|Year : 1964 | Volume
| Issue : 4 | Page : 154-159
Observations on cancer of the eyelids
Santi Pada Das
Eye Infirmary, Medical College Hospitals, Calcutta, India
|Date of Web Publication||13-Feb-2008|
Santi Pada Das
Eye Infirmary, Medical College Hospitals, Calcutta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das SP. Observations on cancer of the eyelids. Indian J Ophthalmol 1964;12:154-9
The clinical characteristics and the histopathological picture of cancer of the eyelids are the same as those of cancer of the face. The additional features of cancer of the eyelids are: (i) excision of the tumour has to be followed by plastic repair and (ii) there may be impairment of vision which may be due either to a direct invasion of the eye by the tumour or as a complication of irradiation treatment.
Lesions which are limited upwards by the upper orbital margin, downwards by the lower orbital margin, laterally by the lateral canthus and medially by the medial canthus come within the domain of the cancer of the eyelids.
The present series of 52 cases of cancer of the eyelids was studied in the Eye Infirmary, Medical College Hospitals, Calcutta over a period of nine years from 1953 to 1961. All the cases were subjected to histopathological examinations.
Epitheliomas can be divided into two main groups-the basal cell carcinoma [Figure - 1] and the squamous cell carcinoma [Figure - 2]. Again there are subtypes. Sometimes a few tumours produce mixed pictures pathologically when they are called baso-squamous epithelioma. Basal cell-carcinoma is definitely the commonest tumour. The types we came across are as follows:[Table - 1]
The occurrence of other malignant tumours of the lids such as melanoma is comparatively very rare and no such case has been detected in the present observation.
The general character of both types of tumours-basal cell and the squamous cell carcinoma is the epidermal invasion of the corium by epithelial cells arranged into groups. There is no basement membrane. Secondary processes arise from the downward growing columns of cells. The groups of cells penetrate the adjacent lymph spaces with fibrous tissue between the groups of cells. The types of cells differ in the two cases.
Squamous cell carcinoma:-
The downward growing columns of cells in squamous cell carcinoma retain the structure of epidermis. There are cylindrical cells in the outer layer, prickle cells in the middle and squamous cells in the inner layer. Like the skin surface, the squamous cells undergo cornification and produce laminated masses that stain strongly red with eosin and are well known as cell-nests, so characteristic of squamous cell carcinoma [Figure - 3]. The mode of spread of the tumour is the lymphatic pathway. According to the lymphatic drainage, pre-auricular and submaxillary lypmh nodes are enlarged.
The downward growing columns of cells in case of basal cell cacinoma has got expanded club-shaped appearance. The cells of this tumour are basophilic and are like the basal cells of epidermis. They are all of one type. Cell-nests, cornification and prickle cells are all absent here [Figure - 4]. Lymphatic spread does not occur in this tumour and the tumour is locally malignant.
In some pathological specimens there are mixed pictures of basal and squamous cell carcinomas and are called baso-squamous epithelioma [Figure - 5].
There are very few subjective symptoms. In most of the cases the only complaint is discomfort. Pain is present only when there is sepsis or marked ulceration as was present in only one of the present series of cases.
The clinical picture is practically the same in both types of tumours. One group of patients comes with nodular tumour and the other group comes with the picture of ulcerative tumour. The early picture starts with hard, indurated nodule. As the tumour becomes bigger, the overlying skin becomes thin and ultimately a typical malignant ulcer forms. As the tumour enlarges it may pursue one of the several courses. It may grow outward producing a large fungating tumour or it may erode the entire free margin of the lid or it may spread into the orbital cavity without attaining a large size.
In the present series of cases, 41 per cent of patients came with the picture of nodular tumour and the rest 59 per cent gave the picture of ulcerative tumour.
Any person above the age of 40 years who comes with a hard nodule or a persistent indurated ulcer of the lid should be looked upon with suspicion of malignancy and a biopsy must be insisted to confirm the diagnosis. The following common conditions come within the differential diagnosis. They are: papilloma, chalazion, non-pigmented nevus, tuberculous ulcer and xanthelasma.
