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Tricho-Epithelioma of Eyelid
NOTES, CASES, INSTRUMENTS
189
REFERENCES 1
Elschnig. Arch, of Ophth., 1910, v. 75, p. 549; 1911, v. 79, p. 428. Woods, A. Arch, of Ophth., 1916, v. 45, p. 557; 1917, v. 46, pp. 8, 283, 503. Jour. Amer. Med. Assoc, 1921, v. 77, p. 1317. Amer. Jour. Ophth., 1936, v. 19, pp. 9, 100. ' Gill, L. D. South Med. Jour., 1941, v. 34, pp. 959-968. 4 Shannon. Arch, of Ophth., 1937, v. 17, p. 186. 5 Verhoeff. Arch, of Ophth., 1924, v. 53, p. 517; 1927, v. 56, p. 28. 0 Heine. Klin. M. f. Augenh., 1923, v. 71, p. 70. 'Gifford, H. Jour. Amer. Med. Assoc, 1900, p. 341. Ophth. Rec, 1908, v. 17, pp. 129, 584; 1914, v. 23, pp. 64, 349. 8 Gamble, R. C. Amer. Jour. Ophth., 1941, v. 24, pp. 49-51. 2
9
Thygeson, P.
Arch, of Ophth., 1943, v. 29, p. 1020.
TRICHO-EPITHELIOMA O F EYELID
CASE REPORT
CASE REPORT* JOHN
E.
L.
KEYES,
LT.
COL.
(MC),
A.U.S., AND FRANK B. QUEEN,
LT. COL. (MC), A.U.S. Tricho-epitheliomata are somewhat rare nonulcerating, nonmetastasizing, often multiple, benign tumors of the skin, of limited growth. Histologically distinctive, clinically they are not distinguishable from many other benign tumors of the skin and dermal derivatives. They pre sent an appearance, in common with tu mors of the sweat and sebaceous glands, of small, slightly elevated, flat, pale or translucent, circular or slightly irregular hard tumors, frequently on or near the face. Very few cases of this uncommon condition have been reported, possibly because the tumor, when uncomplicated, is not of major clinical importance. The authors recently encountered an example of tricho-epithelioma of unusual interest because of its location (on the palpebral margin of an eyelid) and its clinical ap pearance. A brief summary of this case is presented. * From the Department of Surgery, E.E.N.T. Section, and the Laboratory Service, Bushnell General Hospital.
A white corporal, aged 21 years, re ported to the eye clinic at Bushnell Gen eral Hospital on February 17, 1943. He complained of a small recurrent, pain less, localized nodule bordering on the margin of the left upper eyelid. A tuft of material resembling blond hairs pro truded from the swelling. The original nodule was first noticed about January, 1942, when a clump of blond hairs was observed among the cilia of the left upper eyelid. These unusual cilia increased in number and length. A small localized elevation of the skin of the eyelid devel oped concurrent with the abnormal cilia. The patient cut the strand of blond hair when it became noticeably longer than his normal cilia. The growth was never epilated. Prompt recurrence of the growth oc curred after its removal by curretting on or about September 15, 1942. Ulceration was never present. At no time was the growth of the hairy nodule rapid. De velopment, except for growth of the blond hair, was apparently stationary for two months before the patient reported to this clinic. There was no known etiologic factor. Neither this soldier, nor any mem ber of his family, had a history of nodules on the face, forehead, eyelids, or nose. Complement fixation tests for syph-
190
NOTES, CASES, INSTRUMENTS
ilis were negative. Complete physical ex amination revealed no other abnormality than the nodule in the left upper eyelid. Examination of patient's left upper eyelid revealed a tuft of material resem bling finely teased dental floss protruding from the lid margin. This material origi-
a clump of very light brown hair pro truded. Microscopic: There was no evidence of a capsule nor of epithelial covering. The general appearance of the specimen was that of modified corium. The stroma varied in density in different parts of the specimen. One area consisted of firm fibrous tissue with a hyalin keloid ap pearance and very few cellular elements. Other areas contained many structures supported by a less dense, more normalappearing connective-tissue stroma. Each low-power field contained many immature hair follicles, some of which contained a partly developed hair stalk. The internal sheath of the hair contained keratin mingled with the cells of Henle's
Fig. 1 (Keyes and Queen). A drawing of the tumor.
