검안및콘택트렌즈학회지 2019 년제 18 권제 2 호 Ann Optom Contact Lens 2019;18(2):41-45 ISSN 2384-0919 (Print) ISSN 2384-0927 (Online) Original Article 안쪽눈꺼풀테종양과눈물점주위종양의임상양상비교 The Clinical Features of the Tumor on the Lid Margin at Medial Side versus the Tumor around the Punctum 이승현 유혜린 Seunghyun Lee, MD, Helen Lew, MD, PhD 차의과대학교분당차병원안과학교실 Department of Ophthalmology, CHA Bundang Medical Center, Seongnam, Korea Purpose: To compare the clinical features and biopsy results of patients with the tumor on the lid margin at medial side versus those with the tumor around the punctum. Methods: A retrospective medical record review was conducted on 58 patients, each having tumor on the eyelid from March 2001 to June 2018 in CHA Bundang Medical Center. Results: Thirty seven cases with the tumors on the lid margin at medial side and 21 cases with the tumors around the punctum were reviewed. There were increase in size for 18.9% of the tumors on the lin margin and 23.8% of the tumors around the punctum and epiphora for 19.0% of the tumors around the punctum. Histology revealed 70.3% for epidermal tumors, 21.6% for inflammatory and infection lesions, 4.0% for stromal tumors and 2.7% of adnexal tumors in the tumors on the lid margin at medial side. There were 76.2% for epidermal tumors and 23.9% for adnexal tumors in the tumors around the punctum. The tumors occurred more commonly on the upper lid (75.7%) for the tumors on the lid margin, whereas more often on lower lid (81.0%) for the tumors around the punctum. Conclusions: The incidence of adnexal tumors was relatively high and stromal, inflammatory and infectious tumors was low in the tumor around the punctum compared to on the lid margin. And the tumors occur more often at lower lid. There would be a difference in the location, pathology and etiopathogenesis of tumors between on the eyelid margin and around the punctum. Ann Optom Contact Lens 2019;18(2):41-45 Key Words: Lid mass; Lid tumor; Peripunctal mass; Peripunctal tumor 서 론 눈꺼풀은피부층, 근육층, 마이봄샘을포함한눈꺼풀판, 눈꺼풀결막의총 4개층으로구성된다. 눈꺼풀피부는신체에서가장얇은피부조직으로피하지방은적지만모든 Received: 2019. 5. 10. Revised: 2019. 5. 29. Accepted: 2019. 5. 29. Address reprint requests to Helen Lew, MD, PhD Department of Ophthalmology, CHA Bundang Medical Center, #59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea Tel: 82-31-780-5330, Fax: 82-31-780-5333 E-mail: eye@cha.ac.kr 구조적조직을가지고있으며눈꺼풀은부눈물샘과마이봄샘, 짜이쓰샘, 몰리샘등샘조직이풍부하다. 눈꺼풀각각의층으로부터양성, 악성종양이발생할수있으며눈꺼풀종양은주로그기원세포로분류한다. 대부분의눈꺼풀종양은피부층에서기원한다. 1 눈꺼풀주위종양에대한이전보고를살펴보면눈꺼풀종양중양성종양은위눈꺼풀에서, 악성종양은아래눈꺼풀에서더많았으며, 양성종양의경우진피내모반이 43%, 악성종양의경우기저세포암종이 43% 로가장많았다. 2 눈꺼풀종양을위치로분류했을때위, 아래눈꺼풀종양, 안쪽, 가쪽눈꺼풀종양, 안쪽눈꺼풀테종양, 눈물점주위 Copyright 2019, The Korean Optometry Society The Korean Contact Lens Study Society Annals of Optometry and Contact Lens is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 41
