5 years review of periocular basal cell carcinoma and proposed follow-up protocol

Recurrence rates of periocular basal cell carcinoma following intra-operative en-face frozen section margin controlled excision

PURPOSE

To report the margin control process and rate of recurrence of periocular basal cell carcinomas (BCCs) managed by en-face, frozen section margin controlled (FSC), excision by a single surgeon with a 3-year follow-up.

METHODS

A retrospective analysis of all histopathologically proven cases of periocular BCC who underwent surgical excision with intra-operative, en-face, FSC, excision by a single surgeon from 2015 to 2019 was performed. Patients with less than 3-year follow-up were offered a virtual appointment to determine possible recurrence.

RESULTS

A total of 88 BCC excisions from 86 patients were reviewed. Minimum 3-year follow-up data is available for 73 patients. The most common location and histological subtype was the lower eyelid and nodular BCC, respectively (47% and 83% of cases). Primary BCC (pBCC) comprised 98% (86/88) of cases and recurrent BCC (rBCC) comprised 2% (2/88) of cases. Negative frozen section margins were achieved in 93% (82/88) of excisions on the day of surgery. The overall recurrence rate during this time was 1.4% (1/73) at minimum 3 years.

CONCLUSION

Periocular BCC can be managed effectively by en-face, FSC, excision, with a high cure rate and low recurrence rate comparable to alternative excision techniques such as Moh's micrographic surgery. Advantages of en-face excision include same-day excision and reconstruction and reduced theatre time. Primary nodular BCCs with clear margins can be considered for early discharge with advice to self-monitor.

Advanced Periocular Basal Cell Carcinoma with Orbital Invasion: Update on Management and Treatment Advances

Purpose

Basal cell carcinoma (BCC) is the most frequent malignant periocular tumor. It is associated with exposure to ultraviolet radiation, and its incidence is gradually increasing. It may occasionally display more aggressive behavior and result in orbital or intracranial invasion. Mortality from periocular BBC with orbital invasion is very low, but the associated morbidity can be significant, from disfigurement to blindness. Traditionally, these cases have been treated with orbital exenteration or with radiotherapy (RT), but in recent years, hedgehog pathway inhibitors (HPIs) have emerged, are effective in more serious cases, and are used primarily or combined with surgery, changing our perspective on the management of these patients.

Methods

We studied 24 cases of periocular BCC with orbital invasion, some primary and others recurrent, which were treated between 2011 and 2021 in the same hospital. All patients had clinical or radiological evidence of orbital invasion. Orbital exenteration was performed on 9/24 of the patients (1 received vismodegib after surgery), and 12/24 were treated, surgically preserving the eyeball, with 3 of them receiving adjuvant vismodegib. Three of the twenty-four patients were treated exclusively with vismodegib (Erivedge®, Genentech).

Results

One patient died due to poor tumor evolution, but the rest evolved favorably and they have had no recurrences. Vismodegib was generally well tolerated, except for in one patient who discontinued treatment due to the side effects.

Conclusions

In advanced BBC with orbital invasion, mutilating surgical treatments such as exenteration or potentially vision-threatening treatments such as RT remain as options. In recent years, however, very promising new medical therapies have emerged, such as HPI, which can be used effectively instead of surgery or in combination with it, preserving the eye and vision, which implies a new approach to treatment.

Recurrence of Basal Cell Carcinoma Treated with Surgical Excision and Histopathological Analysis with Frozen Section Technique with Complete Margin Control (CMC-FS): A 15-Year Experience of a Reference Center

BACKGROUND

Basal cell carcinoma (BCC) is the most common type of eyelid malignancy and it is considered to be dangerous due to its proximity to functionally essential organs. Early diagnosis and complete excision of the primary lesion are crucial to prevent infiltration and metastasis. The study aims to evaluate the extent of recurrence in subjects affected by BCC of the upper third of the face treated with surgical eradication and the frozen section technique with complete margin control (CMC-FS), in comparison with the gold standard Mohs micrographic surgery (MMS).

MATERIALS AND METHODS

The study included 111 patients with 111 biopsy-proven eyelid BCCs. On clinical examination, all lesions were removed with 2 mm margins clinically free of neoplasm. Prior to reconstruction, CMC-FS analysis of all surgical margins was performed on each tumor for histopathologic confirmation. Subsequently, all margins were presented for the permanent paraffin sections.

RESULTS

There were 69 primary carcinomas and 42 secondary carcinomas among the 111 samples. No recurrence occurred in 109 tumors followed-up for at least 5 years, with a total recurrence rate of 1.8%. The median time between lesion excision and diagnosis of recurrence was 20 months.

