ABSTRACT
Metastasis to eyelids is a rare condition with a poor prognosis, presenting with nonspecific symptoms. Diagnosis can be challenging in such cases, but it is important to consider metastatic disease as one of the differential diagnoses of eyelid lesions in cancer patients.
Keywords: breast cancer, case report, eyelid metastasis, lobular carcinoma
1. Introduction
Breast cancer is one of the most common cancers in women, with about 6% of cancer patients having metastasis at initial presentation and 30% having metastasis during follow‐up [1, 2]. Invasive ductal carcinoma (IDC) is the most common type of breast cancer, with invasive lobular carcinoma (ILC) coming in second [2]. The common sites of metastasis also vary between IDC and ILC. IDC tends to metastasize to bone, brain, lungs, and liver, while ILC, in addition to those sites, also metastasizes to the genitourinary tract, gastrointestinal tract, peritoneum, retroperitoneum, and leptomeninges [2]. Eyelid metastasis is exceedingly uncommon, making up < 1% of all malignant eyelid lesions. The majority of eyelid metastases have breast as the most common primary site of tumor [3]. Other common primary tumors metastasizing to eyelids include melanoma, gastric carcinoma, lung carcinoma, and genitourinary tract tumors [3]. We report a case of a 55‐year‐old female who presented to our hospital with breast cancer metastasis to the left lower eyelid.
2. Case History/Examination
A 55‐year‐old female who is a known case of carcinoma of the right breast with ovarian metastasis (Krukenberg tumor) was admitted to Nepal Cancer Hospital due to gastrointestinal complaints of abdominal pain and diarrhea. During her hospital stay, a mass was noticed in her left lower eyelid. The mass was painless, and she did not have any changes in vision, eyelid swelling, or other ocular symptoms. According to the patient, she had noticed the mass a few months back, and it had gradually increased in size since then.
She was first diagnosed with breast cancer in 2016 when she presented with pain and a lump in her right breast. On investigation, her mammography showed a spiculated density of about 30 × 25 mm size in the upper outer quadrant of the right breast, which was highly suspicious for malignancy. On further investigation, fine needle aspiration (FNA) showed tumor cells with scant cytoplasm, hyperchromatic nuclei, and irregular nuclear shape, arranged in clusters and single patterns. An incisional biopsy from the breast showed a single file pattern and aggregates of tumor cells infiltrating the breast parenchyma. Tumor cells showed mild nuclear atypia and hyperchromatic nuclei. Mitotic figures, perineural invasion, and lymphovascular invasions were seen. A diagnosis of invasive lobular carcinoma of grade I was made. Immunohistochemical analysis showed estrogen receptor (ER) and progesterone receptor (PR) positive and Her2 neu negative. She was started on chemotherapy with docetaxel and epirubicin, with regular follow‐up. The patient remained in remission for five and a half years.
A whole‐body PET CT with contrast, done in 2022 as part of routine follow‐up, showed extensive bone metastasis involving all visualized axial and appendicular skeleton. She was started on Inj. Fulvestrant and Inj. Zoledronic acid. A chest x‐ray done in 2023 revealed multiple bilateral ill‐defined nodular opacities along the line of the ribs for which Tab. Palbociclib and Tab. Letrozole were started. A 2024 whole‐body MRI showed new pelvic lesions and increased bone metastasis. Her treatment plan was changed to Tab. Everolimus and Inj. Zoledronic acid. The patient was under regular follow‐up for ongoing chemotherapy.
3. Methods
During her current admission, her laboratory findings showed elevated CA 125 (571.60 U/mL), normal levels of sodium (142 mEq/L), potassium (4.3 mEq/L), creatinine (0.65 mg/dL), hemoglobin (12.6 g/dL), and vitamin D (34.62 ng/mL). A whole body PET CT was done, which showed new breast nodules in the upper outer quadrants of the right and left breasts and gross ascites. However, the PET CT did not show any ocular involvement. An excisional biopsy of the mass was done. Grossly, the specimen was received in three bits measuring altogether 1 × 0.4 × 0.3 cm. The entire specimen was submitted for histopathological examination. Histopathological examination showed skin tissue lined by keratinized stratified squamous epithelium with underlying stroma infiltrated by tumor cells arranged in cords, trabeculae, Indian file pattern, clusters, and singly. The tumor cells showed moderate pleomorphism, having increased nucleocytoplasmic ratio, some with eccentric nuclei, enlarged hyperchromatic nuclei, conspicuous nucleoli, and moderate cytoplasm (Figure 1). A diagnosis of metastatic carcinoma with a lobular pattern was made. Immunohistochemical analysis showed tumor cells positive for ER (Figure 2), with 90% of the cells showing nuclear staining in the invasive component of the tumor and an Allred score of 8. Tumor cells were negative for PR, with 0% of the cells showing nuclear staining in the invasive component of the tumor and an Allred score of 0. Tumor cells were negative for HER 2neu with a score of 1+, with the cells showing incomplete membrane staining that is faint or barely perceptible and within > 10% of tumor cells. This confirmed breast as the primary site of the tumor. She was given chemotherapy and was discharged in stable condition.
FIGURE 1.
