Squamous cell carcinoma of the eyelid

Clinicopathologic Features of Eyelid Sebaceous Gland Carcinoma Requiring Immunohistochemical Diagnosis

Introduction

The aim of the study was to evaluate the clinicopathological features of eyelid sebaceous gland carcinoma (SGC), which requires immunohistochemical examination for a definitive diagnosis.

Methods

Twenty-seven patients with a final diagnosis of eyelid SGC at Toyama University Hospital between April 2016 and April 2022 were retrospectively studied. In cases with a strong clinical suspicion of SGC, if the initial pathological diagnosis by hematoxylin-eosin staining was non-SGC, additional detailed pathology was performed, including immunostaining for adipophilin (ADP) and androgen receptor (AR).

Results

Five patients (18.5%) had a diagnosis other than SGC, including three with squamous cell carcinoma (SCC), one with basal cell carcinoma, and one with Bowen disease. In these 5 cases, detailed pathology, including immunostaining for ADP and AR, was performed again, which ultimately led to the diagnosis of SGC. ADP was positive in all 5 cases, and AR was positive in 4 cases. The 3 patients diagnosed with SCC were characterized by a high Ki-67 index, active mitosis, and relatively low differentiation.

Conclusion

SGC can be pathologically diagnosed in other cancers, such as SCC and BCC. When SCC was diagnosed, it was often hypo-differentiated and required more attention. Immunostaining for ADP and AR is invaluable for confirming SGC diagnosis.

Outcomes of Mohs micrographic surgery for periocular squamous cell carcinoma

INTRODUCTION

Periocular cutaneous squamous cell carcinoma (cSCC) accounts for 5-10% of all eyelid malignancies. Periocular cSCC carries a low mortality rate but can be destructive to local tissues. Due to the unique function and anatomy of the eyelids, Mohs micrographic surgery (MMS) is gold standard for treating cSCC to preserve healthy tissue and reduce rates of local recurrence. In this study, we describe the success and outcomes of MMS and subsequent oculoplastic reconstruction for periocular cSCC in the North East of England.

METHODS

Retrospective analysis of 34 patients who underwent MMS for periocular cSCC in the North of England between 2013 and 2020. Primary outcome measure of success is defined as no recurrence of cSCC after minimum 24 months' time elapsed post-MMS. Secondary outcome measures included analysis of disease characteristics, describing the surgical techniques utilised for oculoplastic reconstruction following MMS and surgical complications should they occur.

RESULTS

Two patients (5.9%) had local recurrence of periocular cSCC. Median time elapsed since MMS was 60 months. A variety of oculoplastic surgical techniques were utilised in the repair of the Mohs defect. One patient (2.9%) developed a significant post-operative reconstruction complication.

CONCLUSION

Periocular cSCC recurrence following MMS in the North of England is 5.9%, which is comparable to the literature. Significant post-operative complications following oculoplastic reconstruction of periocular MMS are very low, occurring in 2.9% of cases in this study.

Case Report: Primary Squamous Cell Carcinoma of the Orbit in a Patient With Carney's Syndrome Treated With Multidisciplinary Approaches

BACKGROUND

Squamous cell carcinoma (SCC) is a rare malignancy of invasive epithelium with keratinocyte differentiation, and it is the most common form of eyelid malignant neoplasm, comprising 5%-10% of malignancies. While SCC rarely affects the orbit, it may be involved through local invasion from a cutaneous primary site or extension by perineural invasion. Only 12 cases of primary orbital SCC have been reported until now. Here, we present a case of primary carcinoma of the right orbit with coexisting Carney's syndrome, a rare genetic disorder associated with multiple endocrine neoplasias (MEN) syndromes.

CASE

A 62-year-old South Asian male presented with a painful swelling in the lateral aspect of the right eyebrow and protrusion of the eyeball in August 2020. He had a history of excision of Right atrial Myxoma in March 2020. Orbital computerized tomography (CT) and positron emission tomography (PET-CT) scans revealed an enhancing soft tissue lesion in the right orbit with the involvement of frontal and ethmoid sinuses. Biopsy confirmed HPV-related poorly differentiated SCC, positive for HPV-related markers. The patient received concurrent chemo irradiation with Cisplatin. Follow-up PET-CT done 3 months later showed a new lesion appeared in the right orbital region and right lobe of thyroid. Later had surgical excision and total thyroidectomy, and histopathological examination (HPE) from orbit was reported as invasive SCC and from the thyroid was reported as synchronous papillary thyroid cancer. The patient's proptosis resolved, and subsequent PET-CT and magnetic resonance imaging (MRI) scans did not show any residual or recurrent disease.

CONCLUSION

Primary SCC of the orbit is an extremely rare disease, and this case report presents the 13th reported case and the first one associated with Carney's syndrome. As there is no standard treatment regimen for primary SCC of the orbit, this case highlights the use of multimodality treatment, including surgical excision and chemo irradiation. The findings emphasize the importance of early detection and management of this uncommon and life-threatening condition, providing hope for patients and aiding in the prevention of recurrence.

Cutaneous squamous cell carcinoma of the eyelid in northern latitudes, a 25-year experience in Finland

PURPOSE

To evaluate the incidence, clinical features, diagnostic challenges, management and prognosis of cutaneous squamous cell carcinoma of the eyelid (ecSCC) in southern Finland, northern Europe, latitude 62° N.

METHODS

Patients were identified from the Finnish Cancer Registry and the Helsinki University Hospital databases during a 25-year period (1998-2022). Age, sex, location, clinical and histopathological diagnosis, treatment and outcome were retrieved.

RESULTS

Cutaneous squamous cell carcinoma of the eyelid (ecSCC) was diagnosed in 58 patients. The mean age-standardized incidence was 1.03 per 100 000. Median age at the time of histopathological diagnosis was 79 (range 55-93) years; sex ratio was 0.52. Clinical diagnosis in the referral was ecSCC in only three patients. The most frequent misdiagnosis (38%) was basal cell carcinoma (BCC). One or more of the known risk factors (smoking, history of extensive sun exposure, systemic immunosuppression and previous in situ cSCC/cSCC) were documented in 71% of the patients. More than one third (38%) of the patients developed in situ SCC elsewhere on the skin; one third (31%) of the patients had invasive cSCC elsewhere. During the median follow-up time of 24 months, three patients experienced local recurrence, four patients developed metastatic disease (median 19 months) and two patients died of metastatic ecSCC.

