Metastatic Tumors

INTRODUCTION Eyelid metastases from distant sites are uncommon and account for less than 1% of eyelid tumors. When they do occur the most frequent sites for the primary tumor are breast, cutaneous melanoma, lung, colon, and prostate malignancies. Other primary sites including kidney, thyroid, parotid and trachea, have been reported. Females are affected more than males in a ratio of 4:1 reflecting the fact that breast carcinoma represents more than a third of eyelid metastases. Eyelid metastases usually occur in the setting of a known primary cancer elsewhere in the body, but in rare cases an eyelid tumor can be the presenting sign of an occult carcinoma.

CLINICAL PRESENTATION The clinical presentation falls into three main categories: the first and most common is a diffuse, painless, noninflammatory, full-thickness, often leathery induration of the lid that may cause ptosis, lid lag, or epiphora. These lesions usually represent scirrhous or desmoplastic metastases from primary lesions such as breast carcinoma. The second pattern is that of an uninflamed, nontender subcutaneous nodule. The third pattern is a solitary ulcerated lesion. These last two patterns are generally seen with metastatic malignant melanoma, squamous cell carcinoma of respiratory origin, and adenocarcinomas from gastro-intestinal or genito-urinary sites. Similar lesions may be present in other areas of the body. Rarely, multiple metastatic lesions may be seen in one or more eyelids.

(Courtesy of Arthur Chandler, M.D.)

HISTOPATHOLOGY Adenocarcinoma of the breast is the primary tumor that most frequently metastasizes to the eyelid (shown below). Metastatic breast adenocarcinoma resembles the primary tumor, with formation of islands and cords of tumor cells within the dermis. Vacuolation of tumor cells reflects their glandular differentiation, and "signet ring" cells may be present (cell in bottom right corner of the photomicrograph on the right). Cutaneous melanomas metastatic to the eyelid may be recognizable by the presence of melanin, or they can be identified using immunohis-tochemistry. Immunohistochemistry is also crucial in narrowing the possible primary sites for other tumors metastatic to the eyelid when the primary site is uncertain.

DIFFERENTIAL DIAGNOSIS The differential diagnosis includes chalazion, infection, or other benign conditions, xanthomas, squamous cell carcinoma, and basal cell carcinoma.

TREATMENT Biopsy is required for diagnosis. Debulking of large symptomatic tumors may be necessary to restore eyelid function while systemic treatment may be directed towards the underlying primary disease. If the metastatic eyelid lesion does not respond to chemotherapy, 3000 to 5000 cGy of external beam irradiation will often reduce the size of the tumor.

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