Nodular Basal Cell Carcinoma:

49-year-old female with left lower lid lesion

Nodular Basal Cell Carcinoma:

49-year-old female with left lower lid lesion

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Chief Complaint: 49-year-old Caucasian female with a lesion on her left lower lid.

History of Present Illness: The patient noted that the lesion has been present for 2 years. She states that it occasionally gets inflamed, and then heals but it always comes back. She has not noted any change in size of the lesion during that time.

Ocular History: No previous ocular history. No eye surgery nor eye trauma.

Medical History: Hypothyroidism.

Medications: Levothyroxine

Family and Social History: Noncontributory. Patient is a non-smoker and occasional consumes alcohol.

EXAM, OCULAR

• Visual Acuity, with correction: OD, OS-- 20/20
• Pupils, Motility, and Intra-ocular pressure: normal, OU
• External and anterior segment examination:
  • OD: normal; OS: normal but for the eyelid lesion on the left lower lid, as noted (see Figure 1). The lesion is 3x5 mm in size, with central ulceration and rolled, pearly borders with telangiectatic vessels. There are lashes missing (madarosis) in the area of the lesion.

Figure 1: A 3x5 mm ulcerated lesion is evident at the lid margin of the left lower lid. There is central ulceration and rolled, pearly borders with telangiectatic vessels and lash loss (madarosis).

Course: An excisional biopsy was performed (see Figures 2 and 3) which demonstrated skin with central ulceration of the epidermis and multiple islands of basophilic neoplastic cells in the superficial dermis. The neoplastic cells appear to arise from surface epidermis. The diagnosis was consistent with basal cell carcinoma. Mohs surgery with oculoplastic reconstruction was planned.

Figure 2: A 20x magnification demonstrating central unceration of the epidermis and multiple islands of basophilic neoplastic cells in superficial dermis, arising from surface epidermis.

Figure 3

Figure 3A: A 50x magnification demonstrating the neoplastic cells arising from surface epidermis.	Figure 3B: A 200x magnification demonstrating the pallisading quality to the borders of nests of neoplastic cells.

Discussion

Basal cell carcinoma is the most common malignancy of eyelids (90% of eyelid malignancies). Risk factors include exposure to sunlight and the patient may have a history of other skin cancers. Classically the lesion appears as a slowly enlarging ulceration with raised, pearly borders. There are multiple forms that this malignancy can take including nodular (as is this case), morpheaform (see EyeRounds Case #7), pigmented, and multicentric. The lower lid is most commonly involved, followed by the medial canthus and less frequently the upper lid and lateral canthus. Lesions involving the medial canthus are often more deeply invasive. Metastasis is rare with basal cell carcinoma, however these lesions may be deeply invasive and therefore clear surgical margins are extremely important.

The diagnosis is made with biopsy. On pathology, the tumor cells form cohesive nests of cells with bland appearing nuclei with nuclear palisading of the peripheral cell layer. The malignant cells originate from the basal layer of epidermis and only occur in hair bearing tissue. Tissue processing can cause artifactitious separation of tumor from surrounding stroma.

Treatment is with complete surgical excision. Mohs micrographic surgery is a technique described by Dr Frederic Mohs (1910-2002) from the University of Wisconsin. The goal of Mohs surgery is to remove all of the cancer while sparing the most amount of healthy tissue. He initially utilized fixed tissue and in the 1960s used fresh frozen tissue. The frozen tissue technique was first described for basal cell carcinoma of the eyelid. In Mohs surgery, first the visible tumor is removed. Next, thin, horizontal sections through tumor margins are examined under the microscope. Any microscopic "roots" of tumor are mapped to the original tissue and re-excised. This process is repeated as necessary until no tumor remains.

Figure 4: Mohs surgery left a defect that was 4 x 12mm, deep to the tarsus. Oculoplastics planned a myocutaneous advancement flap and free tarsal graft from the right upper lid for repair.

In the patient above, Mohs surgery left a defect that was 4 X 12mm, deep to the tarsus (see Figure 4). Oculoplastics planned a myocutaneous advancement flap and free tarsal graft from the right upper lid for repair.

Diagnosis: Nodular Basal Cell Carcinoma (BCC)

EPIDEMIOLOGY Middle age and older adults; some increasing incidence in young adults Most common eyelid malignancy (90% of eyelid cancers) Risks include sun exposure, lighter skin pigmentation, and smoking. Patients with BCC may have other skin cancers. Can occur with basal cell nevus syndrome and xeroderma pigmentosum	SIGNS Eyelid lesion that is most commonly found on lower eyelid, followed by medial canthus and less commonly upper eyelid and lateral canthus Most common form of BCC is nodular type with ulcerated papule and pearly, raised borders Telangiectasias and madarosis is common as is disruption of the eyelid margin Morpheaform type may have less defined borders and may be plaque-like
SYMPTOMS Non-healing, ulcerated lesion May bleed with local trauma	TREATMENT Biopsy to determine pathology of tumor Complete excision is definitive treatment and may include Mohs surgery Oculoplastic reconstruction is often required after Mohs surgery Close monitoring for recurrence

Differential Diagnoses for Basal Cell Carcinoma

• Actinic Keratosis
• Bowen Disease
• Keratoacanthoma
• Sebaceous Hyperplasia
• Seborrheic Keratosis
• Squamous Cell Carcinoma
• Trichoepithelioma