CONCLUSION

The estimated incidence of ecSCC in Finland (predominantly white Caucasian) was higher than in a previous study from Europe. Clinical diagnosis of ecSCC is difficult and often misdiagnosed as BCC. Immunosuppression as a risk factor should noticed. Recurrences of ecSCC, which may be lethal, were infrequent.

Updates on eyelid cancers

In this review, we aim to provide an overview of the five most common malignant eyelid tumors with current treatment recommendations based on international guidelines. Particular attention is paid to the clinicopathological correlation and the update with regard to adequate treatment. Newer systemic therapies enrich the existing treatment options, of which complete tumor excision remains the most important therapeutic measure.

HPV-Associated Squamous Cell Carcinoma of the Eyelid: Diagnostic Utility of p16 Immunohistochemistry and mRNA In Situ Hybridization

BACKGROUND

High-risk (HR) Human papillomavirus (HPV) has been implicated in pathogenesis of squamous cell carcinomas (SCC) at several sites with mucocutaneous junctions, including the head and neck. SCC is the second most common eyelid malignancy. However, its association with transcriptionally active HR-HPV has not been adequately studied.

METHODS

Two index cases of eyelid HPV-associated SCC are described in detail. A retrospective cohort of eyelid SCC was examined for p16 immunoexpression. Cases demonstrating p16 positivity or equivocal staining were subjected to high-risk HPV mRNA in situ hybridization (ISH). Quantitative real-time PCR (qPCR) was performed in mRNA ISH-positive cases for HPV genotyping.

RESULTS

The two index patients were older adult females, with upper eyelid tumours. On histology, both tumours were non-keratinizing SCC with trabecular and nested architecture reminiscent of oropharyngeal HPV-associated non-keratinizing SCC, prompting p16 immunohistochemistry, which was positive. HR-HPV mRNA ISH was positive, and qPCR detected HPV16 in both cases. Three of 20 (15%) archival cases showed p16 immunopositivity and two (10%) showed equivocal staining. However, mRNA ISH was negative. All cases showing p16 immunostaining and lacking HR-HPV were keratinizing SCCs. Thus, 9% of all eyelid SCC examined demonstrated HR-HPV.

CONCLUSION

The prevalence of HR-HPV in eyelid SCC is low in Indian patients. HPV-associated SCC may mimic commoner eyelid carcinomas as it lacks overt keratinization. In basaloid-appearing eyelid carcinomas, p16 immunopositivity should be followed by reflex HR-HPV mRNA ISH, as p16 immunohistochemistry alone has low specificity. The prognostic role, if any, of HPV association needs further evaluation.

Recommendations for risk stratification of periocular squamous cell carcinoma

Periocular squamous cell carcinoma is a common cutaneous malignancy with generally favorable outcomes; however, the periocular region is intrinsically a high-risk location, and there exist a subset of lesions with a propensity for poor outcomes. Orbital invasion, intracranial perineural spread, nodal and distant metastasis are feared complications. There are several staging systems for eyelid carcinoma and cutaneous squamous cell carcinoma, but the definition of high-risk lesions remains heterogeneous. It is unclear exactly which lesions can be safely deescalated, and which require nodal evaluation and adjuvant multimodal therapy. We seek to answer these questions by summarizing the literature on clinicopathologic variables, molecular markers, and gene profiling tests in periocular squamous cell carcinoma, with the extrapolation of data from the cutaneous squamous cell carcinoma literature. Standardized pathology reports with information on tumor dimensions, histological subtype and grade, perineural invasion, and lymphovascular invasion should become uniform. Integration with gene expression profiling assessments will individualize and improve the predictive accuracy of risk stratification tools to ultimately inform multidisciplinary decision-making.

Primary cemiplimab treatment for orbital squamous cell carcinoma is effective and may alleviate the need for orbital exenteration

PURPOSE

To evaluate the effectiveness of cemiplimab, a Programmed-cell-death-1(PD-1) protein inhibitor, for the treatment of cutaneous periocular-locally-advanced squamous-cell-carcinoma (POLA-SCC) with orbital-invasion.

METHODS

Multicentre real-world retrospective study. Demographic and clinical data were collected and analysed for patients with biopsy-proven POLA-SCC(AJCC-T4) with orbital-invasion who were treated with cemiplimab at one of four tertiary medical centres in 2019-2022.

RESULTS

The cohort included 13 patients, 8 males and 5 females, of median age 76 years (IQR65-86). The median duration of treatment was 5.0months (IQR3.5-10.5) and the median follow-up time, 15.0 months (IQR10.5-30). The overall response rate was 69.2%. Complete response was documented in seven patients (53.8%), partial response in two (15.4%), stable disease in one (7.7%), and progressive disease in two (15.4%); in one patient (7.7%), response was not evaluable. Six complete responders (46.1% of the cohort) received no further treatment and did not have a recurrence during an average follow-up of 6.14 (±6.9) months from treatment cessation. None of the patients underwent orbital-exenteration. The majority of adverse events were mild (grade-1), except for a moderate increase in creatinine level (grade-2), severe bullous dermatitis (grade-3), and myocarditis (grade-5) in one patient each. Four patients (30.7%) died during the follow-up period, all of whom had an Eastern-Cooperative-Oncology-Group score of 4 at presentation.

CONCLUSIONS

To our knowledge, this is the largest study to date on cemiplimab therapy for cutaneous POLA-SCC with orbital-invasion. Treatment was shown to be effective, with an overall response rate of 69.2%. Cemiplimab holds promise for the treatment of patients with tumours invading the orbit as it may alleviate the need for orbital exenteration.

Immune checkpoint inhibitors for treatment of periorbital squamous cell carcinoma

PURPOSE

To report on the outcomes of immunotherapy in patients with locally advanced periorbital squamous cell carcinoma.

METHODS

We performed a retrospective chart review of seven consecutive patients with locally advanced periorbital cutaneous squamous cell carcinoma treated with anti-PD-1 immunotherapy. Treatments and therapeutic outcomes were reviewed.

RESULTS

Of the seven patients, six were treated with cemiplimab, and one was treated with pembrolizumab. Five patients were treated with immunotherapy as neoadjuvant therapy before planned surgical resection; two patients received immunotherapy for treatment of advanced recurrent lesions deemed unresectable following multiple previous excisions and radiation therapy. In all seven patients, measurable clinical and/or radiologic response was observed.

CONCLUSIONS

Our findings support the emerging role of anti-PD-1 immunotherapy in the management of locally advanced periorbital cutaneous squamous cell carcinoma.

