 All right, very good, so I can see everybody's off right now in Bushetail with, you know, this cold, dark, December morning, which we love to hear, listening about dumb pathology. So again, for those of you who weren't here last week, because you are a captive audience, you have to see my travel slides. So we're going back to Lisbon. So this is Lisbon, where the ESCRS was issued as the Castillo on the mountain entrance. Lisbon is a city of hills. There's steep hills, narrow streets. This is how you get around Lisbon. This is a tuk-tuk. And so I asked the guys, why do they call it a tuk-tuk? Well, because in Asia, these are diesel powders, so they go tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk-tuk. Here are their battery power. So in essence, it's a glorified golf cart, hangar. And so you can see this. It's a glorified golf cart, but it's pretty souped up, because it has to get up and down the steep hills. And so, you know, these guys, as you're walking down the street, they are costing you. You know, you go tuk-tuk-tuk-tuk-tuk-tuk-tuk. So finally we got some guys. They give you a tour, one hour, and it says 70 euros. For you, 60 euros. We got the bargain, so he took us around. So he let us pretend we were driving, even though he was horrified. We said, no, we drive this in no way. So this is the good Dr. Crandall, and this is Candy's husband. And so we got a tuk-tuk tour all over. So there's the tuk-tuk. That's the standard street you have there. So you know why you want a tuk-tuk rather than an actual car. All right, so these are what the streets look like. Every once in a while, you just see one that just dead ends, which is interesting. You just pile up here, and it just dead ends. And then they've got little cafes and little shops. You could stop, get something to eat, and come along. Now, the nice thing is because it's Mediterranean, I mean, the temperature over there was 580 Fahrenheit. So beautiful, very, very nice. You're going to have October. There's a good Dr. Crandall in shorts there. Look at his legs. All right, Liz. Nico, what do eyelids, ovars, and onions have in common? Layers. Layers. Okay, so you really need to know your layers. And so when we're looking at an eyelid gross, this is from an exaggeration. What you can see here is you see that the eyelid has several layers. What's the outer layer? Skin. Skin. And then the layer underneath that? Muscle. Muscle. And then the third layer? Arses. Arses, and then the inside layer? Conjure. Conjure. Conjure. We always forget that there's conge lining the inside of the eyelid. So remember that how people conge lines the inside surface of the eyelid. So now we're looking at it in a different stain. Carol, what kind of stain is this? Trichrome. What makes you say it's trichrome? Because you can see the basement membrane of the skin. Actually, does trichrome stain basement membranes? No. So what trichrome does do is it'll stain epithelium. It'll stain muscle and connective tissue red. I mean muscle tissue red. It stains connective tissue and collagen blue. And so I really wanted to show you that because here is the skin. This is upside down. Here's the muscle. And then you can see the tarsus is this dense connective tissue. It is in blue. And so you can see that it just delineates some of the different tissues. And then, of course, the cornea. All right, let's look at the skin. Trawl, tell me about the skin of the eyelids. Stratified squamous curatnides epithelium. Okay. How is skin of the lid different than skin of, say, the cheek? It has a true epithelium. Well, it is an epithelium, but there's one subtle difference. And later, the dermis. There's a true epithelium. Well, when you look at skin elsewhere, there is a true dermis. And in the lid, you don't have dermis. So in the lid, you've got some subtle epithelium of connective tissue, but you don't have dermis. The other thing you don't have is you don't have redurages and pegs. And so, you know, in the normal skin, you've got the interdiction, the redurages, the redpegs. You've got your reticular dermis. You've got your fat underneath there. Now, the lid, you don't normally have dermis underneath it. You don't really don't have fat, except in some veterans. What are you doing? Sorry. You know who does it? The VA or the fat pull-out community comes for them. Okay. So now, where do these hairs drop? Those are hair shots. Exactly. So now, remember, in addition to the lashes, the skin, even on the eyelids, has fine hairs. And so, just like skin elsewhere, you've got the little sebaceous glands that go with them. You've got the little pylosubatius units. And so, you do have fine hairs. Even on the lid, you don't think about that. You don't think there's hair on the lid, but there is. And there's fine hairs that are there. All right. So, we skipped over the muscle layer here. We'll talk about that later. So, you are interdictive, right? So, you are... Theresa. Ah! We had brunch with you. Okay. Just a second. All right, Theresa. So, you're at the VA now? Okay. Very good. So, what are we going to have right here? What is this layer? It's the mambomian glands. Okay. Those are mambomian glands. And what layer do they live in? There's this layer here called... The tarsus. Yeah. Yeah, the tarsus. Tarsus. Exactly. So, the tarsus is this dense, fibrous layer. It really gives body to the lid. It keeps the lid from flopping in and out. And it keeps the lid really stiff and gives it body. What's the difference between tarsus in primate and tarsus in rats and rabbits? I have no idea. Cartilage. Believe it or not, subprimates have cartilage in the tarsus. So, they're really, really strong. So, if you're ever doing research on rabbits and rats, their lids are just really strong and really hard, and it's the cartilage. Whereas in the primates, you don't have that. So, we've got right here the mambomian glands. And it's interesting, they dump into a central orifice here. And then that dumps out at the posterior surface of the lid. So, I say this is akin to grapes on a vine. So, you know how grapes cluster, and then there's a central vine. So, when you look at the mambomian glands, here's the central dud. And then the mambomian glands