ARTICLE
Metastatic eyelid tumors are rare. They represent 0.1 to 1.4% of all
eyelid neoplasms [1]. However, they are great mimickers and should be
included in the differential diagnosis of lid tumours especially in elderly
women with a history of breast cancer, since the breast represents the
most common primary site [1, 2]. We report a case of breast carcinoma
in an 83 year old woman with bilateral metastases to the eyelids. A review
of the literature is given.
Case report
An 83 year old woman presented with a 1-month history of painless red
swollen eyelids on both sides (Fig.
1). Three months earlier breast cancer with metastases to the
bones and stomach had been diagnosed. A palliative treatment had been
proposed associating fentanyl (DurogesicTM), naloxone (ValtranTM)
as needed and intravenous pamidronate (ArediaTM). She was also
taking nitrendipine (BaypressTM), lormetazepam (LorametTM),
progesterone (PoveraTM), a laxative (MovicolTM)
and omeprazole (LosecTM). She was not using any eye cosmetics
or eye drops. There was no history of atopy or seborrheic dermatitis.
On clinical examination, the upper and lower eyelids on both sides showed
red indurated swellings with nodules appearing mainly on the upper eyelids.
A biopsy showed a diffuse superficial and deep infiltrate of medium-size
cells (Fig. 2). They had
a large hyperchromatic and pleiomorphic nuclei with a clear cytoplasm.
Immunohistochemistry showed positivity for low molecular weight cytokeratins
(CAM 5.2), carcinoembryonic antigen (CEA), epithelial membrane antigen
(EMA) and gross cystic disease fluid protein (GCDFP-15) (Fig.
3). These findings confirmed the diagnosis of metastatic mammary
carcinoma. The patient died 2 months later without presenting any other
skin involvement of her neoplasm.
Discussion
Most metastases to the eyelids are adenocarcinomas. Melanoma and clear
cell carcinoma come in second and third places respectively [2]. Sarcoma
metastatic to the eyelids are rare including osteosarcomas, lumbosacral
chordomas and leiomyosarcomas [1]. Hence, breast cancer is the most common
primary neoplasm metastazising to the eyelids. It accounts for about 50%
of cases. Other primary cancer sites frequently mentioned in giving metastases
to the eyelids are the skin, the urogenital, gastro-intestinal and respiratory
tracts and choroid. Rare primary localisations include the thyroid and
parotid glands. The primary site remains unknown in 8-11% of cases [2,
3]. The reason for the specific homing of neoplastic cells to the eyelids
is puzzling and remains unknown. Metastatic tumors to the eyelids are
three times more common in women than in men. This is attributed to the
high incidence of breast cancer in women. The median age is around 60
years of age. Although it was reported that the left eyelid was involved
more frequently than the right, recent studies found an equal proportion.
The upper eyelid is preferentially involved rather than the lower. Bilateral
involvement as presented here is exceedingly rare [1].
Three clinical types of eyelid metastasis are recognized [4]. The most
frequent type (60%) exhibits a nodular presentation. It is characterized
by subcutaneous nodules which are painless, soft and skin-coloured. In
the case of melanomas the nodules may be bluish in colour. The second
type corresponds to the infiltrative type (30%) which is more commonly
seen in breast cancer. In this type there is a skin-coloured to red induration
of the eyelids. The differential diagnoses include chalazion, cyst, xanthoma,
and basal cell carcinoma [2]. The ulcerated type is the result of the
invasion of the epidermis and can happen in any of the above mentioned
types.
Although much has been written about cutaneous metastatic disease, few
articles review the histological aspects. In the case of breast metastases,
the pattern of the adenocarcinoma invasion varies with the clinical presentation
[5, 6]. In metastases to the eyelids, adenocarcinoma cells may take on
a histiocytoid appearance. This pattern, however, is not limited to breast
cancers but can occur with metastases from other sites such as the gastro-intestinal
tract [7]. Immunohistochemistry is helpful in narrowing the site of origin
of the primary tumour. In the case of breast metastases the anti-cytokeratin
antibody CAM 5.2 confirms the epithelial nature. EMA and CEA are expressed
as a marker of glandular differentiation. GCDFP-15 is more specific for
a breast origin. However, reactivity has also been found in adnexal carcinomas
and in extramammary Paget's disease without recognizable underlying malignancy
[1].
Metastases to the eyelids usually develop several years after detection
of the primary tumor as is the case with breast cancer. However, metastases
especially of the respiratory tract and the stomach can be the first sign
of an internal malignancy [9]. In general, metastases to the eyelids occur
in the setting of generalised metastases. Therefore the prognosis is poor
[1]. Treatment is palliative and consists of excision or radiotherapy
[1].
Article accepted on 8/5/00
REFERENCES
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