Common eyelid malignancies by dfsiopmhy6


									Clinical                                               Kenneth CS Fong MA, MRCOphth and Raman Malhotra FRCOphth

      Common eyelid malignancies
      Clinical features and management options
             yelid malignancies are common, with approximately 10% of all

      E      skin cancers occurring in the eyelid region1. Many are induced
             by sun exposure or develop from sun-related benign lesions.

     Incidence studies1 indicate that basal cell      lateral canthus (5%)1. Medial or lateral
     carcinoma (BCC) is the most frequent             canthal BCC are more likely to invade the
     malignant eyelid tumour (14.35 cases per         orbit due to incomplete excision of the
     100,000 individuals per year), followed by       deep component. Extra care should be
     squamous cell carcinoma (SCC) (1.37              taken with the management of BCC in this
     cases per 100,000 individuals per year),         area2.
     sebaceous gland carcinoma (SGC) and                  This tumour may be classified based on                                               Figure 1
     malignant melanoma (0.08 cases per               three distinct histological patterns4 –                       A nodular BCC of the lower eyelid
     100,000 individuals per year). Although          nodular, superficial or infiltrative.                        showing signs of ulceration, pearly
     most eyelid tumours rarely metastasise,                                                                       architecture, loss of normal tissue
     they can be very destructive locally. This       Nodular BCC                                                  architecture and loss of eyelashes
     article reviews the clinical features and        Nodular BCC accounts for 75% of all
     up-to-date management of common eyelid           cases. It typically presents as a shiny, pearly
     malignancies, the main principles of             and telangiectatic nodule (Figure 2). As
     which are detailed in Table 1.                   the lesion enlarges, the pearliness becomes
         It is essential to be aware of the           more evident and dilated capillaries may
     characteristics that are suggestive of eyelid    be seen across the surface. Recurrent
     malignancy. These include development of         ulceration and bleeding is common due to
     a new lesion or a change in size, shape,         necrosis of the tumour centrally. This leads
     colour or surface character of an existing       to central umbilication of the lesion, with
     lesion. The lesion may have poorly defined       a raised and rolled border. The lesion may
     borders and be painless, bleed easily and        become darkly pigmented (Figure 3) and
     ulcerate (Figure 1). It is usually not freely    may be confused for melanoma. Nodular
     mobile and grows progressively. Normal           BCCs progressively enlarge over months to                                                Figure 2
     eyelid architecture, e.g. eyelashes, may be      years.                                                      Nodular BCC presenting as a pearly
     destroyed.                                                                                              telangiectatic nodule on the lower eyelid
                                                      Superficial BCC
     Basal cell carcinoma (BCC)                       This usually presents as a bright pink,
     BCC is a malignant tumour derived from           shiny and well-defined erythematous
     the cells of the basal layer of the              lesion. Stretching the lesion highlights the
     epidermis. If the centre of the tumour           shiny surface and may reveal pearly rims
     becomes necrotic due to insufficient blood       distributed throughout the lesion. These
     supply, it may slough and bleed. This            lesions are sometimes itchy. Many
     usually brings the lesion to the attention       superficial BCCs will progressively enlarge
     of the patient. Although metastasis is rare,     over months. This type of BCC has a
     local invasion is common. This is the most       multifocal pattern of dermal extension,
     common eyelid malignancy and comprises           which makes it difficult for clinicians to be
     90% of all eyelid malignancies2. UV light        sure of complete excision. This makes
     exposure is one of the most important risk       microscopic monitoring of the margins of
     factors, especially in fair-skinned              excision crucial to ensure complete
     individuals of middle age. BCC in men            excision. Even then, complete excision
     and women less than 35 years of age tends        cannot be assumed despite apparent
     to exhibit more aggressive growth3.              histological clearance, due to its multifocal
         BCCs occur most frequently on the            pattern of spread. Superficial BCCs are                                                  Figure 3
     lower eyelid (50%) followed by the medial        often misdiagnosed as solar keratoses,                       A large pigmented BCC of the lower
     canthus (30%), upper eyelid (15%) and            eczema or psoriasis.                                       lid causing a lower lid ectropion. This
                                                                                                                        may be confused for melanoma
                                                                                              Table 1
                                                      Principles of management of eyelid malignancies   Infiltrative BCC
                                                                                                        This type of BCC tends to be detected late
      • Awareness of the clinical features of each type of malignancy
                                                                                                        due to its subtle appearance initially, and
      • Good documentation of the local extent of the lesion, including photography
                                                                                                        is likely to be deeply invasive as well as
      • Confirmation of the diagnosis by histopathology before committing the patient to a major
                                                                                                        having sub-clinical extension. It looks like
        excision or reconstructive procedures
                                                                                                        a pale scar, is frequently asymptomatic and
      • Minimise the risk of recurrence by achieving complete excision, yet preserve normal adjacent
                                                                                                        can be difficult to detect clinically.
        tissue. The current medical literature supports the use of margin-controlled excision with
                                                                                                        Infiltrative BCCs have an aggressive growth
        close communication with the pathologist to choose the appropriate histological sectioning
                                                                                                        pattern and are associated with significant
                                                                                                        tissue destruction. Palpation can reveal