are the grapes that are on here. Okay, so let's go a little bit closer. Now, we can't not talk about glands. I know glands are boring, but we want to talk about glands. So, there are three main categories of glands. So, what is this one? So, this thing is working very hard right now in your body. The sweat glands. The sweat glands, exactly. So, what class of glands are sweat glands? I don't know. Echorin. Echorin. Exactly. So, the lid is interesting because the lid has all three types of glands. And so, echorin glands are what you think of as sweat glands. But also, echorin glands are the lacrimal glands. So, around the eye, the accessory lacrimal glands, the main lacrimal glands, which are, you know, overactive to me right now. I'm going to ask you guys these questions because we want to cry here. But these are the echorin glands. So, echorin glands, they cluster in what are called asinine. And so, they form these little round clusters. They secrete into the center. Eventually, they gather up into ducts and then proceed out. So, these are your echorin glands. And they all have these little eosinophilic steaming secretory granules here from the side of the plant. These are what lacrimal glands look like. These are what sweat glands look like. Now, we're right here at the lid margin. And the reason I'm showing the lid margin is the lid margin has two other types of glands that are in here. So, the second gland I want to show you is this gland. Let's go one more. Okay, so we're looking at this gland right here. What kind of gland is this? Let's see, is this an apocrine gland? It's an apocrine gland. How do we tell apocrine glands from simple echorin glands? So, they have the snouts. They have snouts. Look at these little snouts sticking out. So, apocrine glands, just like the name says, they put their little apexes into the gland. And then, when they secrete, sometimes these little apexes get chopped off. And so, they look like little snouts. Now, what's the name of the apocrine gland that lives in the eyelid? The glands of mole. Gland of mole. And how do we remember that? Because it's like a mole that has a snout. Exactly. So, what kind of animal has a snout? A mole. So, the glands of mole are the apocrine glands. And that's how you remember them because they have snouts. These are the apocrine glands, glands of mole. And as we go back here, what happens is the apocrine glands dump into the eyelash follicles. And so, right at the lid margin is where the lashes come out. You have these glands of mole dumping in. But also, on the eyelashes, you have a second type of gland. And what gland is that? Those are glands of zeis. Glands of zeis. And what group are they in? Holgrin. Holgrin glands. Now, what distinguishes Holgrin glands is Holgrin glands are like kamikaze glands. They secrete their entire contents into the lumen. So, they really regurgitate everything in there. So, for those of you who do in-bib and remember those days in college when you had too many of the two carbon disease and you're praying to the porcelain god to help you live through the night, what were you doing? You were regurgitating all of your contents into that white porcelain god. And so, that's what myomian glands do. They're a sebaceous gland. And so, they dump all of this liquid rich material. Now, for the zeis glands, they dump it into the hair follicle. And for the myomian glands, they dump it into the myomian duct. Now, what's important about the myomian gland glands secretions? What do they do? They form the abortion of the tear film. Exactly. So, they form the outer layer of the tear film. They keep the aqueous tears, which the eccrine lacrimal glands produce, from evaporating. And so, these are lipid-rich glands. If you look at Asian East Stain, they've got kind of this brown-blasty appearance. They've got all this lipid stuff in here. And so, these are the lipid-producing myomian glands. And this is, this is, I'm saying welcome. You can get real pathologists here. So, what's that? I'm Megan. I'm the neuropathologist in case you guys are curious. So, what kind of stain is this? This is oil right on. It's on fresh tissue. Exactly. So, if you want to stain the lipid, remember what we talked about. Oil right now is an easy stain to remember. Because it stains oil, these little red o's. So, little red o's, very easy to remember. And so, this is a piece of fresh myomian gland, stained with the noir red o's stain. So, it shows all the lipid. All right. So, now we're going to look at some lid lesions. And unfortunately, when we look at the lid lesions, they all look kind of the same from the outside. So, you need to try to come up with a differential diagnosis of what you're looking at. So, what do we see in here? So, it's an external photograph of the right eye. And there's a lesion on the lower lid. Looks fairly fleshy colored. Not a lot of pigment changes. Maybe some pigmentation on the upper surface, but it also could just be a shot there. And some irregularity at the lid margin as well. So, when you're looking at lid lesions, one of the important things is you want to look and say, is this something that's potentially bad? Is this a potential tumor? Or is it just a benign lesion? And there's some hints that you can look at it. Some of the things you look at, you say, okay, is there a big notch here? Is there a loss of tissue there? Is there a loss of lashes here? And you kind of see, not really. It's kind of a benign looking just bump on the lid. A lot of people come in and if you look at their eyes, oh, it's a big knock. And so, you have to try to figure out what that could be. Now, the other thing that's important, what else, whether the surgery is this patient has? Unless they have a contact lens in, I can't quite tell. Look closer. Oh, there's a giant PIO top. There's a big PI there. Why would you do a PI? There's an anterior chamber IOL in here. Here's an IOL here. Here's the loop. Here's the loop. An anterior chamber IOL. So this patient has an anterior camera with a big PI in there and anterior chamber IOL. So this surgery was done at least 30 years ago. So a long time ago. All right, so we go ahead and we just show a couple of other lesions just to see