
0
ro
(J)
I
u
0:
<(
~
•
>-
C)
0
_J
0
~ _J
<(
I
f-
I
0...
0
262
1. Theodore FH. Conjunctival carcinoma masquerading as chronic conjunctivitis. Eye Ear Nose Throat Monthly 1967; 46:1419-20. 2. Irvine AR. Diffuse epibulbar squamous cell epithelioma. Am J Ophthalmol 1967; 64:550-4. 3. Irvine AR. Epibulbar squamous cell carcinoma and related lesions. lnt Ophthalmol Cl in 1972; 12:71-83. 4. Boniuk M, Zimmerman LE. Sebaceous carcinoma
13.
14.
of the eyelid, eyebrow, caruncle, and orbit. lnt Ophthalmol Clin 1972; 12:225-56. Brauninger GE, Hood I, Worthen DM. Sebaceous carcinoma of lid margin masquerading as cutaneous horn. Arch Ophthalmol 1973; 90:380-1. Cavanagh HD, Green WR, Goldberg HK. Multicentric sebaceous adenocarcinoma of the meibomian gland. Am J Ophthalmol 1974; 77:326-32 Shields JA, Font RL. Meibomian gland carcinoma presenting as a lacrimal gland tumor. Arch Ophthalmol 1974; 92:304-6. Perlman E, McMahon RT. Sebaceous gland carcinoma of the eyelid. Am J Ophthalmol 1978; 86:699-703. Rao NA, Mclean IW, Zimmerman LE. Sebaceous carcinoma of eyelids and caruncle: correlation of clinicopathologic features with prognosis. In: Jakobiec FA, ed. Ocular and Adnexal Tumors. Birmingham, AL, Aesculapius Publishing, 1978; 461-76. Foster CS, Allansmith MR. Chronic unilateral blepharoconjunctivitis caused by sebaceous carcinoma. Am J Ophthalmol 1978; 86:218-20. Spinak M, Friedman AH. Squamous cell carcinoma of the conjunctiva. Value of exfoliative cytology in diagnosis. Surv Ophthalmol 1977; 21:351-55. Tenzel RR, Stewart WB, Boynton JR, Zbar M. Sebaceous adenocarcinoma of the eyelid. Arch Ophthalmol 1977; 95:2203-4. Callahan MA, Callahan A. Sebaceous carcinoma of the eyelids. In: Jakobiec FA, ed. ocular and Adnexal Tumors. Birmingham, AL, Aesculapius Publishing, 1978; 477-83. Hendley Rl, Rieser JC, Cavanagh HD, Bodner Bl, Waring GO. Primary radiation therapy for meibomian gland carcinoma. Am J Ophthalmol 1979; 87:206-9.
1. Masquerade Syndrome SEYMOUR BROWNSTEIN, MD,*t FRANCOIS CODERE, MD,*t W. BRUCE JACKSON, MD* Abstract: A 52-year-old man experienced chronic blepharoconjunctivitis of the right eye of the three years' duration that was unresponsive to medications. Conjunctival cytologic examinations suggested carcinoma and this was confirmed by biopsy specimens of the conjunctiva. However, only a full-thickness eyelid biopsy established that the tumor was a sebaceous carcinoma. We discuss the importance of considering this condition in all cases of unilateral, persistent, or recurrent eye I id inflammation resistant to the usual therapy; the diagnostic value of conjunctival scrapings and full-thickness lid biopsy; and the necessity of interpretation of the biopsy material by a pathologist experienced with, and alerted to look for, this neoplasm. Early recognition of sebaceous carcinoma followed by prompt adequate therapy should improve the survival of patients with this rare but malignant tumor. [Key words: blepharoconjunctivitis, masquerade syndrome, sebaceous carcinoma.] Ophthalmology 87:259-262, 1980
The masquerade syndrome was first described in 1967 by Theodore 1 and Irvine 2 as chronic blepharoconjunctivitis due to an underlying conjunctival carcinoma. While the originally described neoplasms were squamous cell carcinomas, many of the tumors producing this clinical picture are believed to be sebaceous in origin. 3 Sebaceous carcinoma clinically also mimics chalazion and a variety of benign and malignant eyelid and orbital neoplasms. 4 - 9 Even pathologists have noted difficulty in arriving at a correct histologic diagnosis of this condition. 4 •9 •10 We describe a case of sebaceous carcinoma that had been treated for over three years as a chronic blepharoconjunctivitis. We demonstrate some of the pitfalls that led From the Departments of Ophthalmology* and Pathology,t McGill University, Royal Victoria Hospital. Montreal. Reprint requests to Seymour Brownstein, MD, Department of Ophthalmology, Royal Victoria Hospital, 687 Pine Avenue W, Room E4.61, Montreal, Quebec, Canada H3A 1A1.
