Rapidly Growing Eyelid Mass in an Elderly Man

Abstract

A 90 year-old Chinese man presented with a rapidly-growing left upper lid lesion. The lesion first appeared two months prior to presentation as a 1 cm red, painless nodule. He denied trauma or changes to his vision. His past medical history was negative for malignancy. He had a history of cataract surgery in the left eye and end-staged bilateral nonneovascular age-related macular degeneration. On exam, his vision was hand-motion OD and 20/200 OS. His intraocular pressures were normal and extraocular motility full. His pupils were equal and reactive to light without an afferent pupillary defect. The external exam revealed a left upper lid exophytic mass with areas of necrosis. The mass extended medially to the punctum, superiorly to the upper eyelid crease and laterally to lateral canthus (Figure 1A). He had appreciable lymphadenopathy of the head and neck. Cranial nerves V and VII were intact bilaterally. Anterior segment exam showed diffuse conjunctival chemosis OS, white and quiet conjunctiva and sclera OD, clear corneas OU, deep and quiet anterior chambers OU, a dense cataract OD, and PC/IOL OS. B scan of the right eye showed no masses or retinal detachment. A dilated fundoscopic exam showed evidence of a chronic left hemiretinal vein occlusion.An incisional biopsy was performed, and pathologic inspection revealed pleomorphic, basophilic cells with positive cytokeratin-20 and cytoplasmic synaptophysin staining. Magnetic resonance imaging (MRI) (Figure 1B) revealed a 4.3 cm tumor with periorbital soft tissue extension without post-septal involvement and a 1.4 cm mass of the left parotid gland. DIAGNOSIS Merkel cell carcinomaWhat would you do next? 1.Sentinel lymph node biopsy 2.Full body PET scan 3.Lumbar puncture 4.Fine needle aspiration of the parotid mass