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Year : 2007  |  Volume : 55  |  Issue : 2  |  Page : 137-138

Surgical excision of periocular basal cell carcinomas

Department of Ophthalmology, Bradford Royal Infirmary, Bradford BD96RJ, United Kingdom

Date of Submission20-Aug-2005
Date of Acceptance12-Jun-2006

Correspondence Address:
K Taherian
Consultant Ophthalmologist, Calderdale Royal Hospital, Halifax, HX3 0PW
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.30709

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The purpose of this study was to determine the histological clearance and clinical recurrence rates following excision of primary periocular biopsy-proven basal cell carcinomas (BCCs) in a teaching hospital in United Kingdom and compare it with other published reports. Records of consecutive patients with a biopsy proven diagnosis of primary periocular BCCs treated surgically at our hospital between 1995 and March 2003 were reviewed. Twenty seven cases (25 patients) were identified. Intra-operative frozen sections (IFS) were performed in 17 (63%) of the cases with clear margins on IFS in 16/17 (94%) of these cases. Histology revealed complete excision in 25/27 (92.5%) of cases. The results of excision of periocular BCCs in our setting particularly with IFS are comparable with other published reports. A reaudit is recommended in 5 years to allow a larger patient population with greater follow up, which would enable us to give more definitive judgment on this treatment modality.

Keywords: Basal cell carcinoma, recurrence rate, surgical excision

How to cite this article:
Taherian K, Shekarchian M, Atkinson P L. Surgical excision of periocular basal cell carcinomas. Indian J Ophthalmol 2007;55:137-8

How to cite this URL:
Taherian K, Shekarchian M, Atkinson P L. Surgical excision of periocular basal cell carcinomas. Indian J Ophthalmol [serial online] 2007 [cited 2022 Sep 30];55:137-8. Available from: https://www.ijo.in/text.asp?2007/55/2/137/30709

Histological clearance and clinical recurrence rates with and without intra-operative frozen section

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Histological clearance and clinical recurrence rates with and without intra-operative frozen section

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Basal cell carcinoma (BCC) is the commonest human malignancy[1],[2] and approximately 5-10% of all skin cancers occur in eyelids.[1] Surgical excision is the commonest treatment modality for periocular BCCs and is considered reliable and effective.[1],[3] Completeness of tumor excision is important as recurrences are more aggressive and carry a less favorable prognosis.[1],[2]

The aim of this study was to determine the histological clearance and clinical recurrence rates following excision of primary peri-ocular histologically confirmed BCCs with or without intra-operative frozen section (IFS) control in our teaching hospital in United Kingdom and compare them with other published reports [Table - 1].

  Materials and Methods Top

Records of consecutive patients with a histological diagnosis of primary periocular BCCs treated surgically at our hospital between 1995 and March 2003 were reviewed.

The following variables were extracted: age, gender, date of presentation, tumor location, size, morphology, date of surgery, surgeon's grade, Type of anesthesia, use of IFS, histological type, method of closure, follow up period, clinical recurrence and time between surgery and recurrence. A 2 mm margin had been used for the excision of these BCCs.

  Results Top

Of the 27 cases (25 patients) identified, 14 (52%) were right sided and 13 (48%) were left sided. Age range was 42-94 (mean 76 years). Female:male ratio was 1.4:1. Distribution of anatomical location was medial canthal region in seven (26%), lateral canthal region in three (11%), lower lid central in sixteen (59%) and entire upper lid in one (4%). With regard to clinical appearance, 18 (67%) were nodular and nine (33%) were of other types or not recorded. The surgeon was of consultant grade in 22 cases (81%) and the rest were operated by trainees.

General anesthesia (GA) was used in 20 cases (74%) and the remaining had local anesthesia (LA). Method of surgical closure was; direct closure in 19 (70.4%), Tenzel flap (semicircular rotational flap) in 2 (7.4%), Hughes flap (tarsoconjunctival flap with a vertical upper lid to lower lid-sharing technique) in one (3.7%), O-Z flap(local advancement skin flap) in one (3.7%), V-Y flap (glabellar flap) in one (3.7%), lateral skin flap rotation advancement flap in one (3.7%), post-exentration split skin graft in one (3.7%) and Hughes flap + graft in one (3.7%). IFS was performed based upon perceived clinical need in 17 (63%) cases with clear margins in 16/17 (94%) cases. In the single case where one of the margins was not clear, a further strip of tissue was excised at the same sitting and histology revealed clear margins with no subsequent recurrence. All patients with IFS showed clear margins on subsequent histology. Histology revealed complete excisions in 25/27 (92.5%) cases.

The two patients that had incomplete excision on histology were kept under close clinical observation and one developed a clinical recurrence a year later, which was successfully re-excised. Follow up ranged between 12 and 92 (mean 38 months).

  Discussion Top

This study demonstrates an acceptably low mid- term recurrence rate. Recurrence rates between 0.71 and 5.36%,[4],[5] have been previously reported. Our data support earlier suggestions that surgical excision especially with IFS, can ensure complete tumor removal[4],[5] and the low recurrence rate after IFS is comparable with Moh's surgery,[4],[6] although Moh's surgery is often performed for more difficult cases. The relatively high proportion of our patient's undergoing surgery under GA was due to patient preference. There are advantages of LA such as ability of the patient to align their eye intra-operatively, enabling better lid margin apposition especially during complicated reconstructions. However, we had chosen a 2 mm margin to try and reduce the size of the defect and consequently the need for complicated reconstructions. For simpler excisions and with careful closure we have not found lid margin alignment a problem but we agree that, a move towards greater use of LA is desirable.