(A, B) Skin tissue lined by keratinized stratified squamous epithelium (blue arrow) with underlying stroma infiltrated by tumor cells (yellow arrows) arranged in cords, trabeculae, Indian file pattern, clusters and singly. (A: HE 40×, B: HE 100×). (C) Tumor cells (green arrows) showing moderate pleomorphism with increased nucleocytoplasmic ratio, some cells with eccentric nuclei, enlarged hyperchromatic nuclei, conspicuous nucleoli with moderate cytoplasm. (HE 400×).
FIGURE 2.
Immunohistochemical analysis showing tumor cells positive for ER, with 90% of cells showing nuclear staining in the invasive component of the tumor.
3.1. Differential Diagnosis
As our patient presented with a painless mass in her eyelid, the differential diagnoses included chalazion, metastatic lobular carcinoma, basal cell carcinoma, squamous cell carcinoma, cutaneous malignant melanoma, and sarcoidosis.
4. Conclusions and Results
To date, the patient is on Tab. Capecitabine and Inj. Zoledronic acid. No fresh issues have been identified.
Metastasis to eyelids is a rare occurrence and indicates poor prognosis. It can present with a variety of nonspecific findings. Histopathological examination and immunohistochemical analysis are essential in confirming metastasis and the primary site of origin. Our case presents an unusual case of breast cancer metastasis to the eyelid, emphasizing the importance of maintaining a high degree of suspicion of metastasis in breast cancer patients presenting with eyelid lesions.
5. Discussion
Metastasis to the eyelids is rare, representing a small percentage of eyelid malignancies, and is more common in middle or old age [3]. In a study of 892 eyelid lesions, only 3 cases (0.3%) were of eyelid metastasis. Another study reported only 1 case (0.07%) of eyelid metastasis out of the 1502 eyelid lesions evaluated histopathologically [3]. Breast has been reported as the primary site of cancer in more than 50% of cases of eyelid metastasis. Although the primary tumor is found before eyelid metastasis in most cases, 27% of eyelid metastases can manifest before the diagnosis of a primary tumor [4].
Eyelid metastasis can have variable presentations, manifesting as single or multiple nodules in the eyelid, generalized eyelid swelling, ulceration, or induration [3]. One study reported that breast cancer metastasizing to eyelids mostly presented as painless, generalized eyelid swelling [3]. Due to these nonspecific findings, these lesions can be confused with chalazion, papilloma, allergic contact dermatitis, periorbital cellulitis, or foreign body reaction. Thus, metastatic eyelid carcinoma should be included in the differential diagnosis of eyelid lesions, especially in patients with known primary cancers [5].
Eyelid metastases can involve any of the orbital structures. An MRI or CT scan can help to rule out soft tissue or bony involvement [6]. Histopathological examination is essential for confirmation of metastasis [7]. The metastatic tumor shows similar histopathological features as the primary tumor [6]. Immunohistochemical analysis provides further confirmation of the primary site of the tumor, especially in cases of poorly or undifferentiated tumors [8]. In our case, biopsy from the mass showed stromal infiltration by tumor cells in cords, trabeculae, Indian file pattern, and singly, which was similar to the histological features of the primary breast carcinoma. We then advised an immunohistochemical analysis, which showed ER positive, confirming breast carcinoma as the primary tumor.
The management of eyelid metastasis is guided by the tumor characteristics and extent of spread, and includes excisional biopsy, radiotherapy, chemotherapy, immunotherapy, and observation [3]. Excisional biopsy can be done for a small, single nodule, while radiotherapy can be used to manage multiple or recurrent eyelid lesions [3]. Tumor response can be observed in a patient undergoing systemic chemotherapy/immunotherapy [3]. In our case, excisional biopsy of the lesion was done, and the patient is under chemotherapy for systemic disease.
Eyelid metastasis denotes a poor prognosis as it is associated with widespread metastasis. Even if spread to other sites is not evident, eyelid metastasis suggests the tumor has spread hematogenously [6]. The time interval between diagnosis of the primary tumor and detection of eyelid metastasis ranges from 2 months to 15 years, with the mean interval being 4 years. The mean survival duration after eyelid metastasis manifestation is 9.7 months [4, 6]. Our patient developed eyelid metastasis 7 and a half years after the diagnosis of primary breast carcinoma.
Author Contributions
Karuna Khadka: conceptualization, writing – review and editing. Sarah Suwal: resources, writing – original draft, writing – review and editing. Prakriti Lamichhane: conceptualization, writing – original draft, writing – review and editing. Hari Prasad Dhakal: supervision, validation, writing – review and editing. Purnima Rajkarnikar Sthapit: supervision, validation, writing – review and editing.
Ethics Statement
The authors have nothing to report.
Consent
Written informed consent was obtained from the patient for publication of the case report, including the use of histological images.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors have nothing to report.
Khadka K., Suwal S., Lamichhane P., Sthapit P. R., and Dhakal H. P., “A Rare Case of Breast Cancer Metastasis to the Eyelid,” Clinical Case Reports 13, no. 10 (2025): e70909, 10.1002/ccr3.70909.
Funding: The authors received no specific funding for this work.
Data Availability Statement
The data supporting the findings in this case report is available within the article and its Supporting Information.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings in this case report is available within the article and its Supporting Information.