PHOTO ESSAY: Just A Cutaneous Horn or Squamous Cell Carcinoma?
Save as PDFABSTRACT
Squamous cell carcinoma is an aggressive malignant skin lesion that can involve the eyelids. This case highlights the importance of lid lesion biopsy and obtaining appropriate specialty consults in the management of malignant eyelid lesions.
CASE REPORT
A 75-year-old white male presented to the eye clinic with the complaint of an eyelid growth on his left eye that had been present for approximately one year. He denied bleeding of the lesion, but did report that it sometimes caused irritation. He denied a history of skin cancer. His medical history was positive for hypertension and diabetes. He was best corrected to 20/25 in each eye due to mild cataracts. A lid lesion was noted on the left upper eyelid just above the lash line, measuring 3 mm in width at the base and 7 mm in height. Erythema was noted near the base and the lesion had a keratinized appearance. His dilated ocular health was unremarkable. He was sent for excision and biopsy which revealed an “invasive, moderately-well-differentiated squamous cell carcinoma with a hyperkeratotic cutaneous horn.” Given the positive biopsy for squamous cell carcinoma, he was then referred to oculoplastics and the residual base was biopsied which confirmed squamous cell carcinoma. Next a Mohs surgery was scheduled with dermatology. The eyelid healed well following Mohs surgery and the plan is to follow him every 6 months to monitor for possible signs of recurrence.
Various images of the cutaneous horn
DISCUSSION
Eyelid tumors account for 5-10% of all skin cancers; identifying these tumors should be part of routine optometric exams.1 Most eyelid tumors are benign and account for about 84% of cases.2 Out of the malignant eyelid tumors, the most common malignant lesions are basal cell carcinoma (83.6-92.2%), squamous cell carcinoma (7-16.3%) and sebaceous cell carcinoma (0-3%).3,4 As primary eyecare providers, it is imperative that these malignant lesions are promptly identified and referred to oculoplastics specialists and/or dermatology for management and treatment.
The conjunctiva, cornea, and eyelid tissue can all be affected due to squamous cell carcinoma. On the eyelid, the most common sites of presentation of these lesions are the lower and medial eyelids, followed by the upper eyelids.4 Squamous cell carcinoma in the eyelid may arise spontaneously or at the site of precancerous lesions, such as actinic keratosis.4 Long-term exposure to ultraviolet light radiation is the leading risk factor for developing squamous cell lesions. Other risk factors include age, fair skin, radiation exposure, immunosuppression, a high-fat diet, exposure to cigarette smoke, actinic keratosis, and squamous intraepithelial neoplasia.4 Squamous cell carcinoma is more common in immunocompromised patients, particularly after a solid organ transplant.5 Squamous cell carcinoma is more prevalent in the elderly population, with the mean age of incidence being in the 7th and 8th decades of life.4 It is also more commonly found in males compared to females.
A thorough slit lamp examination is crucial for early diagnosis and prompt management. Lesions that are suspicious for squamous cell carcinoma may present with ulceration and scaling and may be accompanied by madarosis.4 However, there are various clinical presentations of squamous cell carcinoma lesions, and some can present as red and vascularized with papillary-like features.
When evaluating a suspicious lesion, it is important to note the presence or absence of a cutaneous horn since 20-38.9% of cases that present with a cutaneous horn have the potential to be malignant or premalignant.6,7 A cutaneous horn is a hyperkeratotic epithelial lesion resembling an animal horn.6 These can be cutaneous growths caused by benign, premalignant, or malignant processes.6 Squamous cell carcinoma is the most common malignant cause of a cutaneous horn.6 Histologic data reveals that the base of the cutaneous horn is typically actinic keratosis or invasive squamous cell carcinoma.7 Knowing this information, it is imperative to promptly refer patients who present with cutaneous horns for excision and biopsy to rule out malignant eyelid lesions.