CONCLUSIONS

at 5-year follow-up, CMC-FS guided excision of BCCs of the eyelids resulted in recurrence rates equivalent to MMS. Intraoperative microscopic control of all margins reduced the recurrence rate of the upper third of the facial BCCs, correlating with easier reconstruction with better esthetic and functional outcome.

Recurrence Following Globe Sparing Excision for Basal Cell Carcinoma with Anterior Orbital Invasion

PURPOSE

Globe-sparing excision for periocular basal cell carcinoma (BCC) with orbital invasion has evident benefits, but the ensuing morbidity and characteristics of recurrence are not well elucidated. This study aims to describe the extent of visual morbidity following globe-sparing excision, and the clinicoradiological characteristics of tumor recurrence.

METHODS

Multicentre retrospective case series.

RESULTS

Eight patients were identified for inclusion in this series. Time to recurrence following globe-sparing excision ranged from 3 to 12 years. Seven patients (87.5%) presented with recurrent disease originating from the medial canthus. Clinical features at presentation included contracture ( n =4, 50.0%), upper lid ptosis ( n =3, 37.5%), a palpable mass ( n =2, 25.0%), and hypoesthesia ( n =2, 25.0%). Radiologically, tumor recurrence was predominantly characterized by isointense signals on T1 and T2-weighted sequences ( n =5, 62.5%) with moderate contrast enhancement. The most common histologic subtype in recurrent tumors was a mixed nodular and infiltrative growth pattern ( n =5, 62.5%). Perineural invasion was a feature in four (50%) cases. Salvage therapy in the form of exenteration was performed in seven cases. Vismodegib and adjuvant radiotherapy were provided for one case with surgically unresectable tumor recurrence.

CONCLUSIONS

Globe-sparing excision for invasive periocular BCC can be complicated by late recurrence that develops rapidly despite silent neuroimaging for years. Early clinical signs are subtle. High-risk features predictive of recurrence include medial canthus location, mixed histological subtypes, and perineural invasion. Patients with such characteristics require lifelong clinical and imaging surveillance following globe-sparing excision.

Periocular basal cell carcinoma recurrence following surgical treatment: Safe surveillance time

BACKGROUND

To report the rate of primary periocular BCC recurrence following surgical excision in low-risk and high-risk BCCs, and to propose long term follow up guidelines.

METHODS

Retrospective case series of primary BCC treated with surgical excision (Mohs micrographic surgery [MMS], wide local excision [WLE] or fast paraffin excision) who have histologically-confirmed BCC subtype and histologically-measured tumour clearance margins.

RESULTS

77 patients (78 eyelids) were included. Mean age was 72.0 ± 12.8 years with a female predominance (42, 54.5%). Most common histological BCC subtype was nodular (39, 50.0%). 44 (56.47.1%) patients underwent MMS. Tumour clearance was achieved in 59 (75.6%) eyelids after one surgery. 9 had further surgery to achieve tumour clearance while 10 were monitored. There was no statistical significance between recurrence rates in patients who had tumour clearance compared with patients with incomplete tumour clearance after initial surgery (p = 0.15). In patients with incomplete tumour clearance, there was no statistical significance between recurrence rates in those who underwent further surgery versus those monitored (p = 0.47). Average follow-up duration was 37.9 ± 17.2 months. Three (3.9%) cases had recurrent BCC. All three cases had high-risk BCC features (infiltrative subtypes and/or incomplete tumour excision after initial surgery).

CONCLUSIONS

There was no evidence of recurrence of completely excised, low-risk BCCs at three years, regardless of type of surgical excision. We recommend patients with completely excised, primary BCCs without high-risk features be monitored for one year. Patients with any high-risk BCC features, such as incompletely excised tumours or high-risk histological subtypes, should be monitored for five years.

Periocular basal cell carcinoma results and surgical outcome during a 5-year period in a larger Danish population

Background

To report tumour pathology, surgical procedure, complication rates and overall outcome of periocular basal cell carcinoma (BCC) in the Department of Ophthalmology at Sygehus Lillebaelt, Southern Denmark Region over a 5-year period.

Methods

Medical records for all patients who underwent surgery for periocular BCC between January 2016 and December 2020 were reviewed. All tumours were excised with a 3 mm margin beyond the clinically apparent delimitation of the tumour and analysed by frozen section histological examination. Paraffin sections were subsequently examined for a final histopathological diagnosis. Patient age, gender, date of resection, former cancer history, referring unit and follow-up time were recorded. Furthermore, histological subtypes identified from biopsy and resection, lesion location, lesion diameter, free margin after the first operation, lacrimal punctum involvement, reconstructive techniques and complications were also recorded.

