• Written By: Shimon Rumelt, MD

    The authors report a retrospective case series of 20 patients with histologically-confirmed, anterior orbital invasion by medial canthal basal cell carcinoma (BCC) who were managed with conservative, globe-sparing tumor excision. At a mean follow-up of 38 months, there was one recurrence, which required exenteration. The authors conclude that with careful planning and margin control, conservative surgery in this highly selected group proved possible with a low rate of recurrence. Postoperative complications, such as epiphora and ophthalmoplegia, were largely expected and common, with most patients undergoing revision procedures to address complications.

    Patients were identified from the databases of four hospitals in Australia and the United Kingdom. In 12 of the patients (60 percent), the tumor was a recurrence, with one patient having had prior radiotherapy for incomplete excision. Eighteen patients (90 percent) had a palpable mass, 16 (80 percent) had clinical involvement of the nasolacrimal system and one (5 percent) had limited extraocular movements. Preoperative radiologic evidence of orbital invasion was found in 10 patients (50 percent). Histologic evidence of orbital invasion was present in every patient. The subtypes were infiltrative (9/20, 45 percent), nodular (4/20, 20 percent), micronodular (2/20, 10 percent), multifocal (1/20, 5 percent) and mixed (4/20, 20 percent). Extratumoral perineural invasion was present in one patient (5 percent).

    Final margins were clear in 18 of 20 patients (90 percent), positive in one patient (5 percent) and unclear in one (5 percent). Reconstruction was by direct closure in one patient and by a variety of standard oculoplastic flaps and grafts in 19 patients (95 percent). Twelve patients (60 percent) had postoperative extraocular muscle movement restriction. Fifteen patients (75 percent) had epiphora. Subsequent revision procedures were needed in 12 patients (60 percent), including insertion of a lacrimal bypass tube and revision of medial canthal position. Postoperative visual acuity was within 2 Snellen lines of preoperative visual acuity in 17 patients (85 percent).

    There is scant literature on this topic. Patients with a primary tumor that does not invade too deep and without risk factors may be the best candidates for this type of surgery. The tissues around the tumor should be free and patients should be followed meticulously to rule out recurrences since reconstruction may interfere with identifying the recurrence.

    The authors conclude that the decision to exenterate or to pursue a conservative surgical course should be made after a detailed discussion with the patient, with consideration for the level of vision in each eye. In the setting of primary medial canthal BCC with limited anterior orbital invasion, this study's results seem to support a globe-sparing approach, albeit with a high expectation of mainly treatable postoperative complications and possible revision procedures. The presence of features suggestive of greater risk, such as recurrent disease, perineural invasion or restriction of extraocular movements preoperatively, may be associated with a higher risk of recurrence. The authors conclude that in such circumstances, enthusiasm for conservative surgery should be tempered.