There are several reasons why we chose 2 mm margins. Firstly, most of our patients (>2/3) had nodular BCCs and almost 2/3 of our cases had IFS. Secondly, 2 mm margins allow a smaller defect and reduce the need for complicated reconstructions, which in an elderly patient are best avoided if possible. Thirdly, a 2 mm margin may vary from surgeon to surgeon based on their method of marking. Our technique involved marking the tissue 2 mm from the lesion's obvious margin with a surgical marker and then placing the incision at the outer margin of the mark, which was 1 mm wide. If the incision is placed at the inner or center of the mark the excised area can differ by up to 1 mm for each margin or 2 mm in overall diameter [Figure - 1].

Even though results of surgical excision of periocular BCCs are encouraging[3],[4],[5],[6],[7] treatment strategy should be decided on an individual basis, taking into consideration tumor size, location, growth pattern, and the patient's life expectancy. Also, for IFS to succeed, close communication between the surgeon and pathologist is important, allowing prompt feedback and smooth progression of the operation.

Though first described as early as 1941,[8] Moh's surgery remains the gold standard technique for surgical excision of high risk periocular BCCs but is cumbersome, time consuming, costly, requires highly specialized training and facilities and, hence, its availability is limited. When available, Moh's surgery is recommended for BCCs in areas of important tissue preservation such as proximity to the lacrimal apparatus and in those with a high risk for recurrence: such as ill-defined BCCs, history of incomplete removal or previous irradiation or recurrence, very large BCCs and those with perineural, deep tissue or bone involvement.[9],[10]

The limitations of our study, are a relatively small patient group with a shorter follow-up.[11] This is important as recurrences 3 years or later have been observed.[11] We are, however, reassured by the fact that our results are in agreement with other such previously published work.[1],[6] Our results indicate that IFS helps to achieve better results than simple excisions. To conclude, surgical excision especially with IFS remains an effective treatment modality for periocular BCCs with a good primary clearance rate and an acceptably low recurrence rate. It is worth remembering though, that prevention is preferable and the public needs to be kept informed about avoidance of excessive solar exposure especially in susceptible populations.

  References Top

Cook BE Jr, Bartley GB. Treatment options and future prospects for the management of eyelid malignancies: An evidence-based update. Ophthalmology 2001;108:2088-98.  Back to cited text no. 1
Margo CE, Waltz K. Basal cell carcinoma of the eyelid and periocular skin. Surv Ophthalmol 1993;38:169-92.  Back to cited text no. 2
Holbach LM, Jünemann A, Muhammad S. Surgical management of periocular basal cell carcinoma using frozen section control and immediate reconstruction-indications and methods in 106 patients. Klin Monatsbl Augenheilkd 1998;213:278-83.  Back to cited text no. 3
Wong VA, Marshall JA, Whitehead KJ, Williamson RM, Sullivan TJ. Management of periocular basal cell carcinoma with modified en face frozen section controlled excision. Ophthal Plast Reconstr Surg 2002;18:430-5.  Back to cited text no. 4
Pieh S, Kuchar A, Novak P, Kunstfeld R, Nagel G, Steinkogler FJ. Long-term results after surgical basal cell carcinoma excision in the eyelid region. Br J Ophthalmol 1999;83:85-8.  Back to cited text no. 5
Conway RM, Themel S, Holbach LM. Surgery for primary basal cell carcinoma including the eyelid margins with intraoperative frozen section control comparative interventional study with a minimum clinical follow up of 5 years. Br J Ophthalmol 2004;88:236-8.  Back to cited text no. 6
Glatt HJ, Olson JJ, Putterman AM. Conventional frozen sections in periocular basal-cell carcinoma: A review of 236 cases. Ophthalmic Surg 1992;23:6-9.  Back to cited text no. 7
Mohs FE. Chemosurgery: A microscopically controlled method of cancer excision. Arch Surg 1941;42:279-95.  Back to cited text no. 8
Cottell WI, Bailin PL, Albom MJ, Bernstein G, Braun M 3rd, Hanke CW, et al . Essentials of Mohs micrographic surgery. J Dermatol Surg Oncol 1988;14:11-3.  Back to cited text no. 9
Rowe DE, Carroll RJ, Day CL Jr. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989;15:424-31.  Back to cited text no. 10
Steinkogler FJ, Scholda CD. The necessity of long-term follow up after surgery for basal cell carcinomas of the eyelid. Ophthalmic Surg 1993;24:755-8.  Back to cited text no. 11


  [Figure - 1]

  [Table - 1]

This article has been cited by
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Levin, F., Khalil, M., McCormick, S.A., Della Rocca, D., Maher, E., Della Rocca, R.C.
Archives of Ophthalmology. 2009; 127(8): 1011-1015
2 Outcomes of excision of 1750 eyelid and periocular skin basal cell and squamous cell carcinomas by modified en face frozen section margin-controlled technique
Gayre, G.S., Hybarger, C.P., Mannor, G., Meecham, W., Delfanti, J.B., Mizono, G.S., Guerry, T.L., Lacy, J.
International Ophthalmology Clinics. 2009; 49(4): 97-110
3 Outcomes of Excision of 1750 Eyelid and Periocular Skin Basal Cell and Squamous Cell Carcinomas by Modified En Face Frozen Section Margin-controlled Technique
Gregg S. Gayre,C. Patrick Hybarger,Geva Mannor,William Meecham,John B. Delfanti,Gary S. Mizono,Thomas L. Guerry,Jeffrey S. Chien,C. Daniel Sooy,Robert Anooshian,Roderick Simonds,Karen A. Pietila,David W. Smith,Deborah A. Dayhoff,Elaine Engman,John Lacy
International Ophthalmology Clinics. 2009; 49(4): 97
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