ARTICLE
Auteur(s) : Sei-Ichiro Motegi, Atsushi
Tamura, Yoichiro Matsushima, Yayoi Nagai, Osamu Ishikawa
Department of dermatology, Gunma University Graduate School of
Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan
accepté le 2 Août 2005
Squamous cell carcinoma (SCC) of the eyelid mainly develops from
the cutaneous region, and SCC derived from the palpebral
conjunctiva is quite rare. We herein report a 58-year-old Japanese
man with SCC of the left upper eyelid arising from palpebral
conjunctiva.
Case report
A 58-year-old Japanese man had noted a subcutaneous nodule on his
left upper eyelid for ten years. As the nodule had gradually
enlarged for the last year, the patient consulted an
ophthalmologist. The tumor was excised by an ophthalmologist under
the diagnosis of chalazion. However, it recurred and grew larger.
Finally, the histological examination confirmed a diagnosis of SCC.
The patient was referred to our department. Physical examination
revealed a 20 × 12 mm pale-reddish tumor on the lateral side
of the left upper eyelid margin (( figure 1 )). The skin
surface of the tumor was smooth, and the bulbar conjunctiva was not
involved.
We performed a full-thickness excision of the upper eyelid with
a 8 mm safety margin, and reconstructed the upper eyelid by
the technique of Mustarde’s switch flap, utilizing a two-stage
transposition of the lower eyelid [1] (( figures 2A and 2B )). Two
weeks after the first operation, we performed a pedicled flap
division and reconstructed of the lower eyelid by the cheek
rotation flap using a fascia lata as a semi-rigid support tissue
and a buccal mucosa as an inner mucosal layer (( figure 2C )).
Histological examination of the resected tumor revealed a
lobular and island structure of tumor cells invading toward the
eyelid skin from an epithelium of palpebral conjunctiva (( figure 3A )). The
epidermis of eyelid skin was not involved. The tumor mass was
composed of moderately differentiated squamous cells, showing
incomplete keratinization. The tumor cells with atypical nuclei
were conspicuous. There were numerous inflammatory cells in the
stroma (( figure
3B )). The oil red O stain of the frozen section showed no
lipid accumulation in the tumor cells.
The clinico-pathological findings established the diagnosis of
SCC arising from the palpebral conjunctiva. During a 10 month
follow-up, neither local recurrence nor metastasis has been
detected, and the reconstructed eyelids have functioned well with a
good appearance (( figure 2D )).
Discussion
The previous studies of malignant tumors of the eyelid in
Caucasians have reported that basal cell carcinoma is the most
frequent, accounting for over 80% of malignant eyelid tumors [2,
3]. In the Japanese, however, a higher incidence of sebaceous
carcinoma and SCC and a lower incidence of basal cell carcinoma
have been reported [4, 5].
SCCs of the eyelid are usually derived from the epidermis of
eyelid skin, and SCCs of the conjunctiva mainly develop on the
bulbar region of conjunctiva [6, 7]. In contrast, SCCs of the
palpebral conjunctiva origin are quite rare. To the best of our
knowledge, only 10 cases have been reported in the English language
literature. We summarized the clinical features of the 10 patients
with SCC of the palpebral conjunctiva in table 1( Table 1 )[8-13]. Six out of 9 cases were clinically
diagnosed as chronic conjunctivitis [8, 9, 11]. Our patient was
first clinically diagnosed as chalazion before visiting our
hospital. Thus, SCC of the palpebral conjunctiva seems to
masquerade as benign inflammatory conditions such as chronic
conjunctivitis or chalazion.
Recently, human papilloma virus (HPV) antigens and DNA have been
detected in conjunctival neoplasia [14]. However, HPV was not
associated with SCC of the conjunctiva in many cases [12, 15].
Other possible risk factors include ultraviolet irradiation [16],
reduced immunological state, such as acquired immune deficiency
syndrome [17] and chronic inflammation of the conjunctiva [18]. Our
patient had no familial and personal risk factors for carcinoma,
and no history of malignancy arising from the other region.
We used the Mustarde’s switch flap for reconstruction of the
upper eyelid. The secondary defect of the lower eyelid was repaired
with a cheek rotation flap lined with a fascia lata as a support
tissue. A cheek rotation flap is usually lined with a support
tissue such as chondromucosal graft or conchal cartilage [19, 20].
However, Matsumoto et al. reported that the fascia lata could be
used as a support tissue for a cheek rotation flap aimed at the
lower eyelid reconstruction and could solve several problems caused
by cartilage grafting, such as irritation of the bulbar conjunctiva
and postoperative cartilage warping [21]. The reconstructed lid
margin of our patient has been retained for ten months, and no
postoperative ectropion was present.
In conclusion, SCC of the palpebral conjunctiva is quite rare.
The clinical appearance frequently leads to misdiagnosis as benign
lesions, such as chronic conjunctivitis and chalazion, or sebaceous
carcinoma. It is important for clinicians to be aware of the
clinical manifestations of palpebral conjunctiva-derived SCC, since
early recognition and treatment can bring about a favorable
prognosis and functionally and cosmetically satisfactory
results.
