Case Presentation
A 55-year-old African man presented to the ophthalmologist with an 8-month history of growth on his right upper eyelid. Moreover, the swelling started from the orbital ridge, progressing to the entire upper lid eventually. He experienced spontaneous, unprovoked bleeding from the lesion before presentation, along with eye discharge and rashes. He also had difficulty fully opening the affected eye. Notably, he had no history of trauma, photophobia, weight loss, or tearing.
Six years prior, the patient had undergone surgery and chemotherapy for rectal carcinoma. His last chemotherapy dose was administered 5 years prior to his visit. Additionally, he had a medical history of asthma, but no familial history of similar conditions.
Examination
Upon examination of the right eye, a protruding fleshy mass measuring 3.3 × 2.0 cm was observed on the upper eyelid. The mass exhibited firmness, lobulation, and a non-tender nature, with irregular, rough surfaces. Furthermore, a mildly tender, mobile, non-matted lymph node was palpated in the right preauricular region.
Subsequent to evaluation, the patient underwent surgical excision under general anesthesia. The malignancy of the tumour was confirmed via frozen sections, ensuring clear resection margins. However, notably, the resected lymph node did not show infiltration by malignant cells. The surgical procedure was followed by upper eyelid reconstruction utilizing the Cutler-Beard technique, with no postoperative complications reported. The patient remained alive one month post-surgery.
Histological examination of the mass revealed an effaced architecture due to proliferating malignant epithelial cells organized as trabeculae, solid nests, and tongues. These cells exhibited basaloid characteristics, marked nuclei pleomorphism, irregular nuclei outline, open vesicular chromatin with prominent nucleoli, and up to 11 mitoses per high-power field, with a few atypical forms. Additionally, multivacuolated cytoplasm was evident in several areas, indicative of sebaceous differentiation. Squamous differentiation areas were also observed.
Microscopic examination of the lymph node depicted variably sized and shaped lymphoid follicles with few prominent germinal centres. Notably, the lymph node was devoid of malignant cell infiltration.
Conclusion
In conclusion, the clinical presentation, histopathological examination, and surgical intervention confirmed the diagnosis of sebaceous carcinoma. The patient’s favourable outcome post-surgery underscores the importance of timely diagnosis and appropriate management in such cases.
Discussion
Sebaceous carcinoma, a rare malignant tumour originating from skin adnexal structures, occasionally exhibits aggressive behaviour. It has been documented worldwide and is primarily diagnosed through histological examination of tumour biopsies or resections. This type of carcinoma has been linked to other malignancies or cancer treatment modalities. Interestingly, our medical centre has not encountered a case of sebaceous carcinoma in the past decade. However, we present here a rare instance of sebaceous carcinoma in a middle-aged black African man, occurring five years after he underwent chemotherapy for colorectal cancer. Notably, the patient’s age falls within the reported range for sebaceous carcinoma occurrence, which spans from 43 to 85 years, according to studies conducted in Korean populations. Like many cancers, the incidence of sebaceous carcinoma tends to rise with age, likely due to cumulative exposure to carcinogenic factors over time.
Despite being more commonly observed in Caucasians, our patient, being of Black African descent, presented a rarity in our local context, where no cases had been seen in the past decade. This scarcity mirrors the overall low incidence of skin tumors in our region compared to Western regions. However, gauging the true incidence remains challenging due to barriers such as poverty and limited access to quality healthcare facilities, which deter patients from seeking medical attention promptly.
Causes of Sebaceous Carcinoma
The patient, although a male, may have faced an increased risk of developing sebaceous carcinoma due to hormonal influences. While some studies suggest a higher prevalence of sebaceous carcinoma in females, others indicate a male predominance. Notably, sebaceous carcinoma typically expresses androgen receptors, potentially contributing to its higher incidence in males. The reduction in estrogen activity post-menopause may also play a role in tumour development in women. Moreover, male patients with androgen receptor-positive tumours often exhibit a more aggressive disease course. This is likely linked to the proliferative effects of androgens, ultimately resulting in poorer prognoses.
Sebaceous carcinoma can manifest in various anatomical sites, with the ocular region being the most common. In our case, the tumor was located in the upper eyelid, consistent with the typical presentation of ocular sebaceous carcinoma. This localization likely stems from the high concentration of sebaceous glands in the head and neck region, particularly in the eyelids.
Several factors have been implicated as potential risk factors for sebaceous carcinoma, including Epstein–Barr virus (EBV) and ultraviolet radiation exposure. Given the patient’s residence in Africa, where sunlight exposure is relatively higher compared to temperate regions, ultraviolet radiation may have contributed to tumour development. While some researchers have suggested an association between sebaceous carcinoma and the use of eye pencils, widespread usage and the tumor’s low incidence suggest a weak correlation.
Sebaceous Carcinoma: A side-effect of Chemotherapy
Chemotherapy, a common treatment modality for various cancers, has been associated with the development of secondary malignancies, including sebaceous carcinoma. Notably, our patient had previously undergone chemotherapy for colorectal cancer, raising the possibility of chemotherapy-induced tumorigenesis. Furthermore, some cases of sebaceous carcinoma have been linked to Muir–Torre syndrome (MTS), a variant of Lynch syndrome, although genetic testing to confirm MTS was unavailable in our setting.
Histological examination of the tumour revealed characteristic features of sebaceous carcinoma, including infiltrative growth patterns and basaloid cell morphology. Additionally, the patient experienced spontaneous bleeding from the tumour mass, a rare occurrence indicative of poorly developed vasculature within the tumour.
In summary, our case highlights the rare occurrence of sebaceous carcinoma in a black African male, five years after chemotherapy for colorectal cancer. The multifactorial nature of sebaceous carcinoma aetiology underscores the importance of comprehensive evaluation and management strategies tailored to individual patient characteristics.
