
==== Front
Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00781-7
10.1016/j.radcr.2024.07.191
Case Report
Squamous cell carcinoma of the eyelid: A rare tumor with unusual metastasis: A case report
Guemmi Ibtissem MD ibtissemguemmi93@gmail.com
⁎
Mahjouba Hajar MD
Samet Mahdi MD
Betari Hajar MD
Nasri Siham MD
Kamaoui Imane MD
Skiker Imane MD
Radiology Département, University of Mohammed I, Mohammed VI University Hospital, Oujda, Morocco
⁎ Corresponding author. ibtissemguemmi93@gmail.com
05 9 2024
11 2024
05 9 2024
19 11 55445547
12 6 2024
30 7 2024
31 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Squamous cell carcinoma of the eyelid is a rare but severe tumor that causes functional and aesthetic damage and poses a significant threat to life through metastatic spread. It typically affects elderly individuals with fair skin and often develops from pre-existing lesions. Diagnosis is confirmed by biopsy. Imaging, using CT and MRI, is critical for assessing local and distant extension, guiding treatment, and monitoring progress. Primary treatment is surgical, aiming for complete resection and restoration of eyelid function, with radiotherapy or chemo-radiotherapy considered for metastatic cases on an individual basis. This report presents a case of unusual localization of eyelid SCC metastasis, showing the importance of performing a cross sectional imaging, particularly a CT NCAP, for distant extension assessment.

Keywords

Squamous cell carcinoma
Metastasis
Imaging
Abbreviations

SCC Squamous cell carcinoma

NCAP neck, chest, abdomen-pelvis

CT Computed tomography

MRI Magnetic resonance imaging

DCE Dynamic contrast-enhanced
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pmcIntroduction

Squamous cell carcinoma (SCC) of the eyelid is a rare but serious tumor, accounting for 9% of all peri-ocular skin cancers. Despite its rarity, it poses significant risks due to potential functional, aesthetic damage, and life-threatening metastatic dissemination. This condition predominantly affects elderly males with fair skin who have had prolonged sun exposure, often developing from pre-existing lesions [1].

Clinically, SCC of the eyelid can present in various forms, requiring histological confirmation for accurate diagnosis. Imaging plays a crucial role in management, enabling assessment of both local and distant extension, guiding treatment, and facilitating follow-up. This report presents a case of unusual localization of eyelid SCC metastasis, demonstrating the value of performing a CT NCAP, for distant extension assessment.

Case report

The patient, a 79-year-old fair-skinned woman from Oujda, with a history of diabetes and high-blood pressure, presented to the ophthalmology department with a lesion on the upper right eyelid, which she reported appeared de novo. Over 6 months, the patient developed an ulcerating lesion that bled on contact, invaded the orbit, and caused loss of eyelashes. No lymphadenopathy was detected. The rest of the clinical examination was normal. A diagnostic biopsy confirmed invasive SCC. A contrast-enhanced CT scan of the head revealed a tumor in the right upper eyelid, measuring 26 × 23 × 5 mm, invading extraconal fat and adjacent muscles without bone involvement (Fig. 1). Additionally, it identified a lesion extending into the left cavernous sinus and the homolateral orbital region, measuring 30 × 11 mm (Fig. 2). A brain DCE-MRI confirmed the presence of a right eyelid upper side lesion isointense on T1 and T2, with restricted diffusion and a homogeneous enhancing after contrast, extending intra-orbitally, invading extraconal fat, superior obligator muscle, superior eyelid levator muscle and superior rectus muscle, as well as the ophthalmic vein. Intraconal fat, nerve and other occulomotor muscles are respected (Fig. 1). It also objectify the tissue infiltration of the left cavernous sinus isointense on T1, hypointense on T2, without restricted diffusion and a intense enhancing after contrast, encompassing its vascular and nerve and displacing the homolateral temporal lobe. No brain parenchymal involvement (Fig. 2). We also performed a CT neck, chest, abdomen-pelvis with contrast, which revealed a left anterior juxta-renal tissue infiltration above the renal pedicle, which remained permeable, not well limited, enhanced after contrast, measuring approximately 33 × 17 mm, associated with discrete parietal thickening of the homolateral pyelon and proximal ureter, and homolateral retroperitoneal adenomegaly, but no other metastatic lesions. The diagnosis was SCC of the eyelid with orbital extension and distant metastasis to the left cavernous sinus and retroperitoneal region (Fig. 2).Fig. 1 Brain contrast-enhanced CT scan and DCE-MRI showing a tumor process in the right upper eyelid, enhanced after contrast (F)There was no bone involvement (G). The lesion is isointense on T2(A), with restricted diffusion (B et C) and a homogeneous enhancing after contrast (D et E).