Narrower clinical margin in high or very high-risk squamous cell carcinoma: a retrospective, multicenter study of 1,000 patients

BACKGROUND AND OBJECTIVES

In cutaneous squamous cell carcinoma (cSCC), adherence to guideline-recommended fixed surgical margins is often difficult, and narrower margins are preferable. This study aimed to evaluate relapse and disease-specific death with narrower margins for high or very high-risk cSCC.

PATIENTS/METHODS

We retrospectively investigated high or very high-risk cSCC patients who underwent tumor excision. Patients were divided into guideline-recommended standard margin group (SMG) and narrower-margin group (NMG). Co-primary outcomes were local relapse, SCC relapse, and SCC death. Cumulative incidence function (CIF) was used to describe SCC death probability and competing risk mortality. Gray's test was used to compare differences in CIF between the groups.

RESULTS

In total, 1,000 patients with cSCC (high-risk, 570; very high-risk, 430) were included. In the high-risk cohort, there were no significant differences in incomplete excision rate (IER) between SMG and NMG (2.6 % vs. 3.0 %, P > 0.99). However, in the very high-risk cohort, IER in SMG was significantly lower than in NMG (8.9 % vs. 16.2 %, P = 0.03). No significant differences were observed between SMG and NMG for local relapse (high-risk, P = 0.56; very high-risk, P = 0.70), SCC relapse (high-risk, P = 0.30; very high-risk, P = 0.47), and SCC death (high-risk, P = 0.23; very high-risk, P = 0.83).

CONCLUSIONS

Surgical margin size has limited impact on margin control, relapse, and disease-specific death in high-risk cSCC.

Knapperer Resektionsrand bei Plattenepithelkarzinomen mit hohem oder sehr hohem Risiko: eine retrospektive multizentrische Studie mit 1000 Patienten

HINTERGRUND UND ZIELE

Bei kutanen Plattenepithelkarzinomen (PEK) ist die Einhaltung der in Leitlinien empfohlenen festen Resektionsränder oft schwierig und knappere Ränder sind wünschenswert. Ziel dieser Studie war die Bewertung des Auftretens von Rezidiven und krankheitsspezifischen Todesfällen bei knapperen Resektionsrändern für PEK mit hohem oder sehr hohem Risiko.

PATIENTEN/METHODEN

PEK-Patienten mit hohem oder sehr hohem Risiko, bei denen eine Tumorexzision durchgeführt wurde, wurden retrospektiv untersucht. Die Patienten wurden in eine Gruppe mit Standardrand gemäß Leitlinienempfehlung (standard margin group, SMG) und eine Gruppe mit knapperen Rändern (narrower-margin group, NMG) eingeteilt. Gemeinsame primäre Endpunkte waren lokales Rezidiv, PEK-Rezidiv und PEK-bedingter Tod. Die Wahrscheinlichkeit eines PEK-bedingten Tods und konkurrierender Mortalitätsrisiken wurde mittels kumulativer Inzidenzfunktion (CIF) beschrieben. Unterschiede bei der CIF zwischen den Gruppen wurden mit dem Test nach Gray verglichen.

ERGEBNISSE

Insgesamt wurden 1.000 Patienten mit PEK (hohes Risiko, 570; sehr hohes Risiko, 430) eingeschlossen. In der Kohorte mit hohem Risiko gab es keine signifikanten Unterschiede bei der unvollständigen Exzisionsrate (IER) zwischen SMG und NMG (2,6 % vs. 3,0 %, P > 0,99). In der Kohorte mit sehr hohem Risiko war die IER in der SMG jedoch signifikant geringer als in der NMG (8.9 % vs. 16.2 %, P = 0,03). Keine signifikanten Unterschiede zwischen SMG und NMG wurden für Lokalrezidiv (hohes Risiko, P = 0.56; sehr hohes Risiko, P = 0,70), PEK-Rezidiv (hohes Risiko, P = 0,30; sehr hohes Risiko, P = 0,47) und PEK-bedingtem Tod (hohes Risiko, P = 0,23; sehr hohes Risiko, P = 0,83) beobachtet.

SCHLUSSFOLGERUNGEN

Die Größe des Resektionsrands hat einen begrenzten Einfluss auf Randkontrolle, Rezidive und krankheitsspezifischen Tod bei PEK mit hohem Risiko.

Adnexal squamous cell carcinoma: incidence of eyelid margin involvement

PURPOSE

We aimed to perform a review of facial and periorbital squamous cell carcinoma (SCC) cases to assess the relative incidence of eyelid margin involvement.

METHODS

This is a retrospective review of all patients with biopsy-proven SCC who were evaluated at a single oculoplastic surgery practice from 2007 to 2019. The charts were reviewed for the anatomical location of the malignancy, and those involving the eyelid were further divided into marginal and non-marginal lesions. Statistical analysis was performed using a one proportion z-test.

RESULTS

A total of 76 patients with a diagnosis of biopsy-proven periorbital and facial SCC were identified, 67 involved the ocular adnexa. Thirty-nine (58.2%) patients had lesions located on the eyelid. Of these, 33 (84.6% p < 0.0001, 95% CI 69.45-94.13) had lesions located at the margin, six of the 39 lesions were non-marginal. The remaining lesions were present within the brow (n = 10, 14.9%), medial canthus (n = 10, 14.9%), palpebral conjunctiva (n = 1, 1.5%), or orbit (n = 1, 1.5%). In six patients (8.9%) lesions involved multiple anatomic subunits.

CONCLUSION

We present our investigation of the incidence of SCC of the marginal vs. non-marginal eyelid, revealing a statistically significant increased involvement of the eyelid margin. Future investigations are necessary to further elucidate the vulnerability of the eyelid margin to the development of SCC in particular in regards to the role of the unique genetic expression profile of eyelash follicular stem cells.

Human Papillomavirus Related Neoplasia of the Ocular Adnexa

Human papillomaviruses (HPV) are a large group of DNA viruses that infect the basal cells of the stratified epithelium at different anatomic locations. In the ocular adnexal region, the mucosa of the conjunctiva and the lacrimal drainage system, as well as the eyelid skin, are potential locations for HPV-related neoplasia. The role of HPV in squamous cell neoplasia of the ocular adnexa has been debated for several decades. Due to the rarity of all these tumors, large studies are not available in the scientific literature, thereby hampering the precision of the HPV prevalence estimates and the ability to conclude. Nevertheless, increasing evidence supports that defined subsets of conjunctival papillomas, intraepithelial neoplasia, and carcinomas develop in an HPV-dependent pathway. The role of HPV in squamous cell tumors arising in the lacrimal drainage system and the eyelid is still uncertain. Further, the potential of HPV status as a diagnostic, prognostic, or predictive biomarker in these diseases is a topic for future research.

