Basal Cell Carcinoma

INTRODUCTION Basal cell carcinoma is a malignant tumor derived from cells of the basal layer of the epidermis. It represents the most common malignant tumor of the eyelids, comprising 85-90% of all malignant epithelial eyelid tumors. The etiology of basal cell carcinomas is linked to excessive ultraviolet light exposure in fair-skinned individuals. Several types of basal cell carcinoma can occur on the eyelids. The nodular-type is the most common, followed by the mor-phea variety. Over 99% of basal cell carcinomas occur in Caucasians. They are seen typically in middle aged and elderly adults, but are more frequently being seen in younger adults, and several cases have been reported in children without pre-existing genetic syndrome or a history of radiotherapy. Predisposing factors include ionizing radiation, arsenic exposure, and pre-existing scars. Having had one basal cell carcinoma is risk for the development of additional lesions. While metastases are rare (0.028-0.55%), local invasion is common and can be very destructive. Basal cell nevus syndrome, also known as Gorlin-Goltz syndrome or nevoid basal cell carcinoma syndrome, is an autosomal dominantly inherited disorder associated with multiple basal cell carcinomas affecting the face, trunk, and extremities with a high rate of recurrence.

CLINICAL PRESENTATION Basal cell carcinomas are often located on the lower eyelid (50-60%) and near the medial canthus (25-30%). Uncommonly they may occur on the upper eyelid (15%), and lateral

Chalazion CanthusKeratoacanthomas Rodent Pictures

canthus (5%). The nodular-type is the most common form to affect the eyelid and has the classic appearance of a pink or pearly papule or nodule with overlying telangiectatic vessels. As the tumor grows in size a central ulceration may occur surrounded by a rolled border (also known as a "rodent ulcer"). Cystic varieties may occur. The pigmented basal cell carcinoma is similar, but with brown or black pigmentation. These lesions represent the most common pigmented malignancy on the eyelids, and may resemble malignant melanoma. The morphea or sclerosing type appears as a flat, indurated yellow to pink plaque with ill-defined borders. It may simulate blepharitis or dermatitis. This form of basal cell carcinoma is aggressive and can invade the dermis deeply. It characteristically occurs in the medial canthal region and can invade into the paranasal sinuses, lacrimal system, and orbit. Superficial basal cell carcinomas appear as an erythematous, scaling patch with raised pearly borders. Recurrent tumors tend to be more aggressive and infiltrative and show a lower rate of cure than with primary lesions.

HISTOPATHOLOGY Basophilic tumor cells with hyperchromatic nuclei form irregular lobules. Along the periphery of the tumor lobules, the cells often are arranged radially with their long axes parallel to each other, creating so-called "peripheral palisading". Stroma surrounding the tumor is often mucinous and artifactually shrinks away from the tumor islands during histological processing, creating thin clefts. Clefts and mucinous matrix help to distinguish poorly differentiated basal cell carcinoma from poorly differentiated squamous cell carcinoma. Tumor lobules may have central necrosis, a prominent adenoid pattern, or strands of basaloid cells in a dense fibrous stroma (morphea or sclerosing pattern).

Seborrheic Keratosis Adenoid

DIFFERENTIAL DIAGNOSIS The differential diagnosis includes malignant melanoma, sebaceous cell carcinoma, squamous cell carcinoma, actinic keratosis, radiation dermatitis, keratoacanthoma, cutaneous horns, dermoid and sebaceous cysts, eccrine and apocrine cysts, papillomatous lesions, seborrheic kertosis, blepharitis, chalazion, eczema, psoriasis, and seborrheic dermatitis.

TREATMENT The goal of therapy is the complete removal of tumor cells with preservation of uninvolved eyelid and periorbital tissues. If excision is done without histologic control, a 4 mm margin will give adequate results in most cases. It has been shown that even with residual tumor at the cut margin the recurrence rate is only 38%. Mohs' micrographic surgery with frozen section control has proven to yield the highest cure rate with the most effective preservation of normal tissue. Recurrence rates with this technique are reported at 0.5-1%. Radiation therapy in doses of 4,000-6,500 cGy has been reported to yield a 5-year tumor free control rate of 91%. While some have advocated its use for small nodular lesions, it may be more appropriate for the treatment of advanced invasive or recurrent tumors. Cryotherapy is often used to treat non-periorbital lesions but when used on the eyelid, notching of the lid margin, malpositions of the eyelid, symblepharon formation with fornix foreshortening, and pigmentary changes of the eyelid skin may be seen as complications. It is also associated with a higher recurrence rate. Tumor regression has been reported with topical 5% neomycin cream.


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    What is a chalazion in the eye?
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