maybe at least a little bit the frontina. What are you seeing here? Again, for external vertebrate, right and left eyes. See lesions present on both eyes. So starting with the right eye, there's one raised lesion on the lower lip. It does not appear to be disrupting the hair follicles or the lip margin, but it does look a bit kind of erythematous and edematous. On the left side, similar lesions that still don't really look like they're affecting the hair follicles but are more erythematous than it is active inflammatory. Okay, how long is this patient? Younger. Yeah, so it's a child. And so what are you thinking about when you see in multiple lesions like this in a kid? A little shoalazion in there. Exactly, so you're thinking of some kind of a nine, like a shoalazion or a cordiola or something like that. And so we look at the pathology on this lesion. What do we see? We see the foamy macrophages. There are some foamy macrophages in here. What is this thing right here? Very big cell. Giant. In fact, it's a giant cell. You can see a giant cell here, and there's a lot of empty spaces here where the lipid dissolves. Lipogradion is inflammation, so this is a shoalazion. And so if you want to sound intelligent, you say choalazion. So that, I don't know, sounds more European. So if you talk European, it makes you sound intelligent. So choalazion. And so this is a reaction. It's not infectious. It's a backup of lipid in the clogged myomian ducts, which then causes it to swell because lipid is very irritating. And so this is a lipograndiolomus inflammation. This is a shoalazion. Remember this? Maybe you're going to answer this. But can you tell on pathology the difference between a choalazion and a portiolum? Yes. Because in a mortiolum, usually mortiolums are thought to be infectious. In fact, they're usually staff or something that you get an infection around them. So you don't get the grandiolomus inflammation. So that's the difference is you have a lack of grandiolomus inflammation. That's how you tell them apart. Oftentimes on mortiolums, we don't biopsy them or lance them or drain them out. So we often don't see the path on those. So here's another close-up. A giant cell. Look at all those nucleotides around the edges. Look at all this lithium. It's dissolved down here. And so again, a shoalazion. And you can also have NECO. What kind of cells are these? These. Plasma cells? Plasma cells. And you can have these? Lymphocytes. Lymphocytes. So remember, you do have giant cells, but you can have lymphocytes. You can have plasma cells in a chronic shoalazion. All right. That didn't count. Now, I apologize. I took this picture from a quote. I should go to the Iran and get better pictures. But NECO, what do we see right here? So it's an external photograph of the left eye. The extension is drawing the tumor. Laterals. Island. There is a raised nodular. Looks like cystic lesion to me. All right. If you see what you think is a cystic lesion, what's a good way to write in the clinic if it's solid or cystic? You shine the light on it. Exactly. So you take your little fan off head, you put the light right next to it. If it's cystic, the light will transluminate right through. If it's solid, it'll block the light. So that's how you tell the difference between cystic and solid. So, you do the pathology on this one, and what do we see here? So, there's a stratified squamous cyst inside it. There is eosinophilic material. It's like lead keratin. Right. So what do you think this is? They're low inclusion cysts. So this is called an epithelial inclusion cyst. Epithelial inclusion cysts. So we see these non-accommodates. So if we see these in the path lab invariably, it's Megan's turn to do the readout. Which is the cyst queen now. So it's not uncommon that you see these, and we call them inclusion cysts because usually it's a sign that something has been done. Either they have a minor trauma or they have a little surgery or something, but for some reason, surface epithelium gets stuck underneath and then it starts to grow, and it'll grow in a circle. So it'll grow in a cyst, and it'll keep making more and more keratin, and with time, it'll get bigger and bigger. So epithelial inclusion cysts. There's the close-up. There's the stratified squamous epithelium. There is the keratin. So when you look at a cyst, the key thing is you look at the lining of the cyst to see what it was that gave rise to the cyst. Alright, Tara, what are we seeing right here? So it looks like another cystic lesion on the lower end of this room. Alright, so again, we put our little pen-off head on there and it transilluminates so you know what's cystic. Now what do we see on the lining of the cyst here? So this looks like a knot. The lining doesn't look keratinized and it looks like it's in two layers. Okay, two layers, so what's the shape of this one? It's cuboidal. Cuboidal. And so we see a bilier cuboidal lining to assist. What does that mean? Think of like a hydrosystema. Exactly, so this is a hydrosystema and it's derived from what? It's eccrine. So this one, if you look at it, you don't see any snouts, it's very smooth. So this is an eccrine hydrosystema. So some people think these are derived from the little eccrine ducts rather than from the glad themselves, but it's an eccrine hydrosystema. So it's got this bilier cuboidal, it's not stratified, it's not squamous. It's cuboidal and it does not have snouts and so it's an eccrine hydrosystema. So hydrosystema from what language? From the Greek, of course. So hydro means water, system, assistant, water, assistant, just a bit. So always from the Greek. Alright, here's the difference. So it's trough. This seems to have more than two layers, several layers around it. It's not round but more sort of irregularly shaped. It's even filled again. Look, what are these right here? Those are glands of African glands. Yeah, so those are snouts. And so, believe it or not, it depends on how you look at this one, it's rolled over. It really is, in most places, about two cells thick and snout. So what do we call this? Apricrine hydrosystema. So just like we had eccrine hydrosystema, we can have apricrine hydrosystems. And so same thing, they're