|Year : 2023 | Volume
| Issue : 1 | Page : 158-160
Eyelid metastasis after rectal adenocarcinoma
Pratheeba D Nivean1, Nivean Madhivanan2, Vimala Chelladurai3, Shanmuga Devi Priya4
1 Department of Oculoplasty, MN Eye Hospital, Chennai, Tamil Nadu, India
2 Academic Director, MN Eye Hospital, Chennai, Tamil Nadu, India
3 Pathologist, Premier Diagnostic Centre, Chennai, Tamil Nadu, India
4 DNB Resident, MN Eye Hospital, Chennai, Tamil Nadu, India
|Date of Submission||16-Jun-2022|
|Date of Acceptance||18-Sep-2022|
|Date of Web Publication||20-Jan-2023|
Pratheeba D Nivean
MN Eye Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Colorectal carcinoma being one of the most common gastrointestinal carcinomas in humans has few metastatic sites. An unusual presentation of eyelid metastasis in a patient with rectal adenocarcinoma has been discussed in this case report. The patient presented with eyelid secondaries with no other secondaries elsewhere in the body.
Keywords: Carcinoma rectum, lid metastasis, unusual metastatic sites
|How to cite this article:|
Nivean PD, Madhivanan N, Chelladurai V, Priya SD. Eyelid metastasis after rectal adenocarcinoma. Indian J Ophthalmol Case Rep 2023;3:158-60
Colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer-related death. CRC is more common in western countries, but the incidence is gradually increasing in developing countries. There are rapid advancements in the diagnosis and treatment of colorectal carcinoma. The common sites of metastasis are the lungs and liver. Eyelid metastasis from a rectal adenocarcinoma has not been reported. We present this case due to its rarity.
| Case Report|| |
A 50-year-old male came to the ophthalmic outpatient department with symptoms of itching and a mass in the left upper lid that increased in size over the past one and half months. The patient was a known case of adenocarcinoma rectum and had undergone surgical treatment and chemotherapy a few months back. On examination, the patient's best corrected visual acuity in the right eye was 6/6 and left eye 6/6; both eyes' near vision was N12. Intraocular pressure by non-contact tonometry was 10 and 13 mm Hg in the right and left eye, respectively. A 2 × 1.5 cm solid mass, pale pink in color with engorged vessels over it in the lateral one-third aspect of the left upper lid with loss of eyelashes and alteration in the lid margin architecture was observed. [Figure 1]. A positron emission tomography (PET) scan was done, which showed no secondaries elsewhere in the body. The patient was advised of an excisional biopsy. The procedure was however done with 3 mm margin clearance along with lid reconstruction in the left upper lid. The histopathological report was suggestive of metastatic adenocarcinoma from the carcinoma (CA) rectum [Figure 2]. Diagnostic confirmation was done by positive immunohistochemical markers that include CK, CK 20, CDX 2, and CEA. The patient was sent for an oncologist's opinion. The patient was advised observation and follow-up.
|Figure 1: External photograph of the patient before (a) and after (b) excision biopsy|
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|Figure 2: 10× (a) and 40× (b) magnification of tumor cells composed of round-to-polygonal epithelial cells with eosinophilic cytoplasm, nuclear atypia, and prominent nucleoli|
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| Discussion|| |
Mutations in tumor suppressor genes and DNA repair genes cause CRC. Depending on the origin of the mutation, CRC can be classified as sporadic, inherited, or familial. Sporadic CRC is due to the point mutation of the genes responsible for carcinogenesis, and it is the most common cause of up to 70%. Familial CRC is associated with an adenomatous polyp, and it accounts for 15%. Inherited CRC is 5% and is caused by inherited mutations that affect one of the alleles of the mutated gene, and a point mutation in the other allele will trigger the tumor.
Risk factors for developing CRC are lifestyle, age, and sedentary habits. CRC is more common after 50 years of age (except for familial and inherited types). Obesity, alcohol, smoking, and red meat consumption are some of the risk factors.
Dysbiosis has been reported to cause CRC. Bacteroides, Fusobacterium, and E. coli are normal inhabitants of the colon and are responsible for the immune regulation of the body. Alteration in the gut microflora can predispose to CRC. Chronic inflammation caused by pathogenic bacteria could promote carcinogenesis. It is hypothesized that proinflammatory bacteria could inhibit or exacerbate normal host responses, thus leading to abnormal apoptosis, cell proliferation, and inflammation. Another proposed mechanism is the release of bacterial secondary metabolites, free radicals, and toxins, which can damage host DNA and induce cell transformation. Probiotics have been given as part of a therapeutic regimen.
The tumor spreads through direct invasion, cavities, blood, or venous drainage. Colon cancers cause abdominal metastasis. Rectal carcinomas communicate more closely with Batson's venous plexus. Therefore, the sites of metastasis are extra-abdominal and the common ones are the lungs and liver. Metastasis is largely influenced by host factors and tumor factors, including chemotactic, vascular permeability, and cytokine profiles.
The other unusual sites reported are the boned, penis, thyroid, adrenal gland, skin, biliary gland, pituitary gland, and breasts. However, there are no reports of eyelid metastasis from rectal adenocarcinoma in the literature. The source for eyelid metastasis could be vascular.
Our patient had a well-defined mass in his upper eyelid which had a prominent vasculature and loss of lashes, and the lid margin was altered. The differential diagnosis for such swellings is sebaceous gland carcinoma, squamous cell carcinoma, sebaceous adenoma, and keratoacanthoma. PET scan is generally considered the first-line modality to find extrahepatic metastasis, but in our case, the PET scan did not show any hyper-reactivity probably due to the small size of the swelling.
Eyelid secondaries have been reported after systemic lymphoma, and they were found to be more aggressive. Perineural invasion is said to be the cause of such secondaries and authors recommend additional radiation to prevent local recurrence. Eyelid malignancies are common, but eyelid secondaries are less common according to the literature., Mansour et al. have reported the common primary sites from where the secondaries develop in the lid. The order of frequency is breasts followed by the skin, gastrointestinal tissue, and genito-urinary tract.
| Conclusion|| |
Eyelid metastasis though rare should be kept as one of the differentials in the metastasis of rectal adenocarcinoma. Suspicious lid swellings should be removed with margin clearance to avoid post-operative recurrences. Aberrant skeletal metastases from rectal adenocarcinoma are very rare, and they have a bad prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]