Basal cell carcinoma (BCC) is the most common skin cancer and accounts for 80–95% of all eyelid tumors. Prolonged exposure to sunlight seems to be an important predisposing factor [
BCC generally exhibits slow growth. The tumor may invade the adjacent tissues and cause their destruction but it rarely metastasizes [
In the current research, an attempt was made to identify correlations between histopathological features and various clinical characteristics of BCC, such as tumor location, size, and histology type. In addition, the study investigated whether differences exist between primary and recurrent BCC, with respect to various clinical and histological features. No differences found between these two groups of BCC would lend further support to the assumption that the main cause for recurrence is incomplete excision.
In this retrospective study, all patients underwent BCC excision at the Goldschleger Eye Institute during a 3-year period (January 1995 to December 1997).
Data regarding patients’ demographics, tumor location, tumor size, and histological features were collected and analyzed. All lesions involving the canthal area with or without spreading to the eyelids were classified as canthal lesions.
The BCC was classified into 3 groups according to macroscopically measured tumor size: small, <10 mm in its longest axis; medium, 10 to 20 mm in its longest axis, and large, >20 mm in its longest axis. Histological patterns of BCC were determined and when solid and infiltrative patterns were found in the same tumor it was classified as mixed type.
Surgery was performed under local anaesthesia. The first stage involved resection of the macroscopically visible tumor with clinically free margins of 1 mm. The specimen was fixed in formalin for further histopathology. Margins of 1 mm from the remaining tumor bed were then excised, and frozen sections of these tissue strips were evaluated. The results of the microscopic examination were reported to the operating theatre before completion of surgery. If margins were not free of tumor, additional tissue excision from the involved side was performed, and the frozen sections were examined again for tumor presence. Only when all margins were reported to be free of tumor residue was the surgical wound closed and the surgery completed.
After fixation in formalin, the main tissue specimen was measured and sectioned into three pieces that included the various margins of the lesion. These tissue sections were then embedded in paraffin. Sections of 4
All lesions were reevaluated and classified histologically based on the classification described by Wade and Ackerman [
Institutional review board (IRB) was waived for the study.
The Wilcoxon Mann-Whitney test and chi-square nonparametric analyses were used to compare numerical variables and proportions, respectively, between primary and recurrent BCCs. The Fisher’s Exact test was used to examine the probability of a lesion to occur in a specific anatomical location. Statistical analysis was carried out using Microsoft Excel 2003 (Microsoft Corporation, Redmond, WA) and SPSS version 13.0 (SPSS, Inc., Chicago, IL) programs.
Eighty-seven patients (52 males, 35 females, mean age of 70 years, range 33–96 years) participated in the study. Average symptom duration was 34 months (range 1 month to 30 years), and average time to surgery was 2.4 months. The left eye was more commonly affected, with 58% of lesions appearing on this side. Lesion size was 40% of eyelid extent on average. Most lesions appeared on the lower eyelid (55 lesions, 63%), followed by medial canthus (13 lesions, 15%), upper eyelid (12 lesions, 14%), and lateral canthus (7 lesions, 8%). Seventy-one lesions (82%) were primary BCC and 16 lesions were recurrences (18%) that were referred from different hospitals.
Most lesions involved the dermis and orbicularis (65 lesions, 77%), 16 lesions involved the tarsus or conjunctiva (19%), and only 3 lesions (3%) had orbital involvement. No data regarding depth of invasion were obtained from 3 cases.
Most lesions were solid, nodular, or nodular ulcerative (66 lesions, 75.9%), followed by morphea or infiltrative (9 lesions, 10%) and cystic or nodular cystic (7 lesions, 8%). Other histological forms appeared less commonly and included basosquamous and plexiform (adenoid pattern) (Figures
Histology composite of three types of basal cell carcinoma (Haematoxylin and Eosin stain). (A) Nodular type, (B) infiltrative (morpheaform), and (C) mixed.
Histological types of 71 patients with primary periocular basal cell carcinoma (BCC) and 16 patients with recurrent BCCs.
