Tarsal Sebaceoma Presenting as a Papillomatous Lesion

An 81-year-old male presented a painless growing mass under the right upper eyelid over 3 months, with light discharge and blinking disruption. His past medical history included benign prostate hyperplasia under surveillance, thalassemia minor on folic acid, and stable arrhythmia on anticoagulation. On the external examination, there was a papillomatous pedunculated pink lesion with vascularization on the upper eyelid eversion but no signs of deep-plane invasion; a mild tarsal conjunctival papillary reaction was also noticeable (Panels A,B). The remainder of the ophthalmic examination was unremarkable, with corrected visual acuity of 20/30 and well-placed intraocular lens bilaterally. No orbital imaging was deemed necessary, and the lesion was excised with margins and cryotherapy. Histology revealed an exophytic tumor composed of multiple nests of basaloid cells and a random admixture of sebaceous cells (less than 50% of the tumor) (Panel C). Immunohistochemistry (Panel D) showed intact nuclear expression of mutL homolog 1 (D1) and post meiotic segregation increased 2 protein (D2) associated with loss of expression of mutS homolog 2 (D3) and mutS homolog 6 (D4), compatible with deficient mismatch repair. Based on this, further genetic testing was conducted to rule out Muir-Torre syndrome, revealing no germline mutations and suggesting a sporadic etiology. A 2-year follow-up revealed no other lesions or need for additional treatments. This case shows the unique and variable presentation of the periorbital sebaceoma by an atypical presentation from the meibomian glands on the distal inner eyelid. It also highlights the relevance of molecular testing to confirm no systemic involvement as a part of a syndrome inducing sebaceous neoplasms.FIG.ACKNOWLEDGMENTS The authors thank the patient for authorizing this information.