nated in a small localized firm subcuticular swelling. Viewed through a magnify ing loupe, the strand of light-colored ma terial was identified as immature hairs of varying lengths and sizes. The longest hair measured about 10 mm. The termi nal one third of the strand of hair curved downward. The tumor and attached cilia were ex tirpated by operation on March 17, 1943. The skin of the eyelid was split over the upper limit of the tumor. The skin was undermined and easily freed from the underlying nodule. The tumor was re moved without trauma or rupture. Re covery was uneventful. Nine months af ter operation there was no evidence of recurrence. PATHOLOGIC REPORT
Gross: The specimen consisted of a small round firm elongated piece of tis sue (0.4 by 0.3 by 0.3 mm.) from which
Fig. 2 (Keyes and Queen). Histologic detail of a portion of the tumor nodule. Ace. No. 91883 U. S. Army Medical Museum.
and Henkle's layers. Occasionally a glass membrane was present. Many irregularly shaped masses of basal cells were noted. There was an effort at palisading of the basal layer of cells. Some of these cell masses were solid, suggestive of the ap pearance of Krompecher's carcinoma.
NOTES, CASES, INSTRUMENTS
No prickle cells nor other cytologic evi dence of malignancy was observed. Other cell masses contained cystic spaces in which keratinous material was concen trically arranged. Hair shafts were defi nitely present in some of these cystic spaces. The appearance of the hair fol licles suggested a hamartomatous reac tion, possibly based on lanugo or infan tile hair follicles. Sebaceous glands and ducts of sweat glands were also present in the specimen. The blood supply was scant. Col. J. E. Ash (MC), U.S.A., curator of the Army Medical Museum, reported on this specimen as follows: "I do not believe it is malignant, more of a nevoid lesion, some of the hair follicles being im mature, of the lanugo type. I am not too fond of the term tricho-epithelioma, but it would seem to fit this tumor." Diagnosis: Tricho-epithelioma, benign, of eyelid. COMMENT
The term tricho-epithelioma is used in a histologic sense. The trichomatous na ture of this solitary lesion was obvious
191
clinically and histologically. The pres ence of immature hair differentiated the growth clinically from the tumors of Brooke,1 Jarisch,2 and Fordyce. 3 Refer ence is made to the articles of McDonagh4 and Traenkle 5 for a discussion of the relationship of epithelioma adenoides cysticum, tricho-epithelioma, and basalcell cancer. A search of the available medical liter ature failed to reveal a report of a similar lesion on the margin of the eye lid. Definite, clear-cut descriptions of tricho-epitheliomata are difficult to find. Many of the standard texts dealing with tumors do not mention the condition, as Boyd (Surgical pathology, ed. 5), Pack and Livingston (Treatment of cancer and allied diseases). Ewing (Neoplastic diseases, ed. 4 ) , in his discussion of epi dermal carcinoma, does not refer to tricho-epithelioma as such, though he does mention (p. 904) that "some basal cell tumors witfi compact groups of small elongated cells, or occasionally with adenoid characters, arise from the hair follicles."
REFERENCES 1
Brooke, H. G. Epithelioma adenoides cysticum. Brit. Jour. Derm., 1892, v. 4, Sept., p. 269. ' Jarisch. Zur Lehre von den Hautgeschwiilsten. Arch. f. Derm. u. Syph., 1894, v. 28, p. 163. 3 Fordyce, J. A. Multiple benign cystic epithelioma. Jour. Cutan. Dis., 1892, v. 10, Dec, p. 459. 'McDonagh, J. E. R. Pathology of skin from the eyelids and nasofacial grooves. Brit. Jour. Derm., 1912, v. 24, p. 291. 5 Traenkle, H. L. Epithelioma adenoides cysticum, tricho-epithelioma and basal cell cancer. Arch. Derm, and Syph., 1940, v. 42, Nov., p. 822.
E N D O P H T H A L M I T I S SUBSIDING AFTER T R E A T M E N T W I T H PENICILLIN* MARTIN I. GREEN, M.D., R A F A E L JAKOBOVITS,
AND M.D.