Results

A total of 242 surgical excisions from 237 patients were recorded. The mean age was 69.7 ± 12.6 with women significantly predominant compared to men (1.8:1, p < 0.0001, binomial test). The mean tumour diameter was 4.29 mm (range 0.5–20 mm). The most common location and histological subtype was the lower eyelid and nodular BCC respectively (64.9% and 74.0% of cases). In 17.4% of the patients, the initial resection margin on the frozen section histology was not free of tumour cells and the risk was significantly greater for BCC subtypes considered aggressive in terms of growth pattern (morphea form, infiltrative and micronodular features) as compared to non-aggressive BCC subtypes (nodular and superficial) (p = 0.002, X²). In 239 (98.8%) of the patients, the BCC was found to be radically removed after final histopathological examination.

The sensitivity of identification of aggressive subtypes of periocular BCC in biopsies was 47.7%. No recurrences were found during the 5-year period.

Conclusion

This study demonstrated a tendency towards more women than men being diagnosed with periocular BCC. The initial biopsy performed for all patients underestimated the aggressiveness of BCC in almost half of the cases while aggressive BCC subtypes were more likely to need further resection after frozen section compared to non-aggressive subtypes.

Healthcare Resource Utilization and Cost of Care in Patients With Periocular Basal Cell Carcinoma: A Real-World Study

PURPOSE

To date, there are no studies on healthcare resource utilization (HRU) and costs for treating periocular basal cell carcinoma (pBCC). We investigated real-world HRU and costs of patients with limited versus extensive pBCC.

DESIGN

This was a retrospective cost analysis.

METHODS

Administrative claims database was mined for basal cell carcinoma (BCC)-related claims from January 2011 to December 2018. Patients had ≥1 inpatient or ≥2 outpatient nondiagnostic claims for pBCC ≥30 days apart, ≥6 months of continuous enrollment in a health plan before the index date, and ≥18 months of continuous enrollment after the index date. Patients were categorized by disease severity (limited or extensive) using Current Procedural Terminology codes. A total of 1368 patients were propensity matched 1:1 for limited and extensive pBCC (n = 684 each). Outcomes were cost and HRU measures during the 18-month follow-up period.

RESULTS

Patients with extensive disease had a higher number of outpatient visits (32.47 vs 28.81; P < .0001), radiation therapies (0.53 vs 0.17; P = .001), surgeries (1.82 vs 1.24; P < .001), days between first and last surgery (40.82 vs 16.51 days; P < .001), outpatient pBCC claims (3.89 vs 3.38; P < .001), and days between pBCC claims (170.43 vs 144.01 days; P < .001). Patients with extensive disease incurred higher total all-cause costs ($36,986.10 vs $31,893.13; P = .02), outpatient costs ($20,450.26 vs $16,885.87; P = .005), radiation therapy costs ($314.28 vs $89.81; P = .01), and surgery costs ($3,697.08 vs $2,585.80; P < .001) than patients with limited disease.

CONCLUSIONS

Patients with extensive pBCC incurred higher costs, greater HRU, and longer time between first and last surgery versus patients with limited pBCC. Early diagnosis and early treatment of pBCC have economic benefits.

Recurrence rate of basal cell carcinoma among different micrographic surgery techniques: Systematic review with meta-analysis

In high-risk basal cell carcinomas (BCCs), micrographic surgery (MS) has high tissue preservation and low recurrence rates. The Mohs technique is the most commonly used technique, with limited use of other MS techniques. No studies have been designed to compare the MS methods. This review aimed to assess BCC recurrence rates of different MS techniques. A systematic review and meta-analysis was conducted to search for related studies in PubMed, LILACS, EMBASE, SCOPUS, WEB OF SCIENCE, CINHAL, and COCHRANE until March 2021. Randomized clinical trials (RCTs) and observational studies involving patients with BCC and indications for different MS techniques were included. Study selection and data extraction were performed independently by three peer reviewers, as was the risk of bias assessment using the Joanna Briggs Institute tool. Pooled estimates were assessed using the random-effects model (Logit), and heterogeneity was assessed by the chi-square test (χ² ). Stata Software version 17.0 was used for analysis. Eighteen studies were included, 2 RCTs and 16 observational studies. The overall recurrence rate was 2% (95% CI, 1.0-3.0%; χ² = 46.2; p = 0.00; 18 studies, 10,424 BCCs). In studies using the Mohs technique, the recurrence rate was 3.0% (95% CI, 1.0-5.0%; χ² = 11.0; p = 0.00; 6 studies; 1,582 BCCs), with the Munich technique 3.0% (95% CI, 2.0-5.0%; χ² = 0.0; no heterogeneity; 3 studies; 404 BCCs), with Tubingen technique 1% (95% CI, 1.0-2.0%; χ² = 12.1; p = 0.00; 8 studies; 8,374 BCCs) and with the Muffin technique 0.0% (95% CI, 0.0-6.0%; 1 study; 64 BCCs). Relapse rates between MS techniques were low and appeared to be similar. However, the design of this review and the absence of primary studies that directly compare the techniques do not allow us to assert the superiority between them.

