Signet ring cell carcinoma of the eyelid – the monocle tumour

Signet-Ring Cell/Histiocytoid Carcinoma: Report of Two Cases and Systematic Review of the Literature on the Epidemiology, Clinical Characteristics, and Pathological and Molecular Findings

ABSTRACT

Signet-ring cell/histiocytoid carcinoma (SRCHC) is a rare appendageal tumor, mainly considering eyelids, more rarely axillae. This article describes 2 novel SRCHC cases of 71- and 66-year-old men and systematically reviews the literature on SRCHC. Of all cases reported in the literature, 73 (91.2%) were men and 7 (8.8%) were women. The median age at diagnosis was 71 years. Skin changes were located in the eyelids (68%) and axillae (32%). In all tested cases, SRCHC cells expressed CK7, CKAE1/AE3, EMA, CAM5.2, and AR and PIK3CA mutations. Future research should determine whether AR/PIK3CA-targeted therapies influence patients' survival.

Effective diagnosis and surgical management of primary signet ring cell carcinoma of the eyelid

Primary signet ring cell carcinoma of the eyelid is an aggressive and rare neoplasm. It generally develops from the eccrine sweat gland and diffuses to the dermis and subcutis of the eyelid or axillae. The lesion usually presents as a progressive, diffuse and painless swelling of the eyelid with or without erythema and is frequently misdiagnosed as a chalazion or a chronic blepharoconjunctivitis leading to delayed management. The histology typically shows a signet ring cell or histiocytoid morphology. The authors present a case of a 76-year-old woman with a diagnosis of a primary signet ring cell carcinoma of the eyelid with atypical presentations. With this report, we seek to increase clinician awareness toward this tumor and to highlight the need for systematic recommendations in order to improve the management of these patients.

Primary Adnexal Signet-Ring Cell/Histiocytoid Carcinoma

An 84-year-old man presented with a 2-year history of a progressive left-sided ptosis. Examination demonstrated a mechanical ptosis and concentric constriction of the palpebral aperture. CT imaging revealed demonstrated diffuse soft tissue infiltration of the upper and lower eyelids with extension into the anterior orbit. This case was diagnostically challenging because of a history of multiple other primary tumors. However, clinicoradiologic and histopathologic findings were consistent with a diagnosis of primary adnexal signet-ring cell/histiocytoid carcinoma. The patient underwent surgical excision but local recurrence was noted 2 months postoperatively.

Signet-ring cell/histiocytoid carcinoma of the axilla: a clinicopathological and genetic analysis of 11 cases, review of the literature, and comparison with potentially related tumours

AIMS

The aim of this study was to determine the clinicopathological and genetic characteristics of axillary signet-ring cell/histiocytoid carcinoma (SRCHC) and the relationship between axillary SRCHC, eyelid SRCHC, and conventional apocrine carcinoma (AC).

METHODS AND RESULTS

Eleven cases of axillary SRCHC, four cases of eyelid SRCHC, eight cases of axillary AC and five cases of invasive lobular carcinoma (ILC) were retrieved. Additionally, 14 axillary and 43 eyelid SRCHC cases from the literature were reviewed. Male predominance was prominent for axillary SRCHC (24:1) and eyelid SRCHC (42:5). Axillary SRCHC formed a circumscribed plaque or nodule, unlike eyelid SRCHC. Lymph node metastasis was predominantly seen in axillary SRCHC cases (72%, 18/25), but not in eyelid SRCHC cases (19%, 9/47). Axillary SRCHC and eyelid SRCHC were histopathologically similar and showed rare tubular formations. Immunoexpression of cytokeratin 7, cytokeratin 19, mucin 1, mucin 5AC, BerEP4 and androgen receptor was seen in all tested cases of the four diseases. Oestrogen and progesterone receptors were negative in both types of SRCHC and AC, but were strongly positive in ILCs. Complete loss of E-cadherin expression was seen in approximately one-quarter of both types of SRCHC and in all ILCs. PIK3CA mutations were detected in all three sequenced cases (two axillary SRCHCs and one eyelid SRCHC).

CONCLUSION

The histopathological, immunohistochemical and genetic findings suggest that both types of SRCHC are phenotypic variants of AC, although there are differences in sex, macroscopic findings and the frequency of lymph node metastasis among the three. In contrast, ILC differs from the other three tumour types.

