A 75-year-old man presented with a left lower eyelid lesion that had progressively enlarged over 2 months without bleeding, irritation, or change in vision. Shortly after noticing the eyelid lesion, he also noted hoarseness of his voice and enlarged lymph nodes in the left side of his neck. His review of systems was otherwise negative for fevers, chills, night sweats, weight loss, chest pain, shortness of breath, cough, sputum production, hemoptysis, difficulty swallowing, or gastrointestinal symptoms. He had no recent travel and no known tuberculosis exposure. His past medical history included colon polyps and actinic keratosis. He was not taking any medications. His family history was notable for a brother with prostate cancer and melanoma. He smoked 0.25 packs per day for 5 years and quit 50 years ago.
On examination there was a yellow, raised, left lower eyelid mass measuring 6 × 4 mm (Figure 1). On eversion of the eyelid there was ulceration of the lesion through the conjunctiva and tarsus (Figure 1). The rest of the ophthalmologic examination was normal. The head and neck examination revealed an approximately 1-cm firm, superficial, left retroauricular mass that was not tender to palpation. The lungs were clear to auscultation and percussion. The chest wall had no areas of tenderness on palpation, and there was no visible chest wall deformity. Results from cardiovascular, abdominal, and neurological examinations were unremarkable.
Assessment
The differential diagnosis of this eyelid lesion includes benign entities such as a chalazion, pyogenic granuloma, and inclusion cyst, or malignant entities including basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma, and eyelid metastasis. The tarsal and conjunctival ulceration is highly suggestive of malignancy. Biopsy of the lesion revealed infiltrating adenocarcinoma with dense desmoplastic stroma. Computed tomography of the neck and chest revealed a spiculated left upper lobe mass measuring 2.6 × 2.9 cm and enlarged left hilar and mediastinal lymph nodes (Figure 2). The patient was referred to otolaryngology for evaluation of progressive hoarseness and was found to have left vocal cord paralysis. Transbronchial biopsy of a left paratracheal lymph node showed adenocarcinoma of the lung.
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-Shannon S. Joseph, MD, MSccorrespondencePress enter key for correspondence informationemailPress enter key to Email the author, Sarah E. Yentz, MD, Shravani Mikkilineni, BS, Christine Nelson, MD, Gregory P. Kalemkerian, MD
This article originally appeared in the September 2016 issue of The American Journal of Medicine.