Primary periocular squamous cell carcinoma in central Spain: Factors related to recurrence

PURPOSE

To describe the characteristics and recurrence rates of primary periocular squamous cell carcinoma (SCC) in Spain.

METHODS

This retrospective study investigates the characteristics of primary periocular SCC at two tertiary centers in Spain from 2000 to 2020. Data were collected on demographics, skin phenotype, location, clinical and histological diagnosis, the commitment of surgical margins, recurrence, and risk factors. Multivariate analysis and risk factors were used to investigate recurrence rates, considering p < 0.05 as statistically significant.

RESULTS

Over the 20-year studied period, 107 patients with primary periocular SCC were assessed. The mean age of SCC was 76.8 ± 12.8 years, 55 (50.9%) were females, and 105 (98.1%) had Fitzpatrick skin phenotype type II or III. SCC lesions affected less than 1/3 of the eyelid (56/52.3% cases), mainly the lower lid (42/39.3% lesions). Sixty (56.1%) cases were SCC differentiated, 76 (71%) had clear margins. Clinical diagnosis of SCC corroborated with histological in 84 (78.5%) cases and orbital involvement occurred in 18 (16.8%) cases. Recurrence was observed in 13 (12.1%) cases, occurring more in large tumors and undifferentiated subtype (53.8%), with committed margins (69.2%) (p = 0.001), being the commitment of margins a significant predictor for recurrence, although thickness was an independent predictor.

CONCLUSION

Periocular SCC in Spain showed a similar pattern as in the world. The risk of recurrence is increased in undifferentiated and large periocular SCC, partially removed with committed margins.

Diseases of the Eyelids and Orbit

The eyelids and orbit encompass intricate bony and soft tissue structures that work harmoniously in concert to protect, support, and nourish the eye in order to facilitate and maintain its function. Insult to periorbital and orbital anatomy can compromise orbital and ocular homeostasis. This article provides a foundational overview of eyelid and orbital anatomy, as well as common and key disorders that may confront internists and medical subspecialists.

Epidemiological Profile and Clinical Stage at Presentation of Eyelid Malignancies in a Multi-Ethnic Country

ABSTRACT

Eyelid malignancies are frequently seen in clinical practice. There is a lack of studies that have assessed the features of these lesions in mixed population countries. The epidemiologic profile, clinical stage at presentation, management, and outcomes of patients with eyelid malignancies were assessed, in order to better understand the features of these lesions in a multi-ethnic country. The medical records of patients who underwent eyelid tumor excision in a tertiary service in Brazil, from 2014 to 2019 were retrospectively reviewed. It was recorded for each patient: age, gender, time of onset, location, diagnosis, management, and follow-up. The medical records of 298 patients who presented with eyelid tumors were evaluated and 67 (22.4%) were malignant. The mean age of patients with malignancies was 52.93 years and 50% were male. Basal cell carcinoma was the most prevalent (61.2%), followed by squamous cell carcinoma (SCC) (29.9%) and sebaceous gland carcinoma (3%). The average time it took from appearance to surgical treatment was 3 years; the lower eyelid was the most affected for both basal cell carcinoma and SCC; 70% of SCCs were locally invasive at presentation and metastasis occurred in 15%. Basal cell carcinoma was the most common eyelid malignancy observed, however, its frequency was lower when compared to other western countries. The advanced stage at presentation may reflect the lack of education of the population to seek early care, and the lack of specialized tertiary centers in remote areas, resulting in delayed diagnosis.

Epidemiological characteristics and clinical course of eyelid squamous cell carcinoma patients from a large tertiary centre between 2009 and 2020

BACKGROUND/AIMS

To assess epidemiological tumour features, risk factors, clinical management and outcome of eyelid squamous cell carcinoma (SCC) and changes thereof. Furthermore, we searched for validating predictors of the American Joint Committee on Cancer (AJCC) 8 classification system.

METHODS

We evaluated data of 117 patients with histologically proven eyelid SCC at a large tertiary German university centre between January 2009 and March 2020. This retrospective, monocentric analysis included descriptive statistics and non-parametric tests (p<0.05).

RESULTS

Histologically controlled excision and follow-up was performed in 88 (75.2%) patients. In the remaining patients with higher T-category, individual adjuvant therapy combinations were initiated. We found higher numbers of nodal metastasis and recurrence for male patients and higher T-category (p=0.035, p=0.008 and p=0.001, p<0.001). Recurrence rates proved higher for patients with multiple lesions (p=0.008). Disease-specific survival (DSS) was 95.7% at 2 and 94.9% at 5 years of follow-up. Six patients (5.1%) died from eyelid SCC with nodal metastasis and higher T-category being negative prognostic factors (p<0.001 and p=0.009). Mortality was associated with tumour location in the medial upper eyelid, nodal metastasis being more frequent (p=0.001 and p=0.009) and tumour of the lower eyelid alone as positive predictor (p=0.012). T category differed in 34 (29.1%) patients when comparing AJCC 7 and 8 (p<0.001). Changes in T category as per the AJCC 8 classification resulted in better prediction of DSS (p=0.024).

CONCLUSION

Special attention should be paid to male patients, tumour location in the upper medial eyelid and lymph node diagnostics. Prediction of DSS proved superior as per the AJCC 8 staging system.

Massive Orbital Myiasis Caused by Sarcophaga argyrostoma Complicating Eyelid Malignancy

Purpose. To report a case of massive orbital myiasis caused by the larvae of Sarcophaga argyrostoma, complicating eyelid malignancy. Observations. A 98-year-old man first presented to our clinic noted to have a fast-growing lesion on his right upper and lower eyelids. Squamous cell carcinoma of the eyelids was highly suspected, and surgical excision was advised, but the patient refused any surgical or nonsurgical intervention. For the next eight months, the patient's family members continued to observe a high rate of tumor growth accompanied by deterioration of the general condition. During this whole period, the patient rejected admission to the hospital and was observed by nursing home staff. He was admitted to the emergency room in cachexic, unresponsive condition with fetid discharge and multiple live maggots crawling out from a large necrotic mass over the right orbit. On examination, no eyelids, eyeball, or other ocular tissue could be seen, while an extension of necrotic mass to forehead and midcheek was noted. Manual removal of larvae was performed. The patient passed away eight hours after his admission and larval removal. The maggots were identified as the third-instar larvae of Sarcophaga argyrostoma. Conclusions and Importance. This is the first reported case of home-acquired, massive orbital myiasis by S. argyrostoma. This case illustrates the crucial role of fly control as part of medical and home care in immobile patients. Moreover, it shows the importance of awareness by nursing home staff, paramedical, and medical personnel of possible myiasis, especially in bed-bound patients with skin malignancies and open wounds.

