Invasive Squamous Cell Carcinoma: Diagnosis and Management Jacquelyn Cosgrove, OD Louis Stokes Cleveland VAMC Abstract: Orbital malignancy is relatively rare and often is misdiagnosed initially. This case report focuses on the diagnosis and management of a patient with squamous cell carcinoma of the medial canthus with lacrimal system involvement.

I. Case History • Patient demographics: 81 year old Caucasian male • Chief complaint: Patient presents with new lesion on nose and medial canthus of the left that has rapidly grown over past month. Patient reports the mass started as small scab on nose then started affecting medial canthus and both . Recently the lesion has started to produce mucopurulent discharge and blood. • Ocular history: glaucoma suspect OS>OD, pseudophakia, trichiasis, entropion o Last eye exam: 4 months ago • Medical history: prostate cancer, hypothyroidism, chronic sinusitis, COPD, GERD, gout, hyperlipidemia, hypertension, basal cell carcinoma of left middle finger, tobacco use, depression • Medications: 90mcg albuterol, 81mg aspirin, budesonide 160/formoter 4.5mcg, 25mg hydrochlorothiazide, 0.1mg levothyroxine, 20mg lisinopril, 20mg omeprazole, 40mg simvastatin, 0.4mg tamsulosin

II. Pertinent findings • Clinical: o Stable BCVA; OD: 20/40- OS: 20/30 o EOMS: Full, no pain o Pupils: PERRLA (-)APD o SLE: OS: 8.0mm x 3.0mm ulceration of area with irregular, raised edges. Mucopurulent discharge draining from lacrimal lesion. Large, vascularized mass at the caruncle adherent to upper , making the upper puncta no longer visible. Upper eyelid is thickened, has irregular borders, and is firm to touch, with madarosis nasally. Significant conjunctival injection nasally. Epiphora is present. • Cultures: obtained on initial visit, swab of mucopurulent discharge. o Results: Staphylococcus Aureus Methicillin Resistant (MRSA) –Quantity: Heavy • CT Facial Bones with Contrast: obtained same day as initial visit o Enhancing soft tissue mass between the left globe and left nasal bone measuring approximately 1.9 x 2.0 centimeters. This appears contiguous with the . Mass directly abuts anterior margin of left and left aspect of nasal bones. Mass is suspicious for neoplasm. No associated bony erosion. • Biopsy: ordered on initial visit, obtained from left medial canthus/nasal sidewall o Results: Invasive moderately differentiated squamous cell carcinoma

III. Differential diagnosis for lesion involving medial canthus, lacrimal sac, and eyelids • Dacryocystitis presents with unilateral pain, redness, discharge, and swelling over the lacrimal sac. Typically responds well to systemic antibiotics.2 • Canaliculitis presents with unilateral redness, discharge, and mild tenderness over nasal aspect of eyelids. Expression of mucopurulent discharge or concretions from puncta is diagnostic.2 • Basal cell carcinoma (BCC) is the most common malignant eyelid tumor, is usually slow growing and presents most often on the lower eyelid followed by the medial canthus. BCC is locally invasive and rarely metastasizes. Histopathologic confirmation with biopsy.1,3

IV. Diagnosis and discussion • Squamous cell carcinoma (SCC) is the second most common malignant eyelid tumor, with an incidence of 0.09 to 2.42 cases per 100,000.3 It occurs most often on the lower eyelid, followed by the medial canthus, upper eyelid, and lateral canthus.3 • The patient presented with many common signs and symptoms of SCC including rapid onset of a painless nodule with irregular, firm, rolled edges, and central ulceration. The patient also had madarosis of , epiphora, a mass located above the medial canthal tendon, and fistula formation, all of which are indications of orbital invasion.1,3 • Risk factors for developing SCC include UV exposure, HPV, exposure to chemicals, history of prior radiation or skin malignancy, and immunosuppression. SCC occurs more frequently in fair-skinned, elderly individuals with a mean presentation in the seventh decade, which coincide with the patient’s demographics.1,2,3 • Lacrimal system involvement can be confirmed with MRI or PET imaging or post- excision biopsy. Squamous and transitional cell carcinomas are the most common lacrimal sac carcinomas and have a 50% recurrence rate and a 37.5% mortality rate.1,4

V. Treatment, management • Treatment options include: Mohs surgery, photodynamic therapy, radiation therapy, and exenteration.1,2,3 • Determination of treatment depends on histological findings, extent of the tumor, and the overall health of the patient.1,3 • Otorhinolaryngology clinic recommended complete excision of mass, to include at least 50% of upper eyelid, partial rhinectomy, and appropriate reconstruction with local rotational flap, performed in conjunction with oculoplastic surgeon. The patient elected to proceed with recommended treatment.

VI. Conclusion • Commonly misdiagnosed as dacryocystitis, malignancy involving the medial canthus and lacrimal sac is potentially life-threatening, so early diagnosis and treatment is particularly important. • Orbital tumors require lifelong management, as recurrence and metastasis can occur years after initial treatment.1

VII. Bibliography 1. Parmar DN & Rose GE. Management of lacrimal sac tumours. Eye (2003) 17, 599–606 & 2003 Nature Publishing Group. 2. Ehlers JP & Shah CP (2010). The Wills eye manual: office and emergency room diagnosis and treatment of eye disease (6th ed.). New Delhi, India: Wolters Kluwer. 3. Melicher Larson JS, Jones YJ, & Nerad, JA. Secondary Orbital Tumors. EntoKey.com (2016). 4. Rahangdale SR, Castillo M, Shockley W. MR in squamous cell carcinoma of the lacrimal sac. AJNR Am J Neuroradiol.1995 Jun-Jul; 16(6):1262-4.