     30 | November 18 | 2005 OT

firm induration, which may extend more
widely and deeply than is evident on
inspection. This BCC is often undetected
for many years and may reach a large size
deep beneath the epidermis before
treatment is given.

Treatment of BCC
The goal of treatment of any malignant
eyelid lesion is the complete removal of
tumour cells, with preservation of the
unaffected eyelid and periorbital tissues.
Although non-surgical treatments such as
cryotherapy, radiation and laser therapy
are advocated as treatment options,                                                        Figure 4                                            Figure 5
surgical excision is generally accepted as                 Superficial BCC of the lower lid with           Infiltrative BCC of lower eyelid with faint
the treatment of choice for the removal of                            pink and shiny patches on                   indurations and loss of lashes along
BCCs5. Some BCCs, especially the                                                   the lower lid                                      the lower eyelid
infiltrative type, may extend far beyond the
area that is clinically apparent. Therefore,                                                                                           Step 4:
histological monitoring, that is to say,                          Step 1: Remove all visible tumour                                    Second layer
microscopic examination of the tumour                             Step 2: Remove first layer                                           taken at sight of
                                                                                                                                       residual tumour
margins by a pathologist before
reconstruction, is essential.
                                                                                                                                       Step 5:
                                                                  Step 3: Map first layer with                                         Map second layer
                                                                          residual tumour                                              with residual
There are various methods of excising BCC                                                                                              tumour
of the eyelids. Mohs’ micrographic surgery
(MMS), or surgical excision with frozen-                                                   Figure 6                                            Figure 7
section control, are two of the more                Steps in MMS. The top image is a side view        Steps in MMS. This figure describes the second
popular techniques available.                      while the bottom image is a superior view of         level of the procedure, i.e. further excision is
    Mohs’ micrographic surgery6 has set a                                        the procedure              being carried out after initial histological
new paradigm in the treatment of eyelid                                                                        examination showed residual tumour at
malignancies. It offers the highest cure rate    extent of reconstruction required.                                                     particular sites
with the most effective preservation of              MMS has limited use once the tumour
                                                                                                                                        Step 6:
normal tissue. The literature suggests an        has extended into orbital fat and bone.                                                Third layer
overall five-year cure rate of 98% to 100%       Hence, it is only useful for skin extension.                                           taken at sight of
for primary BCC and 93% for recurrent            Another disadvantage is that it is time-                                               residual tumour
BCC after MMS7-9. Tissue is excised in           consuming and expensive. MMS requires
layers, which provide a three-dimensional        the close collaboration of a trained Mohs’                                             Step 7:
                                                                                                                                        Map of third
map of the excised tumour (Figures 6             surgeon, dermatopathologist and                                                        layer tumour
to 8). These layers are usually processed as     reconstructive surgeon. It is not widely                                               free
frozen sections and viewed under the             available and patients may have to travel
microscope. Any areas of residual tumour         far between two centres for excision and                                                      Figure 8
are identified and the map is used to direct     reconstructive surgery.                              Steps in MMS. This figure shows that complete
additional tumour excision10. Once the               When performed by a collaborative                     clearance is confirmed histologically after
whole tumour is excised, the resulting           surgeon-pathologist team, the results of             further layers of tissue is excised from sites of
defect can then be repaired by an                frozen-section control may equal those                                                residual tumour
oculoplastic surgeon at a scheduled time         from the MMS technique11. With standard
within two days.                                 frozen-section and traditional paraffin-
    MMS is particularly useful for ‘high risk’   section techniques, ‘bread-loaf’ sectioning
BCC, i.e. BCC at high risk of aggressive         of the specimen occurs. In this method,
growth and extension, incomplete excision        the pathologist normally takes three to five
and recurrence. These include infiltrative       slides of a specimen from its centre and
and superficial multi-centric type BCCs in       examines it microscopically. The
the medial or lateral canthal region, which      pathologist cannot be certain that all outer
may exhibit sub-clinical extension to the        margins are clear of tumour (Figure 9). In
orbit. One advantage of MMS is the ability       contrast, with ‘en-face’ sections such as
to examine the entire outer face of the          that used in MMS, the entire outer surface              Missed
tumour. This is not possible with standard       of excised tissue is examined histologically.           cancer
histological ‘bread-loaf’ sectioning             With frozen-section control, surgical
techniques. Also, the Mohs’ surgeon is able      reconstruction is delayed until the                                                           Figure 9
to correlate clinical and pathological           pathologist’s report is received. This means               Bread-loaf sectioning through a tumour
features of the tumour as they perform           that the patient and the surgeon may have             specimen may miss the margins where tumour
both the excision and microscopic                to wait during the theatre session for up to                                        is still present
examination of the tumour. As the Mohs’          an hour while the specimens are being
surgeon usually only excises the tumour          processed and examined in the laboratory.            Radiation therapy
and is not involved in the subsequent            The patient usually waits in the ward for            Radiation therapy is not recommended in
reconstructive surgery, objective assessment     the result and, needless to say, good                the initial treatment of eyelid BCCs,
of tumour removal is possible. Excision is       communication with the pathologist is                but may be useful as an adjunctive
not avoided or compromised by fear of the        necessary.                                           modality in combination with surgery in