to the incorrect clinical and pathologic diagnoses and we recommend some measures to avoid these misinterpretations which often result in a delay in definitive therapy.
CASE REPORT A 52-year-old man presented in April 1978 with a three-year history of redness of the inferior bulbar conjunctiva of the right eye associated with itching, burning, tearing, crusting. and some morning discharge. He had been treated by three physicians with a variety of topical medications containing antibiotics and corticosteroids without much improvement. He was otherwise in good health. Ocular examination revealed a correctable visual acuity of 20/20 in each eye. Examination of the right eye revealed slight thickening of the lower lid with marginal crusting and missing eyelashes (Fig I). The inferior tarsal conjunctiva was hyperemic with a mild papillary reaction while the superior tarsal conjunctiva appeared normal. A diffuse injection of the bulbar conjunctiva and a micropannus with epithelial erosions were noted inferiorly. The left eye showed only mild marginal crusting of the eyelids. The initial diagnosis was severe chronic marginal blepharitis with an associated keratoconjunctivitis. Cultures from the right eyelids and conjunctiva revealed a light growth of Staphylococcus epidermidis. Cytologic examination of a scraping from the right inferior tarsal conjunctiva showed many poorly differentiated, pleomorphic epithelial cells (Fig 2) and some acute and chronic inflammatory cells. Multiple conjunctival biopsies showed carcinoma in situ in the right inferior tarsal, forniceal and bulbar conjunctiva (Fig 3) and chronic conjunctivitis in the right superior bulbar and tarsal conjunctiva while a full-thickness right lower lid biopsy was interpreted as invasive squamous cell carcinoma (Figs 4, 5). This diagnosis was revised when the sections were re-examined in June 1978 and were noted to show features of a sebaceous carcinoma arising from the glands of Zeis and the meibomian glands with the presence of some foamy, well-differentiated sebaceous carcinoma cells surrounded by many vacuolated, more basophilic, anaplastic cells and with pagetoid invasion of the epithelium of the lid margin (Figs 4-6). The right lower lid was irradiated between May 19 and June 6, 1978 with a total dosage of
(f)
z
<{
0
z
::J
u
0::
0
lL
>-
<.9 0 _j
0 I
f-
<{
0.. 0::
:5:::J
u 0
•
z
w z
f-
(f)
s0
0::
(!)
259
C')
a: w
Cil
::'j!
=>
z
•
r--ro
w
::'j!
=> _j
0
>
•
0
ro
0)
I
0
a:
::'j!
•
>-
(9
0 _j 0
::'j! _j
I-
I
()_
0
260
Figs 1- 5 left column: Figs 6 - 9 right column . Fig I. Hype re mia of inferior bulbar and palpebral conjuncti va a nd thi cke ning of right lower lid with cru~ting a nd lo ss of lashe s (April 1978) . Fig 2. Co njun cti va l scraping (April 1978) . An
4,500 roentgens and a right inferior bulbar conjunctivectomy was performed on June 7, 1978. Sections of the excised bulbar conjunctiva revealed carcinoma extending to the margins of the specimen. Subsequent bulbar conjunctival biopsies taken in July and August 1978 showed only mild inflammation. In November 1978, a moderate papillary reaction was evident in the right superior tarsal conjunctiva (Fig 7). Scrapings and a biopsy from this region and from the inferior tarsus revealed carcinoma (Fig 8). The right orbital contents were exenterated. The lower lid showed findings similar to those noted in the full-thickness lid biopsy of June 1978. Tumor cells were present in the superficial bulbar and superior and inferior forniceal conjunctiva and were noted to replace the superior corneal epithelium (Fig 9). There was no evidence of recurrent or metastatic tumor during the following six months.