Lateral frontal galeal-cutaneous flap for reconstruction after orbital exenteration for advanced periorbital skin cancer

Background/aim

Orbital exenteration (OE) is one of the most disfiguring procedures leading to significant deformity. Defect reconstruction is challenging, especially in elderly patients. Herein, experiences with orbital exenteration and primary reconstruction with lateral frontal galeal-cutaneous flap based on superficial temporal artery were reviewed.

Materials and methods

Data on patients treated for nonmelanoma skin cancer invading the orbit during a 10-year period were analyzed. The patient demographics, tumor features, reconstructive techniques used, complications, and survival were recorded with a median follow-up of 27.5 months.

Results

Included in the study were 26 patients in whom OE was performed, comprising 14 males and 12 females, with a mean age of 75.29 years (range: 61–87). The majority of the patients were treated for basal cell carcinoma with medial cantus as the primary site. All of the defects were closed using a lateral frontal galeal-cutaneous flap based on the superficial temporal artery, and in 2 patients, a temporalis muscle pedicle flap was used as an additional flap for reconstruction of the orbital roof in order to separate the brain from the empty orbit, and it was then covered with the same galeal-cutaneous flap. In 19 patients, the frontal area was closed primarily, and in 7 patients, skin graft was used for the secondary defect. There was no flap loss. Tumor-related death was registered in 3 patients (inoperable recurrent tumors) (11.5%), 7 died from complications that were unrelated to the tumors (2 were operated for recurrent orbital tumors), and 16 survived.

Conclusion

The preferred method for reconstruction after OE at our university affiliated center is lateral frontal galeal-cutaneous flap based on the superficial temporal artery. Flap harvesting is simple, safe, and obtains enough tissue to cover the defects, even after extended exenteration. The complication rate is low. The simultaneous use of this flap with pedicle temporalis muscle flap is suggested only for reconstruction of the scull base after anterior cranial fossa resection.

Periocular basal cell carcinoma: recurrence risk factors/when to reoperate?

Introduction

The aim of periocular basal cell carcinoma (BCC) surgery is radical excision of the tumour while maintaining eyelid functionality and facial aesthetics. Differences in management of the patients after excision of eyelid BCC with a narrow margin are described in the literature.

Aim

This study concerns the correlation between the recurrence rate in the periorbital area and the narrow safety margin of excision in the histopathological report with respect to various clinical and histopathological features.

Material and methods

A retrospective non-randomized analysis was conducted on 158 patients with BCC of the periorbital area. These patients were operated on between January 2002 and December 2016. A database was created, comprised of patient age, sex, location of the lesion, TNM, method of reconstruction, result of the histopathological examination, date and location of the recurrence.

Results

In 66 (41.77%) patients BCC was radically removed. In 50 (31.65%) patients BCC was removed with a narrow margin and in 42 (26.58%) cases, radical excision was not achieved. The recurrence rate was significantly higher in the aggressive BCC group compared to those with non-aggressive BCC (p = 0.004). The recurrence-free rate for non-aggressive subtypes was 98.11% in both the first and fifth years, but in aggressive subtypes it was 89.06% in the first year but fell to 80.16% in the fifth year.

Conclusions

An aggressive subtype of BCC significantly influences the risk of non-radical excision of the lesion. Aggressive BCC subtypes should have more frequent check-ups. There is no need to reoperate patients with a narrow margin of BCC excision.

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta‐analysis*

BACKGROUND

Keratinocyte or nonmelanoma skin cancer (NMSC) is the commonest malignancy worldwide. The usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates.

OBJECTIVES

We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta-analysis of primary clinical studies.

