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Eyelid Skin Cancer & Eyelid Reconstruction

BASAL CELL CARCINOMA (EYELID CANCER)

Basal cell carcinoma is the most common form of skin cancer and the most common eyelid cancer. It is associated with sun damage and is the least aggressive skin cancer. It is slow growing and does not spread to the rest of the body. While most basal cell carcinomas can be removed with surgery, if left untreated, these tumors can grow around the eye and into the orbit, sinuses and even the brain. Basal cell carcinomas are more commonly found on the lower eyelids and almost never spread to other parts of the body (metastasize).

Sometimes a central ulcer with pearly edges may develop, which does not ultimately heal. If left untreated, it will damage structures in the surrounding area. Treatment is by excision, followed by reconstructive surgery. If small, this may be done with local anesthetic injection. If larger, it is usually performed in a surgery center with local anesthetic and intravenous sedation (sleepy and relaxed but not general anesthetic).

SYMPTOMS

Patients with basal cell carcinomas most commonly notice a reddish nodule slowly forming on their eyelid. The tumor is most commonly found on the lower eyelid, followed by the medial canthus (toward the nose) and can occur on the upper eyelid. Eyelash loss (around the tumor) suggests that a tumor is malignant.

Less commonly, basal cell cancers can be pigmented or are present without any nodule at all. When the tumor does not make a nodule and grows within the eyelid, it can induce pulling of the eyelid (away from the eye). These cases are much more difficult to treat because the edges are harder to define.

RISK FACTORS

A risk factor is anything that increases an individual’s chance of developing cancer. Although certain factors often influence the development of cancer, most do not directly cause cancer. Some people who display multiple risk factors never develop cancer, while others who do not experience any risk factors do. However, knowing your risk factors and discussing them with Dr. Paul will help you make more informed lifestyle and health care choices.

Cancer.net details how the following factors can increase the risk of developing eyelid cancer:

  • Exposure to UV radiation: Sunlight includes both ultraviolet A (UVA) and ultraviolet B (UVB) radiation. UVB radiation produces sunburn and plays a role in the development of basal cell carcinoma, squamous cell carcinoma, and melanoma. UVA radiation penetrates the skin more deeply, causing photoaging or wrinkling. The role of UVA radiation in the development of non-melanoma eyelid cancer is suspected, but not certain. People who live in areas with year-round, bright sunlight have a higher risk of developing an eyelid cancer. So do people who spend significant time outside or on a tanning bed, which produces mostly UVA radiation.
  • Fair skin: Less melanin (pigment) in skin offers less protection against UV radiation. People with light hair and light-colored eyes are more likely to develop eyelid cancer.
  • Age: Most basal and squamous cell cancers appear after the age of 50.
  • A history of sunburns or fragile skin: Skin that has been burned, sunburned, or injured from disease is at higher risk for eyelid cancer. Squamous cell and basal cell cancers more often occur with repeated, long-term exposure to the sun. Melanoma more often occurs with short-term intense exposure to sun.
  • Individual history: People with weakened immune systems are at higher risk for developing squamous cell and basal cell cancers. People with rare, predisposing genetic conditions such as xeroderma pigmentosum, nevoid basal cell carcinoma syndrome, or albinism are at much higher risk for eyelid cancer.
  • Previous skin cancer: People who have had any form of skin cancer are at higher risk for developing another skin cancer. For instance, about 35% to 50% of people diagnosed with one basal cell cancer will develop a new cancer within five years.
  • Precancerous skin conditions: Two types of lesions may be related to the development of squamous cell cancer in some people. Actinic keratoses is characterized by rough, red or brown, scaly patches on the skin. Bowen’s disease is characterized by bright red or pink, scaly patches located on previously or presently sun-exposed skin. Bowen’s disease in areas not exposed to the sun may be related to arsenic exposure.

DIAGNOSIS

People with eyelid cancer may experience the following symptoms or signs. Sometimes people with eyelid cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer:

  • A change in appearance of the eyelid skin
  • Swelling of the eyelid
  • Thickening of the eyelid
  • Chronic infection of the eyelid
  • An ulceration (area where skin is broken) on the eyelid that does not heal
  • A spreading, colored mass on the eyelid

If you are concerned about one or more of the symptoms or signs on this list, give us a call to schedule an appointment with Dr. Paul. He will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This will help him find out the cause of the problem, called a diagnosis. If Dr. Paul suspects basal cell carcinoma, the most common protocol will be to collect a simple eyelid biopsy. This specimen is then sent to a pathologist to confirm the diagnosis prior to complete removal of the tumor. Dr. Paul will call you when the results are back from the pathologist to determine next steps.

If a diagnosis of Basal Cell Carcinoma is confirmed by the pathologist, complete excision under frozen section control or Moh’s Technique will be recommended. Both techniques require the removal of the tumor until the margins (edges) are negative (free of tumor). Unlike most areas of skin, the eyelids are a complex functional apparatus that require special reconstruction techniques.

Most basal cell carcinomas can be cured when they are small. That is why it is very important to make an appointment with a specialist like Dr. Sean Paul to evaluate your condition and determine the best course of action.

Unfortunately, some patients choose to ignore or deny the existence of these tumors. Those patients allow their tumor to invade behind the eye and become difficult or impossible to remove. In these cases radiation and chemotherapy may be suggested to control or destroy the tumor.

TREATMENT OPTIONS

After the diagnosis, surgery may be required for the removal of the tumor depending on how much it has spread. Different types of surgical procedures may be used depending on the size of the cancer and where it is located. Eye surgery should only be performed by an experienced ophthalmologist like Dr. Paul at a surgery center that suits the patient’s needs.

Extensive surgery may result in scarring and deformity of the eyelid, enucleation (removal of the eye), and/or may cause problems with tear drainage.

  • Biopsy: A surgical biopsy may remove part of the tumor (incisional) or the entire tumor (excisional). If the tumor is found to be cancerous, and Dr. Paul has managed to remove a sufficient margin of healthy tissue along with the tumor, an excisional biopsy may be the only treatment needed.
  • Mohs’ surgery: This technique involves removing the visible tumor and small fragments of the edge of where the tumor existed and will typically involve another physician as well as Dr. Paul. Each small fragment of the tumor will be examined under a microscope until all cancer is removed. This procedure is most often used for a larger tumor in hard-to-reach place, and for cancer that has come back to the same place. However, it is increasingly becoming a preferred technique for removing an eyelid tumor. After Mohs’ surgery, the patient will undergo reconstructive surgery with Dr. Paul who an expertly trained oculofacial plastic surgery specialist.
  • Reconstructive surgery: Many patients with eyelid cancer require reconstructive surgery. Reconstructive surgery differs from cosmetic surgery in that it is generally performed to improve eye function, although it may also be done to approximate a normal appearance. Oftentimes, multiple surgeries are done and spread out over a period of time.
  • Radiation: Radiation therapy may be used for a cancer that is hard to treat with surgery and several treatments may be needed. If radiation therapy is required, Dr. Paul will likely discuss a few options with you including the involvement of an oncology specialist to assist in your comprehensive care.
  • Enucleation: Although rare, it is sometimes medically necessary to remove the eye due to the size and extent of the tumor. Because of this visual loss, a person with one eye may have trouble with depth perception. To fill the area left by the missing eye, Dr. Paul will refer the patient to a specialist who is an expert in prosthetics. The patient will then get fitted for a prosthesis (artificial eye) which is meant to look and behave almost the same as a natural eye. For example, the artificial eye will move along with the person’s remaining eye, just not as much as a natural eye moves.