Figure 1

Fig. 2 Brain CT scan and MRI + abdominal CT scan showing a tumoral infiltration extending into the left cavernous sinus and the homolatral orbital region enhacend after contrast (D et F) and a left anterior juxta-renal tissue infiltration (A,B et C).

Figure 2

The patient case was discussed at a multi-disciplinary meeting and the patient was subsequently treated with radio-chemotherapy. Follow-up imaging after 6 months showed regression of the eyelid lesion and stability of the distant metastases. Unfortunately, the patient passed away 3 months later (Fig. 3).Fig. 3 Control CT scan : regression of the eyelid tumor (A) and stability of the distant metastasis ( B et C).

Figure 3

Discussion

Malignant palpebral tumors account for 5%-10% of all skin cancers, with SCC being relatively rare, representing 3.4%-12.6% of these tumors [1]. Limited studies in Africa suggest a higher prevalence in tropical regions compared to Europe [2]. A study in Morocco reported 36 cases of advanced palpebral carcinoma over 6 and a half year, with an incidence of 5.53 carcinoma/year and 1.38 SCC/year [3].

SCC of the eyelid typically affects elderly individuals, predominantly men, with the primary risk factor being cumulative UV exposure [4,5]. Other risk factors include fair skin, immunosuppression, radiation exposure, high-fat diet, exposure to chemicals, and HPV infection [6,7]. It often develops on actinic keratosis or Bowen's disease [8] but can also arise on normal skin.

The lower eyelid and inner canthus are common sites, though the upper eyelid and outer canthus are more frequently affected by SCC than basal cell carcinoma [5]. Clinically, SCC may appear as an indurated, painless plaque or nodule with central ulceration and irregular margins, but variations exist. Associated symptoms may include loss of eyelashes, blepharitis, and resistant conjunctivitis [4]. Histological confirmation via biopsy is essential. The invasive nature of the tumor and its metastatic potential, requires the use of imaging.

Contrast-enhanced brain CT and MRI are crucial for determining the extent of orbital and the involvement into the muscles, intra- and extra-conal fat, optic nerve, bones and sinuses, and brain parenchyma. CT scans are more effective for bone [9]. MRI is particularly valuable for assessing intra-orbital and cerebral contents, providing sensitivity for detection, locoregional assessment, and monitoring.

It provides an objective assessment of the extent of the tumor in order to determine whether it can be resected, to look for peri-nerve involvement, and to provide reproducible target measurements for monitoring patients undergoing radio-chemotherapy. MRI is also the gold standard for exploring the brain. In particular, it detects meningeal invasion by showing thickening and enhancement of the meningeal envelopes. It can also be used to look for brain metastasis.

Most studies report regional adenopathy in 24% of cases particularly in the parotid, preauricular and sub-maxillary regions, with distant metastases less frequently described at 6.2% [4].

Cervical ultrasound can be a good examination for exploring regional lymph node areas, and can also guide a possible biopsy.

A neck, chest, abdomen-pelvis CT scan with contrast is the gold standard in the assessment of distant extension; it detects adenopathy and suspicious tissue lesions, allowing a disease staging. In our case, it revealed metastases in an unusual location, in the retroperitoneal region and around the contralateral cavernous sinus.

Management is primarily surgical, aiming for complete resection while preserving eyelid function and appearance. Intra-operative histological analysis ensures clean margins, enabling wider resection if necessary. Radiotherapy may be adjunctive, particularly for local adenopathy, and chemo-radiotherapy is considered for advanced cases with distant metastases [10,11].

Conclusion

SCC of the eyelid, although rare, is an aggressive tumor with significant morbidity and mortality due to potential orbital invasion and metastatic spread. Early histological diagnosis and comprehensive imaging are essential for effective management. Contrast-enhanced brain CT and MRI are indispensable for assessing locoregional spread, while NCAP CT is crucial for detecting distant metastases. This approach ensures optimal therapeutic guidance and follow-up for affected patients.

Patient consent

The patient has been informed and consents to the publication of this article.

Competing Interests: The authors declare no conflict of interest.
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