METHODS

A PRISMA-compliant systematic review and meta-analysis was performed using methodology proposed by Cochrane (PROSPERO CRD42019157936). A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000-27 November 2019). All studies were included except those on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. Risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random-effects model for pooling of binomial data was used. Differences between proportions were assessed by subgroup meta-analysis and meta-regression, which were presented as risk ratios (RRs).

RESULTS

Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCCs) and 21 569 squamous cell carcinomas (SCCs). The proportion of incomplete excisions for BCC was 11·0% [95% confidence interval (CI) 9·7-12·4] and for SCC 9·4% (95% CI 7·6-11·4). Proportions of incomplete excisions by specialty were: dermatology, BCCs 6·2% and SCCs 4·7%; plastic surgery, BCCs 9·4% and SCCs 8·2%; general practitioners, BCCs 20·4% and SCCs 18·9%. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCCs (RR 3·9, 95% CI 2·0-7·3) and SCCs (RR 4·8, 95% CI 1·0-22·8). Studies were heterogeneous (I²  = 98%) and at high risk of bias.

CONCLUSIONS

The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision.

Periocular Basal Cell Carcinoma: 20-Years Experience at a Tertiary Eye Care Center of South India

PURPOSE

To study the clinical profile and management outcomes of periocular basal cell carcinoma (BCC).

MATERIALS AND METHODS

A retrospective analysis of all histopathologically proven cases of BCC between 1995 and 2015 was done. The demographic data, clinical presentation, histopathological subtype, and management outcomes were analyzed.

RESULTS

We had a total of 185 malignant eyelid tumors during the study period, out of which 37 (20%) were BCC. Thirty-two (86.5%) out of 37 cases were primary BCC. The mean age was 63.3 years. Pigmented ulcerative lesion (14, 38%), lower eyelid (19, 51%), and nodular BCC (15, 40%) were the most common presentation, periocular site, and histological subtype, respectively. 28 patients underwent excision under frozen section with an average tumor-free margin of 3.5 mm. Mean follow-up period was 18.78 months. Recurrence rate of 0% and 3.1% was noted in primary and recurrent BCC, respectively.

CONCLUSION

Periocular BCC commonly presents as pigmented ulcerative lesion in the lower lid. Excision biopsy under frozen section with an average tumor-free margin of 3.5 mm offers cure in most cases.

A multicentre review of the histology of 1012 periocular basal cell carcinomas

AIMS

To evaluate primary periocular basal cell carcinomas (BCCs) in depth including comparing histological margins with subtype, location and surgical specialty after wide local excision.

METHODS

A retrospective review was performed for all BCCs excised from three hospitals over 5 years, covering a population of just over 1 million. Tumours were classified according to histological subtype location. Incomplete excision rates and margins were analysed in detail and comparisons made.

RESULTS

The most common subtype found was nodular followed by infiltrative. Lesions were most commonly located at the lower lid. Infiltrative BCCs were associated with perineural invasion and incomplete excision despite the largest peripheral margins. Superficial BCCs had the smallest mean peripheral margin but the largest mean deep margin. 2 mm histological margins gave an 83.7% complete excision rate, 6.4% incomplete excision rate and 7.1% where the clearance margin was 0.3 mm or less.

CONCLUSION

Distribution of eyelid BCCs based on subtype and periocular location mirrored the general consensus. Infiltrative BCCs should be excised with wider margins or referred for Mohs surgery, especially if the medial canthus is involved. Superficial BCCs should be excised with wider but shallower surgical margins. Ophthalmologists were more likely than dermatologists or plastic surgeons to incompletely excise a periocular BCC, which is reflective of their more difficult case mix.

Relation of the eighth edition of the American Joint Committee on Cancer staging system with histological risk classification for primary eyelid basal cell carcinoma

PURPOSE

To investigate the relation between the eighth edition of the American Joint Committee on Cancer staging system and histological risk classification for primary eyelid basal cell carcinoma.

METHODS

Retrospective, observational case series of patients undergoing excisional biopsy for primary eyelid basal cell carcinoma in two tertiary centres between 2008 and 2018. Patients with <6 months of follow-up were excluded. Outcomes measured included histological subtype, American Joint Committee on Cancer 7 and 8 staging.