DISCUSSION Sebaceous carcinoma of the eyelid is a relatively rare condition comprising about 1% of all malignant tumors of the lid. 4 It is an important lesion, however, since it is one of the most malignant primary tumors of the lid with 5-year and 10-year actuarial tumor death rates of 15% and 28% respectively. 9 A delay in establishing a correct diagnosis is a key factor for this high mortality and may necessitate radical surgery. It has been shown that the four-year death rate increased from 13% to 43% when the duration of symptoms before excision of the tumor was greater than six months. 9 Factors that contribute to this delay include the rarity of the lesion, its resemblance to a variety of benign conditions, and the inexperience of many clinicians and pathologists with this entity. All cases of persistent or recurrent unilateral external ocular inflammation should be viewed with a high index of suspicion for a possible underlying malignancy. The differential diagnosis would include an infective agent, chronic lacrimal obstruction (dacryostenosis or canaliculitis), a foreign body, and other inflammatory conditions. Since the conjunctival and corneal changes are frequently due to carcinoma in situ or pagetoid involvement of the affected epithelium in the masquerade syndrome, early cytologic examinations should be performed on all cases of chronic conjunctivitis that are unresponsive to the usual medications. This is a relatively simple technique that can be repeated readily. 11 Conjunctival biopsies are indicated in resistant cases especially if there is thickening of the eyelid and loss of lashes; these specimens usually demonstrate carcinoma in situ which cannot be differentiated from squamous cell carcinoma or from other ad-
nexal neoplasms with similar superficial spread. Therefore it is imperative to perform a full-thickness biopsy of the clinically more involved area of the eyelid in order to demonstrate the sebaceous origin of the surface carcinoma. 10 Sebaceous carcinomas are uncommon tumors and are rarely encountered in other parts of the body. The general pathologist usually lacks experience with this condition which most commonly occurs in the eyelid. Of 95 cases of sebaceous carcinoma of the eyelid that were referred to the Armed Forces Institute of Pathology, the correct diagnosis was made by the contributing pathologist in only 47 cases with the most frequent misdiagnoses being squamous cell, basal cell, and adnexal carcinomas and adenocarcinoma not further specified. 9 Even many ophthalmic pathology laboratories encounter this lesion infrequently and may arrive at a similar misdiagnosis. The clinician may help to prevent this problem by alerting the pathologist of his suspicion of sebaceous carcinoma. The criteria for the histopathologic diagnosis include the demonstration of the origin of the tumor from the meibomian glands and/or glands of Zeis, and showing within the neoplasm varying degrees of sebaceous differentiation (Fig 5). It is best to conserve some of the submitted tissue in formalin so that fat stains prepared from frozen sections may demonstrate the sebaceous material of the tumor cells in specimens with less obvious sebaceous differentiation. In cases when there is any doubt of the diagnosis, it is advisable to refer the material to a major center of ophthalmic pathology where there is greater expertise with this condition. Because of difficulty in identifying the margins of sebaceous carcinoma of the eyelid clinically and even histologically and because of the multicentric origin of some of these tumors, the management is prompt wide excision of the involved tissues. 3 •6 •7 •9 • 12 Histologic monitoring of the surgical margins is mandatory. 6 • 12 Exenteration of the orbital contents may be deemed necessary in extensive cases especially if there is orbital invasion. 6 •8 · 9 • 13 The regional lymph nodes may be excised, when they are involved, with good results. 4 •6 •9 •13 Another surgical approach for diffuse cases may be wide excision of nodular lesions of the eyelid combined with total conjunctivectomy and, if indicated, superficial keratectomy in order to eradicate the areas of intraepithelial involvement (personal communication, Dr. F. A. Jakobiec); this procedure may have been beneficial in the preservation of the globe and orbital structures of our patient. Radiotherapy, either alone or combined with surgery, is
(f)
z
<{
0
z
_J
u
n:
0
LL
>-
(_')
0
_J
0 I
1--
<{ D..
