Basal Cell Carcinoma

SIGNS AND SYMPTOMS
Basal cell carcinoma is the most common malignancy of the eyelid, accounting for over ninety percent of all cancerous lid lesions. Often, this tumor is discovered during routine slit lamp evaluation. There is usually no associated pain or discomfort. Basal cell carcinoma is more common in older, fair-skinned individuals, especially with a history of prolonged or excessive exposure to sunlight. The lower lid margin and medial canthus are the most common areas involved.

The basal cell lesion presents in one of three ways: (1) the nodular form appears as a small, translucent, raised area with poorly defined edges, and is firm to the touch; (2) the classic ulcerative presentation is a nodular lesion that over time has developed telangiectasia (a reddish hue caused by persistent, and virtually permanent, dilation of capillaries) along the surface and an atrophied inner portion, creating a "pearly," indurated outer margin with an excavated center; and (3) less frequently, the sclerosing or morpheaform basal cell carcinoma form, which has a firm, pale, waxy yellow plaque with indistinct borders.

PATHOPHYSIOLOGY
While there is no single known cause for all forms, there is a distinct association with increasing age and exposure to ultraviolet radiation. In addition, Caucasians have a much greater chance of developing basal cell carcinoma than other races. The progression of this tumor is, in most cases, exceedingly slow. If left untreated, however, the lesion may in time invade deeper structures. Fortunately, metastasis is rare, and complete recovery is possible with proper therapy.

MANAGEMENT
Basal cell carcinoma can be treated with surgical excision, radiation therapy or chemotherapy. The preferred course for most cases is surgery, with broad margins to ensure complete removal. Local radiation therapy and/or systemic chemotherapy can manage basal cell carcinoma when surgery is intolerable or refused by the patient. Both of these modalities carry significant side effects, however, and neither is as effective as surgical intervention.

CLINICAL PEARLS

Basal cell carcinoma is rarely life-threatening because of its non-metastatic, slow-growing nature. However, this tumor does possess the capacity, over time, to cause significant local destruction, and must always be treated appropriately.
Early biopsy is often the key to diagnosis. Biopsy all suspicious lid lesions which demonstrate irregular growth, changes in color or appearance, or purulent or bloody discharge to rule out cancer. You should refer confirmed malignancies promptly to an oculoplastics specialist or, if possible, an ocular oncologist.