                                                                                                                     31 | November 18 | 2005 OT
Clinical                                              Kenneth CS Fong MA, MRCOphth and Raman Malhotra FRCOphth

                                                      temperatures as low as -40˚C. While some         Treatment of SCC
                                                      good results have been shown14,                  The management options for SCC are
                                                      cryotherapy has similar drawbacks to             similar to those for BCC. Surgical excision
                                                      radiation therapy. Complete destruction of       of eyelid SCC is preferred to radiation
                                                      the tumour is impossible to confirm due          therapy or cryotherapy, as surgery offers
                                                      to the absence of histological tissue to         the best cure rate5. It also gives tissue
                                                      examine, and surrounding tissue damage.          diagnosis, information about the thickness
                                                      Incomplete treatment is also likely if the       of the tumour, and can confirm complete
                                                      tumour is inadequately frozen at the             excision of the tumour. MMS or excision
                                                      deepest level. If the tumour recurs, it is       with any form of margin-controlled
                                                      harder to treat as the tumour is more            excision, e.g. paraffin-section or frozen-
                                         Figure 10    spread out. Cryotherapy on its own may be        section, are the main surgical options. This
                    SCC of the upper eyelid with a    an option in patients who are too frail to       is particularly important when PNI is
                      plaque-like and scaly nature    undergo surgery or who decline surgery.          suspected so that all involved neural tissue
                                                                                                       can be identified16.
                                                      Squamous cell                                        In the largest reported series of
                                                      carcinoma (SCC)                                  periocular SCC treated with MMS (79
                                                      SCC is a malignant tumour of the                 patients), the Australian Mohs Database17
                                                      squamous layer of the epidermis. It is the       found a recurrence rate of 3.64% after a
                                                      second most common eyelid malignancy             mean follow-up of 6.5 years. In another
                                                      and accounts for 5-10% of periocular             series of standard surgical excision for
                                                      malignancies15. It occurs most commonly          periocular SCC with frozen en-face (rather
                                                      in fair-skinned elderly patients with a          than bread-loaf) section control,
                                                      history of chronic sun exposure and skin         Donaldson et al18 reported a recurrence
                                                      damage. SCC has a greater potential for          rate of 2.8% after a mean follow-up of 31
                                          Figure 11   metastatic spread than BCC. SCCs of the          months.
                         SCC of the medial canthus.   eyelids occur most frequently on the lower           Invasion of deep orbital tissues
             This was initially misdiagnosed as BCC   eyelid, followed in order of frequency by        frequently requires orbital exenteration
                                                      the medial canthus, upper eyelid and             and resection of regional lymph nodes,
                                                      lateral canthus15.                               combined with radiotherapy and
                                                          SCC is difficult to diagnose clinically as   chemotherapy for cure.
                                                      it has no pathognomonic features, which
                                                      allow its differentiation from other skin        Sebaceous gland
                                                      conditions. A biopsy is therefore critical to    carcinoma (SGC)
                                                      establish its diagnosis. SCCs often appear       SGC is a highly malignant tumour that