The role of infectious agents in cancer of the ocular region

The purpose of the study was to investigate the association between infectious agents and the development of cancer in the ocular adnexa. A comprehensive literary study was carried out, reviewing and summarizing previous reports on the topic. A broad range of malignancies of the ocular adnexa are associated with infectious agents. A strong association and possible causal relationship between the infectious agent and the development of ocular adnexal cancer are seen in Merkel cell carcinoma (Merkel cell polyomavirus), Burkitt lymphoma (Epstein-Barr virus) and Kaposi sarcoma (human herpesvirus 8). Infection with Chlamydia psittaci has been associated with the development of extranodal marginal zone B-cell lymphoma in Italy. Human papillomavirus infection has been associated with the development of squamous cell carcinomas of the ocular adnexa, although with a highly variable reported prevalence. By exploring the role of infectious agents in the ocular adnexa and the mechanism by which they contribute to oncogenesis, the diagnostics, management and prevention of these malignancies may also improve. Antibiotic treatment and vaccines against infectious agents may be valuable in future treatment. Additionally, the presence of infectious agents within the tumours may have a prognostic or predictive value.

Clinical Characteristics and Outcome of Malignant Eyelid Tumors: A Five-Year Retrospective Study

Introduction

To the best of our knowledge, this is the first study about malignant eyelid tumors in the region of Tuzla, Bosnia and Herzegovina, and it shows similar results comparing with other countries (the annual incidence of eyelid tumors in Tuzla region is about 3.73/100 000 population). Malignant eyelid tumors are relatively uncommon, but potentially fatal disease. However, if detected early and treated adequately, the prognosis is generally excellent.

Aim

The aim of this study was the clinical and microscopical analysis of malignant eyelid tumors in treated patients, the presentation of surgical treatment and reconstructive methods of eyelid tumors.

Methods

This retrospective study included 60 patients surgically treated at the University Clinical Center Tuzla from January 2012 to December 2016, who were initially diagnosed with malignant eyelid tumors in accordance to the final results obtained by histological examination of excised lesions.

Results

In the group of malignant tumors, the most common tumors were BCC (85%), which were predominantly found on the lower eyelids (92.16%) and showed female predominance (51.06%). SCC was the second most common eyelid malignancy (15%) and showed a predilection for the lower eyelid involvement and male predominance (55.56%). Tumors up to 2 cm in diameter (clinical stage T1) were found in 78.33% of cases, 95.74% of which with radical excision, while 4.26% with non-radical excision.

Conclusion

Treatment by complete excision with histological confirmation of tumor clearance is recommended. Perineural spread is an adverse prognostic sign, which may require postoperative radiotherapy. Orbital invasion is a rare complication but, if recognized early, it can be treated effectively with exenteration. Because presentation varies and histological examination is required for accurate diagnosis, any suspicious lesion occurring on the eyelids should be excised or biopsied. All patients with malignant tumors should be advised of the risk of recurrent or new tumors and encouraged to attend lifelong follow up.

PET/CT and PET/MRI in ophthalmic oncology (Review)

Orbital and ocular anatomy is quite complex, consisting of several tissues, which can give rise to both benign and malignant tumors, while several primary neoplasms can metastasize to the orbital and ocular space. Early detection, accurate staging and re-staging, efficient monitoring of treatment response, non-invasive differentiation between benign and malignant lesions, and accurate planning of external radiation treatment, are of utmost importance for the optimal and individualized management of ophthalmic oncology patients. Addressing these challenges requires the employment of several diagnostic imaging techniques, such as high-definition digital fundus photography, ultrasound imaging, optical coherence tomography, optical coherence tomography (OCT)-angiography, computed tomography (CT) and magnetic resonance imaging (MRI). In recent years, technological advances have enabled the development of hybrid positron emission tomography (PET)/CT and PET/MRI systems, setting new standards in cancer diagnosis and treatment. The capability of simultaneously targeting several cancer-related biochemical procedures using positron emitting-radiopharmaceuticals, while morphologically characterizing lesions by CT or MRI, together with the intrinsic quantitative capabilities of PET-imaging, provide incremental diagnostic information, enabling accurate, highly efficient and personalized treatment strategies. Aim of the current review is to discuss the current applications of hybrid PET/CT and PET/MRI imaging in the management of patients presenting with the most commonly encountered orbital and ocular tumors.

Periocular Squamous Cell Carcinoma: TNM Staging and Recurrence

PURPOSE

To analyze the TNM stage, management, and recurrence rates of patients with histologically confirmed squamous cell carcinoma (SCC) of the eyelid.

DESIGN

Retrospective case series from 3 Australian centers.

PARTICIPANTS

A total of 254 cases of eyelid SCC from 254 patients (median age, 73 years; range, 28-102 years; 159 were male).

METHODS

Tumors were staged according to The American Joint Committee on Cancer 7th edition TNM criteria for eyelid carcinoma.

MAIN OUTCOME MEASURES

Outcomes and recurrence rates according to TNM stage at presentation.

RESULTS

A total of 25 cases (9.8%) were recurrent tumors. TNM classifications were as follows: T1N0M0, 74 patients (29.1%); T2aN0M0, 92 patients (36.2%); T2bN0M0, 50 patients (19.7%); T3aN0M0, 31 patients (12.2%); T3bN0M0, 5 patients (2.0%); T2bN0M1, 1 patient (0.4%); and T3bN1M1, 1 patient (0.4%). Perineural invasion (PNI) was present histologically in 8.3% of cases. Treatment modalities included Mohs microsurgery (31.1%), wide local excision (WLE) with paraffin section control (21.7%), WLE with frozen-section control (19.3%), and excision without margin control (24.4%). Three cases did not receive treatment. Median follow-up was 40 months (range, <1-132 months). Local recurrence occurred in 17 treated patients (6.8%). The recurrence rate was 5.3% (12/226 patients) for primary tumors and 20% (5/25 patients) for recurrent tumors (P = 0.019). Four patients (1.6%) died of their disease during follow-up. Higher T stage was significantly associated with both PNI (P = 0.035) and local recurrence (P < 0.001). We could not identify a T-stage threshold below which there was no risk of recurrence, as evidenced by 3 T1 primary tumors that recurred.