less common. Because obviously, glands of more are less common than some of the apricrine glands. And so, which you can still get in the way, it's apricrine hydrosystema. So same thing, they're about to be apricrine derived. What do we see in right here? So it's a color photograph of the right eye. And kind of along the eyelid, along between some of the lashes, and then above the lashes are these small, kind of like nodular lesions that are flesh colored, don't have any ulceration or anything. So you see a little ulceration in the center. And there's like, oh, there is ulceration in the center. There's ulceration in the center, almost like a little crater in the air. And then you can arrange for the gorgeous cluster out. What does that tell you? I've never seen them in a cluster, not as an ulcerated center. Did you think about like, molusco? Exactly. So now actually moluscans usually do come in clusters. So they're often in clusters. So this is molusco. This is a good classic appearance of molusco. You can see it's got the raised pearly borer, the little indentation in the center, and there's a cluster out. And so when you look at the path, nothing else looks like this. So tell me what the path shows here. There's like all these keratinocytes that are all like, heaped up and below. There's an ulcerated center that has some inflammation at the top. I think they're like, kind of like the top layers, ulcerated, and there's all the inflammatory cells. So when we look at a close-up, one of these little eosinophilic areas here is kind of started the base and then worked there a little bit at the top. They almost look like, are they capillaries? Believe it or not, those are actually viral inclusions in the cells. And so what happens with molusco is that the virus gets into the epithelial cells, it'll start growing, and eventually it pushes the nucleus to the side, and by the time you get to the top, it just pushes that nucleus out completely and the virus takes over the whole cell. So the cell right here is nothing more than a bag of viruses, which is why you get these clusters. And so you'll get the little viruses spread all over. What kind of virus is this usually? It's one of the poxvirus, as usually. So that's most common. So this is classic molusco. When you see these eosinophilic-staining inclusions, and then you see that the epithelium is thickened, it's raised on the edges, it's umbilicated in the center, and you've got all these just bags of viruses ready to dump it out in the tissue next to it. So this is classic molusco. They call it contagiosa. You know, contagion means, you know, germ spreading all over. And so it's because it spreads all over. It's molusco contagiosa. All right. Yeah, I took this picture out of the book because I don't care if cameras are coming off the plastic. All right, what do we see in here? Okay, so this is an external photograph of the left and right eye. It looks like on the right eye we have a lesion on the superior eyelid nasally. It looks flesh-colored. It doesn't look like there's any erythema surrounding it. Slightly raised. No ulceration. What would you think? What would your differential be here? Um, so this looks like it could be, uh, what's it called? Uh, zanthalasma? Exactly. Zanthalasma. All right. So when you see this, we call it pipeline. So instead of the big cyst sticking out where something, you know, located and ulcerated, this is like a flatter plaque that's elevated. And it's almost kind of yellow in color. So you look at it. When you think yellow, you think more liquid. So this is a xanthalasma that's called. And when we look at it, what kind of cells characterize zanthalasma? Um, so it's going to be, uh, lipid-filled. Okay. So, um... What kind of cells got all that liquid if you filled with them? Aprilcrack? No. Macrophage. Macrophage. Okay. Macrophage. So, and you can see they're just stuffed. I mean, they just come in there and they just, you know, Pac-Man, all that lipid, you know, just stuffed with lipid. And you can see right here, these are macrophages. Just stuffed with lipid. Now, it used to be top... Yes, sir. So if you're just looking at that photo there, how would you differentiate a foamy macrophage from an adipocyte? Because it actually has a body to it where the adipocyte is just filled with just pure fat. Well, this actually has got this kind of granularity to it. And it's got the nucleus there that's rounded to the side as opposed to the adipocyte where it's flat and pushed over. So the adipocyte, the nucleus is pushed over really flat and then the cytoplasm is empty. This actually has some substance to it and the nucleus is round while it's still pushed to the side. Some of them can see the nucleus more than the center. So it was taught at one time that these were a sign of high cholesterol. So people used to get worked up all the time with high cholesterol. But it really doesn't turn out to be true. Now, you can get these with high cholesterol but it doesn't necessarily mean if you have this amylasma that you have high cholesterol. So it just turned out not to be true. All right, different kind of lesion here. All right, this is a color photo externally of the right eye and it looks like the lesion is below the lower lid margin. It's a little more, it does look raised but not quite a cystic like we'd seen before. A little more plaque, like a rough surface on top and very flesh colored. What do we see in here on the lower lid? So it looks so that the epidermis looks a little thickened. Okay, it looks a lot thickened. Yeah, a lot thickened. So you've got thick epithelium. What is this stuff here? Is it keratin? Keratin, so you've got these big crypts filled with keratin. You've got this big cyst filled with keratin. So thick epithelium. You've got all these big crypts and cysts filled with keratin. When you look at a close up here. Yeah, you've got keratinization. All these crypts filled with keratin here. So what do you think this would be? Looks like a squamous papilloma. Exactly, so this is a papilloma and so the way we remember this, a papilloma looks like a glove hand sticking out. So it's got a thick glove, which is the epithelium. It's got these little