Probable Lid Margin Melanoma

We all see pigmented lesions on the lid margin as a matter of daily practice, and the challenge is in distinguishing between benign and malignant lesions.  This case is illustrative of the challenges which face us when we are confronted by such a lesion.

The patient presented to me yesterday and stated she had the lesion for six months or so, and that it had grown significantly over the last six months.  She had permanent eye liner put in approximately seven years ago.

Since I don't have the path yet, I will give you what I see and you can take it from there.  I see a bluish-black pigmented papule on the free margin of the lid, which looks like it extends roughly 2 mm above the surrounding skin.  It is a bit sunken in in the center, and on the conjunctival aspect of the lid, there are areas of what appears to be regression.  Extending further toward the lateral aspect of the conjunctiva, we see extension of the pigment, blue-black proximally,  jet black distally.  

When dealing with pigmented lesions of the lid, there is one rule which almost always is valid: if it extends onto the conjunctiva, it is bad.  In this case, really bad.

The only serious ddx for this (besides perhaps a cellular blue nevus) is that of a pigment granuloma, but the extension onto the conj is so unlikely in that scenario as to be eliminated as a serious consideration.

I will inform you when the dx is out, but I am at this time only giving credit for r/o melanoma.