Basal cell carcinoma of the eyelid skin is also known as a BCC, or rodent ulcer.
The important thing to remember is that these cancers do not spread to other body sites, and so if the tumor is destroyed, then you can be virtually certain that you are cured.
The treatment options which are available to you include:
1. Surgery. I remove the tumour with a margin of healthy tissue on either side. The pathologist will check that removal is complete.
2. Moh’s surgery. I refer you to a specially trained dermatologist. Tumour removal is checked with the microscope throughout the procedure. The procedure is time-consuming and you will have to return to me for subsequent treatment, so it is reserved for tumours in difficult locations, or recurrent tumours.
3. Radiation therapy. This may be necessary after surgery when it has not been possible to remove the whole tumour mass. It is also useful if you are not fit for surgery.
4. Crotherapy (freezing treatment). This is occasionally useful with very small tumours.
Whichever mode of treatment we decide on, after we discuss your particular situation, there is a small risk of the tumour coming back, so I shall ask you to attend my outpatient clinic for a period of five years for monitoring.
MALIGNANT MELANOMA
This tumour is common in fair-skinned individuals exposed to sunlight. It may arise de novo or in a pre-existing naevus (mole). The signs that a naevus is undergoing malignant change are growth in size, change in shape, change in pigmentation, bleeding or ulceration. Melanoma often undergoes a phase of intra-epidermal growth before invading the dermis. This phase may last many years in lentigo maligna but is only a few months in superficial spreading melanoma. In these conditions, the development of nodules correlates with deep invasion. Nodular melanoma is the most aggressive variant and often arises in healthy skin.
In all forms, the prognosis relates inversely to the depth of invasion of the dermis in mm. Cryotherapy may be used in lentigo maligna. Surgical excision is the treatment of choice in more aggressive forms, and chemotherapy has a developing role in metastatic disease.
SQUAMOUS CARCINOMA
These present as rapidly-growing ulcerated nodules or as hyperkeratotic papules. They spread locally into the orbit, and by lymphatic spread to the submandibular and pre-auricular nodes. They can be graded histologically according to their degree of differentiation. The usual cause is ultraviolet light, and rarer causes are radiation, arsenic ingestion (Bowen's disease) and xeroderma pigmentosum, an autosomal recessive fault in DNA repair mechanisms.
The fact that you have developed a skin tumour means that you have vulnerable skin and are prone to this condition. You should, therefore, be on the lookout for tumours in other skin sites, so that these can be treated at an early stage. If you do notice anything suspicious on any area of your skin then please mention this to me so that I can arrange referral for you.
The main factor in the development of skin tumours is exposure to sunlight. You should take steps to protect yourself from further exposure.
1. Stay indoors in bright conditions, particularly around noon (mad dogs and Englishmen…!)
2. Wear a long-sleeved shirt, long pants and a wide-brimmed hat when outdoors.
3. Avoid sunbeds.
4. Wear good quality sunscreen with a high sun protection factor on exposed skin sites.
EYELID RECONSTRUCTION
Eyelid reconstruction is necessary after all or part of the eyelid has been removed.
The eyelid may have been removed for tumour or occasionally as a result of injury or burns.
The techniques for eyelid reconstruction depend on your age and skin type, the size of the area to be repaired and whether it is the upper or the lower eyelid which is affected.
In all cases there are two layers to be repaired.
On the back surface of the lid there must be a smooth, moist surface to slide over and protect the eye. Suitable materials include conjunctiva from the same or opposite eye, the lining of the cheek inside the mouth, the hard palate from the roof of the mouth, or the lining and cartilage from the septum of the nose.
On the front surface of the lid, skin cover must be provided either in the form of a local flap or as a graft from a distant body site. Skin flaps are commonly swung into place from one of the other eyelids, the cheek, the forehead or the side of the nose. The common sites for skin grafts are behind or in front of the ear, one of the other eyelids, the region above the collar bone and the inner arm.
In some cases the reconstruction can be accomplished as a single procedure. All that will be necessary afterwards is wound care, removal of sutures, and follow-up for the original problem.
In other cases the procedure may be divided into two stages, particularly when a flap has to be divided. You will be given a date for the second stage at your fist post -op visit. This will generally be after six weeks to allow the graft to “take”.
It is not always possible to determine the best procedure for your reconstruction until you are under anaesthetic, so when you consent to lid reconstruction you are consenting to the removal of tissue from any of the above body sites, including the mouth, the ear, the nose, the limbs and the opposite eye. You should anticipate that both eyes may be padded when you waken from anaesthesia , and that if a flap has been used you may be unable to open one eye in the period between operations.
If the tear duct is removed as part of your tumour resection then you may unfortunately be left with a watering eye.
John Pitts is an oculoplastic surgeon in full-time private
practice in London and Barbados following a substantive NHS consultant
position. He graduated MB ChB from Glasgow University in 1983 and,
in 1987, after working in pathology and neurology, he trained in ophthalmology
in Glasgow, Nottingham and London. He has travelled extensively, working
in centres of excellence in Los Angeles, New Orleans, Melbourne, Barbados,
Brunei and Vancouver. He has undertaken Fellowship training in
oculoplastics at Moorfields Eye Hospital.