fibrovascular cores in the center. And so papilloma is the lesion. And sometimes when you see them in cross section, you see the thick epithelium surrounding these little fibrovascular cores and think of it as someone took the glove hand and then just cut the fingertips off. And so when you see it in a flat-prepared cross section, you see the little fibrovascular core in the center. You see the thick epithelium around it. You see the hyperkeratosis. So these can be either infectious or not. So they can sometimes just be something that irritates the squamous epithelium. Sometimes these can be infectious also. All right? What do we see in here? This looks like a pedunculated lesion. It's flushed hard. There's a little more arithema to it, though. It's like there's multiple subunits that kind of stuck on like maybe a conservatious care. Yeah, you see that kind of stuck on a little bit. That kind of dried, crusty care of the looking stuff on there. So this would be more like a seborrheic keratosis. And so sometimes every keratosis would look a lot like papillomas. It's hard to tell. The way you could tell on the part is, remember the papillomas come out like the gloved hand, the seborrheic keratosis. The epithelium tends to go down in like a hairy spider. The big hairs surround it. Then you get the little areas of the glands inside and the little vessels inside. Now the other thing is right along the basilar layer here, you see this very often at seborrheic keratosis. What's going on here? Did you call that palisading? Well, it always palisades at the base. And the squibbous epithelium will palisade at the base. But what else do you see on here? Pigment. Oh, yeah. And so you see some benign melanocytes lining up along the base. And so for some reason, seborrheic keratosis tend to pigment. So when you look at them, they'll often be brown. In fact, people will often mistake them for neem iron melanoma and they'll remove them and biopsy them in. It turns out that you will see increased pigmentation of the basilar layer of the seborrheic keratosis. And that gives them its kind of brown or tannish appearance. All right, what do we see in right here? This almost looks like that first picture we showed. So this is an external photo of people left and right. In the lower lid there seems to be, again, this fleshy color raised. It has some white looks on it, but kind of possibly stuff on it. Kind of almost stuff on it. And we look at the path here. And what do we see in here? So it's a hyperkeratosis, squintous cell, benethylium with acanthosis, and it means market, atybia. Yeah, a little nucleolide, and it's called chromatin. So so many tibia here. What's going on underneath here? It's like there was a seborrheic keratosis to this connective tissue. Okay, so this is definitely on sun-exposed skin. You've got this seborrheic keratosis underneath here. So we think this would be an actinic keratosis. Exactly. So this is kind of, animals call this a pre-premoling. And so you're starting to get a tibia and the epithelium and you're getting a lot of breakdown and stuff like epithelial tissue. And so an actinic keratosis is when it's starting to get more active than a simple seborrheic keratosis or papilloma. So as it's getting more active, you get more concerned because there's a clear line in here. It's a little bit more active. Still lots of keratin. Still thick epithelium. Definitely intra-epithelium. You know, the epithelium these membranes are completely intact. So this is called an actinic keratosis. So kind of almost beginning of a carcinoma in situ, but not quite. And I was like, oh, that's not a condition. I'd better re-take that. So you can see another close-up here. You can see how you get these keratin worlds in here. You get a lot of nucleoline in here. A lot of activity in here. So this is almost like a carcinoma in situ at this point because it's got a lot more activity, but it's still intra-epithelium. All right. What are we looking at right here? So this looks like the left eye and the lower lid margin. Do you see any regular ulcerative lesion? It's about midline in the eye. And it has kind of curly borders. What would your concern be here? I would be concerned about a squamous cell carcinoma or some sort of pre-coilinid cell carcinoma in situ. So when you look right here, it's also basal cell carcinoma. Okay, basal cell. So, you know, again, when you hear or hopefully you just want to think of courses rather than zebras, so if you were to just pick a random tumor of lid on what would be more common, squamous or basal? Are we at the VA or not? Even at the VA, I believe, or not. Is basal no common? Yeah, exactly. As a matter of fact, if you look at all lid tumors that have been removed, 90% are basal cell. And squamous cells maybe 5% or 6%. So really basal cell is by far and away the most common. And you see the pearly raised edges there with the ulceration in the center. Now, this is a bit of a concern because what else are you seeing aside from that? There's a lot of blood around the inferior ulceration. This is kind of ulcerated and so is blood. How far do you think we need to remove tissue to make sure we get this all? Probably to the medial amount of reporters. I mean, you can kind of see it in the study. I think that it is all the way to there and even all the way to here. And look how you've lost lashes here. So it's thick. You've lost lashes. I mean, this patient is we're talking major reconstructive surgery because they're losing that whole lower layer right there. Now, sometimes these lesions can look different. And instead of being ulcerated, this almost looks like a cyst but it's a solid. It's kind of a solid looking motor engineer. But again, you see lots of lashes over here. You see a little notch in the lip margin. Believe it or not, those two are the same thing. This is what it shows. So what is this? So this is going to be morphiiform and nodular basal cell carcinoma. Exactly. So this is a basal cell carcinoma and basal cell is characterized by this palisade now. I remember I said that just the basal layer, the epithelium, you get normal palisade. But this says these are now little nodules of tumor that are below the surface