Severe bleeding eyelid after trivial trauma: conjunctival metastasis of a renal cell carcinoma

Abstract

Dear Editor, A 70-year-old woman was referred to our clinic with a persistent bleeding of the eye following a minor injury, having slipped and bumped her head against a bedside table that morning. The right upper eyelid contained a subtarsal lesion and a hyposphagma in the temporal superior quadrant of her right eye. There was no evidence of a penetrating eye injury. Due to a permanent conjunctival hemorrhage, inspection of the wound was difficult. As the source of bleeding could not be identified using the slit-lamp, surgical exploration and wound care were planned. The wound exploration and haemostasis were performed as an emergency procedure. Next to the wound, a whitish gelatinous nodule could be identified as the source of the bleeding (Fig. 1a). An excisional biopsy of this nodule was taken and the bleeding was stopped with an electrosurgical cauter. The patient’s medical history revealed a renal cell carcinoma (initial pT3, pNx cM0 G2 R0 L0 V1). A nephrectomy on the left side had been performed in July 2006 as well as consecutive resections of metastases of the diaphragm, the right lung, and the right breast in November 2007. In September 2008, partial resection of the 6th rib was performed, as well as a resection of a second metastasis of the right lung. Since January 2009, a further 20 smaller metastases of the lungs had been removed, and in February 2009 the patient presented with cerebral metastases. These were treated with a radiosurgical procedure in April 2009. The patient is still alive and in moderate condition. Histology of the conjunctival specimen showed a low differentiated malignant epithelial tumor (Fig. 1b). There were only a few small vessels supplying the tumor. Immunohistochemistry was positive for pancytokeratine AE1/AE3 (Fig. 1c) and CD10 (Fig. 1d). Examination of the primary tumor showed identical histological and immunohistochemical findings. In summary, the histopathological findings confirmed the nodule as a conjunctival metastasis of the known renal cell carcinoma. In 2004, Shields and co-worker analyzed a series of 1,643 conjunctival tumors [1]. In this large cohort they found only 13 metastases, i.e., metastases accounted for less than 1% of all conjunctival tumors. Five of these 13 metastases were associated with breast cancer, three with pulmonary cancer, two with a malignant melanoma of the skin, one with a carcinoid, one with a laryngeal carcinoma, and one metastasis of unknown origin. These data illustrate the rarity of conjunctival metastases in comparison to primary conjunctival tumors. However, renal cell carcinomas (RCC) represent approximately only 1–3% of all adult visceral cancers [2]. One of the common characteristics of RCCs is their tendency to metastasize without showing early clinical symptoms. The most common locations of metastases are the lungs (>50%) and the bones (up to 30%), followed by regional lymph nodes, the liver, and the brain [3]. Only in very rare cases do RCCs affect the eye. In a T. Lapp (*) Division of Infection and Immunity, University College London, The Cruciform Building, Gower Street, London WC1E 6BT, UK e-mail: T.Lapp@ucl.ac.uk