n:
:5::::J
u 0
•
ro
Q)
zw
1--
(f)
z
:5:
0
n:
aJ
261
controversial in the management of this disease. 3 • 9 • 14 Although sebaceous carcinoma is generally believed to be radioresistant and this therapy was ineffective in our patient, it has been shown that tumor regression is possible and that there may be indications for this modality in selected cases. 14 A long-term follow-up of many patients is necessary in order to assess the efficacy of radiotherapy and of newer surgical approaches for this condition.
5.
6.
7.
8.
9.
ACKNOWLEDGMENTS
C')
Drs. David Samsome, Ross Harris, and Robert Orton provided clinical and pathologic material. Drs. Lorenz E. Zimmerman and M. Nisar Ahmed reviewed the pathologic and cytologic findings respectively.
0:
LlJ
10.
11.
CD
~
::J
z
,._•
REFERENCES
12.
ro
LlJ
~
::J
_J
0
>
•
0
ro
(J)
I
u
0:
<(
~
•
>-
C)
0
_J
0
~ _J
<(
I
f-
I
0...
0
262
1. Theodore FH. Conjunctival carcinoma masquerading as chronic conjunctivitis. Eye Ear Nose Throat Monthly 1967; 46:1419-20. 2. Irvine AR. Diffuse epibulbar squamous cell epithelioma. Am J Ophthalmol 1967; 64:550-4. 3. Irvine AR. Epibulbar squamous cell carcinoma and related lesions. lnt Ophthalmol Cl in 1972; 12:71-83. 4. Boniuk M, Zimmerman LE. Sebaceous carcinoma
13.
14.
of the eyelid, eyebrow, caruncle, and orbit. lnt Ophthalmol Clin 1972; 12:225-56. Brauninger GE, Hood I, Worthen DM. Sebaceous carcinoma of lid margin masquerading as cutaneous horn. Arch Ophthalmol 1973; 90:380-1. Cavanagh HD, Green WR, Goldberg HK. Multicentric sebaceous adenocarcinoma of the meibomian gland. Am J Ophthalmol 1974; 77:326-32 Shields JA, Font RL. Meibomian gland carcinoma presenting as a lacrimal gland tumor. Arch Ophthalmol 1974; 92:304-6. Perlman E, McMahon RT. Sebaceous gland carcinoma of the eyelid. Am J Ophthalmol 1978; 86:699-703. Rao NA, Mclean IW, Zimmerman LE. Sebaceous carcinoma of eyelids and caruncle: correlation of clinicopathologic features with prognosis. In: Jakobiec FA, ed. Ocular and Adnexal Tumors. Birmingham, AL, Aesculapius Publishing, 1978; 461-76. Foster CS, Allansmith MR. Chronic unilateral blepharoconjunctivitis caused by sebaceous carcinoma. Am J Ophthalmol 1978; 86:218-20. Spinak M, Friedman AH. Squamous cell carcinoma of the conjunctiva. Value of exfoliative cytology in diagnosis. Surv Ophthalmol 1977; 21:351-55. Tenzel RR, Stewart WB, Boynton JR, Zbar M. Sebaceous adenocarcinoma of the eyelid. Arch Ophthalmol 1977; 95:2203-4. Callahan MA, Callahan A. Sebaceous carcinoma of the eyelids. In: Jakobiec FA, ed. ocular and Adnexal Tumors. Birmingham, AL, Aesculapius Publishing, 1978; 477-83. Hendley Rl, Rieser JC, Cavanagh HD, Bodner Bl, Waring GO. Primary radiation therapy for meibomian gland carcinoma. Am J Ophthalmol 1979; 87:206-9.