epithelium. And so these tend to have these nuclei lined up around the edge of the region called this palisade. And when you look close, the nuclei look pretty benign. You have a pretty benign nuclei and I'm loving to play a lie. Large nuclei, it takes up most of the cell, pre-scan, cytoplasm around them. And this looks pretty benign. And the nice thing is this behaves the way it looks. And these are pretty benign lesions. They don't metastasize. They usually, I mean they can invade locally, but they don't metastasize. So when you're looking at a melanocytic nest versus a basothelic nest, are you looking for that architectural separation? Well the other thing is when you see nest of cells like melanocytes form, the cells are all solid. Whereas if you look at this, the cells are lined up around the edge so they're not solid in here. They're lined up on the edge so it looks different. And there you see the close-ups are very benign, appear. Now they can be nodular, which is the most common. They can be nodulocystic. They can even have cysts in the center of them. But again, look at the pelvis area around the edge. Now the other thing that you get is because these cells are pretty densely packed, as we process them, methodologically, the tumor cells shrink a little bit more in processing then do the tissue around them. So we call it a meaningful artifact. You get this little halo of shrinkage around them. And it's an artifact. I mean, it's good processing, but you see this in basal cells, you won't see this in other regions. So it's a meaningful artifact. So here you can see that little differential shrink in the tissue around the basal cells that are here. Alright, Becca, what's different about this picture as opposed to the previous one? But it looks like a different stain there. It's just different with the same stain. The same stain. The pattern of the cellular architecture there. Alright, so we still kind of see this shrinkage here, right? But instead of those big nodules, there's little small fingers of tumor. And what's the cells in between? What kind of cells are these right here? Fibroblasts. Fibroblasts. And so you've got little tiny fingers of tumor cells in between all this background of this spherus of fibroblastic, you know, connective tissue. What is this? It's still a basal cell. It's still a basal cell, but what kind? This isn't the kind I want you to remember. This is a morphea. And so morphea form basal cells have a worse problemosis than nodular and nodular cystic. The reason is these little fingers of tumor cells will grow underneath the epithelium and they'll induce this connective tissue reaction around them. And so when you've got a nodular basal cell you cut the whole thing out and you know you've got it all. With these, they can spread under the skin. They can spread around the sides of these are difficult to know if you've got it all out. This can you ever have like both occurring at the same time? Oh yeah, you could have all kinds of varieties and just depending on what part of the tumor you look at. But when you do these, if you see a morphea form then in order to ensure that you've got all of that out you want to consider doing what's called Moe's surgery. So Moe, M-O-H-S, not Moe, you know, you know, Moe Howard. Moe's M-O-H-S. So Moe's surgery is where you cut out little pieces of tissue and you set it for frozen and then you do it right on the spot to make sure you get all out. So if you see a morphea form you may want to do Moe's surgery. Now sometimes these can look different. Tina, what's different about this one as opposed to the previous one? The pattern looks different. Also seeing a lot more of keratin. Alright, so up here there's those nice palisading, nice looking basal cell. Now down here you've got all this pink. You've got keratin here. More squamacy. More squamacy, but it still looks basal-y-y. Here, so we call this... Here we saw the basal. It's both. It's both. So you just put the two words in. That's how I remember it, it's basal-squain. And so you can get, now basal cells are interesting. They arise from a pluripotential cell that lives along the basal layer to get the feeling. And so that cell can give rise to different other types of cells. And so you can sometimes get pure basal cells. You get a basal cell that looks like a squame next to it. So this is called a basal-squame. These are important because a lot like a morphea form these could be more aggressive. And so you want to make sure that you get all of these out. You get a squamous element into them. You get a morphea form element into them. Then they have more chance they get sprayed. So I said that basal cells are benign. But if you let them go, this can happen. So this was a lady, Rick Anderson saw her. She's rancher from the bad. Stubborn a little bit later. They said, you've got a morphea form basal cell. We have to go do more surgery and remove it. She said, I'm an old lady. I'm going to die. Leave me alone. So she went back to her ranch 10 years later her daughter dragged her in. And why? Because it smelled. And so if you look, the tumor is not only taking over half of her face, but it goes back into here. There was even CSF there being half of you. And so even though basal cells are benign tumor, if you let it grow for 10 years, I mean this is beyond housekeeping. This is a hemmy headectomy now at this point. And you know, she's a tough old rancher lady. She said I'm old. I was 80. Now she's 90. She has this. And so take care of these because even though they're relatively benign. If you let it grow for 10 years, they can cause this. So always especially this morphea form basal squamous, something like that. Alright, Nico. So in the upper eye, we see this large leak and the surface looks like there's some alterations. How is this different than the basal cell? So it's kind of a bigger solid and it's not ulcerated in the center. It's got almost this parchment paper look to it. And it's kind of orange and it's big and so what do you think this could be? This could be a squamous cell. Alright, so this is more consistent with the squamous cell. Now if you think about basal cells, basal cells are definitely sudden news. So where