- 검안및콘택트렌즈학회지 2019 년제 18 권제 2 호 - 종양등으로나눌수있고눈물점주위종양의경우눈물점폐쇄나위치변화등을야기할수있어치료방법에있어차이를가져온다. Rumelt et al 3 의보고에따르면, 눈물점주위종양은멜라닌세포성모반이가장많고, 대부분이아래눈물점주위에위치하였다. 또눈물점주위에상피하조직이거의없기때문에대부분이상피세포로부터기원하였다. 본연구의저자들은안쪽눈꺼풀테종양과눈물점주위종양환자들의임상양상과조직검사결과의차이에대해알아보고자하였다. 대상과방법 2001년 3월부터 2018년 6월까지눈꺼풀주위종양을주소로본원안과에의뢰되거나직접내원하여, 이후절제생검및조직검사를시행받은환자 58명 ( 남 : 여, 22명 :36명; 나이 58.8 ± 10.3세 ) 의의무기록을후향적으로분석하였다. 세극등사진을기준으로하였고, 눈꺼풀안쪽 1/2에위치하며눈꺼풀테에서 10 m 이내에위치한종양을안쪽눈꺼풀테종양으로진단하였고, 눈물점을침범하거나눈물점에서 3 mm 이내로매우근접하여발생한종양을눈물점주위종양으로진단하였다. 대상환자의성별, 나이, 이전에병변재발여부, 발생후진단까지의기간등을분석하였고, 환자의증상으로는종양의크기변화여부와그기간, 눈물이나오는증상여부와그기간을알아보았다. 절제생검을시행한조직은 Hematoxylin and Eosin (H&E) 염색을시행하였고통계학적분석은 SPSS 17.0 for Windows (IBM Corp., Armonk, NY, USA) 을이용하여 Mann-Whitney U test를사용하였다. 본연구는본원의임상시험심사위원회 로부터승인을받았다 (IRB No. 2018-12-016-002). 결과 총 58명의환자중 37명 (63.8%) 은안쪽눈꺼풀테종양 ( 남 : 여, 14명 [37.8%]:23명[62.2%]) 이었고, 21명 (36.2%) 은눈물점주위종양 ( 남 : 여, 8명 [38.1%]:13명[61.9%]) 이었다. 환자들의평균나이는각각 49.4 ± 12.1세, 51.8 ± 8.9세였고, 종양이발생한기간은 18.2 ± 2.7년, 14.5 ± 2.2년, 경과관찰기간은 1.5 ± 0.8년, 2.1 ± 1.0년으로차이가없었다. 종양과관련된증상을살펴보면, 안쪽눈꺼풀테종양환자의경우 18.9% (7명) 에서종양크기의증가가있었고, 눈물점주위종양의경우 23.8% (5명) 에서종양크기의증가, 19.0% (4명) 에게서눈물나는증상이있었다. 안쪽눈꺼풀테종양환자중 24.3% (9명), 눈물점주위종양환자중 23.8% (5명) 는이전에재발한과거력이있었다 (Table 1). 안쪽눈꺼풀테종양의경우위눈꺼풀안쪽이 75.7% (28명), 아래눈꺼풀안쪽이 24.3% (9명) 로위눈꺼풀종양이대부분이었다. 눈물점주위종양의경우에는위눈물점주위종양이 19.0% (4명), 아래눈물점주위종양이 81.0% (17명) 로아래눈물점주위종양이대부분을차지하여차이를보였다 (Fig. 1). 조직검사결과를살펴보면, 안쪽눈꺼풀테종양의경우상피종양이 70.3% (26명), 부속기종양이 2.7% (1명), 기질종양이 5.4% (2명), 염증및감염관련종양이 21.6% (2명) 였다 (Fig. 2). 이를더정밀하게나누어보면모반이 56.8% (21명), 염증 13.5% (5명), 물사마귀 8.1% (3명), 지루각화증 5.4% (2명), 유두종 5.4% (2명) 등의순이었다. 가장많 Table 1. Demographics and clinical characteristics of the patients with the tumors on the lid margin at medial side versus the tumor around the punctum On the lid margin Around the punctum p-value Number of patients 37 (63.8) 21 (36.2) Male:female 14:23 (37.8:62.2) 8:13 (38.1:61.9) Age (years) 49.4 ± 12.1 51.8 ± 8.9 >0.05 Recurrence 9 (24.3) 5 (23.8) Duration (years) 18.2 ± 2.7 14.5 ± 2.2 F/U duration (years) 1.5 ± 0.8 2.1 ± 1.0 Symptom Increase in size 7 (18.9) 5 (23.8) The period of increase in size (months) 1.0 ± 0.6 1.0 ± 0.6 Epiphora 0 4 (19.0) 0.03 The period of epiphora (months) 0 0.6 ± 0.5 Values are presented as mean ± standard deviation or number (%). F/U = follow up. 42
