eMedicine Specialties > Ophthalmology > Lid

Basal Cell Carcinoma, Eyelid: Differential Diagnoses & Workup

Author: Hon-Vu Q Duong, MD, Ophthalmologist, Department of Ophthalmology, Westfield Eye Center
Coauthor(s): Robert Copeland, MD, Chair, Associate Professor, Department of Ophthalmology, Howard University College of Medicine
Contributor Information and Disclosures

Updated: Mar 9, 2007

Differential Diagnoses

Blepharitis, Adult
Chalazion
Hordeolum
Pigmented Lesions of the Eyelid
Sebaceous Gland Carcinoma
Squamous Cell Carcinoma, Eyelid

Other Problems to Be Considered

Actinic keratosis
Sebaceous hyperplasia
Nevi malignant melanoma
Keratoacanthoma
Seborrheic keratosis
Bowen disease
Cutaneous T-cell lymphoma (mycosis fungoides)
Metastatic malignancies

Workup

Imaging Studies

  • Radiological imaging of the facial and orbital bones and soft tissues may be helpful for an invading or deep tumor in the medial canthus.
  • The use of ultrasonography is currently controversial. High-frequency (20 MHz) and ultra–high-frequency (40-100 MHz) ultrasound systems have been used; however, their accuracy in delineating malignant lesions from benign lesions remains inadequate with a success rate of approximately 20%. Furthermore, the claims of reliable tumor sizing and depth of invasion are promising but still passionately debated.
  • Laser Doppler may be a useful tool in delineating the tumor margin. It is reported that cutaneous perfusion to the eyelids is statistically significantly higher than other regions of the body (eg, forearm). Furthermore, the mean perfusion in pretarsal skin was 50% greater than preseptal skin. In histologically documented BCC of the eyelid, cutaneous perfusion was significantly greater. As an adjunct tool, laser Doppler may assist ophthalmologists in distinguishing benign versus malignant adnexal skin lesions and in establishing the tumor margin.

Other Tests

  • Cytology
    • To accurately and definitively diagnose BCC of the eyelid, histological confirmation is required and is most commonly obtained through excisional biopsy. However, cytology does provide a rapid alternative that may yield and even help confirm a diagnosis during the initial visit.
    • The accuracy of this technique has been reported to be good, but its sensitivity in diagnosing BCC of the eyelid is unknown. In a paper by Barton et al, patients who underwent cytology followed by excisional biopsy showed that cytology had a sensitivity of 92% in diagnosing BCC with a predictive accuracy of 75%. These values were compared to a second group of patients who had incisional biopsy and histological examination followed by excision with histological confirmation. The second group showed a sensitivity of 100% in diagnosing BCC with a predictive accuracy of 96%.
    • Cytology may play a role in helping to diagnose BCC. It is sufficiently accurate; however, it is not sufficiently sensitive in planning surgical management.

Histologic Findings

Nodular type: The nodular type accounts for more than 70% (73.4%) of the histologic type. Nests of basaloid cells in different sizes are present. Tumor cells show peripheral palisading. Cells have large, oval or elongated nuclei with scant cytoplasm. Cells may be pleomorphic or atypical and may contain mitotic figures. Sharp demarcation between normal cells and neoplastic cells is well visualized on microscopy. Contraction artifact at the periphery of the tumor lobules is seen; this histologic feature results from shrinkage of the mucin-rich stroma during specimen processing. Desmoplasia (pseudocarcinomatous changes) of the surrounding stroma is seen.

Variants of the nodular type include the following:

  • Cystic - Cyst fills with blood (hemorrhage) and necrotic tumor cells. This often is seen in a large tumor mass and possible fast-growing tumors.
  • Basosquamous - Possesses a basal and squamous component in the tumor
  • Sebaceous - Rare; if present, should suspect Muir Torre syndrome
  • Keratotic - Nest of keratin
  • Adenoidal - Mucin producing (foamy, lucent, slightly basophilic)
  • Pigmented - Melanoma versus nevi versus iron deposition (hemosiderin)

Paavilainen et al recently described nodular subtypes, to include micronodular (4.9%) and superficial (1.9%), both with a low incidence of occurrence compared to the nodular form.

Morpheaform (fibrosing) type: Tumor cells grow in thin, elongated strands or cords. Usually, this type is one cell layer thick (Indian file pattern). This type lacks desmoplasia. Proliferation of connective tissue into dense fibrous stroma is seen. Contraction artifact is observed histologically. This type tends to be more aggressive, invades deeper into the underlying tissue, and is likely to recur.

Staging

Unlike other carcinomas (eg, colorectal cancer), BCC is not commonly staged because it rarely metastasizes. Staging BCC often is reserved for large or widespread basal cell cancers. If staging is necessary, the most widely used method is the TNM system.

  • TNM classification
    • The primary tumor (T) is classified as follows:
      • TX: The primary tumor cannot be assessed.
      • T0: No evidence of primary tumor is present.
      • T1: Tumor is less than or equal to 2 cm in the greatest dimension.
      • T2: Tumor is greater than 2 cm but less than 5 cm in the greatest dimension.
      • T3: Tumor is greater than 5 cm in the greatest dimension.
      • T4: Tumor invades the deep and/or extradermal structures.
    • The regional lymph nodes (N) are classified clinically into the following:
      • NX: Regional (nearby) lymph nodes cannot be assessed.
      • N0: No metastasis to regional lymph node is present.
      • N1: Regional lymph node metastasis is present.
    • Metastasis (M) is classified as follows:
      • MX: Distant metastasis cannot be assessed.
      • M0: Distant metastasis is not noted.
      • M1: Distant metastasis is present.
  • Clinical staging
    • Stage 0 (carcinoma in situ [CIS]): Abnormal cells are found but have not invaded deeper tissue.
    • Stage 1: Tumor cells are found and measure less than 2 cm in greatest dimension and have not spread to regional lymph nodes.
    • Stage 2: Tumor measures greater than 2 cm in greatest dimension and has not spread to regional lymph nodes.
    • Stage 3: Tumor has metastasized to the tissues under the skin (muscle, bone, or cartilage) or to the regional lymph nodes.
    • Stage 4: Tumor (any size) has metastasized to distant organ(s).

More on Basal Cell Carcinoma, Eyelid

Overview: Basal Cell Carcinoma, Eyelid
Differential Diagnoses & Workup: Basal Cell Carcinoma, Eyelid
Treatment & Medication: Basal Cell Carcinoma, Eyelid
Follow-up: Basal Cell Carcinoma, Eyelid
Multimedia: Basal Cell Carcinoma, Eyelid
References
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Further Reading

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Keywords

eyelid basal cell carcinoma, BCC, skin tumors, skin malignancies, skin cancer, epithelial tumors

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Contributor Information and Disclosures

Author

Hon-Vu Q Duong, MD, Ophthalmologist, Department of Ophthalmology, Westfield Eye Center
Hon-Vu Q Duong, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Robert Copeland, MD, Chair, Associate Professor, Department of Ophthalmology, Howard University College of Medicine
Robert Copeland, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado
Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, Utah Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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