are basal cells more commonly seen? Lower lead, medial canvas. Why? Because your brow shapes the upper lid. And so some of them, I don't see any chromatinins in here. Some of them have bigger brows than others and so they're even more protective. I don't see any here, but the squamous can grow lower and upper lead. That's why I'm up here in the upper lid. And now sometimes squamous can look like this. How is this one different? There's ulceration cell and this is the it looks more flat. It's the rodent. So this is called the rodent ulcer and how do you remember that? Somebody taking a bite. It looks like a rodent ate it. I mean that's not what a rodent needs. That's how you remember it. A rodent ulcer. So a rodent took a nip out of that cheese right there and left it in. So there's your rodent ulcer. You can see that. But look at the rest of their skin. I mean this person has been out and I think they're probably a rancher or construction worker or something. Look at the skin, the sun damage on their skin all over. So this is again a different way that this can present. You can sometimes a squamous cell can have this little rodent, this little ulcerator look to it. So this is squamous. What do we see? We just have lots of cells underneath. So you look, here's the epithelium and here's the cells broken right through the epithelium and they're down here. The predominant color basal cell is blue. Basil, those things. Squamous cells are pink because there's keratin in them, there's pink in them, there's proliferation of the squamous cells. And the large squamous cell carcinoma it's pink when you look at it. I have terror. What are these things right here? Keratin worlds. Exactly. So you see these keratin worlds, keratin furls. You can see the nuclei have a lot of nucleol in them. There's preomorphism, some are big, some are small. And then you can see that the keratin is here but you see it's pink. It's not blue. So, all right. Drop, what do we see here? It's an external color photograph of the right eye and it looks like there's a lot of either bleeding or ulceration of the upper lids and the spartan to the congenitiva as well, lower lids, medial canthus. So what's your concern here? Is there any tumor of some sort that's very invasive at this point? So this is very concerning lesion. Look, there's lots of lashes here. It's really thick. It's got kind of this yellowish, whiteish look to it. What do you think would your concern be here? What kind of tumor? Like a sebaceous carcinoma. So, the problem is this is called the great mimicry. And so this particular patient went to dock in the box with my blepharoconjunctivitis and so every dock in the box gives any patient with the red eye they get genomycin. Now, I don't know, have you ever used genomycin? I mean, we haven't used it for 30 years but every dock in the box gives everybody with the red eye genomycin. So we play it or they're not better. So then they go to the optometrist. The optometrist says, oh, yeah, this is definitely blepharoconjunctivitis. We're going to give you Tobardex. And so, you know, another week later this is indeed a mybomian gland, sebaceous carcinoma. So, this is not blepharoconjunctivitis. Look how thick that lid margin is. Look at the loss of lashes. Look at the yellowish here. So, this is called the great mimicry because if it's diffusive and look like blepharoconjunctivitis if it's focal it can look like a Shalacia. And so you really want to not miss these. So, this is indeed a sebaceous kind. Now, sometimes they're not quite this yet. Look at this lid. It's diffusely thickened all the way over here. Loss of lashes, yellowish dots in there. So, this is a mybomian sebaceous gland carcinoma. And so, if you look at it sometimes these can be fairly differentiated. And so, if you look at this it almost still has like a sebaceous type of ovule here. But look at the cells. Look at the nucleolite. Here's the dissolved lipid. There's lots of lipid in here. So, all these little empty spaces are lipid. Now, if you look at it remember I said a sebaceous cell looks benign, behaves benign. A sebaceous gland carcinoma looks malignant, behaves malignant. These can metastasize. So, you've got to not miss these. People can die from these. And so, this looks very aggressive and indeed it is very aggressive. And the other thing is if you look at it there's something right here. Is that right there? It's my tautic figure. You've got my tautic figures, conchromatin, multiple nucleolite dissolved lipid. That's nasty looking. And so, you don't have to be a pathologist to realize that that's something that is bad. And what is this stain again? An oil red-o. So, it stains oil. Those red little holes. What kind of tissue do you have to have in order to do an oil red-o stain? A sebaceous gland. Fresh tissue. So, just remember your our normal processing when we dehydrate and we put other materials, xylenes in there and itches out the fat. So, if you want to stain lipid, you have to have fresh tissue. So, this is a fresh tissue. Alright, what are we seeing right here? Okay, external photograph of maybe right eye. Lower lid lesion that's pigmented. There is no loss of eyelashes. It's slightly raised, but no surrounding erythema. So, I would think at this point, it would either be I mean, best case scenario just like an EVIS, worst case scenario, you want to look at more characteristics or roll out like a melanoma. So, when you see a pigment lesion like this, you want to measure it, you want to take a picture of it, but you don't see loss of lashes, you don't see notching of the lid margins, probably an EVIS, but what you want to do, you don't want to watch it. So, you just watch it carefully, make sure it doesn't grow and we do the path and indeed, what do we see here? So, we see like nest-like cells of pigment. So, Lee, remember you asked about the difference between palisading and all, you see that the nest is totally filled with cells, as opposed to cell lining up on the side. So, the nine melanocytes here, now, how do we classify EVI? So, it depends on where they're located. Okay, so how would you classify this one? So, this one looks like it's more in the dermis than in the, like, the