- 이승현 유혜린 : 눈꺼풀테종양과눈물점주위종양 - On the lid margin Around the punctum Figure 1. Comparison of location of tumors between on the lid margin versus around the punctum. Table 2. The biopsy results of the tumors on the lid margin at medial side versus the around the punctum Figure 2. The biopsy results of the tumors on the lid margin at medial side versus the around the punctum. 은모반의경우 90.4% 가진피내모반 (19안, 전체의 51.4%) 였다 (Table 2). 눈물점주위종양의경우경우상피종양이 76.2% (16명), 부속기종양이 23.9% (4명), 기질종양과염증및감염관련종양은 0명이었다. 모반이 61.9% (13명), 땀샘, 피지샘관련종양 19.0% (4명), 섬유화가 9.1% (2명), 지루각화증, 낭종이각각 4.5% (1명) 순이었고역시가장많은모반의경우 53.8% 가진피내모반 (7안, 전체의 33.3%), 38.5% 가복합모반 (5안, 전체의 23.8%) 이었다. 눈물점주위종양환자의 5명 (23.8%) 에서실리콘관, 누점플러그삽입술등이시행되었다. 눈꺼풀종양환자의예로서, 1달전부터좌안하안검에무통성의 3 3 mm 크기의덩어리가생겨내원한 8세남자환자는임상소견을바탕으로 (Fig. 3A, B) 3개월동안경과관찰을했으나크기변화가없어절제생검을시행하였고, H&E 염색을시행하여현미경검사상크고균질한세포질내부포함체 ( 연속종소체 ) 가관찰되어물사마귀 (Molluscum contagiosum) 로최종진단을내릴수있었다 (Fig. 3C, D). 이와유사하게 3년전부터좌안하안검눈물점근처에 On the lid margin Around the punctum Epidermal Melanocytic Intradermal nevus 19 (51.4) 7 (33.3) Compound nevus 1 (2.7) 5 (23.8) Congenital nevus 1 (2.7) 1 (4.8) Epithelial Seborrheic keratosis 2 (5.4) 1 (4.8) Papilloma 2 (5.4) Fibroepithelial polyp 1 (2.7) Fibrosis 2 (9.5) Adnexal Sweat gland Hidrocystoma 1 (4.8) Cystic dilatation of apocrine duct 2 (9.5) Sebaceous gland Sebaceous gland hyperplasia 1 (4.8) Cystic Epodermal cyst 1 (4.8) Hair follicle Pilomatrixoma 1 (2.7) Stromal Vascular Hemangioma 1 (2.7) Fibrohistiocytic Xanthogranuloma 1 (2.7) Inflammatory and infectious Inflammation 5 (13.5) Infectious Contagiosum 3 (8.1) Total 37 (100) 21 (100) Values are presented as number (%). 43
- 검안및콘택트렌즈학회지 2019 년제 18 권제 2 호 - A B E F C D G H Figure 3. Comparison of the slit photo and pathology of the tumors on the lid margin versus the around the punctum. (A, B) Clinical photographs of the patient s eyelid with the diagnosis of Molluscum contagiosum. (C, D) Histologic findings of mass on the lid margin on the excisional biopsy. The centrally located cells are filled by intracytoplasmic inclusion bodies, the molluscum bodies, which appear as round-to-oval eosinophilic structures, a single structure in each cell, which become darker toward the surface epithelium (Hematoxylin and Eosin [H&E] stain [C] 100, [D] 400). (E, F) Clinical photographs of the patient s eyelid with the diagnosis of aggregation of sebaceous glands. (G, H) Histologic findings of mass around the punctum on the excisional biopsy. Biopsy reveals aggregates of cells with small central nuclei and abundant clear granular cytoplasm with foam-like fat droplets (H&E stain [G] 100, [H] 400). 생긴종괴를주소로내원한 60세여성은세극등현미경검사상눈물점을포함하는 3 3 mm의노란색을띠는종양이관찰되었다 (Fig. 3E, F). 이물감이있었으나관류검사상이상소견은없었고눈물흘림도없었다. 절제생검후시행한조직검사상작은중심핵과거품모양의지방방울 (foam-like fat droplets) 이포함된풍부한과립세포질을가진세포들의응집이관찰되었고피지선이응집된것으로진단하였다 (Fig. 3G, H). 눈물점과눈물길은침범되지않아추가수술은진행되지않았다. 고찰 눈꺼풀종양은주로기원세포에따라분류하는데, 상피종양, 부속기종양, 기질종양, 염증및감염성병변, 이차성종양, 전이성종양등으로분류한다. 