Adenoid Basal Cell Epitheliomas
Basal-cell epitheliomas may arise from the glandular appendages of the lids and are known as adenoid basal cell epithelioma. They formed 11 per cent of the series in the present observation. They can arise from (I) Meibomian glands, (2) sweat glands or (3) hair follicles.
Only one case of epithelioma of sweat gland was come across within the present series and no case of epithelioma of hair follicle was detected.
Fpithelioma arising from Meibomian gland:
Epithelioma from Meibomian gland is not common, but actual incidence is difficult to determine since histopathological examination is not done in every case of chalazion removed. Like epithelioma elsewhere it has an age incidence of 40 years and above. The average age in the present observations was 51 years.
The mode of onset is gradual. It starts as a small hard nodular tumour and simulates a chalazion in every way. So it is very difficult or rather impossible to diagnose until biopsy is clone. In over 50 per cent of cases they were noted after removal of a chalazion, so recurrence of a chalazion after surgical removal should lead one to think of the possibility of an epithelioma of Meibomian gland. Treatment is the same as that for epithelioma of lid. [Figure - 6],[Figure - 7].
Prognosis and Result
Cancer of the eyelids occurs in the most exposed part of the body. So it is expected that patients with such tumours will come early. But in practice this is not what usually happens. In most of our cases patients came usually after one year from the onset of the disease. Still, cancer of the eyelids is rarely a fatal disease. It is quite controlable with proper treatment even with recurrence of the tumour if the patient comes before metastasis have occured. A few of the present series of cases came to this institution with recurrence after surgical treatment elsewhere, but with adequate surgical treatment and post-operative deep X-ray therapy the patients are doing well at present. One of the patients refused post-operative deep X-ray therapy and came back with recurrence of the tumour after nearly two years. None of the patients with basal cell carcinoma in the present observation showed metastasis, but one patient with squamous cell carcinoma showed metastasis and is known to have died even after the usual treatment. The mortality in the present series of cases is therefore 1.9 per cent.
The main principles of treatment of cancer of the eyelids are (1) complete destruction of the tumour thereby attaining permanent eradication and (2) the minimum impairment of the function of the eye. There are mainly three methods of treatment : surgery, irradiation and combination of the two. Different workers received good results with different methods of treatment, but the best result was obtained with combination therapy.
The routine method of treatment adopted in the present series of cases was a combination of surgery and postoperative deep X-ray therapy. Before the operative procedure, the usual method was to determine the extent of the lesion. This can best be attained by the usual technique of grasping the tumour mass between the fingers. The actual surgical procedure is extended a few millimetres beyond the tumour mass so as to include some of the surrounding normal tissue during the operative removal. After the operation the patient is always sent to the radio-therapy department for deep X-ray therapy. Plastic repair is done wherever it is necessary and the result is then good.
| Discussion|| |
Incidence: Innocent looking tumours of the eyelids can be cancerous. In 1936 O'Brien and Braley noted malignancy in 15 out of a 100 consecutive tumours of the lids. In a series of 300 consequtive malignant tumours at Moorfields Eye Hospital, neoplasms of the lids (largely carcinoma) constituted 42%.
In the Eye Infirmary, Medical College Hospitals, Calcutta, 52 cases of Cancer of the eyelids were noted over a period of 9 years in 138 tumours of the lids.
Age: It is a disease encountered at the age of 40 years and over and is rare after the age of 80 years, although it has been noted at the age of 32 years by Birge (1938) and at 85 years by Hischfelder and Frost (1948). Any tumour of the eyelids above the age of 40 years should be looked upon with suspicion for malignancy and a biopsy is essential to confirm the diagnosis. The average age of the patients in the present series was 47.50 years, the youngest being 17 years old and the oldest 85 years.