RESULTS

A total of 222 cases were included over a 10-year period, with a mean (range) follow-up of 25.74 (6-120) months and a median (range) age of 70 (28-93) years. According to American Joint Committee on Cancer 8, the most common T category was T1a (64%), followed by T1b (18%) and T2a (8%). Of the 222 specimens, 183 (82.43%), 17 (7.66%), 19 (8.56%) and 3 (1.35%) were staged as IA, IB, IIA and IIB, respectively. The most common histological subtype was nodular in IA category and infiltrative in categories IB and IIA. Histologically, low-risk basal cell carcinomas were related to lower American Joint Committee on Cancer staging (IA), whereas high-risk basal cell carcinomas were related to American Joint Committee on Cancer stages IB and IIA (p < 0.001). No significant relation was found between T categorisation and risk stratification when adopting American Joint Committee on Cancer 7.

CONCLUSION

American Joint Committee on Cancer 8 staging system is strongly related to primary eyelid basal cell carcinoma histological risk classification.

Characteristics and Recurrence of Primary Eyelid Basal Cell Carcinoma in Central Spain

Purpose:

To define the incidence, characteristics, and management of eyelid basal cell carcinoma (BCC) in Central Spain.

Methods:

This retrospective study investigates the characteristics and the outcome of eyelid BCC from 2000 to 2016 in a central region of Spain. Data were collected on demographics, skin phenotype, location of the eyelid lesion, clinical and histological diagnosis, surgery, commitment of surgical margins, and recurrence rate.

Results:

Primary eyelid BCC occurred in a mean of 20.6 lesions a year or 9.4/100,000 inhabitants/year. The mean age of BCC carriers was 69.4 ± 16.2 years, with no gender difference (P = 0.479), predominantly affecting Fitzpatrick II–III skin (81.3%) (P < 0.001). The most common location was the inner canthus (154/45.7%) (P < 0.001) and type nodular (215 cases/63.8%) (P < 0.001). The surgical margins were affected in 69 (20.5%) individuals, and the recurrence rate was 5.6 (95% confidence interval, 3.2–8.3) significantly higher in affected margins (P < 0.001). The most common location for recurrence was the inner canthus (P = 0.003), and the most common histological type for recurrence was sclerosing (16.7%), then multinodular (12.5%), and infiltrating (10.4%) with no significant difference (P = 0.27).

Conclusions:

The frequency of occurrence of eyelid BCC is much less than the estimated crude incidence for skin tumors involving all areas of the body in the Spanish population. Eyelid BCC is more common in the seventh decade of life, with no predilection for gender. Nodular histological type is the most common. The recurrence rate is 5.6%, depending on site and affected margins, even though clear free margins also can present with recurrence.

Periocular basal cell carcinoma - clinical perspectives

Basal cell carcinoma (BCC) as a non-melanoma skin cancer type is the most common malignant tumor throughout the world. The incidence is higher in age over 60. The intense of exposure to ultraviolet radiation is one of the known risk factors. Over 50% of BCC of the periocular region initially occur on the lower lid and inner angle. Literature review of treatment options for basal cell carcinoma, which consist of surgery, or combined techniques plus vismodegib, radiotherapy and imiquimod. The first consideration for treatment of periocular BCC is radical surgical excision using Mohs micrographic technique. Functional and esthetic outcome in patients are important after clear excisions and reconstruction should be carefully considered. Radical exenteration is considered in the case of orbital invasion of high-risk aggressive BCC.

Small margin (up to 2 mm) excision of periocular basal cell carcinomas in the setting of a one-stop clinic - long-term outcomes at a minimum of 11 years' follow-up

OBJECTIVES

To analyse the long-term outcome of small margin (up to 2 mm) excision of clinically well-demarcated primary periocular basal cell carcinomas (BCCs).

METHODS

Retrospective evaluation of 185 patients with excised well-demarcated primary BCCs at a minimum of 11 years following excision. All patients underwent tumour excision with maximum margins of 2 mm. Resulting defects were, if possible, closed directly. Reconstruction requiring flaps or grafts was delayed until receipt of the histological report, which was obtained in all cases.

RESULTS

Of 185 patients evaluated, 69 (37.3%) were still alive at the time of the study, at least 11 years post excision. One-stage excision and direct closure was performed in 60/69 patients (86.96%). In 9/69 patients (13.04%), excision was undertaken with reconstruction 4 days later, after receipt of the histopathology report. Histological assessment confirmed complete initial excision in 59/69 patients (85.5%) rising to 68 (98.6%) after two excisions. Mean follow-up was 13 years, with no recurrence in the living cohort. Three deceased patients had a recurrence, one of whose tumour was reported histologically as incompletely excised but declined further surgery, giving an overall recurrence rate of 3/185 (1.62%). For patients who completed treatment, the recurrence rate was 2 in 184 (1.09%). Six of the sixty-nine patients (8.7%) developed new tumours on the contralateral eyelid or the forehead.

