aCase 19a

by Dr.Chua
 

A 72 year-old man from a remote village complained of poor vision in his left eye (Figure 1). The cause for the poor vision was a dense left cataract. He also had a right complete ptosis of 5-year duration which did not appear to bother him. Attempt to open the right eye was difficult as the lid was firm and rubbery (Figure 2). The globe was visible through the slit but immobile ie. a 'frozen' globe. A lesion was noted on the lateral aspect of the lower lid and the CT scan revealed an infiltrative lesion involving the inferior orbit. There is no bony lesion or cerebral infiltration (Figrue 3).

Biopsy of the skin and the orbit through a subciliary incision revealed palisading of neoplastic cells consistent with basal cell carcinoma.

Figure 1. Right complete ptosis and a left dense cataract.

Figure 2. Attempt to lift the right lid was difficult. Arrow shows a raidsed skin lesion.

Figure 3. Coronal CT scan shows an infiltrative lesion in the inferior orbit.

a. What are the risk factors for orbital invasion by basal cell carcinoma?

Basal cell carcinomas grow by direct extension and invasion of adjacent structures. The growth is usually slow with a doubling time of at least six months.

 

The two main risk factors for orbital invasion are:

 

a. Histology types of the tumour: The sclerosing variety is more infiltrative than the nodular type tend to be deeply invasive and are often neglected until they have caused extensive damage. Sclerosing tumors frequently invade muscle, nerve and bone. Our patient has the sclerosing variety which infiltrate deeply and gave the skin a firm and rubbery consistency.

 

b. Location of the lesion: Basal cell carcinoma that involves the medial canthus is the most likely to invade the deep orbital structure¹.
 

b. What are the treatment options and what is the best option in this patient?

Several options alone or in combinations are available:

 

a. Radical surgery that involves exenternation which allows removal of all tumours.

 

b. Radiotherapy can be used in conjunction with radical surgery to prevent recurrence or alone to decrease the disease process in patients not suitable for surgery.

 

c. Chemotherapy with cisplatin alone or in combination with doxorubicin can be used to decrease tumour size prior to tumour excision or in conjunction with radiotherapy².

 

The long-standing nature of our patient's disease suggests the basal cell carcinoma is not aggressive. As the patient declines radical surgery, we refer the patient for radiotherapy with regular scan to monitor the size of the lesion. In the mean time, the patient is listed for left cataract surgery which appears to concern him more than the fellow eye.

 

 

References:

 

1. Leibovitch I, McNab A, Sullivan T, Davis G, Selva D. Orbital invasion by periocular basal cell carcinoma. Ophthalmology. 2005 Apr;112(4):717-23.

2. Neudorfer M, Merimsky O, Lazar M, Geyer O. Cisplatin and doxorubicin for invasive basal cell carcinoma of the eyelids. Ann Ophthalmol. 1993 Jan;25(1):11-3.