British Journal of Ophthalmology, 1988, 72, 868-870

Testicular cancer presenting as a red swollen lidJ A HAM' AND N J CARR2

From the 'Department of Ophthalmology, Royal Air Force Hospital, Wegberg, West Germany, and2Department ofHistopathology, Institute ofPathology and Tropical Medicine, Royal Air Force Halton,Aylesbury, Bucks HP22 SPG

SUMMARY A case is reported in which a testicular cancer presented as a metastatic deposit in theeyelid. The histological appearances of both the metastasis and the subsequently detected primarywere diagnostic of malignant teratoma trophoblastic (MIT). After comments on the testiculartumour, metastases occurring in the eye and adnexa are discussed.

A 19-year-old Army sapper was referred to theOphthalmic Department at the Air Force Hospital inGermany from a nearby station medical centre with afive-day history of a painless red and swollen leftupper lid. He had no other compaints, and there wasno relevant past ocular or medical history. Onexamination the lateral aspect of the left upper lidshowed a very vascular swelling. On lid eversion thesubtarsal tissue was soft, friable, and bled to touch.There was no bulbar conjunctival injection, and theglobe assessment, which included a fundal examina-tion after mydriasis, was normal. Preauricular lymphnodes were not enlarged. The affected lid wasinfiltrated with 1% lignocaine, and piecemeal biop-sies were taken from the subtarsal tissue and fromjust anterior to the lash line. Histological examina-tion revealed metastatic tumour (see below).Correspondence to Flight Lieutenant N J Carr.

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| _...Fig. 1 Left eye: the eyelid lesions on the day ofadmission.

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Four days later the patient was found to havespontaneous bleeding from his left eyelids. Anincrease in the size of the upper lid swelling hadoccurred, and a fresh haemorrhagic lesion in thelower fornix was noted (Fig. 1). A verbal reportidentifying the lid lesion as metastatic MTT wasavailable, and the patient was admitted for furtherinvestigations immediately. He denied any lassitude,anorexia, or weight loss. He also denied any testicu-lar abnormality, even on direct questioning. Onexamination he was a hirsute young man with nogynaecomastia or palpable lymphadenopathy. The

Fig. 2 Chest radiograph showing round opacities in the leftmid zone and right lower zone.

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Fig. 3 Section from an eyelid lesion showing metastaticMTT within the dermis. Multinucleate syncytial cellsoverlying cytotrophoblastic cells are clearly visible in relationto a bloodfilled space. The epidermis is seen in the upperpartof the figure. HandE, xI IO.

only abnormality on clinical examination was an

obviously enlarged, nodular, non-tender, lefttesticle. Laboratory investigation revealed a haemo-globin concentration of 7-8 g/dl, and his chest radio-graphy showed multiple round opacities in both lungfields (Fig. 2). An urgent orchidectomy was per-formed in Germany and histological examinationconfirmed the testis as the primary site of the MTT.Four days postoperatively he returned to the UnitedKingdom for further treatment in an oncologicalunit.

HISTOPATHOLOGICAL FINDINGSThe metastatic tumour in the eyelid was located inthe dermis and composed of trophoblastic tissuesurrounding blood spaces (Fig. 3). Immunohisto-chemical stains' showed the malignant cells to bestrongly immunoreactive with antibody directedagainst human chorionic gonadotrophin (Fig. 4) and

Fig. 4 Eyelid lesion: the syncytiotrophoblasts show strongimmunoreactivity with antibody directed against HCG.Immunoperoxidase, x67.

cytokeratin, but negative for a-fetoprotein and S100protein.The testicular lesion was composed of extensive

areas of necrosis and haemorrhage within whichtumour tissue was sparsely distributed. Syncytiotro-phoblastic and cytotrophoblastic elements wereclearly visible in relation to vascular spaces (Fig. 5).Also present were areas of organoid differentiation,which included cysts lined by squamous epitheliumand bland cartilage, and partially differentiatedareas. No yolk sac components were identified.