CONCLUSIONS

Primary, clinically well-demarcated periocular BCCs can be safely treated using small (up to 2 mm) excision margins in a one-stop setting with immediate reconstruction for those defects which can be closed directly without recourse to flaps or grafts.

SYNOPSIS

A retrospective study of 185 patients who had small margin (≤2 mm) excision of clinically well-demarcated primary periocular BCCs demonstrated a recurrence rate of 3/185 (1.62%) at a minimum of 11 years' follow-up.

Access to intraoperative tumour margin control: a survey of the British Oculoplastic Surgery Society

Background

Periocular malignancy is common and in most cases will undergo excision with pre-determined margins and subsequent histological examination. Intraoperative margin control (IOMC) modalities such as fast frozen section (FFS), fast paraffin (FP) and Mohs micrographic surgery (MMS) are being increasingly widely used, though there is a lack of information regarding utility. The aim of this study was to survey members of the British Oculoplastic Surgery Society (BOPSS) to determine attitudes and access to different modalities of IOMC.

Methods

A 12-question online survey was disseminated via an e-mail to full members of the BOPSS. The survey was hosted using Qualtrics software via the University of Sussex.

Results

The overall response rate was 64 of 165 (38.8%). MMS was readily available in a neighbouring trust to 23 of 64 respondents (35.9%). Seven respondents (10.9%) reported no regional access to MMS. Twenty-nine members had readily available access to FFS (45.3%) and 37 of 64 to FP (57.8%) in their own institution. There is variation in what tumour types would be considered appropriate for IOMC, though most thought clinically ill-defined (morphoeic) basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) should undergo one form of IOMC (90.6% and 81.3%, respectively).

Conclusion

This study highlights variation in availability and utilisation of IOMC amongst oculoplastic surgeons and in different regions of the UK. While the exact place of IOMC in periocular tumour excision is debated, there is a consistent view that it should be available for some tumours. Greater consistency in provision may improve patient outcomes.

Recurrence rates following surgical excision of periocular basal cell carcinomas: systematic review and meta-analysis

Background: Basal cell carcinomas (BCCs) remain one of the most common non-melanoma skin cancers (NMSCs). Surgical options include primary excision with predetermined margins, frozen section controlled excision, and Mohs micrographic surgery (MMS). There is no randomized study comparing recurrence rates between different surgical techniques for periocular BCCs.Methods: A meta-analysis of proportions was conducted for recurrence rates. Meta-regression was used for subgroup analysis to compare results in those undergoing MMS versus FSE or paraffin controlled sections (WLE).Results: The pooled recurrence rate for periocular BCCs excised via MMS was 2.9% (95% CI 1.9-4.4%) over an average of 48.8 ± 14.9 months. The pooled recurrence rate for FSE was 1.9% (95% CI 1.9-2.4%) over an average of 70.7 ± 48.0 months. By comparison, the pooled recurrence rate following WLE was 5.9% (95% CI 3.9-8.9%) over an average of 49.2 ± 29.3 months. Meta-regression demonstrated that the recurrence rate for WLE was significantly higher compared to MMS and FSE techniques (p<.001) but similar for MMS and FSE (p=.65).Conclusions: Our results highlight the importance of intraoperative margin assessment in the management of BCCs in order to reduce recurrence. These factors should be taken into consideration in the workup and management of patients with periocular BCCs.

Ocular basal cell carcinoma: a brief literature review of clinical diagnosis and treatment

Basal cell carcinoma (BCC) is a common malignant tumor throughout the world. One of the known risk factors of BCC is intense exposure to ultraviolet radiation. More than 50% of BCCs of the eyelid initially occur on the lower lid. The gold standard of diagnosis of BCC is histopathology. Treatment options for BCC consist of surgery, vismodegib, radiotherapy and imiquimod. Surgical excision using Mohs micrographic surgery or wide surgical excision with frozen section margin control is the first consideration for treatment of periocular BCC. Eyelid reconstruction should be carefully considered as both function and esthetic outcome in patients are important after clear excision of tumors. Exenteration is considered in the case of extensive orbital invasion or high-risk aggressive tumors in order to reduce the rate of recurrence.

The Importance of Frozen Section-Controlled Excision in Recurrent Basal Cell Carcinoma of the Eyelids

Objectives:

To show the importance of frozen section-controlled excision to avoid the re-recurrence of recurrent basal cell carcinoma (BCC) of the eyelids.

