Metastatic pleural mesothelioma initially masquerading as chalazion

Metastases confined to the eyelid are rare. They usually derive from breast, skin, gastrointestinal, and urogenital tracts.¹ Malignant pleural mesothelioma is an uncommon malignancy presenting a steady rise in its incidence over the past 25 years.² It usually gives local metastases, although distant metastases are also reported.²

To our knowledge, an eyelid metastasis from pleural mesothelioma has never been reported. We describe a patient with pleural mesothelioma who developed a solitary eyelid metastasis. The lesion initially manifested as a recurrent chalazion. Histological confirmation has been obtained antemortem. Histopathology was consistent with the primary tumour.

Case report

A 57 year old man presented with unilateral painful swelling of the left upper eyelid followed by high fever and weight loss. During the previous 6 weeks, he had been treated with local and systemic antibiotics for recurrent chalazia without any improvement. His medical history included pleural malignant mesothelioma for which he had undergone surgery combined with chemotherapy. Eighteen months elapsed between the diagnosis of mesothelioma and the presentation of the eyelid lesion. During that time he remained asymptomatic without any local recurrences or metastases to any of the common sites at the regular follow up.

On examination, a diffuse thickening of the eyelid with ill defined margins was noted (fig 1). The lesion seemed multifocal. The overlying skin was not movable but there were no surface irregularities or hyperkeratoses. The eyelid was too sensitive to invert. Examination of the right eye was unremarkable. There was no double vision. Visual acuity was 20/20. Slit lamp and fundus examination, and intraocular pressures were normal. The tumour did not extend into the orbital cavity, as seen on the magnetic resonance image.

Figure 1 Diffuse thickening of the left upper eyelid corresponding to the metastatic lesion. The multifocal pattern of the infiltration is apparent. There was some loss of eyelashes. The lesion had a deep reddish, non‐nodular appearance.

A biopsy was taken from the eyelid. Examination of the specimen showed a malignant epithelioid neoplasm with histological and immunohistochemical features similar to those of the primary pleural tumour, and consistent with malignant mesothelioma (fig 2). The patient was referred to the oncology department. Metastatic investigation revealed no other metastatic sites. Chemotherapy was initiated but without any response. The patient died 3 months later of lung metastasis.

Figure 2 (A, B) Histopathological examination demonstrates a population of large, epithelioid cells with severe pleomorphism, atypia, and abundant cytoplasm, infiltrating striated muscle (A) and skin adnexae (B). A hair follicle, sweat glands, and part of a sebaceous gland can be seen on the left of (B) (haematoxylin and eosin; original magnification ×400). (C, D) Immunoreactivity of neoplastic cells for both vimentin (A) and pankeratin AE1/AE3 (B) (amplified avidin‐biotin method with Ventana's “NexES” automatic immunostainer; original magnification × 400). The cells were negative to antibodies against calretinin, CD141 (thrombomodulin), TTF1, cytokeratin 5/6, CEA (polyclonal) BerEP4, HMB 45, MART1, EMA, and CD30 (Ki 1).

Comment

Malignant mesothelioma is an aggressive tumour with a dismal prognosis.² This is consistent with the short lifespan of our patient after the detection of the eyelid lesion. There have been few reports of orbital metastasis of malignant mesothelioma but we are unaware of any previous report of an eyelid metastasis.³

Misdiagnosis of eyelid metastases is not uncommon. In a clinicopathological study of 31 patients with metastatic disease to the eyelid, metastasis was suspected in only 32% of the cases.¹ Chalazia can simulate other lesions. In a series of 1060 cases with the clinical diagnosis of chalazion, 6.4% were clinically misdiagnosed.⁴ In an otherwise healthy man the persistent eyelid infiltration of the present case, besides chalazion, would also recall a sebaceous carcinoma. The associated loss of lashes makes it suspicious of such a tumour. In the reported case pathological evaluation of the recurrent, atypical “chalazion” proved critical. Thus, any recurrent chalazion should be evaluated histopathologically. Accumulation of tumour cells in a multifocal pattern is indicative of a “field effect” at the level of the eyelid.⁵

We conclude that metastatic disease should be considered in the differential diagnosis of eyelid lesions. The present case emphasises the need for a good medical history in cases of persistent eyelid swelling. Even in the case of a history of an atypical primary tumour, like pleural mesothelioma, histopathological examination is necessary if those lesions fail to respond to treatment.