Protocol for diagnosis and treatment of a patient with basal cell carcinoma of the eyelid margin

Yulia Bondar, dermatovenerologist, dermato-oncologist, trichologist at the Multimed clinic (Ukraine)

Basal cell carcinoma is more often found in women aged 45⎼50 years (60⎼65.5%). This form occurs in 69% or more of skin cancers. In 80⎼96% of cases it is localized in the skin of the face or head, as well as on the anterior surface of the chest and the skin of the upper extremities. Most often, the tumor occurs in people with fair skin (types I and II). The tumor grows slowly, does not affect regional lymph nodes, rarely metastasizes, local invasive growth and destructive nature are typical, and does not have infiltrative growth.

There are several clinical variants of basal cell carcinoma, these include:

• nodular;
• pigmented;
• superficial spreading;
• scleroderma-like;
• micronodular basal cell carcinoma.

Most often, skin cancer develops from the surface epithelium, much less often from skin appendages. Skin cancer can develop not only from precancerous lesions, but also on completely normal skin. Such forms are prognostically more favorable than those developing from precancerous conditions.

Diagnostics

Diagnostic criteria : description of reliable signs of the disease depending on the severity of the process.
Complaints: the appearance and gradual growth of skin tumors.

Diagnostic measures:

• examination of the skin and lesion, including optical enhancement methods (if necessary);
• palpation examination of the skin in the area of tumor localization;
• palpation of regional lymph nodes;
• in the absence of convincing clinical and cytological data, an incisional (at the border with healthy tissues) or excisional (for small tumors) tumor biopsy is performed;
• in the presence of enlarged regional lymph nodes, a fine-needle puncture (aspiration) biopsy is performed.

Laboratory research

There may be no changes in laboratory parameters for a long time. As the disease progresses (disintegration), an increase in ESR and the appearance of leukocytosis are possible.

Treatment

The goal of treatment is to eradicate the tumor and restore normal anatomical form and function. Treatment for basal cell carcinoma depends on the size and location of the tumor, its histological type, and the patient's concerns.

Clinical case

Patient K., 74 years old, came to the hospital about 1.5 years ago with complaints of a formation in the lower eyelid of the right eye. According to the patient, the formation appeared about 8-9 months ago, gradually increased in size, and an ulcer appeared on the surface of the formation ( photo 1 ).

Patient management protocol

Clinical picture: In the central part of the lower eyelid of the right eye, grouped nodules of flesh-pink color with a pearlescent tint are revealed; on their surface, tree-like dilated vessels and dense nodules sitting on a wide base are clearly visible.

If there is an injury while wiping the face with a towel, the integrity of the nodule is disrupted and it bleeds slightly. The bleeding quickly stops, leaving a scab on the tubercle. The scab falls off and the nodule regains its previous appearance. However, sooner or later the nodule in the center ulcerates. The ulcer is flat, oval in shape, its bottom is red, smooth, covered with a small amount of serous fluid.

Subsequently, the ulcer increases in size, deepens, and its bottom becomes uneven. The ulcer may scar on one edge and progress towards the other edge.

On palpation ⎼ regional lymph nodes are not enlarged.

This type of tumor does not give metastasis, and its involvement in malignant tumors is determined only by the infiltrative nature of growth, slow and steady, allowing it to spread over time into the orbital cavity and neighboring areas of facial skin.

Conclusion: basal cell carcinoma of the lower eyelid margin?

Cytological examination: the presence of small hyperchromic cells located in the form of dense tissue shreds. Along the edges of the clusters, the cells are polygonal, sometimes with short processes. The nuclei occupy almost the entire cell, are located centrally in it, are polymorphic, have uneven contours, hyperchromic and diffusely colored, the nucleoli are not distinguishable. The cytoplasm of the cells is scanty and inhomogeneous, intensely basophilic in color.

Conclusion: basal cell carcinoma, superficial spreading form, of the lower eyelid of the right eye.

Recommendations: combination therapy - tumor removal using radio wave radiation in fulguration mode, followed by application of liquid nitrogen.

conclusions

• Treatment of basal cell carcinoma in such a localization is a complex problem, since treatment methods often lead to gross scar changes, disruption of the shape and oval of the eyelid, and ectropion.
• The recommended therapy was chosen taking into account the patient's age and insufficient financial resources.
• Without treatment, basal cell carcinoma persists, enlarges, ulcerates and invades, and destroys surrounding structures.
• In large lesions, areas of spontaneous healing with scarring may appear. With inadequate treatment, basal cell carcinoma recurs, often under areas of scarring, which leads to its late detection. In patients with one basal cell carcinoma, the annual risk of developing another lesion is 5–8%.
• Non-drug treatment:
• Avoiding prolonged exposure to direct sunlight;
• Use of sunscreens.
• observation by an oncologist at the place of residence (examination of the area of the removed tumor, palpation of peripheral lymph nodes) once every 3 months ⎼ during the 1st year of observation; Once every 6 months ⎼ in the 2nd year of observation and once a year ⎼ in the 3rd year.

First published: "Les Nouvells Esthetiques Ukraine" 2/2016