CONCLUSIONS

Higher T stage was significantly associated with local recurrence, and recurrent tumors had a 4-fold increased risk of further recurrence compared with primary tumors. Therefore, it may be reasonable to consider sentinel lymph node biopsy or close nodal surveillance and follow-up for patients with recurrent or high T-stage tumors. Of note, we could not identify a T-stage threshold below which there was no risk of recurrences; therefore, clinicians should be aware of the potential for low T-stage tumors to recur.

Cutaneous squamous cell carcinoma of the eyelid masquerading as a chalazion

Chalazia are among the most common eyelid lesions presenting to eye care providers. Often successfully managed conservatively, some require more invasive intervention such as incision and drainage or steroid injection. Lesions that recur, do not respond to treatment, or are atypical in appearance or natural history should prompt more thorough analysis, often with biopsy and subsequent microscopic analysis. Not uncommonly, such atypical chalazia may be masking a more serious diagnosis. Eyelid cutaneous squamous cell carcinoma masquerading as a chalazion is exceedingly rare. We present a case report of an atypical chalazion that was refractory to incision and drainage as well as intralesional steroid injection. Incisional biopsy revealed the lesion to be a cutaneous squamous cell carcinoma requiring full-thickness excision and subsequent reconstruction. The patient provided written informed consent, and the contents herein are acceptable under the provisions of the institutional review board. Following Mohs excision and oculoplastic reconstruction with a Hughes flap, the patient has had a good outcome and is currently free of recurrence. Recurrent chalazia that are defiant to surgical and medical interventions should prompt biopsy and evaluation by pathology. Cutaneous squamous cell carcinoma should be considered in the differential diagnosis as early intervention can save a patient's eye and, not infrequently, their life.

Postoperative interstitial brachytherapy in eyelid cancer: long term results and assessment of Cosmesis After Interstitial Brachytherapy scale

Purpose

To analyse feasibility and safety of postoperative interstitial brachytherapy (IBRT) in patients of eyelid cancer treated primarily by surgical excision.

Material and methods

In this series, 8 patients with eyelid cancer were treated using postoperative interstitial brachytherapy. Patients were followed up for local control, cosmetic outcome, and acute and late toxicities. Cosmetic outcome was measured using a 6 point indigenous Cosmesis After Interstitial Brachytherapy (CAIB) scale.

Results

The patients were between 23-82 years (median: 71 years). There were 3 females and 5 males, and 3 patients had lesions in upper eyelid. Postoperative high-dose-rate brachytherapy was used in all with 2 catheters implanted in most of them (6 out of 8). Local control was calculated from end of treatment to last follow-up. At last follow-up, all patients remained locally controlled. Two patients had nodal recurrence 6 months after interstitial brachytherapy and were salvaged effectively by external beam radiotherapy. At last follow-up, 7 patients were loco-regionally controlled and one was lost to follow up. All patients had Radiation Therapy Oncology Group (RTOG) grade 1 acute toxicity and 2 had grade 1 Common Terminology Criteria for Adverse Events (CTCAE) version.3 late toxicities. The cosmesis score for the whole group ranged between 0-1 indicating excellent to very good cosmesis.

Conclusions

Postoperative high-dose-rate brachytherapy resulted in excellent disease control and cosmesis without significant acute or late toxicities. It is an effective modality for treatment of eyelid cancers in selected patients. Future prospective studies with the validation of CAIB scale would give us more insight to this effective yet often ignored modality of IBRT.

Massive periocular squamous cell carcinoma engulfing the globe: a rare case report

The eyelid tumors are rare neoplasms in head and neck oncological practice. The maximum incidence is after sixty years and most of the tumors are situated in the lower eyelid and medial canthus. A wide range of clinical presentations contribute to a high risk of misdiagnosis. The factors such as very large lesions, incomplete excision, histopathologic features such as poor differentiation, multicentric origin, pagetoid spread, and delayed diagnosis are associated with poor prognosis. Because of different tissues at eyelid level, a variety of tumor types and subtypes can arise, but most of them are carcinomas. A rare case of eyelid carcinoma spreading and engulfing the whole of globe which was treated by orbital exenteration and postoperative radiotherapy is presented with a disease-free follow-up of 10 months which, considering its size, is extremely rare. The early diagnosis and proper treatment of such rare tumors still remain the mainstay to predict favourable prognosis.

Squamous Cell Carcinoma of the Caruncle

Squamous cell carcinoma (SCC) of the lacrimal caruncle is a rare entity. The authors report the management and outcomes of 3 cases of caruncle SCC. Case 1 underwent wide margin surgical excision with adjuvant topical chemotherapy for a poorly differentiated SCC. He later developed regional lymph node metastasis and required modified radical neck dissection. Case 2 underwent wide margin surgical excision with cryotherapy and adjuvant topical chemotherapy for an invasive moderately differentiated SCC. She later developed a recurrence and underwent orbital exenteration. Case 3 was a moderately differentiated SCC treated with wide margin excision alone and had no recurrence during 5-year follow up. Careful surveillance of caruncle SCC is required, given the observed propensity for local recurrence and/or regional metastasis.

Impact of AJCC 'T' designation on risk of regional lymph node metastasis in patients with squamous carcinoma of the eyelid

BACKGROUND/AIMS

Squamous cell carcinoma (SCC) of eyelid is the second most common cancer of the eyelid with the potential for nodal metastasis. The purpose of this report is to determine whether primary tumour size and 'T' designation in the American Joint Committee on Cancer (AJCC) staging system, 7th edition, correlate with the risk of regional nodal metastasis in patients with eyelid SCC.

METHODS

Sixty-five consecutive patients with eyelid SCC treated by one ophthalmologist from March 1999 through July 2011 were included in this retrospective cohort study. Disease was staged using the AJCC 7th edition criteria based on clinical, pathological and radiographical data. Main outcome measures included regional lymph node metastasis at presentation, local recurrence, distant metastasis and survival at last follow-up.