San Francisco 9 T h e prognosis in cases of fully devel oped suppurative endophthalmitis is * From Greens' Eye Hospital.
grave, and, as a rule, after all therapeutic measures to save the eye have failed, evisceration must be performed. Recent ly, however, the introduction of penicillin offers a new therapeutic approach in the treatment of many purulent ocular con ditions, as may be illustrated by the fol lowing case. History. A man, aged 70 years, was re ferred to the Greens' Eye Hospital on
189
REFERENCES 1
Elschnig. Arch, of Ophth., 1910, v. 75, p. 549; 1911, v. 79, p. 428. Woods, A. Arch, of Ophth., 1916, v. 45, p. 557; 1917, v. 46, pp. 8, 283, 503. Jour. Amer. Med. Assoc, 1921, v. 77, p. 1317. Amer. Jour. Ophth., 1936, v. 19, pp. 9, 100. ' Gill, L. D. South Med. Jour., 1941, v. 34, pp. 959-968. 4 Shannon. Arch, of Ophth., 1937, v. 17, p. 186. 5 Verhoeff. Arch, of Ophth., 1924, v. 53, p. 517; 1927, v. 56, p. 28. 0 Heine. Klin. M. f. Augenh., 1923, v. 71, p. 70. 'Gifford, H. Jour. Amer. Med. Assoc, 1900, p. 341. Ophth. Rec, 1908, v. 17, pp. 129, 584; 1914, v. 23, pp. 64, 349. 8 Gamble, R. C. Amer. Jour. Ophth., 1941, v. 24, pp. 49-51. 2
9
Thygeson, P.
Arch, of Ophth., 1943, v. 29, p. 1020.
TRICHO-EPITHELIOMA O F EYELID
CASE REPORT
CASE REPORT* JOHN
E.
L.
KEYES,
LT.
COL.
(MC),
A.U.S., AND FRANK B. QUEEN,
LT. COL. (MC), A.U.S. Tricho-epitheliomata are somewhat rare nonulcerating, nonmetastasizing, often multiple, benign tumors of the skin, of limited growth. Histologically distinctive, clinically they are not distinguishable from many other benign tumors of the skin and dermal derivatives. They pre sent an appearance, in common with tu mors of the sweat and sebaceous glands, of small, slightly elevated, flat, pale or translucent, circular or slightly irregular hard tumors, frequently on or near the face. Very few cases of this uncommon condition have been reported, possibly because the tumor, when uncomplicated, is not of major clinical importance. The authors recently encountered an example of tricho-epithelioma of unusual interest because of its location (on the palpebral margin of an eyelid) and its clinical ap pearance. A brief summary of this case is presented. * From the Department of Surgery, E.E.N.T. Section, and the Laboratory Service, Bushnell General Hospital.
A white corporal, aged 21 years, re ported to the eye clinic at Bushnell Gen eral Hospital on February 17, 1943. He complained of a small recurrent, pain less, localized nodule bordering on the margin of the left upper eyelid. A tuft of material resembling blond hairs pro truded from the swelling. The original nodule was first noticed about January, 1942, when a clump of blond hairs was observed among the cilia of the left upper eyelid. These unusual cilia increased in number and length. A small localized elevation of the skin of the eyelid devel oped concurrent with the abnormal cilia. The patient cut the strand of blond hair when it became noticeably longer than his normal cilia. The growth was never epilated. Prompt recurrence of the growth oc curred after its removal by curretting on or about September 15, 1942. Ulceration was never present. At no time was the growth of the hairy nodule rapid. De velopment, except for growth of the blond hair, was apparently stationary for two months before the patient reported to this clinic. There was no known etiologic factor. Neither this soldier, nor any mem ber of his family, had a history of nodules on the face, forehead, eyelids, or nose. Complement fixation tests for syph-
190
NOTES, CASES, INSTRUMENTS
ilis were negative. Complete physical ex amination revealed no other abnormality than the nodule in the left upper eyelid. Examination of patient's left upper eyelid revealed a tuft of material resem bling finely teased dental floss protruding from the lid margin. This material origi-
a clump of very light brown hair pro truded. Microscopic: There was no evidence of a capsule nor of epithelial covering. The general appearance of the specimen was that of modified corium. The stroma varied in density in different parts of the specimen. One area consisted of firm fibrous tissue with a hyalin keloid ap pearance and very few cellular elements. Other areas contained many structures supported by a less dense, more normalappearing connective-tissue stroma. Each low-power field contained many immature hair follicles, some of which contained a partly developed hair stalk. The internal sheath of the hair contained keratin mingled with the cells of Henle's
Fig. 1 (Keyes and Queen). A drawing of the tumor.