Primary Signet Ring Cell/Histiocytoid Carcinoma of the Eyelid: Somatic Mutations in CDH1 and Other Clinically Actionable Mutations Imply Early Use of Targeted Agents

Primary signet ring cell/histiocytoid carcinoma of the eyelid is a rare ocular malignancy and its diagnosis is often delayed. This neoplasm presents as an insidious, diffusely infiltrative mass in the periocular area that later infiltrates the orbit. An exenteration is usually indicated; however, nearly one-third of patients develop local recurrence or metastasis. Morphologically, it resembles signet ring cell carcinoma of the stomach and breast, raising the possibility of mutations in CDH1, the gene encoding E-cadherin. To determine whether primary signet ring cell/histiocytoid carcinoma harbors the CDH1 mutation or other actionable mutations, we analyzed the tumor tissue via next-generation sequencing. We identified only one case of primary signet ring cell carcinoma of the eyelid with adequate DNA quality for sequencing from the pathological archive during the period 2000 to 2020. A comprehensive evaluation including histopathology, immunohistochemistry, and next-generation sequencing assay was performed on tumor tissue. Immunohistochemically, the tumor exhibited E-cadherin membranous staining with the aberrant cytoplasmic staining of β-catenin. Using next-generation sequencing, we demonstrated the mutation in the CDH1 gene. In addition, other clinically actionable mutations including ERBB2 and PIK3CA were also detected. The alterations in other actionable genes indicate a need for larger studies to evaluate the pathogenesis and potential therapies for primary signet ring cell/histiocytoid carcinoma of the eyelid.

Diagnostic and treatment challenges of a case of primary cutaneous signet-ring cell/histiocytoid carcinoma of the eyelid

Background

Primary cutaneous signet-ring cell/histiocytoid carcinoma of the eyelid is an extremely rare but aggressive neoplasm diagnosed primarily in elderly men. Until now there are 32 published cases of signet-ring cell carcinoma or histiocytoid carcinoma of the eyelid. We report the clinical, radiographic and histological features of the 33rd reported case of PCSRCC in the eyelid of a 73-year-old male, and review diagnostic and treatment challenges of this rare entity.

Case presentation

Our case highlights a 73-year-old male who was referred for surgical correction of right eye ptosis that was present for 2 years. Upon assessment, he was noted to have an upper lateral orbital rim mass. Computed tomography (CT) noted ill-defined soft tissue thickening anterior to the right globe, predominantly pre-septal but with slight post-septal extension. The pathology revealed diffusely and deeply infiltrating tumour cells extending through the dermis, subcutis, orbicularis muscle bundles and nerve fibers; the tumour cells were noted to have a monotonous histiocytoid appearance with foamy granular eosinophilic cytoplasm. At high magnification, intracytoplasmic vacuoles and occasional intermixed signet ring cells were identified. Immunohistochemical staining revealed the tumour cells to be AE1/AE3, CK7, GCDFP-15, E-cadherin, androgen receptor stain and GATA3 positive. Final pathology report confirmed the diagnosis of primary cutaneous signet-ring cell/histiocytoid carcinoma. Further imaging failed to identify a distant primary malignancy or metastatic disease. The decision was made to attempt surgical excision of the tumor. After the bulk of the grossly apparent tumor was removed, intraoperative frozen sections were sent. Superficial biopsies of the right periorbital region were performed, which revealed extension significantly further than the gross disease. Thereafter, the patient underwent a wide orbital exenteration with reconstruction using a temporary split-thickness skin graft. Due to positive margins on final permanent sections, the patient underwent further wide resection with free muscle-skin flap reconstruction followed by adjuvant radiation treatment.

Conclusion

Our case represents the 33rd case of primary signet-ring cell/histiocytoid carcinoma of the eyelid in a 73-year-old male, the first documented case with GATA3 positivity and the second documented case with androgen receptor stain positivity.

Molecular profiling of a primary cutaneous signet-ring cell/histiocytoid carcinoma of the eyelid

Primary cutaneous signet-ring cell/histiocytoid carcinoma of the eyelid is a rare and aggressive neoplasm. Fewer than 50 cases have been reported in the literature, and the genetic driving mutations are unknown. Herein, we present a case of this rare disease along with the results of molecular profiling via targeted next-generation sequencing. The patient is an 85-year-old man who presented with left eyelid swelling initially thought to be a chalazion. After no response to incision and drainage and antibiotics, an incisional biopsy was performed. Histopathologic sections revealed a proliferation of cells with signet-ring and histiocytoid morphology arranged singly and in cords infiltrating the dermis, subcutaneous tissue, and muscle. The lesional cells strongly expressed cytoplasmic cytokeratin 7 and nuclear androgen receptor. Next-generation sequencing revealed a CDH1 mutation, which is known to confer signet-ring morphology in other carcinomas. Pathogenic mutations in NTRK3, CDKN1B, and PIK3CA were also detected. To our knowledge, this is the first documented genetic analysis of this rare disease with findings that offer insights into disease pathogenesis and potential therapeutic targets.

Unusual case of primary cutaneous signet-ring cell (histocytoid) carcinoma

Signet-ring cell (histocytoid) carcinoma is a rare and aggressive skin neoplasm that most commonly affects elderly men. It typically originates from the upper or lower eyelid, with bilateral involvement only in rare cases, and results in a diffuse and infiltrative appearance clinically, radiologically, and histologically (the "monocle" sign). It is essential to carry out a full investigation to rule out metastasis from an internal origin.