RESULTS

40 men and 25 women had a median age of 67.0 years (range 41-89). TNM designations at presentation per the AJCC 7th edition were as follows: T1N0M0, 6 patients; T2aN0M0, 11 patients; T2bN0M0, 17 patients; T2bN1M0, 2 patients; T3aN0M0, 22 patients; T3bN0M0, 2 patients; T3bN1M0, 1 patient; T4N0M0, 3 patients; and T4N1M0, 1 patient. Median follow-up was 27 months (range 1-150). Four patients had nodal metastasis at presentation. Two of these four patients had T2bN1M0 disease, one had T3bN1M0 disease and one had T4N1M0 disease. Two patients, with T3aN0M0 and T4N0M0 tumours, respectively, at presentation, developed lymph node metastasis at 2 weeks and 8.4 months, respectively, after tumour excision. The four patients who had lymph node metastases at presentation and the two who developed lymph node metastases during follow-up had tumours ≥18 mm in greatest dimension or T2b or higher at presentation. Seven local recurrences were observed during follow-up. Two-year and 3-year recurrence-free survival rates were 93% (95% CI 80% to 98%) and 82% (95% CI 63% to 92%), respectively. No distant metastasis or tumour-related death was observed during follow-up. The 2-year and 3-year disease-free survival rates were 90% (95% CI 77% to 96%) and 79% (95% CI 61% to 89%), respectively.

CONCLUSIONS

Regional nodal metastases were observed among patients who presented with tumours >T2b. Tumour size and the AJCC TNM designations correlate with metastasis and should be reported more often for eyelid SCCs to allow comparisons across centres.

Squamous Cell Carcinoma of the Eyelid Treated with Photodynamic Therapy

The ocular tissues can be the site of a number of malignant tumors in adults. Approximately 5% to 10% of all skin tumors occur in the eyelid. Incidence studies indicate that basal cell carcinoma is the most frequent malignant eyelid tumor (90%) followed by squamous cell carcinoma (9%). A 55-year-old man presented a squamous cell carcinoma (SCC) of 8 mm diameter, localized in the middle third of the lower eyelid, 3 mm under the eyelid margin on the eyelids. The histopathologic examination of a biopsy specimen showed the typical features of squamous cell carcinoma. Photodynamic therapy (PDT) with topical 5-aminolevulic acid (ALA) after Frost suture was employed. Very good results were obtained with rapid healing, without invasiveness, and without anesthesia. There was no evidence of scar formation and no signs of recurrence at 6 months follow-up. Many therapeutic methods have been suggested for squamous cell carcinoma of the eyelid. We consider photodynamic treatment of eyelid skin malignancies to be of great interest and it may represent an interesting future perspective for their management especially when surgical intervention cannot be tolerated by the patient.

Mohs micrographic surgery of the eyelid: an overview of anatomy, pathophysiology, and reconstruction options

BACKGROUND

Mohs micrographic surgery (MMS) is the ideal treatment for skin cancer removal. The advantages of MMS in the eyelid area include its high cure rate, tissue-sparing effects, and overall cost effectiveness.

OBJECTIVE

To review eyelid anatomy, detail ocular tumors that are amenable to MMS, and examine the surgical repair options commonly used in this area.

MATERIALS AND METHODS

A review of the literature on MMS of the eyelid was performed with specific reference to ocular anatomy, eyelid malignancy types, and surgical reconstruction.

CONCLUSION

Eyelid function is critical for the maintenance of ocular health and vision. MMS is an ideal skin cancer treatment for the delicate structure of the eyelid, where maximal tissue preservation is critical. There are a plethora of reconstruction options to consider after MMS has been performed in this area. The choice of repair and surgical outcome depend, in part, on the surgeon's knowledge of eyelid anatomy and his or her ability to assess the repair requirements of the post-MMS defect. Dermatologic surgeons can effectively work with other specialists to help ensure that their patients receive a cure with restored ocular function and optimal cosmesis.

Periocular cutaneous malignancies: a review of the literature

BACKGROUND

The periocular skin is susceptible to numerous benign and malignant neoplasms. Periocular malignancies may present differently, behave more aggressively, and pose greater challenges for treatment and repair than malignancies at other cutaneous sites. Between 5% and 10% of cutaneous malignancies occur periorbitally, with basal cell carcinoma reported as the most common malignant periocular tumor, followed by squamous cell carcinoma, sebaceous gland carcinoma, cutaneous melanoma, Merkel cell carcinoma, and other rare tumors.

OBJECTIVE

To review the current literature on cutaneous malignancies of the periocular region pertaining to etiology, incidence, clinical presentation, differential diagnosis, complications, and treatment options.

MATERIALS AND METHODS

An extensive literature review was conducted using PubMed, searching for articles on periocular and periorbital cutaneous malignancies.

CONCLUSIONS

Timely diagnosis and management of periocular malignancies is essential because of their proximity to and potential to invade vital structures such as the orbit, sinuses, and brain. Surgical excision remains the standard of care for the majority of periorbital malignancies, but given the sensitive anatomic location, tissue-sparing techniques with margin control such as Mohs micrographic surgery are the preferred method for most nonmelanoma skin cancers. Depending on tumor type, other treatment modalities may include radiation, chemotherapy, cryosurgery, topical medications, and photodynamic therapy.

Feasibility of using American Joint Committee on Cancer Classification criteria for staging eyelid carcinomas

PURPOSE

 To evaluate the feasibility of staging eyelid carcinomas using the American Joint Committee on Cancer (AJCC) criteria, and to compare the 6(th) and 7(th) editions.

METHODS

 The records of 27 consecutive patients who underwent excision of eyelid carcinoma between April 2007 and April 2008 were reviewed. Patients with melanoma, lymphoid tumors, nonmeasurable disease, or medial or lateral canthal tumors were excluded. Each patient was staged using the AJCC 6(th) and 7(th) edition criteria based on clinical, pathologic, and radiographic data.

RESULTS

 The study included 13 men and 14 women aged 32 to 93 years (median, 65 years). Seventeen patients had basal cell carcinoma; 3, squamous cell carcinoma; 6, sebaceous carcinoma; and 1, Merkel cell carcinoma. Tumor location was lower eyelid in 20 patients and upper eyelid in 7. TNM designations were reliably determined for all 27 patients and were: A) using the 6(th) edition: T1N0M0, 6 patients; T2N0M0, 6; T2N1M0, 1; T3N0M0, 4; T4N0M0, 9; and T4N1M0, 1. B) using the 7(th) edition: T1N0M0, 6 patients; T2aN0M0, 8; T2aN1M0, 1; T2bN0M0, 2; T3aN0M0, 6; T3aN1M0, 1; T3bN0M0, 2; and T4N0M0, 1. Pathologic tumor size and nodal status, and systemic work-up were recorded for all patients.