상피종양이가장많으며이는멜라닌세포기원과비멜라닌세포성으로나뉜다. 부속기종양에는피지샘종양, 땀샘종양, 모낭종양, 낭성병변이있고, 기질종양에는섬유조직종양, 섬유조직구종양, 지방종, 평활근종, 골격근종, 혈관종등이있다. 양성상피세포성종양, 기저세포암, 낭성종양, 멜라닌세포성종양이눈꺼풀종양의 85% 이상을차지하고, 편평세포암, 악성흑색종, 부속기와기질종양은발생률이훨씬낮다. 1 눈물점주위종양은눈물점폐쇄나눈물점의위치이동을야기할수있기때문에다른눈꺼풀종양들과구별되어 생각되어야한다. 또악성종양의경우눈물소관을따라눈물기관으로전파될수있고, 반대로눈물점주위종양이눈물기관의종양이전파되어온 2차병변일수있어주의가요구된다. 4 종양이눈물점과눈물소관등에영향을주는정도에따라실리콘튜브삽입술, 누점플러그삽입술, 눈물점성형술등이필요할수있다. 눈물점주위종양은눈꺼풀종양중에서도그빈도가낮으며관련연구가많이이루어지지않았다. 2004년 Rumelt et al 3 의보고에따르면, 눈물점을부분적, 전체적으로침범한 14안의눈물점주위종양은모두양성이었고멜라닌세포성모반이 50% 이상으로가장많았다. 이들은위눈물점주위에 20%, 아래눈물점주위에 80% 가위치하였고 92.9% (13안) 가상피세포로부터, 7.1% (1안) 가상피하세포기원이었다. 이는눈물점주위에상피하조직이거의없기때문일것으로생각되며, 눈물점주위는근위부눈물소관, 눈꺼풀결막, 눈꺼풀등이인접해있기때문에이런다양한조직에서각각종양이발생될수있다고보았다. 3 2013년 Ho et al 2 이 10년간홍콩환자들의눈꺼풀종양, 가성종양등에대해보고하였고, 양성종양은위눈꺼풀 (54%) 에서, 악성종양은아래눈꺼풀 (61%) 에서더많았다. 양성종양의경우진피내모반이 43%, 악성종양의경우기저세포암종이 43% 로가장많았다. 본연구에서는모든눈꺼풀종양이아니라눈꺼풀안쪽 44
- 이승현 유혜린 : 눈꺼풀테종양과눈물점주위종양 - 1/2에위치하며눈꺼풀테에서 10 m 이내에위치한종양을안쪽눈꺼풀테종양으로진단하였고, 이를눈물점주위종양과비교하였다. 이는앞에서언급했던것처럼눈물점은눈꺼풀피부, 눈꺼풀결막, 눈물소관등이인접해있는조직이므로다양한세포기원의종양이발생가능하다. 눈꺼풀전반에비해눈꺼풀테는샘조직이밀집되어있고눈꺼풀피부와눈꺼풀결막이인접한부위이기때문에비교에있어더의미가있다고보았다. 2 안쪽눈꺼풀테종양에비해눈물점주위종양에서부속기종양의비율이의미있게높고, 기질, 염증, 감염성종양의비율이낮았다. 눈꺼풀테와눈물점주위에서샘조직의분포정도에대한연구는아직알려져있지않지만, 눈물점주위에그밀도가더높을것이라고추측할수있다. 또눈물이눈꺼풀결막구석을지나눈물점을통해빠져나갈때, 그유속이눈물점근처에서가장빨라감염이나염증을일으키는물질들이제거되는속도가높기때문에눈물점주위종양에서는염증및감염관련종양의빈도가낮았다고예상할수있다. 눈물점주위종양은아래눈꺼풀의눈물점에서그비율이상대적으로높았는데이는선행연구들의결과와도일치한다. 5-7 위눈꺼풀보다아래눈꺼풀이자외선에더많이노출되기때문이라는가설이있는데병변의대부분을차지하는멜라닌세포성모반의발생에자외선이관여함을고려할때이는그가설을뒷받침할수있겠다. 8 하지만본연구에서안쪽눈꺼풀테종양은위눈꺼풀에서더많았는데이를설명할수있는연구가더필요하겠다. 안쪽눈꺼풀테종양에비해눈물점주위종양의경우기질, 염증및감염관련종양의비율이상대적으로적고땀샘, 피지샘관련종양비율이높으며발생위치에서도아래눈꺼풀에서높은발생빈도를보였다. 따라서눈꺼풀의안쪽테에발생하는종양과눈물점에발생하는종양의임상적차이점을염두에두는것이환자의진단과치료에도움이될것으로사료된다. REFERENCES 1) Pe'er J. Pathology of eyelid tumors. Indian J Ophthalmol 2016;64: 177-90. 2) Ho M, Liu DT, Chong KK, et al. Eyelid tumours and pseudotumours in Hong Kong: a ten-year experience. Hong Kong Med J 2013;19:150-5. 3) Rumelt S, Pe'er J, Rubin PA. The clinicopathological spectrum of benign peripunctal tumours. Graefes Arch Clin Exp Ophthalmol 2005;243:113-9. 4) Suh JY, Jung HM, Ahn HB, Kim MH. Clinical features and treatment of peripunctal tumors. J Korean Ophthalmol Soc 2012;53:918-23. 5) Welch RB, Duke JR. Lesions of the lids; a statistical note. Am J Ophthalmol 1958;45:415-26. 6) Aurora AL, Blodi FC. Reappraisal of basal cell carcinoma of the eyelids. Am J Ophthalmol 1970;70:329-36. 7) Tesluk GC. Eyelid lesions: incidence and comparison of benign and malignant lesions. Ann Ophthalmol 1985;17:704-7. 8) Folberg R, Jakobiec FA, Bernardino VB, Iwamoto T. Benign conjunctival melanocytic lesions. Clinicopathologic features. Ophthalmology 1989;96:436-61. 45