Given the variable presentation of malignant lesions, it may be difficult to distinguish between types of malignant eyelid lesions on clinical exam, so excision and biopsy are crucial in the diagnosis. Squamous cell carcinoma lesions can be staged according to the American Joint Committee on Cancer TNM Staging. TNM staging corresponds to the primary tumor size, location and invasion level, lymph node invasion, and metastasis.8 These cancerous lesions may also be classified into different grades. The grades range from GX to G4, with G4 having the worst prognosis.8
Management is aimed at complete surgical excision of the malignant lesion. Mohs micrographic surgery is the most common treatment in patients with squamous cell carcinoma.9 This surgical procedure is commonly used in the eyelid and periorbital areas as tissue conservation is essential. It is also used in cancerous lesions where there is a high risk of recurrence.10
There are also newer procedures aimed at treating and managing these lesions, especially for those who are poor candidates for surgery. Targeted therapy involving the hedgehog pathway and epidermal growth factor receptor is useful in these patients with advanced disease.5
Exenteration may be performed in severe cases where orbital involvement is present. Other treatment options for premalignant lesions include cryotherapy, photodynamic therapy, and topical chemotherapeutic agents; however, these are not recommended for malignant lesions.
As a primary eye care provider, it is important to carefully examine the adnexal and periorbital regions. Knowing the possible treatment options that may be offered to the patient can also aid in patient education. Co-management with the appropriate specialists is crucial in the management of these patients.
References
- Sullivan TJ, Boulton JE, Whitehead KJ. Intraepidermal carcinoma of the eyelid. Clin Exp Ophthalmol 2002;30:23–7.
- Deprez, Manuel MD, PhD*†; Uffer, Sylvie MD, PhD*. Clinicopathological Features of Eyelid Skin Tumors. A Retrospective Study of 5504 Cases and Review of Literature. The American Journal of Dermatopathology 31(3):p 256-262, May 2009. | DOI: 10.1097/DAD.0b013e3181961861
- S.Y. Sendul, C. Akpolat, Z. Yilmaz, O.T. Eryilmaz, D. Guven, F. Kabukcuoglu. Clinical and pathological diagnosis and comparison of benign and malignant eyelid tumors. Journal Français d’Ophtalmologie, Volume 44, Issue 4, 2021, Pages 537-543, ISSN 0181-5512
- Yasuyoshi Sato, Shunji Takahashi, Takashi Toshiyasu, Hideki Tsuji, Nobuhiro Hanai, Akihiro Homma, Squamous cell carcinoma of the eyelid, Japanese Journal of Clinical Oncology, Volume 54, Issue 1, January 2024, Pages 4–12, https://doi.org/10.1093/jjco/hyad127
- Sun MT, Huang S, Huilgol SC and Selva D. Eyelid lesions in general practice. Australian Journal of General Practice. Vol 48, Issue 8, Aug 2019, doi: 10.31128/AJGP-03-19-4875
- Thiers BH, Strat N, Snyder AN, et al. Cutaneous Horn. [Updated 2024 Feb 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563280/
- Meghwal L, Balai M, Sehgal S, Gupta LK. A Squamous Cell Carcinoma Presenting as a Giant Cutaneous Horn over the Lower Lip in a Patient with Chronic Disseminated Lupus Erythematosus. Indian Dermatol Online J. 2023 Feb 23;14(2):284-286. doi: 10.4103/idoj.idoj_275_22. PMID: 37089833; PMCID: PMC10115329.
- American Joint Committee on Cancer. Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010:301-314.
- Mehta, Viraj J. MD, MBA; Ling, Jeanie MD; Sobel, Rachel K. MD. Review of Targeted Therapies for Periocular Tumors. International Ophthalmology Clinics: Winter 2017 – Volume 57 – Issue 1 – p 153–168 doi: 10.1097/IIO.0000000000000149
- Prickett KA, Ramsey ML. Mohs Micrographic Surgery. [Updated 2023 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441833/
Dr. Kelly graduated from the University of Houston College of Optometry. She completed an ocular disease/primary care residency at The Veteran’s Health Care System of the Ozarks. She has served on staff there since the completion of her residency and works with students and residents. She enjoys hiking, cycling and traveling with her husband and two daughters.
Dr. Natarajan graduated from the University of Missouri St. Louis College of Optometry in 2018. She then completed an ocular disease/primary care residency at the Veterans Healthcare System of the Ozarks in Fayetteville, Arkansas from 2018-2019. Thereafter, she joined on as an attending optometrist and contact lens coordinator at the St. Louis VA Medical Center.
