On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.79 no.4 Rio de Janeiro July/Aug. 2004
CLINICAL, LABORATORY AND THERAPEUTIC INVESTIGATION
Basal cell carcinoma of the eyelid factors related to recurrence*
Luciana Akemi IshiI; Ivana Cardoso PereiraI; Silvana Artioli SchelliniII; Mariângela Esther Alencar MarquesIII; Carlos Roberto PadovaniIV
IResident, Dept. of Ophthalmology,
Otorhinolaryngology and Head and Neck Surgery Botucatu School of Medicine/Unesp
IIPost-Doctoral Studies Professor, Dept. of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery Botucatu School of Medicine/Unesp
IIIPh.D., Professor, Pathology Dept., Botucatu School of Medicine/Unesp
IVTitular Professor, Biostatistics Dept., Institute of Biosciences/Unesp, Botucatu
BACKGROUND: Basal cell carcinoma (BCC)
is the most common malignant tumor located in the eyelid and there is a possibility
of recurrent tumor after excision.
OBJECTIVE: This study was done to evaluate the features related to recidive basal cell carcinoma.
METHODS: A retrospective survey was done at Botucatu School of Medicine - UNESP, from 1998 to 2001. A total of 23 patients presented recidive basal cell carcinoma. The patients were studied according to sex, age, solar exposure, tumor localization, histological presentation, resection margins and follow up.
RESULTS: Recidive BCC occurred in Caucasians, mostly in females (52.0%), all in the lower eyelid, mainly in the internal canthus (74.0%), ulcerated solid histological form (34.7%) and 66.6% had clear resection margins.
CONCLUSION: The majority of recurrent BCC were solid and occurred in the internal canthus. Clear margins do not guarantee that a new lesion will not occur.
Keywords: carcinoma, basal cell; histology; neoplasms; recurrence; neoplasm recurrence, local.
Basal cell carcinoma (BCC) accounts for 75.01 to 92.0%2 of malignant tumors of the eyelid. They usually occur in the elderly, especially those aged 50 to 70 years,3,4 and their occurrence before 40 or after 80 years of age is rare.
It has already been widely demonstrated that such tumors are more frequent among people that present inappropriate solar exposure and more specifically to ultraviolet radiation. However, besides solar exposure, there must be other factors related to the development of BCC, since polymer film used to measure radiation placed on seven areas of the upper and lower eyelids has showed that a similar amount of radiation is received by both,5 thus it is difficult to explain the much greater incidence of tumors in the lower eyelid.
Therefore, ultraviolet radiation is important, but other factors are involved, such as a predisposition to the development of tumors (33.4% of individuals with BCC of the eyelids present other tumors in the face), exposure to carcinogens, genetic predisposition (patients with xeroderma pigmentosum and albinism develop BCC more frequently and more precociously). Another observation that reinforces the theory of genetic predisposition or of immunological factors is the high percentage (approximately 41%) of patients with eyelid tumor and more tumors detected in the skin or in other areas.6
BCC is formed due to a deficiency in the maturation and keratinization of the cell. It grows and penetrates the dermis, forming a nodular invasive mass that rarely metastasizes. Sometimes, however, recurrence of the tumor is seen after exeresis. Several reasons have been proposed for the recurrence but these are not always clearly understood.
The present study was performed with the objective of identifying factors related to the tumoral recurrence of BCC in the eyelid.
MATERIAL AND METHODS
From 1998 to 2001, 23 patients were seen at the School of Medicine of Botucatu/Unesp that presented recurrence of BCC of the eyelids. These individuals were analyzed according to the variables of: age, sex, history of solar exposure, location of the tumor, clinical diagnosis, histological diagnosis, involvement of surgical margins and follow-up time.
Of the 23 patients studied, six presented the first and the second surgical pieces analyzed by the Pathology Service (Unesp, Botucatu). These pieces were compared, in order to evaluate the histological characteristics of the primary and the recurrent tumors.
The data collected were submitted to descriptive statistical evaluation.
The characteristics of the 23 patients are presented in table 1. There was no predominance according to gender, 12/23 (52%) patients with recurrent BCC of the eyelids were female. The mean age of the patients was 72.9 years.
There was a history of involuntary excessive solar exposure in 19 (83%) cases and all the patients (100%) were white.
The lesions had appeared from one to five years previously.
All the patients (100%) presented the tumor recidive in the lower eyelid, of these 57% were located in the left eyelid and the remaining 43% in the right eyelid; 74% involved the internal canthus and 26% the external canthus (Graph 1).
Clinical diagnosis was confirmed by histopathology in 82.6% of the patients (Graph 2).
Regarding the histological diagnosis, the cases were all of BCC, and the most common was the ulcerated solid type (34.7%) (Graph 3).
The time the patients were followed up before onset of the recurrence varied from one to five years.
Of the patients studied, 16 (69.5%) presented surgical margins free of neoplasia, and seven (30.4%) presented involvement of the resection margins (Graph 4).