Table 1 Reported cases of SCC on the palpebral
conjunctiva
|
No
|
Author
|
Year
|
Age/Sex
|
Location
|
Clinical diagnosis
|
Treatment
|
Course
|
|
1
|
Theodore
|
1967
|
-
|
-
|
Chronic conjunctivitis
|
Radiation therapy
|
-
|
|
2
|
Theodore
|
1967
|
-
|
-
|
Chronic conjunctivitis
|
Radiation therapy
|
-
|
|
3
|
Theodore
|
1967
|
-
|
-
|
Chronic conjunctivitis
|
Radiation therapy
|
-
|
|
4
|
Thygeson
|
1969
|
65M
|
Upper lid
|
Chronic conjunctivitis
|
Radiation therapy
|
No recurrence for 2 years
|
|
5
|
Thygeson
|
1969
|
54M
|
Lower lid
|
Meibomian-gland Granuloma chronic Conjunctivitis
|
Tumor resection
|
-
|
|
6
|
Blodi
|
1973
|
75F
|
Upper lid
|
-
|
Tumor resection
|
No recurrence for 1 year
|
|
7
|
Blodi
|
1973
|
52F
|
Lower lid
|
Acute stye
|
Tumor resection
|
No recurrence for 1 year
|
|
8
|
Goldberg
|
1993
|
85F
|
Upper lid
|
Chronic conjunctivitis
|
Radiation therapy
|
Local recurrence after 7 weeks
|
|
9
|
Matsumoto
|
1997
|
69F
|
Upper lid
|
Papilloma
|
Tumor resection, cryotherapy
|
No recurrence for 1 year
|
|
10
|
Whittaker
|
2002
|
62M
|
Lower lid
|
Leukoplakia
|
Tumor resection
|
Local recurrence for 7 months
|
References
1 Mustarde JC. In: Repair and reconstruction in the orbital
region. Edinburgh: Churchill Livingstone, 1966: 198-201.
2 Aurora AL, Blodi FC. Lesion of the eyelids: a
clinicopathologic study. Surv Ophthalmol 1970; 15: 94-104.
3 Cook Jr. BE, Bartley GB. Epidemiologic
characteristics and clinical course of patients with malignant
eyelid tumors in an incidence cohort in Olmsted County, Minnesota.
Ophthalmology 1999; 106: 746-50.
4 Abe M, Ohnishi Y, Hara Y, Shinoda Y,
Jingu K. Malignant tumor of the eyelid: clinical survey during
22-year period. Jpn J Ophthalmol 1983; 27: 175-84.
5 Kawana K, Goto H, Mori H, Usui M,
Nomoto T. Clinical analysis of 60 cases of malignant eyelid
tumors. Jpn J Opthalmic Surg 2003; 16: 407-10.
6 Grossniklaus HE, Green WR, Luckenbach M,
Chan CC. Conjunctival lesions in adults. A clinical and
histopathologic review. Cornea 1987; 6: 78-116.
7 Erie JC, Campbell RJ, Liesegang TJ.
Conjunctival and corneal intraepithelial and invasive neoplasia.
Opthalmology 1986; 93: 176-83.
8 Theodore FH. Conjunctival carcinoma masquerading as
chronic conjunctivitis. EENT Monthly 1967; 46: 1419-20.
9 Thygeson P. Observations on conjunctival neoplasms
masquerading as chronic conjunctivitis or keratitis. Trans Am Acad
Ophthalmol Otolaryngol 1969; 73: 969-78.
10 Blodi FC. Squamous cell carcinoma of the conjunctiva.
Doc Ophthalmol 1973; 34: 93-108.
11 Goldberg SH, Riedy DK, Lanzillo JH. Invasive
squamous cell carcinoma of the palpebral conjunctiva. Graefes Arch
Clin Exp Ophthalmol 1993; 231: 246-8.
12 Matsumoto CS, Nakatsuka K, Imaizumi M.
Squamous cell carcinoma of the palpebral conjunctiva. Br J
Ophthalmol 1997; 81: 804-5.
13 Whittaker KW, Trivedi D, Bridger J,
Sandramouli S. Ocular surface squamous neoplasia: report of an
unusual case and review of the literature. Orbit 2002; 21:
209-15.
14 McDonnell JM, Mayr AJ, Martin WJ. DNA of human
papillomavirus type 16 in dysplastic and malignant lesions of the
conjunctiva and cornea. N Engl J Med 1989; 320: 1442-6.
15 Tuppurainen K, Raninen A, Kosunen O,
Kankkunen JP, Kellokoski J, Syrjanen S,
Mantyjarvi M, Syrjanen K. Squamous cell carcinoma of the
conjunctiva. Failure to demonstrate HPV DNA by in situ
hybridization and polymerase chain reaction. Acta Ophthalmol
(Copenh) 1992; 70: 248-54.
16 Lee GA, Williams G, Hirst LW, Green AC.
Risk factors in the development of ocular surface epithelial
dysplasia. Ophthalmology 1994; 101: 360-4.
17 Margo CE, Mack W, Guffey JM. Squamous cell
carcinoma of the conjunctiva and human immunodeficiency virus
infection. Arch Ophthalmol 1996; 114: 349.
18 Napora C, Cohen EJ, Genvert GI,
Presson AC, Arentsen JJ, Eagle RC, Laibson PR.
Factors associated with conjunctival intraepithelial neoplasia: a
case control study. Ophthalmic Surg 1990; 21: 27-30.
19 Mustarde JC. Major reconstruction of the eyelids:
functional and aesthetic considerations. Clin Plast Surg 1981; 8:
227-36.
20 Matsuo K, Hirose T, Takahashi N,
Iwasawa M, Satoh R. Lower eyelid reconstruction with a
conchal cartilage graft. Plast Reconstr Surg 1987; 80: 547-52.
21 Matsumoto K, Nakanishi H, Urano Y,
Kubo Y, Nagae H. Lower eyelid reconstruction with a cheek
flap supported by fascia lata. Plast Reconstr Surg 1999; 103:
1650-4.
|
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