Materials and Methods:

Thirty-five cases who underwent eyelid tumor excision in different centers and were admitted to our clinic with recurrent eyelid tumors. Recurrent tumors were resected by excision 1-2 mm from the tumor’s visible margin and sent to pathology for frozen section examination. Eyelid reconstructions with flap and graft were performed after confirming that the surgical margins were negative.

Results:

Twenty-one (60%) of our patients were male and 14 (40%) were female. Median age of our group was 63.4±14.2 years. Excision and sending the excised material for frozen section control was performed once for 11 patients, twice for 12 patients, 3 times for 8 patients and 4 times for 4 patients to confirm that the surgical margins were clean. All pathology samples were reported as BCC. All patients had eyelid reconstruction with flap and graft. Recurrence was detected in 2 patients (5.7%) during 1 to 8 years (mean 4.3 years) of follow-up and those patients were reoperated; no recurrence was detected in the remaining 33 patients (94.3%).

Conclusion:

Frozen section control can provide low re-recurrence rate in patients with recurrent BCC of the eyelids.

Retrospective clinicopathological study of 129 cancerous and 18 precancerous lesions of the eyelids in North-Western Greece

This study aimed to present precancerous and cancerous epithelial eyelid lesions, their histopathological features, and possible correlations with clinical parameters. The retrospective study included 147 formalin-fixed, paraffin-embedded samples. We studied precancerous and cancerous epithelial eyelid lesions. Preneoplastic tumors were represented by 12 actinic keratoses and 6 in situ squamous cell carcinomas (Bowen disease) and skin epithelial tumors by 119 basal and 10 squamous cell carcinomas. We recorded the clinicomorphological and histopathological features of the specimens and investigated possible correlations. In our study, the vast majority of pre-malignant and malignant tumors occurred in advanced age (mean age of occurrence: 70.18 years). The data analysis showed that inflammation in patients with basal cell carcinoma (BCC) positively correlated with advanced age (p < 0.01), tumor diameter (p < 0.05), and the appearance of ulceration (p < 0.001). A prevalence of female sex was noted in the BCC group. We also found that inflammation with or without the presence of ulceration was more commonly seen in carcinomatous lesions than in preneoplastic lesions (p < 0.05). Inflammation occurrence is present in high proportions in the tumors studied and correlates with some clinicopathological parameters such as the age of patients, the mean tumor diameter, and the presence of ulceration. The comparison between premalignant and malignant conditions showed that inflammation probability increases as we move toward the more aggressive tumor phenotypes.

Hedgehog Pathway Inhibition for Locally Advanced Periocular Basal Cell Carcinoma and Basal Cell Nevus Syndrome

PURPOSE

To review our experience treating patients with the Hedgehog pathway inhibitor, vismodegib, in patients with orbital or periocular locally advanced or metastatic basal cell carcinoma (BCC) or basal cell nevus syndrome.

DESIGN

Retrospective interventional case series.

METHODS

We reviewed all patients with locally advanced or metastatic orbital or periocular BCC or basal cell nevus syndrome treated with the Hedgehog pathway inhibitor, vismodegib, at a comprehensive cancer center from 2009 through 2015. Reviewed data included age; sex; American Joint Commission on Cancer tumor, node, metastasis staging system designation; type and grade of drug-related side effects; response to treatment; duration of follow-up, and status at last follow-up.

RESULTS

The study included 10 white men and 2 white women; the median age was 64.5 years. Ten patients had locally advanced BCC; 2 had basal cell nevus syndrome. Among the patients with locally advanced BCC, 5 had T3bN0M0 disease at presentation; 1 each had T3aN0M0, T3bN1M0, T2N1M1, T4N1M1, and T4N2cM1 disease. Overall, 3 patients had a complete response, 6 had a partial response, and 3 had stable disease at last follow-up. Two patients developed progressive disease after a complete response for 38 months and stable disease for 16 months, respectively. All patients developed grade I drug-related adverse effects, most commonly muscle spasms (12 patients), weight loss (10), dysgeusia (9), alopecia (9), decreased appetite (5), and fatigue (4). Five patients developed grade II adverse effects. At last follow-up, none of the 5 patients presenting with T3bN0M0, nor the patient with T3bN1M0 disease, had required orbital exenteration.

CONCLUSION

Hedgehog pathway inhibition produces a significant clinical response in most patients with locally advanced or metastatic orbital or periocular BCC or basal cell nevus syndrome and can obviate orbital exenteration in some patients. Drug-related adverse effects are manageable in most patients.