Abstract Lymphatic mapping and sentinel lymphade-
nectomy on a rare malignant blue nevus of the eyelid are
reported. The treatment was wide excision and recon-
struction. A 72-year-old male was referred with a pro-
gressively growing right lower eyelid mass on a blue flat
lesion. Incisional biopsy confirmed malignancy. After
wide tumor excision the resulting defect was reconstruct-
ed with Mustardé's cheek flap and a chondromucosal
graft. A submandibular lymph node was found with in-
traoperative lymphatic mapping and sentinel lymphade-
nectomy technique. Histopathologic examination re-
vealed a malignant blue nevus with sentinel lymph node
involvement. Additional surgery or chemotherapy was
not possible because of the patient's unfavorable general
health. He was followed for 1 year without local or dis-
tant metastasis. Sentinel lymphadenectomy should be in
the armamentarium of surgeons. This method provides
important information about regional lymph node status
and staging of patients as in malignant melanoma.
Malignant blue nevus is a rare skin tumor; it usually aris-
es from a cellular blue nevus, but may appear de novo.
About 50 documented malignant blue nevus cases have
been reported and the largest series is comprised of only
12 cases . Eyelid involvement is also rare.
A rare malignant blue nevus case is reported. The
treatment was wide excision, lymphatic mapping, senti-
nel lymphadenectomy, and reconstruction.
A 72-year-old male was referred with a right inferior orbital mass
(Fig. 1 a). History revealed that there had been a bluish flat lesion
at his right lower eyelid for over 20 years. A small nodular lesion
appeared 6 months previously over this lesion and enlarged with
time. Physical examination revealed a large nodule over the right
lower eyelid, it extended to the nasojugal area. The nodule was
bluish, 4 cm in diameter, firm, and fixed to the tarsal plate. The
patient had chronic obstructive pulmonary disease, hypertension,
and his general condition was not good.
Preoperatively, a punch biopsy was performed on the lesion;
this was reported as malignant melanoma. Tumor excision and
sentinel lymph node dissection was planned. Preoperative lympho-
scintigraphy by injecting thin colloid (Hepatat) around the primary
lesion 2 h before surgery showed drainage to a submandibular
lymph node. Methylene blue was given intradermally around the
tumor just before the operation to provide intraoperative sentinel
The patient was operated on under general anesthesia. The le-
sion was excised with 2 cm of normal margin with total lower eye-
lid excision. The periosteum of the orbital rim was also included
in the resection (Fig. 1b). The resulting defect was repaired with
Mustardé's cheek flap and a chondromucosal composite graft from
the nasal septum to reconstruct the lower eyelid. A 2-cm trans-
verse incision was made over the premarked submandibular senti-
nel node. By using a hand-held gamma probe (Europrobe), one
sentinel lymphatic node was found within the submandibular lym-
phatic basin that was dyed with methylene blue(Fig. 1c).
Microscopic examination of the nodular lower eyelid lesion re-
vealed a pigment-rich melanocytic tumor with infiltrative borders in
the dermis and extending to the subcutaneous fatty tissue (Fig. 1d).
There was no epidermal involvement or junctional activity. The tu-
mor was composed of bipolar, dendritic melanocytes with abundant
melanin granules. The melanocytes showed atypia and pleomor-
phism of the nuclei (Fig. 1e). Areas of necrosis and mitotic activity
of a magnitude of five mitoses per square millimeter were detected.
As a result of these findings, the diagnosis of malignant blue nevus
was established. Although the whole tumor mass was sampled and
serial sections were taken, no associated cellular blue nevus was de-
tected. In the histologic examinations of the sentinel lymph node
within the marginal sinus, there was a group of atypical melanocytes
with the same cytologic features described above for the main tumor.
It was concluded that this was sentinel lymph node involvement.
Presented at the XXII National Plastic and Reconstructive Surgery
Congress (poster), Izmir, Turkey, October 1, 2000.
Y. Aydin (
) · B. Erdinç
Department of Plastic and Reconstructive Surgery,
University of Istanbul, Cerrahpasa Medical Faculty,
Mine sok. Camlik apt. No: 3/7, Suadiye-Istanbul 81070, Turkey
Tel.: +90-216-359-8842, Fax: +90-216-586-1566
Department of Pathology, University of Istanbul,
Cerrahpasa Medical Faculty, Istanbul, Turkey
Eur J Plast Surg (2002) 25:101–103
Y. Aydin · B. Erdinç · C. Demirkesen
Sentinel lymphadenectomy on a rare eyelid malignant blue nevus case
Received: 19 March 2001 / Accepted: 12 July 2001 / Published online: 4 May 2002
© Springer-Verlag 2002