Basal cell carcinoma of the eyelid

I.        Describe the approach to establishing the diagnosis

A.     Describe the etiology of this disease

1.      Neoplastic transformation of normal skin cells into a malignant cell line

B.     Define the relevant aspects of epidemiology of the disease

1.      Decreased racial skin pigmentation (red or blonde hair, blue eyes, fair skin)

2.      Living in areas with high ultraviolet (UV) exposure

3.      Basal cell nevus syndrome

C.    List the pertinent elements of the history

1.      Unprotected extensive sun exposure

2.      Skin radiation for inflammatory (acne) or malignant skin conditions

3.      Previous skin cancer

4.      Non healing, ulcerated skin lesion

D.    Describe pertinent clinical features

1.      Often elevated, but may be flat

2.      Central ulceration possible (See Oculoplastic Figure 22)

3.      Irregular margins

4.      Often elevated pearly margins

5.      Non tender

6.      Loss of normal skin or eyelid margin architecture (i.e., loss of lashes)

7.      Occasionally pigmented or cystic

E.     Describe appropriate laboratory testing for establishing the diagnosis

1.      Incisional or excisional biopsy depending on clinical presentation

II.      Define the risk factors

A.     Sun exposure

B.     Previous skin cancer

C.    Previous skin therapeutic radiation

D.    Basal cell nevus syndrome

E.     Xeroderma pigmentosum

F.     Skin type

1.      Skin that easily sunburns

2.      Fair skin with blue eyes

G.    Racial predilection (i.e. Irish descent), usually reflecting skin type

III.    List the differential diagnosis

A.     Squamous cell skin cancer

B.     Actinic keratosis

C.    Chronic inflammatory blepharitis

D.    Keratoacanthoma

E.     Papilloma

IV.   Describe patient management in terms of treatment and follow-up

A.     Describe medical therapy options

1.      Incisional biopsy mandatory before consideration of non-surgical alternatives

2.      Cryotherapy for small lesions and in patients that are not surgical candidates

3.      Radiation for palliative treatment only

4.      Photodynamic therapy indicated for basal cell nevus syndrome or an extensive lesion that had failed conventional therapies

B.     Describe surgical therapy options

1.      Incisional biopsy to confirm clinical diagnosis

2.      Total excision of the lesion with either frozen section control of margins or Mohs micrographic surgery

3.      Reconstruction to re-establish function and aesthetic appearance

V.   List the complications of treatment, their prevention and management

A.     Basal cell carcinoma (BCC) recurrence

1.      Regular follow-up for early detection of any recurrence or new tumor

B.     Eyelid/facial dysfunction with ocular surface compromise or other ocular/facial functional compromise (tearing, diplopia, ptosis), especially with large tumors

1.      Appropriate reconstruction is directed to restore adequate function

2.      Secondary procedures may be used to restore function. 

a.      For example, loss of the canalicular system may be addressed with a Jones tube, but only when adequate follow-up insures that recurrence is unlikely

3.      Orbital exenteration is required if clinical orbital extension of tumor is confirmed histopathologically or radiologically

C.    Unacceptable eyelid/facial aesthetic result

1.      Reconstruction is designed to provide the best cosmetic result possible.

a.      Procedures such as flaps, rather than skin grafts, are chosen, when possible, to provide the best aesthetic result.

b.      Additional procedures may be undertaken to correct functional or aesthetic issues

VI.   Describe disease-related complications

A.     Direct tumor extension into orbit with functional compromise (vision, diplopia, pain)

B.     Direct tumor extension in adjacent facial tissues (lacrimal drainage, perineural)

C.    Rare intracranial extension

VII.   Describe appropriate patient instructions

A.     Avoid unprotected sun exposure (hat, topical sun block)

B.     Appropriate medical evaluation of any non-healing skin lesions

C.    Routine periodic follow up examination of all sun exposed skin areas

Additional Resources

1. AAO, Basic and Clinical Science Course. Section 4: Ophthalmic Pathology and Intraocular Tumors; Section 7: Orbit, Eyelids, and Lacrimal System, 2004-2005.

2. AAO, Surgery of the Eyelid, Orbit & Lacrimal system, Vol. 1, 1993, p. 160-162.

3. AAO, Focal Points: Management of Malignant Eyelid Tumors, Module #6, 1989, p. 1-2.