CONCLUSIONS

 Eyelid carcinomas can be reliably staged using the AJCC criteria. There are notable differences between the 6(th) and 7(th) editions of AJCC TNM designation. We recommend AJCC staging using the latest published edition during the initial work-up for all patients with eyelid carcinoma to make reporting of outcomes more reliable and reproducible.

The clinical usefulness of (18)F-FDG PET/CT for the evaluation of lymph node metastasis in periorbital malignancies

Objective

The aim of this study was to assess the clinical role of ¹⁸F-FDG PET/CT for the evaluation of lymph node metastasis in periorbital malignancies, compared with CT alone.

Materials and Methods

We analyzed eighteen PET/CT and CT scans in 15 patients with biopsy-proven periorbital malignancies. We compared the diagnostic capabilities of PET/CT and CT with regard to nodal metastasis by level-by-level analysis and by N staging prediction. The reference standards were surgical pathology (n = 7) from dissected lymph node specimens and the results from radiological follow-up (n = 11, mean 20.5 months; range 10-52 months). Moreover, any changes in patient care as prompted by PET/CT were recorded and compared with treatment planning for CT alone.

Results

PET/CT had a sensitivity of 100%, while CT had a sensitivity of 57% (p = 0.03) for nodal metastasis by level-by-level analysis. PET/CT had a specificity of 97%, positive predictive value of 93%, negative predictive value of 100%, and diagnostic accuracy of 98%, while the CT values for these same parameters were 97%, 89%, 82%, and 84%, respectively. PET/CT correctly predicted N staging with an accuracy of 100%, while CT was only 83% accurate (p = 0.01). Regarding the impact on patient care, the extent of surgery for regional lymph nodes and the treatment decision were modified by PET/CT in 39% of patients.

Conclusion

PET/CT could provide useful information in the management of regional lymph node metastases in patients with periorbital malignancies.

Eyelid neoplasms in the Beijing Tongren Eye Centre between 1997 and 2006

BACKGROUND AND OBJECTIVE

To examine the spectrum of eyelid neoplastic specimens obtained at the Beijing Tongren Eye Centre between 1997 and 2006.

PATIENTS AND METHODS

A total of 2,639 eyelid neoplasms were included in the study.

RESULTS

Of the 2,639 eyelid specimens, 2,276 (86.2%) were benign and 363 (13.8%) were malignant. The most common benign lesions were inflammatory lesions, melanocytic nevi, papillomas, dermoid and epidermoid cysts, and epithelial cysts. The most common malignant or semi-malignant tumors were basal cell carcinomas, sebaceous gland carcinomas, lymphomas, squamous cell carcinomas, and malignant melanomas. The mean age at diagnosis was 41 years for benign lesions and 60 years for malignant tumors. There was no significant gender predilection among the five major non-benign eyelid tumors.

CONCLUSION

At the BeijingTongren Eye Centre between 1997 and 2006, the predominant non-benign eyelid tumors were basal cell carcinoma and sebaceous gland carcinoma, followed by lymphoma. The non-benign lesions occurred predominantly in elderly patients who were 60 years of age and older.

Outcomes after radiotherapy for squamous cell carcinoma of the eyelid

BACKGROUND

Squamous cell carcinoma (SCC) of the eyelid is a rare malignancy with metastatic potential. In the current study, the outcomes of patients with SCC of the eyelid were evaluated after definitive and postoperative radiation therapy.

METHODS

The medical records of all patients treated with radiotherapy for SCC of the eyelid at 1 institution between 1950 and 2005 were reviewed. Patient records were analyzed for clinical characteristics, pathologic features, radiation techniques, and outcomes. Survival rates were calculated using the Kaplan-Meier method; factors affecting survival were assessed using the log-rank test.

RESULTS

During the study period, 39 patients with 42 eyelid SCCs were treated with radiotherapy. Thirty-two tumors were treated with primary radiotherapy and 10 were treated with postoperative radiotherapy after wide local excision. Surviving patients were followed for a median of 76 months. The 5-year disease-specific and overall survival rates for all patients were 86% and 71%, respectively. At 5 years, local, regional, and distant disease control rates for all tumors were 88%, 95%, and 97%, respectively. There were no significant differences in the 5-year local, regional, and distant control rates between tumors treated with definitive and those treated with postoperative radiotherapy. There were no grade 3 or 4 complications.

CONCLUSIONS

Primary radiotherapy for SCC of the eyelid provides excellent locoregional control with reasonable complication rates and should be considered an alternative to surgery in selected patients.

Periocular squamous cell carcinoma

Squamous cell carcinoma (SCC) is the second most common eyelid malignancy and its incidence is increasing. Because of its variable clinical presentation, SCC may be difficult for even the experienced clinician to diagnose. Hence, all suspicious lesions warrant biopsy. As SCC behaviour may range widely in aggression, management should be individualized based on tumour (e.g. size, location, grade, histological subtype, previous recurrence, perineural invasion) and patient factors (e.g. age, health). Treatment of eyelid SCC should include margin control whenever possible for the highest cure rate in this high-risk area. Immediate histological monitoring of surgical margins with frozen sections or Mohs' micrographic surgery also allows for smaller margins of excision in an area where tissue conservation is important. Other special considerations in the periocular area include maintaining a high level of suspicion for perineural invasion as this may be associated with a poorer prognosis.

Neglected Squamous Cell Carcinoma of the Eyelid

An 89-year-old woman was referred with several years' history of enlarging lesions on her right eyelid. The patient did not seek medical aid during disease progression. On admission, a large, ulcerated lesion was seen on her right upper eyelid, covering the globe completely, and the eye was completely blind and hypotonous. A fine-needle biopsy of the lesion was performed. Histopathologic evaluation of the eyelid lesion disclosed a poorly differentiated squamous cell carcinoma. The patient refused any surgical intervention and was treated with electron beam radiotherapy (a total of 4000 cGy) with some decrease in the size of the eyelid and skin tumors. After 2 weeks of hospitalization, the patient was followed-up at home and died 2 weeks later of unknown causes. Squamous cell carcinoma of the periocular region can follow a fulminant course in advanced, neglected cases.