Average inflammation score (on an arbitrary scale of 1–3) was 2.1 while spaces in lesions (on a similar scale) was 1.5. Necrosis appeared in 22 cases (25%).
Clinical and histological characteristics of primary and recurrent peri-ocular basal cell carcinoma (BCC).
Primary BCC | Recurrent BCC | |||
Age | 0.7 (ns) | |||
Duration | (months) | 0.2 (ns) | ||
Time to surgery | (months) | 0.6 (ns) | ||
Size | (percentage) | 0.009 | ||
Eyelid location | Lower | 45 (63%) | 10 (62%) | |
Medial canthus | 8 (11%) | 5 (31%) | 0.2 (ns) | |
Upper | 11 (15%) | 1 (6%) | ||
Lateral canthus | 7 (10%) | 0 (0%) | ||
Histology | Nodular | 63 (89%) | 12 (75%) | |
Baso-squamous | 2 (3%) | 0 (0%) | 0.1 (ns) | |
Morphea | 6 (8%) | 3 (19%) | ||
Plexiform | 0 (0%) | 1 (6%) | ||
Depth of invasion | Dermis | 32 (45%) | 5 (31%) | |
Orbicularis | 25 (35%) | 5 (31%) | ||
Tarsus | 10 (14%) | 1 (6.2%) | 0.006 | |
Conjunctiva | 3 (4.2%) | 2 (12.5%) | ||
Orbit | 1 (1.4%) | 2 (12.5%) |
Recurrent BCCs were significantly larger than primary lesions (recurrent BCCs involved 46% of eyelid extent versus 36% of eyelid extent in primary lesions,
However, no differences between recurrent and primary BCCs were found with respect to age at presentation, eyelid location, and histological differentiation (Table
In the current study, similar clinical and histological features were found in patients with primary and recurrent BCC of the eyelid. No differences in tumor location or histology type were found between the two groups of patients, suggesting that incomplete tumor excision may be the major cause of lesion recurrence.
In our study, the left periocular region was found to be involved more commonly than the right side. This may reflect greater sun exposure on that side during driving, in agreement with the fact that in Australia, where drivers sit on the right side, involvement of the right peri-ocular region is more common than the left [
The fact that recurrent lesions tend to be of longer duration and to involve a greater extent of the eyelid is somewhat surprising, since patients who have already undergone eyelid surgery for the primary lesion should be more aware of the possibility of recurrence. This observation was noted in a previous study regarding recurrent lesions that were larger with more subclinical extension [
Recurrence after incomplete excision is reported to be 20% with 5 to 9 years of followup [
Similar histological differentiations and eyelid location were found in both groups of primary and recurrent lesions, in contrast to many studies reporting certain features more common in recurrent BCCs [
Incomplete excision of BCC is associated with tumor location on the face or inner canthus as well as with infiltrative and multifocal histology types with a reported rate of 10% [
Eyelid location along with basosquamous or morpheaform BCCs are reported to be high-risk tumors with extensive subclinical spread that require more MMS levels for tumor clearance [
Limitations of the current study stem from its retrospective design. All recurrent BCCs were referrals and no data were obtained regarding the type of initial excision. Similarly, it was not possible to reevaluate the first histological specimens to examine for BCC residues at the margins of dissection. Referral bias may exist, as small lesions might have been excised without margin control during primary surgery or followed up long enough to examine recurrence and more extensive lesions were preferentially sent to our department. In addition, a relatively small number of patients was analyzed in this study, especially in the recurrent BCC group.
Despite these limitations, our study suggests that primary and recurrent peri-ocular BCCs have similar clinical and histological features including eyelid location and tumor type. Medial canthal location, morpheaform, and/or sclerosing histology were not more common in the recurrent BCC group implying that incomplete surgical excision may be the main cause for recurrence.
This paper supported in part by the Talpiot Medical Leadership program, Sheba Medical Center, Teal Hashomer, Israel.