nated in a small localized firm subcuticular swelling. Viewed through a magnify ing loupe, the strand of light-colored ma terial was identified as immature hairs of varying lengths and sizes. The longest hair measured about 10 mm. The termi nal one third of the strand of hair curved downward. The tumor and attached cilia were ex tirpated by operation on March 17, 1943. The skin of the eyelid was split over the upper limit of the tumor. The skin was undermined and easily freed from the underlying nodule. The tumor was re moved without trauma or rupture. Re covery was uneventful. Nine months af ter operation there was no evidence of recurrence. PATHOLOGIC REPORT
Gross: The specimen consisted of a small round firm elongated piece of tis sue (0.4 by 0.3 by 0.3 mm.) from which
Fig. 2 (Keyes and Queen). Histologic detail of a portion of the tumor nodule. Ace. No. 91883 U. S. Army Medical Museum.
and Henkle's layers. Occasionally a glass membrane was present. Many irregularly shaped masses of basal cells were noted. There was an effort at palisading of the basal layer of cells. Some of these cell masses were solid, suggestive of the ap pearance of Krompecher's carcinoma.
NOTES, CASES, INSTRUMENTS
No prickle cells nor other cytologic evi dence of malignancy was observed. Other cell masses contained cystic spaces in which keratinous material was concen trically arranged. Hair shafts were defi nitely present in some of these cystic spaces. The appearance of the hair fol licles suggested a hamartomatous reac tion, possibly based on lanugo or infan tile hair follicles. Sebaceous glands and ducts of sweat glands were also present in the specimen. The blood supply was scant. Col. J. E. Ash (MC), U.S.A., curator of the Army Medical Museum, reported on this specimen as follows: "I do not believe it is malignant, more of a nevoid lesion, some of the hair follicles being im mature, of the lanugo type. I am not too fond of the term tricho-epithelioma, but it would seem to fit this tumor." Diagnosis: Tricho-epithelioma, benign, of eyelid. COMMENT
The term tricho-epithelioma is used in a histologic sense. The trichomatous na ture of this solitary lesion was obvious
191
clinically and histologically. The pres ence of immature hair differentiated the growth clinically from the tumors of Brooke,1 Jarisch,2 and Fordyce. 3 Refer ence is made to the articles of McDonagh4 and Traenkle 5 for a discussion of the relationship of epithelioma adenoides cysticum, tricho-epithelioma, and basalcell cancer. A search of the available medical liter ature failed to reveal a report of a similar lesion on the margin of the eye lid. Definite, clear-cut descriptions of tricho-epitheliomata are difficult to find. Many of the standard texts dealing with tumors do not mention the condition, as Boyd (Surgical pathology, ed. 5), Pack and Livingston (Treatment of cancer and allied diseases). Ewing (Neoplastic diseases, ed. 4 ) , in his discussion of epi dermal carcinoma, does not refer to tricho-epithelioma as such, though he does mention (p. 904) that "some basal cell tumors witfi compact groups of small elongated cells, or occasionally with adenoid characters, arise from the hair follicles."
REFERENCES 1
Brooke, H. G. Epithelioma adenoides cysticum. Brit. Jour. Derm., 1892, v. 4, Sept., p. 269. ' Jarisch. Zur Lehre von den Hautgeschwiilsten. Arch. f. Derm. u. Syph., 1894, v. 28, p. 163. 3 Fordyce, J. A. Multiple benign cystic epithelioma. Jour. Cutan. Dis., 1892, v. 10, Dec, p. 459. 'McDonagh, J. E. R. Pathology of skin from the eyelids and nasofacial grooves. Brit. Jour. Derm., 1912, v. 24, p. 291. 5 Traenkle, H. L. Epithelioma adenoides cysticum, tricho-epithelioma and basal cell cancer. Arch. Derm, and Syph., 1940, v. 42, Nov., p. 822.
E N D O P H T H A L M I T I S SUBSIDING AFTER T R E A T M E N T W I T H PENICILLIN* MARTIN I. GREEN, M.D., R A F A E L JAKOBOVITS,
AND M.D.
San Francisco 9 T h e prognosis in cases of fully devel oped suppurative endophthalmitis is * From Greens' Eye Hospital.
grave, and, as a rule, after all therapeutic measures to save the eye have failed, evisceration must be performed. Recent ly, however, the introduction of penicillin offers a new therapeutic approach in the treatment of many purulent ocular con ditions, as may be illustrated by the fol lowing case. History. A man, aged 70 years, was re ferred to the Greens' Eye Hospital on