                                                      as painless nodular or plaque-like lesions       arises from the meibomian glands, glands
                                                      with irregular rolled edges, chronic scaling,    of Zeiss and the sebaceous glands of the
                                                      fissuring of the skin and central ulceration     caruncle and eyebrow. This tumour has a
                                         Figure 12    (Figures 10 and 11). Surface crusting is         high recurrence rate, significant metastatic
           SGC of the upper eyelid showing diffuse    common due to the propensity for SCCs            potential and a five-year mortality rate as
                    thickening of the upper eyelid    to produce keratin. SCC can arise on its         high as 30%19. SGC is ‘the great
                                                      own or from a pre-existing lesion like solar     masquerader’ and is often misdiagnosed
     the treatment of recurrent or advanced           keratoses.                                       initially as recurrent chalazion, chronic
     lesions. A recurrence rate of 16% after a            Immunosuppresion for organ                   blepharitis and unilateral
     mean follow-up time of 5.3 years was             transplantation strongly predisposes to          blepharoconjunctivitis20. It can also mimic
     noted in one series after radiation therapy      SCC that is more aggressive. Advanced            other disease processes like BCC, SCC or
     for medial canthal BCCs12. Surgical              cases of eyelid SCC may be associated with       ocular cicatricial pemphigoid both
     management in recurrent lesions that have        metastasis to preauricular and sub-              clinically and histologically. It is therefore
     been treated by radiation treatment is very      mandibular lymph nodes, and carries a            notorious for having a delay in diagnosis.
     difficult, as the tumour margins can be          more guarded prognosis. The malignant                SGC tends to affect females (73%)
     hard to identify both clinically and             potential of SCC depends on several              older than 60 years of age21, although it
     histologically. More importantly, tissue is      factors, including differentiation, degree of    may occur in younger patients with a
     damaged and made ischaemic. Tumours              atypia, and depth of invasion15.                 history of radiation exposure22. It is the
     that recur, tend to do so within five years          Perineural invasion16 (PNI) describes        third most common eyelid tumour and
     and are considered to be more spread out         tumour growth in or around a nerve, and          accounts for 1-5% of all eyelid
     and aggressive in invasion12. Subsequent         is associated with large SCCs. PNI is            malignancies19. Some studies suggest that
     surgery is often complicated by wound            associated with increased aggressiveness,        it may be more a common eyelid tumour
     breakdown and poor healing.                      sub-clinical extension and a propensity for      in Asians, for example in India23 and
     Complications of radiation treatment             recurrence among cutaneous malignancies.         China24. SGC is most commonly found in
     include skin atrophy and necrosis, loss of       A high index of suspicion is needed to           the upper eyelid (75%), followed in order
     eyelashes, cicatricial entropion and             diagnose PNI, as it is often asymptomatic        of frequency by the lower eyelid (22%),
     ectropion, corneal ulceration and cataract.      with no obvious clinical signs. Symptoms         the bulbar conjunctiva and the caruncle21.
                                                      of facial pain, anaesthesia or paraesthesia,     This is not surprising, as the meibomian
     Cryotherapy                                      such as tingling, burning or shooting            glands are more abundant in the upper
     While cryotherapy is often used to treat         pains, often present late in the course of       eyelid. It is wise to consider any suspected
     BCCs outside the eyelid area, it is              the disease. The pain associated with PNI        tumour in the upper eyelid to be SGC
     considered to have a limited role for eyelid     gradually increases with severity as the         until proven otherwise.
     BCCs as it is associated with a higher           tumour exerts increasing pressure on the             SGC usually presents with diffuse eyelid
     recurrence rate than surgery13. Cyrotherapy      involved nerve. Numbness along the               thickening (Figure 12) associated with
     is carried out using either a probe or spray.    course of a nerve is also highly suggestive      inflammation in 60% of cases, or as a
     Liquid nitrogen is used to freeze tissue to      of PNI.                                          distinct eyelid nodule or mass in 40% of

