Basal cell carcinoma (BCC) (periocular)

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Contents

Aetiology

Commonest (80-90%) malignant tumour of the skin of white-skinned populations
Commonest periocular malignancy.
Incidence of BCC shows marked geographic variation; has been reported as 233 per 100,000 population per annum (in Wales) while in Australia incidence has been estimated as high as 884 per 100,000 per annum
Arises from the basal layer of the epidermis
Rarely metastasises (incidence <0.1%) and so rarely fatal
Slow growing, locally invasive

Predisposing factors

Older patients (median age at diagnosis 67 years; rare under 40 years)
M:F = 3:2
History of sunlight (UVB) exposure (particularly during childhood and adolescence)
Outdoor workers are at significantly increased risk
Fair complexion
History of previous BCC or other non-melanoma skin cancer
Immune compromise (e.g. HIV infection, immunosuppression)

Symptoms of basal cell carcinoma

Slow developing, non-resolving lesion of eyelid skin
usually painless, may bleed

Signs of basal cell carcinoma

Location in order of prevalence (commonest first):

  • lower lid (48%)
  • medial canthus (deeper tissue penetration more likely with possible invasion of orbit or paranasal sinuses) (may be hidden by spectacle nose pad) (27%)
  • upper lid (25%)

Three clinical presentations in order of prevalence (commonest first)

  • nodular (hard nodule, pearly appearance, abnormal (telangiectatic) vessels)
  • nodulo-ulcerative (as nodular but with raised rolled border surrounding central ulcer, may bleed)
  • morphoeic or sclerosing (flat hardened plaque of thickened skin, without surface vascularisation, ill-defined border making it difficult to determine area of involvement)

Occasional secondary infection or inflammation

  • overlying purulent discharge or crusting

Change in lid contour/redirection or loss of eyelashes
Loss of texture of surrounding skin
Later cases sometimes pigmented (more prominent in dark skinned races)

Differential diagnosis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere.

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological 

Document with photography if possible
Refer with details of location, size and history (to aid assessment of urgency)
Advise patient of possible diagnosis
Reassure that this is a low risk skin cancer
Advise on sun protection measures
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Pharmacological 

None

Management category

B1: no treatment by optometrist; routine referral
This slow growing neoplasia rarely metastasises but if left untreated could threaten sight (or life if BCC invades beyond orbit)

Possible management by ophthalmologist

Biopsy for histopathology analysis to confirm diagnosis

Surgery and radiotherapy appear to be the most effective treatments with surgery showing the lowest failure rates. Mohs micrographic surgery is considered the better alternative for treatment of certain types of periocular BCC because it has the highest chance of curing the disease and minimises the size of the defect that needs to be repaired. It has been reported to have the lowest recurrence rate of any treatment modality (approx 3% over four years).

Other treatment modalities that are sometimes recommended include cryotherapy, photodynamic therapy, carbon dioxide laser ablation, and chemotherapy including Imiquimod (topical immune response modulator) and Hedgehog Pathway Inhibitors such as Vismodegib

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation. (www.gradeworkinggroup.org)
 

Sources of evidence

Ashraf DC, Vagefi MR Hedgehog Pathway Inhibitors for Periocular Basal Cell Carcinoma. Int Ophthalmol Clin. 2020;60(2):13-30

Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database, part I: periocular basal cell carcinoma experience over 7 years. Ophthalmology 2004; 111(4):624–30

Moran JM, Phelps PO. Periocularskin cancer: Diagnosis and management. Dis Mon. 2020;66(10):101046

Narayanan K, Hadid OH, Barnes EA. Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma. Cochrane Database Syst Rev. 2014;12:CD007041

Phan K, Oh LJ, Goyal S, Rutherford T, Yazdabadi A. Recurrence rates following surgical excision of periocular basal cell carcinomas: systematic review and meta-analysis. J Dermatolog Treat. 2020;31(6):597-601

Trakatelli M, Morton C, Nagore E, Ulrich C, Del Marmol V, Peris K, Basset-Seguin N; BCC subcommittee of the Guidelines Committee of the European Dermatology Forum. Update of the European guidelines for basal cell carcinoma management. Eur J Dermatol. 2014;24(3):312-29

Zhang Z, Behshad S, Sethi-Patel P, Valenzuela AA. Glasses: Hiding or causing skin cancer? Orbit. 2016;35(5):262-6

Summary

What is Basal Cell Carcinoma?

Basal Cell Carcinoma (BCC) is a low-risk cancer that is the most common malignant tumour of the skin in white people. BCC rarely spreads to other parts of the body. Instead, it slowly enlarges, causing no pain, though bleeding may occur from the surface. Around the eye, the most usual form and location is a small hard whitish nodule that appears on the lower eyelid.

Figures from Wales indicate that BCC occurs in just under 0.25% of the population every year. In other parts of the world, especially where ultra-violet (UV) exposure is higher, more people are affected; for example, the figure may be three to four times higher in Australia. People who work outdoors are more likely to develop BCC.

It is very important to distinguish BCC from other growths that sometimes appear on the eyelids. It is usual to take a small sample of the tumour (known as a biopsy) for examination in the laboratory, so that the diagnosis can be confirmed and a treatment plan developed.

How is Basal Cell Carcinoma managed?

The usual treatment is either radiotherapy or surgery to remove the tumour. A special kind of surgery, known as Mohs micrographic surgery, is sometimes recommended. In this procedure, thin slices of the tumour are removed one after another and examined under the microscope until the surgeon is satisfied that all of the tumour has been removed. The result is complete removal of the tumour with the smallest possible wound.

Basal cell carcinoma
Version 8
Date of search 16.08.21
Date of revision 25.11.21
Date of publication 06.04.22
Date for review 08.08.23
© College of Optometrists