Introduction
Background
Squamous cell carcinoma skin cancer of eyelid is a relatively rare malignant epithelial tumor that typically affects elderly fair-skinned individuals.1,2,3 Certain benign and malignant epithelial tumors may simulate squamous cell carcinoma both clinically and histopathologically; earlier studies may have overestimated the frequency of squamous cell carcinoma.4
Although not nearly as common as basal cell carcinoma skin cancer of the eyelids, previous studies have found it to be the second or third most common eyelid malignancy, accounting for approximately 5% of all eyelid neoplasms.5 Squamous cell carcinoma may arise de novo or from preexisting lesions such as actinic keratosis. It also may develop in patients with xeroderma pigmentosum or following radiation therapy to the eyelids.6,7
Pathophysiology
Squamous cell carcinoma is found frequently in areas of the body that are exposed to sunlight. Similarly, many precancerous lesions (eg, actinic keratosis, Bowen dermatosis) also appear to be related to ultraviolet light exposure. Squamous cell carcinoma can develop even if the history of sun exposure occurred decades prior to development of the skin lesion.8
Occupations with considerable exposure to oils or tar may be associated with increased incidence of squamous cell carcinoma of eyelids. In patients with xeroderma pigmentosum, defective DNA repair causes predisposition for development of malignant epithelial lesions, including squamous cell carcinoma.
Although typically observed in elderly patients, squamous cell carcinoma may be seen in younger patients with a history of radiotherapy or in patients infected with HIV. Human papillomavirus infection or p53 overexpression may play a role in development of squamous cell carcinoma in patients who are infected with HIV.9,10
This 35-year-old man who is HIV positive presented with a 2-year history of a slowly enlarging, left lower eyelid lesion; incisional biopsy revealed squamous cell carcinoma.
Frequency
United States
Incidence of squamous cell carcinoma has been reported in the literature to account for 2.4-30.2% of malignant eyelid tumors. Kwitko found that out of 115 tumors originally diagnosed as squamous cell carcinoma at the Armed Forces Institute of Pathology, only 12 were diagnosed correctly after reevaluation.6,5 More recent studies have estimated that squamous cell carcinoma accounts for approximately 5% of malignant eyelid tumors.
Mortality/Morbidity
Unlike basal cell carcinoma of eyelid, squamous cell carcinoma can be an aggressive tumor that has potential to invade the orbit, metastasize to lymph nodes and distant sites, and cause death.11,1,2,12,4
- Incidence of metastasis from cutaneous squamous cell carcinoma has been found to be 0.23-2.4% of cases. However, tumors arising from areas of previous radiation therapy may have an incidence of metastasis as high as 20%.13,14
- Squamous cell carcinoma may be more aggressive in patients who are immunocompromised.
Race
Squamous cell carcinoma is more common in fair-skinned individuals, especially those who have been chronically exposed to sunlight.
Sex
Squamous cell carcinoma may be slightly more common in males than in females. However, this may be due to certain occupations that entail more significant exposure to sunlight or other occupational hazards such as soot, oils, or tars.
- Age-adjusted incidence rates from Olmsted County, Minnesota are 2.42 (men) and 0.67 (women) cases per 100,000 population per year.1
- In Sweden, relative incidences are 0.13 (men) and 0.093 (women) per 100,000 population per year.
Age
Incidence of squamous cell carcinoma increases significantly with age.
- Cook and Bartley reported age- and gender-adjusted incidence rate per 100,000 per year to be 0.00 in men aged 40-49 years and 29.99 in men older than 80 years. Incidence rate was 1.21 for women aged 40-49 years and 11.44 in women older than 80 years.1
- Dailey found that 80% of their patients with squamous cell carcinoma were older than 60 years.2
- Patients who are immunocompromised develop squamous cell carcinoma at a younger age. In a study of cutaneous squamous cell carcinoma, mean age of patients infected with HIV was 49 years, whereas mean age of patients who were not immunocompromised was 75 years.9,10
Clinical
History
A complete past medical and ocular history should be obtained.
- Existing medical conditions such as xeroderma pigmentosum, or previous history of cutaneous malignancies (basal cell, squamous cell, sebaceous cell carcinoma, malignant melanoma)
- Immunocompetency of patient (HIV risk factors, history of organ transplant, current chemotherapy)
- History of significant sun exposure, occupational exposures (oils, tars, soot)
- Previous history of benign eyelid lesions (actinic keratosis, chalazion); recurrence after treatment of eyelid lesion
- Duration for which eyelid lesion has been present
- Change in size, contour, or color of lesion
- Ocular symptoms (decreased vision, diplopia, increasing proptosis, ocular surface irritation)
Physical
- External examination
- Location of lesion (upper/lower eyelid, medial/lateral/central eyelid); squamous cell carcinoma more common on lower eyelid
- Size of lesion
- Character of lesion (smooth/nodular, vascularity, color); squamous cell carcinoma may appear as plaques or nodules with variable degrees of scale, crust, or ulceration
- Presence of ulceration
- Loss of lashes or destruction of normal eyelid architecture
- Evaluation of subcutaneous tissues (depth of lesion, bony involvement)
- Examination of conjunctiva for involvement (hyperemia, dyskeratosis)
- Hertel exophthalmometry, if orbital extension is suspected
- Palpation of preauricular, submandibular, and cervical lymph nodes
- Ocular examination
- Visual acuity
- Slit lamp examination and fundus examination to exclude other causes of symptoms
Causes
- Risk factors for squamous cell carcinoma include the following:
- Sunlight (ultraviolet light) exposure, especially in fair-skinned individuals
- Soot, chimney sweepers
- Arsenic fumes or medications
- Coal tar
- Paraffin oil
- Radiation exposure
- Precancerous dermatoses
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References
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Further Reading
Keywords
eyelid squamous cell carcinoma, eyelid skin cancer, eyelid malignancy, eyelid neoplasm, SCC, facial skin cancer, skin carcinoma, adenoacanthoma, adenoid squamous cell carcinoma, invasive squamous cell carcinoma, malignant squamous cell carcinoma, pseudoglandular squamous cell carcinoma, actinic keratosis, xeroderma pigmentosum, eyelid radiation therapy