Periocular Histiocytoid Carcinoma: Potential Diagnostic Challenges

Cutaneous histiocytoid carcinoma can occur as a primary tumor of the periocular region. Morphologically similar histiocytoid carcinomas arising as primary tumors of the breast have a predilection for orbital metastases. They can occasionally contain regions with prominent vacuolated cytoplasm and minimal nuclear atypia, which mimic benign histiocytic lesions. Differentiating nonneoplastic, primary neoplastic, and metastatic histiocytoid lesions involving the periorbita can be challenging for both the clinician and the pathologist, and this distinction has management implications. Herein, we present 3 cases to illustrate the challenges of diagnosing periocular histiocytoid carcinoma.

Primary Signet-Ring Cell/Histiocytoid Carcinoma of the Eyelid: A "Binocle" Presentation of the "Monocle Tumor"

Primary cutaneous signet-ring cell carcinoma is a rare and aggressive neoplasm which diffusely involves dermis and subcutis of the eyelid or axillae. Neoplastic cells show a signet-ring cell or histiocytoid morphology in variable number, and can be found intermingled among collagen bundles, sparing the epidermis. This neoplasm typically appears in the eyelids of elderly men, in the form of a painless infiltration and swelling but with no other specific clinical feature, and frequently causes diagnostic retardation and worse prognosis. Frequent involvement of both eyelids of the same eye has given it the name of monocle tumor. Only 29 cases have been described in English literature to date, of which 7 developed metastases, mainly on regional lymph nodes. The authors present a case of involvement of contralateral eyelid, which has only been described previously in 2 cases. The immunohistochemical profile of the involvement in the contralateral eye, and the absence of other metastasis, suggest that it is locally spread from the initial lesion. However the possibility of being a second primary tumor or metastasis cannot be readily ruled out.

Primary signet ring cell carcinoma of the eyelid

Primary signet ring cell carcinoma of the eyelid (PSCE) is a very rare tumour. Only a few cases having been reported to date. The majority of patients have been middle-age to elderly men. Different treatment modalities have been applied in cases of PSCE. Here, we report a case of PSCE in a man treated with orbital exenteration and radiotherapy.

A brief review of different types of sweat-gland carcinomas in the eyelid and orbit

Sweat-gland carcinoma is a rare cutaneous appendage malignant tumor. Primary sweat-gland cancer can arise in the eyelid and orbit and is extremely rare. It has been classified into different types, and is usually locally recurrent after surgery. The tumors also appear in the orbit, which is characterized by metastasis. Therefore, great attention should be paid to the development of sweat-gland carcinomas. Specifically, our report briefly reviews the types of sweat-gland carcinomas that occur in the eyelid and orbit according to pathological classifications.

Cutaneous metastases from internal malignancies: a clinicopathologic and immunohistochemical review

Skin metastases occur in 0.6%-10.4% of all patients with cancer and represent 2% of all skin tumors. Skin metastases from visceral malignancies are important for dermatologists and dermatopathologists because of their variable clinical appearance and presentation, frequent delay and failure in their diagnosis, relative proportion of different internal malignancies metastasizing to the skin, and impact on morbidity, prognosis, and treatment. Another factor to take into account is that cutaneous metastasis may be the first sign of clinically silent visceral cancer. The relative frequencies of metastatic skin disease tend to correlate with the frequency of the different types of primary cancer in each sex. Thus, women with skin metastases have the following distribution in decreasing order of frequency of primary malignancies: breast, ovary, oral cavity, lung, and large intestine. In men, the distribution is as follows: lung, large intestine, oral cavity, kidney, breast, esophagus, pancreas, stomach, and liver. A wide morphologic spectrum of clinical appearances has been described in cutaneous metastases. This variable clinical morphology included nodules, papules, plaques, tumors, and ulcers. From a histopathologic point of view, there are 4 main morphologic patterns of cutaneous metastases involving the dermis, namely, nodular, infiltrative, diffuse, and intravascular. Generally, cutaneous metastases herald a poor prognosis. The average survival time of patients with skin metastases is a few months. In this article, we review the clinicopathologic and immunohistochemical characteristics of cutaneous metastases from internal malignancies, classify the most common cutaneous metastases, and identify studies that may assist in diagnosing the origin of a cutaneous metastasis.

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.

A case of histiocytoid variant eccrine sweat gland carcinoma of the orbit

A 79-year-old male presented with left ocular pain. Evisceration and silicone ball implantation were performed after a diagnosis of phthisis. He returned six weeks later because of left facial erythematous swelling, tenderness, mild fever, chills and cough. His condition was diagnosed as orbital cellulitis. Despite two weeks of empirical antibiotic therapy, the symptoms worsened. A subsequent orbital computed tomography scan revealed enhanced soft tissue infiltrations in his left orbit and eyelid. Biopsy showed a diffusely infiltrating tumor of signet ring cell cytology. A systemic evaluation revealed multiple bone metastases. Based on this evidence, the patient was diagnosed with a very rare case of histiocytoid variant eccrine sweat gland carcinoma with multiple bone metastases.