junction of the epidermis and dermis. I would still say this is the junction right here. Yeah, you're right. So, it's probably junctional. So, it's a junctional, but it also has nest melanocytes down in the dermis. So, we would call this junctional. It's called compound. Compound. So, just up here at the junction, the melanocytes are there, we call it junctional. If some of the melanocytes drop down deeper into the dermis, we call it compound, meaning both junctional and dermal. And then, if it's purely underneath like this one, then we call it dermal. Now, again, that's a misnomer because there's no dermis in the eyelid, but it's entrenched in the literature. We should call it subepithelial, but we call it dermal. So, you see right here you've got the nest melanocytes and you've got no junctional component. Why that's important is, if the melanocytes still have junctional component, they still theoretically have a malignant potential. Once they've lost that junctional component, they kind of mature and they drop down below, they really don't have malignant potential. So, once they're pure dermal, you don't see malignant potential. Is that because you would think it's kind of counterintuitive because the lower they go, you think the more invasive they might be. Actually, the lower they go, the more mature they are. So, initially when the melanocytes come out from the neural crest and migrate to the junction, they'll start to grow and then as they drop off, it means they've been growing for a long time and they won't mature. Alright, what do we see in here? So, this is the extra color photo of the right eye or sorry, left eye. And this is a pigmented, very extensive lower lid lesion that does look like it's disrupted the I don't see many, if any, hair follicles. Yeah, so you'd really be worried about this. So, this would be a lesion of concern and when we look at it you know initially, you look at these there are some benign looking melanocytes here that was probably needless to begin with, but then we look deeper and what do we see? So, I look I see some nucleolide Exactly, look at those nucleolides look at the different sizes and shapes and so this is now gone from a simple nevus to a superficially invasive melanoma. And again, these get in the cascades Now, unfortunately when you look at all the lid tumors melanomas and my romeo and carcinomas are only about one or two percent. So, unfortunately uncommon, but they're getting more common. Why? Because my generation, the baby boom generation spent time in the sun and got that beautiful healthy tan a healthy glow of your skin. So, melanomas are really going up now as the baby boom generation ages so we may see more and more of these as you guys get out into practice Okay, what do we see in here? So, something wrong with the left eye looks like a very I couldn't say if it's dark or not, but the left bloat lid is very much hanging down over major ptosis, major swelling So, how do you feel this? It's not hot, it's not infected, this has been slowly going on, it's very doughy you feel it's solid, it's doughy Okay, so, you know I can tell you guys to be on the differential, but maybe lower down based on that description Maybe that is like a lipoma or Here's the path So, that looks like a lot of lymphocytes Yep So, lymphoma would definitely be high Exactly, so now lymphoma lymphoma is more common in the collagen in the orbit, but you can still get lymphoma on the lid Usually it's a spread from an orbital lymphoma but don't forget, you can get lymphoma off the lid too, and it's very solid and doughy That's the key thing, so it's not a hot, acute you know, preceptile cellulitis or something like that, it's a doughy infiltrating it so you can actually get lymphoma on the lid And last but not least, just this weird thing, um, Lee, what do we see in here? So, external color photo with the face and you see this Marge, well I would say Ulcerated, but it looks like it's an elevation It's erythematous, it's kind of crusted, riled So it's kind of reddish blue, it's solid it's plastic because there's stuff on it and when you get it, it has all these monotonic figures really active, it's got these big cells, we finally worked it out, it's got these little this is called a merkle cell It's very weird, I think it's maybe one of the little nerve endings derived tumors, and I wanted to show you that there's all kinds of weird tumors you can see sometimes in a day So this happens to be a merkle cell It just looks so cool to see if there's nothing that looks like that So I've seen two of these in 35 years, so not really a common not really a common tumor And last but not least you can remember there's other tumors that you show up here, look at this this is a isomepithelial cells here, almost forming little ducts, they look kind of glandular and they're surrounded by this stuff right here, and we do a special U.C. Carmean stain, the stain from Usin So this is a carcinoma This is actually a mucinous adenocarcinoma and just again to show you that weird tumors can occur in the lids, and so Fred Jakobiak who is like the most brilliant lecturer in all of ophthalmology who's now, and he's going to be 80 I think he still kind of sees people in Boston, but he describes this as an island of you know, adenocytes swimming in the sea of mucin there's this sea of mucin on these islands of these cells, and it's just because it looks cool and there's no other tumor that looks like this, so you can get rare tumors that, you know, the the technicality is unfortunately they don't put too many of these seabirds on boards and so the key thing is know your basic tumors, know your basal cell your spring cell your melanomas and your myeloma and carcinomas, and if you know those cold, then you know you can use it as far as it works and there you see, this is what I love this is what a city in contrast there's laundry hanging out on the windows here they're just hanging out all over here yet, right here is a satellite dish for the TV they've got the satellite dish you've still got laundry hanging out on the balcony, and this is the restaurant right here okay, so next week is college so know your college, and we'll see you next Tuesday