Sex has got no special significance and either sex was about equally affected in our series---57.50 per cent. males, 42.50 per cent. females.
All cases showed a single tumour manifestation, although the very rare phenomenon of multiple independent tumours has been reported by Cochran and Robinson (1931).
Cause: Like all cancers, the cause of cancer of the eyelids is not known though it is attributed to chronic irritation. In the present observation, only 35 of the series gave history of some chronic irritative factor like trauma or exposure to irritant dust and mineral particles. It is interesting to note that the incidence of cancer of the eyelids is less common in workers who work with carcinogenic agents like tar and pitch than in ordinary men (Kennaway, 1925: Lane, 1937).
Heredity: No association with heredity was traceable in the present series.
The Lower and the upper eyelids were the commonest sites of affection in. this series. The distribution was as follows:[Table - 2]
It is very difficult or rather impossible to differentiate clinically between the basal cell carcinoma and the squamous cell carcinoma. Only biopsy will definitely differentiate the two.
Treatment: In the treatment of cancer of the eyelids, the methods that are usually practised are surgery, irradiation and a combination of the two. Each method has got advantages and disadvantages and different workers claim good results in each case. In well-advanced inoperable cases, irradiation is the only course of treatment, but in other cases surgery is preferable to irradiation as it ensures complete destruction of the tumour and thereby removes the uncertainty of permanent cure as found in irradiation. Moreover irradiation creates complications of its own, namely iridocylitis, keratitis, conjunctivitis, cataract and skin necrosis. Combination therapy has got advantage over surgery alone in that it gives the patient better certainty about the destruction of the tumour and thereby permanent cure of the disease. In surgery excision should be wide and free involving some of the surrounding healthy tissue. The few cases of recurrence that were observed in the present series were due to inadequate removal of the tumour and even these patients are doing well at present with adequate surgery and post-operative deep X-ray therapy. Plastic repair of the lid may be undertaken immediately after surgical excision or later after combined therapy, depending upon the extent of involvement of the lids.
None of the patients in the present series came in the inoperable stage. Martin in his series of cases found mortality less than 6 per cent and most of the fatalities were from metastasis of squamous cell carcinoma. Although the incidence of squamous cell carcinoma is comparatively high, in the present series of cases, combination therapy gave a very good result Giving a mortality of only 1.9 per cent.
Epithelioma arising from the Meibomian glands is not uncommon. Any recurrence of a chalazion or a chalazion above the age of 40 years should be subjected to histopathological examination for malignancy.
Summary and Conclusion:
52 cases of cancer of the eyelids were detected in the Eye Infirmary, Medical College Hospitals, Calcutta over a period of 9 years and all cases were examined histopathologically. Cancer of the eyelids is one of the common tumours of the lids. Any tumour of the eyelids, more especially if the patient is near about 40 years of age should be examined histopathologically to confirm the diagnosis. Early diagnosis and complete and wide excision with post-operative deep X-ray therapy gave a very good result in the present series of cancer of the eyelids with a mortality of only 1.9 per cent.
I am indebted to Dr. P. K. Sarkar, pathologist and to Dr. B. M. Chatterjee, Professor of Ophthalmology Eye Infirmary. Medical College Hospitals. Calcutta for all their help and guidance in publication of this paper.
| References|| |
Birge, H.L., (1938). Arch. Ophth., 20: 254.
Cochran, A. H., (1931), Arch. Ophth., 5: 936.
Hirschfelder, M. and Frost, J., (1948), Amer. J. Ophthal., 31: 999.
Kennaway, E. L., (1925), J. Indust. Hyg.. 7: 69.
Lane, L. A. (1937), Surg. Gynec. And Obst., 64: 458
O'Brien, C. S. and Braley, A. E.. (1936), J.A.M.A., 107: 933.
Reese, A. B., (1951), Tumours of the Eye, P. 1. Paul Hoeber. Inc., New York.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
[Table - 1], [Table - 2]