     32 | November 18 | 2005 OT

cases21. There is destruction of the posterior    patients not willing to undergo radical
lamella architecture of the eyelid. Eyelash       surgery, such as exenteration. Radiotherapy
follicles are often destroyed as the tumour       and electron beam therapy are ineffective
infiltrates the eyelid leading to madarosis.      and recurrences are common after such
The tumour may appear yellow due to its           treatment29. This form of treatment should
fat content. SGC can be ‘multi-concentric’        be considered palliative and only offered
and involve multiple areas in the upper           to patients unwilling or unable to undergo
and lower eyelid19. Rarely, the tumour may        surgery.
affect the lacrimal apparatus and this is             Due to the high recurrence rate of
presumed to be either due to spread of the        this tumour, patients require long-term
tumour by tears, ‘oncorrhoea’19, or due to        follow-up.
diffuse pagetoid conjunctival spread.
    Prior to the 1980s, patients with SGC         Malignant melanoma
had a poor prognosis due to delayed               Cutaneous malignant melanoma is due to                                            Figure 13
diagnosis and non-margin controlled               malignant proliferation of melanocytes                      Conjunctival map biopsy in SGC
excision. This has improved significantly         accounting for only 1% of malignant
since then and in the largest series              eyelid tumours, but it is the leading cause
reported from a single centre, Shields et al21    of death from primary skin tumours5. Risk
found a local recurrence rate of 18%,             factors for developing malignant
metastatic rate of 8%, and metastatic death       melanoma include excessive sun exposure,
rate of 6% in 60 patients with a mean             Caucasian race and an age greater than 20
follow-up time of 41 months. Orbital              years. Malignant melanoma is 12 times
invasion occurs in 6-45% of cases and is          more common in Caucasians than in
associated with a poorer prognosis21,25.          Afro-Caribbeans. In contrast to BCC, a
                                                  history of severe sunburns, rather than
Treatment of SGC                                  cumulative sun exposure, is thought to be
The management of this highly malignant           a major risk factor for developing
tumour is multi-disciplinary, with the            malignant melanoma30.
involvement of head and neck oncologists              The common forms of melanoma in
in order to identify and manage the extent        the eyelid region are lentigo maligna                                             Figure 14
of systemic disease. There must be a high         (LM), lentigo maligna melanoma (LMM)               Lentigo malignant melanoma of the eyelid
index of suspicion to diagnose SGC, and           (Figure 14) and nodular melanoma
full thickness rather than shave or punch         (Figure 15). Recent papers31 suggest that
eyelid biopsies should be taken to confirm        LMM is the most common form in
the diagnosis. The biopsy specimen must           contrast to earlier papers32, which stated
include fresh tissue for the pathologist to       that nodular melanoma was the most
stain, especially for fat, due to the fact that   common eyelid melanoma. LMM of the
fat is lost in conventional paraffin-sections.    eyelid region is thought to be
Any detected lymph node swelling requires         underdiagnosed because it occurs
biopsy and if positive, radical neck              primarily in the elderly, is often not
dissection may be required.                       recognised and probably passed off as
    Conjunctival map biopsy26 (Figure 13)         ‘age-spots’ by ophthalmologists31.
combined with MMS or excision with                Furthermore, in the absence of a nodule,
frozen-section or paraffin-section control        LMM is clinically indistinguishable from                                         Figure 15
is the recommended treatment for eyelid           the non-invasive LM.                                        Nodular melanoma of the eyelid
SGC5. Conjunctival map biopsy helps                   Nodular melanoma typically has a dark
exclude diffuse conjunctival ‘pagetoid’           colour, irregular surface and irregular       horizontal growth phase, in which the
intraepithelial spread. This helps delineate      outline. It may rapidly increase in size      pigmentation extends for up to many
the true extent of the lesion and leads to a      with bleeding and ulceration. The clinical    centimetres in diameter and lasts for many
more accurate amount of full-thickness            features of melanoma can be easily            years. There may be spontaneous
eyelid and conjunctival resection. Patients       remembered by the mneumonic ‘ABCD’,           regression of the lesion with alteration in
with diffuse conjunctival involvement may         which stands for: Asymmetry, irregular        pigmentation. Surface elevation or nodule
require orbital exenteration in order to          Borders, irregular Colour and Diameter of     formation heralds malignant
achieve local control.                            more than 6mm33. Nodular melanomas            transformation in LM. The lower eyelids
    When resecting the lesion, a wide-            developing at the mucocutaneous junction      and medial canthus are most commonly
margin of excision (5mm) is usually               of the eyelid appear to carry a worse         involved32.
applied due to the possibility of skip-           prognosis. This may be due to the                The prognosis and metastatic potential
lesion spread at the edge of the tumour.          presence of efferent blood vessels and        of melanomas are related to the depth of
Rushed-paraffin (permanent) sections are          lymphatic drainage at the eyelid margin,      invasion and thickness of the tumour. Two
preferred to frozen-sections as the               together with repeated minor trauma           methods are generally used to express the
detection of SGC in frozen-sections is            caused by blinking. The five-year mortality   depth of invasion of malignant melanoma.
often difficult. Topical mitomycin-C              rate for this type of eyelid melanoma has     Clark et al35 developed prognostic criteria
0.04%, applied four times daily for three         been reported to be 16.7%32.                  by dividing the depth of invasion into five
one-week cycles, is an emerging adjunctive            LM is a very slowly progressive,          anatomic levels. Breslow36 developed a
therapy that may help improve local               irregular pigmented macule commonly           quantitative method that measures the
control and reduce the risk of potential          found on the face of sun-damaged elderly      depth of invasion in millimetres. Patients
spread into the lacrimal system27.                patients. LM is considered to be pre-         with tumour thickness less than 0.75mm
    Adjunctive cryotherapy28 can be used to       invasive melanoma-in-situ, and it is          thick have a 100% five-year survival rate,
treat patients with residual conjunctival         estimated that the lifetime risk of           while tumours thicker than 3mm have a
disease but because of its many damaging          developing invasive LMM for a 45-year old     poor prognosis. There is a non-linear
side effects, it should only be reserved for      with LM is 4.7%34. LM may have a long         relationship between depth of invasion