Discussion

Testicular tumours are almost invariably primary andmalignant, presenting most commonly between theages of 20 and 40.2 Approximately 65% of patientspresent with a painless swelling, 20% complain ofpain with or without swelling, and 10% of tumoursare asymptomatic and detected on routine clinicalexamination. In less than 5% of cases does thepatient present because of metastases. Initially meta-stases tend to occur in the para-aortic nodes andlungs; pulmonary spread may be detected by routine

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J8A Ham and NJ Carr

Fig. 5 Part ofthe testicular tumour showing similarmorphology to that seen in the eyelid lesion. H and E, x 93.

chest x-rays. A dermal metastasis is an unusualpresentation for a testicular tumour. In this case theprimary could have been detected earlier, but thepatient failed to present in spite of marked painlessswelling of one testicle.Teratomas account for approximately 30% of

testicular tumours, and about 4% of these are MT],also known as testicular choriocarcinoma. Thehistology of teratomas varies from well differentiatedlesions, commoner in childhood, to the more malig-nant lesions graded intermediate or undifferentiated.According to the British Testicular Tumour Panel thefollowing criteria are required for the histologicaldiagnosis of MTT:3 the presence of recognisablesyncytiotrophoblastic and cytotrophoblasticelements, and their arrangement in a papillarypattern. Both the eyelid lesion and the testiculartumour satisfy these criteria. The appearances

closely resemble those seen in gestational choriocar-cinoma in the female.Most metastases encountered by the ophthalmolo-

gist are intraocular or orbital; metastatic deposits inthe eyelid are rare. Only 15 cases of secondarytumour in the eyelid were seen at the Mayo Clinic

between 1922 and 1969.4 The lesions in this seriestended to occur as a manifestation of generalisedcarcinomatosis, and in only two cases (both of whichwere adenocarcinoma of the stomach) were theeyelid lesions the presenting complaint. Deposits inthe eyelid from primaries in the breast, skin (malig-nant melanoma), and lung have been reported inparticular, but other primary sites include colon,stomach, prostate, thyroid, kidney, and cervix.45

Metastatic lesions of the eyelid are said to take oneof three forms.6 Firstly, solid subcutaneous nodulesoccur which may be mistaken for chalazia. Secondly,an ulcerating lid lesion may occur which may mimic abasal cell carcinoma clinically. Thirdly, a diffuseswelling may result with non-tender thickening andinduration of the eyelid. This case was unusual in thatthe trophoblastic nature of the deposit caused bleed-ing on eversion of the lid. With metastatic tumours ofthe eyelid the vascular reaction may suggest aninflammatory lesion rather than a neoplasm, and inthis case the initial referring medical officer had madea provisional diagnosis of an inflammatory lesion.

In contrast to eyelid metastases, metastases to theeye and orbit are well described in the literature. Themajority are blood borne following pulmonaryinvolvement. In a review of 220 cases of carcinomametastatic to the eye or orbit,7 which comprised allcases on file in the Registry of Ophthalmic Pathologyat the Armed Forces Institute of Pathology,Washington, DC, 28 patients had orbital metastasesand in 17 cases symptoms of the orbital lesionspreceded detection of a primary tumour elsewhere inthe body. One patient in this series was a 20-year-oldmale with intraorbital metastasis from a testicularchoriocarcinoma.

We thank the Director General of Medical Services, Royal AirForce, for permission to publish this paper, and Mrs ConnieSimmons for preparing the manuscript.

References

1 Risdon RA. Germ cell tumours of the testis. J Pathol 1983; 141:355-61.

2 Mostofi FK. Testicular tumours, epidemiologic, etiologic andpathologic features. Cancer 1973; 32: 1186-201.

3 Pugh RCB, Cameron KM. Teratoma. In: Pugh RCB, ed.Pathology ofthe testis. Oxford: Blackwell, 1976: 199-244.

4 Riley FC. Metastatic tumours of the eyelids. Am J Ophthalmol1970; 69: 259-64.

5 Bloch RS, Gartner S. The incidence of ocular metastaticcarcinoma. Arch Ophthalmol 1971; 85: 673-5.

6 Duke-Elder S, MacFaul PA. The ocular adnexa. In: Duke-ElderS, ed. System ofophthalmology. London: Kimpton, 1974: 536-8.

7 Ferry AP, Font RL. Carcinoma metastatic to the orbit. Mod ProblOphthalmol 1975; 14: 377-81; 1970; 69: 259-64.

Acceptedfor publication 3 September 1987.

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