Lids: Lumps to Watch For

“Hmm,” I say, noting a patch of redness on my patient’s lower eyelid margin. The irregularity is fairly subtle, with no well-defined swelling of a chalazion to be seen.

“It’s been there for a year or two,” my patient says, “and it just keeps flaring up. I tried everything: heat, massage, ointment, antibiotics… I’m ready to have it out!”

“Sure,” I say, noting the small gap in his lashes, “I’ll take a look.”

On the slit lamp, a short length of the lower eyelid, measuring a couple of millimetres at most, looks eroded. The area is not big enough to show obvious rolled edges or pearly telangiectasia. What I can appreciate is a change in the lash growth—there are not as many lashes as there should be.

In a busy clinic, spotting a lid lesion like this can make a difference. Treatment is less invasive when the basal cell carcinoma (BCC) is still at a paltry few millimetres, before the inexorable growth spreads further along the eyelid and leads to a technically challenging subsequent reconstruction. A ‘rodent ulcer’ is an apt term for these skin lesions, as they can nibble along the lid at the normal adnexal structures, most obviously causing madarosis on the lid margin.

Basal cell carcinoma is the most common skin cancer, and about 20% of these appear on the eyelids. Clinical features vary, and classification is useful as different subtypes may be more or less aggressive in their clinical behaviour and risk recurrence, which is overall about 5%.

Nodular BCC is the most common subtype and features classic rolled borders, often with a central eroded space. Superficial spreading BCC is flatter in comparison and can appear red and ulcerated. Both superficial spreading and nodular BCC have a more benign clinical course and have a lower risk of recurrence. In comparison, infiltrative BCC can be more difficult to recognise, resembling a scar, and the margins can be challenging to define clinically. Recurrence risk and risk of invasion to adjacent structures, including the orbit or paranasal sinuses, are higher.

What did I do for my patient? In my clinic, I am fortunate to work with Michelle Walsh, an excellent oculoplastic nurse, who is happy incising and draining cysts and taking biopsies of more suspicious lid lumps. We usually use a 3- or 4-mm punch, under subcutaneous anaesthetic such as lidocaine with adrenaline. Patients go home with a double pad for a couple of hours, and we usually receive our histology result within a week or so. I would biopsy every case, even if the diagnosis seems clinically obvious, as surprises arise. Occasionally, I have seen a benign lid margin cyst associated with madarosis, or conversely, a BCC that looks little more than a patch of meibomian gland dysfunction.

Once BCC is confirmed, treatment can be planned. Usually, this involves complete surgical excision. Issues arise in equity of access to some of the most useful, effective ways of managing periocular BCC. Particularly for invasive BCC that has entered the orbit, there can be limited access to Mohs surgery and to the small-molecule inhibitor vismodegib.

Risk of BCC recurrence is lowest—and the excised tissue can be limited to the tumour as much as possible—when a margin-controlled excision can be completed. Margin control is a process through which the edges of the excised tissue can be examined before lid reconstruction. In my hospital, we are fortunate to have access to a Mohs micrographic surgery service. Mohs surgeons, typically dermatologists who have undergone subspecialty fellowship training, excise the BCC. They evaluate all margins of the excised tumour for any signs of remaining neoplastic cells. There are alternatives, including frozen-section margin control or fast paraffin-embedded sections, though Mohs is generally considered the gold standard.

Once a BCC invades the orbit, it is not amenable to simple excision and reconstruction, and clearance would require orbital exenteration—a disfiguring procedure that can be used as a last measure to reduce intracranial extension risk. Ideally, treatment with vismodegib can shrink BCC and obviate the need for exenteration.

This is the first in a series of columns discussing eyelid conditions.

Clare Quigley MD is a Consultant Eye Surgeon in private practice in Progressive Vision and in public practice in the Royal Victoria Eye and Ear Hospital and St James’s Hospital, Dublin, Ireland.