                                                                                                              33 | November 18 | 2005 OT
Clinical                                               Kenneth CS Fong MA, MRCOphth and Raman Malhotra FRCOphth

     and survival for tumours between 0.75mm           especially in the periphery of the             lymph node dissection49 or sentinel lymph
     and 3mm36. Malignant melanomas                    melanoma, difficult40. Furthermore, vertical   node (SLN) biopsy and lymph node
     involving the eyelid margin have a poorer         sections through the tumour, rather than       mapping50,51. SLN biopsy has emerged as a
     prognosis and this is attributed to               sole peripheral en-face sections, are          technique for early detection of
     conjunctival involvement37.                       recommended for melanoma in order to           microscopic metastases in regional lymph
                                                       determine thickness and spread of              nodes. This could then direct further
     Treatment of                                      invasion, as well as pattern of melanocytic    radical lymph node dissection and
     malignant melanoma                                spread towards the periphery. Rush             adjuvant therapy in patients with such
     The management of malignant melanoma              processing of paraffin-embedded sections       metastases. However, there is no
     is multi-disciplinary, as it has a high rate      in combination with MMS has emerged as         convincing evidence to date to suggest that
     of systemic metastases. The involvement of        a viable treatment option for both LM and      the use of SLN biopsy or radical lymph
     a clinical oncologist is essential both to        LMM43. These mapped serial excision            node dissection improves the survival of
     help exclude systemic spread and for long-        (MSE) techniques combine the margin            patients with eyelid melanomas. Lastly,
     term follow-up. A biopsy of any suspected         control and tissue conservation achieved       SLN has is not indicated in the
     melanoma lesion is essential to confirm           with MMS, with the high-quality                management of thin melanomas (1mm
     the diagnosis, as well as to determine the        histopathologic tissue features of paraffin    thickness or less) which tends to be the
     thickness of the tumour. This can be done         sections. Reported cure rates for this         most common type of malignant
     with either an incisional or punch biopsy         variation in MMS are between 97% and           melanoma in the eyelid region.
     method. Biopsies should be taken at               100% with a mean follow-up of two to five         There is no clear evidence as to the
     several sites within the lesion primarily         years43-45.                                    ideal adjuvant therapy for use in
     directed towards raised, darker and more             A major controversy in the treatment of     conjunction with surgery, but currently
     central areas.                                    cutaneous melanoma is the required             available adjuvant therapies include
         The use of a Wood’s light38 is useful in      surgical margin for complete excision.         immunotherapy with melanoma vaccines
     determining the potential extent of the           Current standards are based on consensus       or monoclonal antibodies, interleukin-2,
     melanoma beyond that which is apparent            decision46 and prospective surgical trials     dacarbazine, and interferon alfa-2b
     clinically. The Wood’s light generates a          recommend that in-situ melanoma be             therapy52.
     long wavelength ultraviolet light that            excised with 5mm margins. Invasive
     causes collagen in the dermis layer of the        melanomas that are less than 1mm in            Key summary points
     skin to fluoresce. When the Wood’s light is       Breslow thickness should be excised with       • BCC is the most common eyelid
     illuminated over a heavily melanised              1cm surgical margins, and melanomas that         malignancy. Morphoeic BCCs look like
     epidermis, for example in melanoma,               are between 1mm and 2mm thick should             a scar and tend to be deeply invasive
     most of its output is absorbed, while the         be excised with margins of 3cm47.              • SCC is difficult to diagnose clinically
     less darkly pigmented adjacent skin               However, recommendations for surgical            and often arises in areas of chronic sun
     scatters and reflects light as usual, resulting   margins for all cutaneous sites do not           exposure. Be suspicious of new and
