Basal cell carcinoma (BCC) (periocular)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

Commonest (80-90%) malignant tumour of the skin of white people

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 metastasizes (incidence <0.1%)

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

Slow developing, non-resolving lesion of eyelid skin

Painless, may bleed

Signs

Location in order of prevalence (commonest first):

  • lower lid
  • medial canthus (deeper tissue penetration more likely with possible invasion of orbit or paranasal sinuses)
  • upper lid
  • lateral canthus

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

  • Squamous cell carcinoma, chalazion, keratoacanthoma, actinic keratosis, molluscum contagiosum, papilloma
  • Anterior marginal blepharitis can resemble sclerosing BCC
  • BCC diagnosis is suspected clinically but is usually confirmed by histology which can also help to define the clinical subtype

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 (up to 98% success). 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 in a large prospective case series from Australia, although this has yet to be confirmed by RCTs

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

Evidence base

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

Sources of evidence

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

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

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

Lay summary

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.

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 6
Date of search 21.06.17
Date of revision 19.12.17
Date of publication 06.04.18
Date for review 20.06.19
© College of Optometrists

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