     in enhanced contrasts at the border zone          apply to the eyelid and periocular skin, as      tender erythematous lesions that show
     between areas of differing melanisation.          these sites were excluded in the studies,        hyperkeratosis
     Variations in epidermal pigmentation thus         whose results these recommendations are        • Mohs’ micrographic surgery is the
     become more apparent under Wood’s light           based upon. The routine use of 1-3cm             treatment of choice in the excision of
     than under ordinary room light.                   margins on this area would yield                 BCCs and SCCs
         A variety of methods have been used in        unnecessarily large surgical defects, and is   • SGC is a clinical and pathological
     the management of LM and LMM,                     considered to have no influence on               ‘masquerader’. Be suspicious of SGC in
     including surgical excision as well as            mortality in relation to more conservative       patients with chronic unilateral
     destructive techniques such as cryotherapy,       margins.                                         blepharoconjunctivitis, recurrent
     radiotherapy, topical treatment with                 Furthermore, there is less evidence           unilateral chalazion or any suspected
     azelaic acid, and curettage                       available for the ideal management of            tumour of the upper eyelid
     electrodesiccation39. The destructive             nodular melanoma of the eyelid. There is       • Malignant melanoma is rare but has a
     techniques may spare deep periadnexal             currently no agreement among specialists         poor prognosis – two thirds of deaths
     melanocytes and are associated with high          about the margins of excision, but thicker       from skin cancer are due to melanoma
     rates of tumour recurrence40. Surgical            melanomas appear to do badly in terms of       • The management of SGC and
     excision has the advantages of treating           local recurrence, regardless of the size of      malignant melanoma must involve
     these deep periadnexal melanocytes,               the excision margins48. In practice, the         other disciplines, like head and neck
     detecting unsuspecting invasive                   most tissue-conserving approach is to use        oncology, as both tumours have a
     melanoma, and permitting histological             margin-controlled MSE techniques with            significant rate of systemic metastases
     assessment of the margins for atypical            5mm initial margins and paraffin-              • Conjunctival map biopsies combined
     melanocytes beyond the clinically                 embedded vertical tissue-sections                with MMS is recommended for surgical
     apparent borders41. Excision with 5-10mm          examined by a dermato-pathologist to             excision of SGC. Orbital exenteration
     margins is reported to have a local control       ensure adequate clearance before eyelid          may be necessary in cases with diffuse
     rate of approximately 90%42.                      reconstruction is considered.                    conjunctival involvement
         Conventional MMS using frozen-                   Melanoma of the eyelid is thought to        • Surgical excision of eyelid melanoma
     sections may not be the best method of            metastasise to the regional lymph nodes in       should be performed by mapped serial
     detecting melanoma invasion, as freeze            a third of patients48. If there is any           excision techniques with permanent
     artifact and frozen-section tissue                suspicion of metastatic spread of the            tissue-section control to detect sub-
     morphologic changes can make                      tumour, primary excision of the melanoma         clinical disease
     identification of atypical melanocytes,           could be combined with prophylactic
                                                                                                      About the authors
                                                                                                      Kenneth Fong is Specialist Registrar and
                                           Remember...Remember                                        Raman Malhotra is Consultant
                                                                                                      Ophthalmologist and Oculoplastic
                                          Join now in the OT contact lens fitting                     Surgeon at the Corneo-plastic Unit,
                                             today series Phone 01252-816266                          Queen Victoria Hospital, East Grinstead,

     34 | November 18 | 2005 OT

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