Evaluating the patients that had the two surgical pieces analyzed, it was observed that the recurrence presented the same pattern as the initial lesion in 50% of the cases and that about 66.6% of the individuals presented clear margins following the first removal of the lesion and nevertheless were recidivists (Table 2). The lesions were considered recurrent or non-recurrent according to whether they were present in the original site of the first lesion, but the possibility of the lesion occurring de novo cannot be discarded.
BCC is characterized by slow growth, with little possibility of lymphatic involvement or metastases. Lesions located in the eyelid are easily visible, yet in Brazil, it is common for the patient to delay seeking treatment. This leads to the probability of more extensive lesions, thereby hindering exeresis.
Recurrent BCCs have been reported at frequencies of 9.5%,7 14.3%,8 17.8%9 e 22.0%,4 which indicates the need for a meticulous and prolonged follow-up of these patients.
There are several causes that lead to the recurrence of the lesion, including genetic factors, maintenance of aggressive predisposing factors in the environment, histological type and inadequate surgical management of the tumor.
In the region in which the present study was undertaken, there are many descendants of Europeans that are farm workers, these individuals are more predisposed to the development of tumors as they cannot avoid the solar exposure linked to their profession.
The recurrences occurred equally among both sexes, and were more frequent exactly in the age group most affected by the tumor, it was not possible to characterize this as a predisposing factor.
Tumors located in the lower eyelid, mainly in the internal canthus, presented the most recurrences. A possible explanation for this could be related to the greater occurrence of tumors in this location or to the performing of conservative surgical resections, in order to preserve important structures in this area.
It is important to emphasize that the resections of tumors should be complete and that one should not attempt to preserve structures that are potentially involved, mainly given the risk of orbital invasion of the tumors in the internal canthus that can occur in 2.09% of patients with BCC of the eyelids,10 as has already been observed in the service in which this study was carried out.11 Besides the orbit, the tumor can involve the nasal cavity and the paranasal sinuses. When there is need for conservative resection in order to preserve noble structures, Mohs micrographic surgery can be used as this allows an analysis of all of the margins in frozen sections during the surgical act.
The most frequent BCC in Brazil is the solid type, responsible for 64.0% of BCCs.4 It is perhaps the greater prevalence of this type of tumor that has lead to the observation of a higher number of recurrences of this tumoral type, in that solid ulcerated tumors are responsible for about 34% of the recurrences, since solid BCC is not the most aggressive form of BCC.
Pigmented BCC have very well-defined margins, which facilitates complete removal of the tumor. The metatypical, morphea or sclerodermiform types of BCC, however, present higher recurrence rates12 due to the difficulty in precisely determining appropriate surgical margins for the complete removal of the area involved, that can be represented by small blocks of tumoral tissue constrained amid intense fibrosis, characteristic of these types of basal cell carcinomas. For the above reasons, the greater rate of surgical margin involvement and, therefore, risk of recurrence lies in the sclerodermiform lesions. It should be remembered, however, that involvement of the surgical margins does not necessarily lead to recurrence, since these tumor remnants can be destroyed by the inflammatory reaction and cicatrization. Also, several small focuses of tumoral growth often exist, which is known as multicentric BCC, making the complete removal of the tumor difficult to be accomplished.
The histological exam is important for diagnostic confirmation, definition of the histological type, evaluation of the presence of microscopic ulceration and determining involvement of the surgical resection margins, as well as observing the distance of the tumor in relation to these margins.
The presence of involved surgical resection margin does not necessarily imply in recurrence, a fact confirmed by observation of the patients reported in this work. This discrepancy can be explained by the action of the inflammatory-reparative process that follows the surgery and plays a role in the destruction of residual tumor. According to other authors, the percentile of recurrence varies from 11.8% to 27.2% in the cases of individuals with involvement of the surgical margins.4,7
Consequently, the histological exam is essential in the study of those tumors, given the importance of confirming the diagnosis, determining the histological type of the tumor (indicative of aggressiveness) and the interest in evaluating the deep and lateral surgical margins. One should be attentive to the fact that a routine histopathological exam does not allow evaluation of the entire extension of the lateral and deep surgical margins, especially in large lesions. This fact should be considered when recurrences occur in tumors whose margins were free of neoplasia in the previous histological evaluation. Another consideration concerns the distance of the lesion in relation to the resection margins. Such an evaluation is rarely found in the pathologist's report, except in those cases in which the tumor was very close to the surgical margin. Likewise, it is uncommon to see any reference to precise or irregular delimitation of the neoplasia close to the resection margin.
The evaluation of predisposing factors for the development of tumoral recurrence in BCCs of the eyelid, as done in this work, does not allow the relationship to be ascertained between recurrence and sex, age or histological type of the tumor.
Patients with this type of lesion should be informed as to the possibility of recurrence and be advised of the need for accompaniment throughout their lifetime.
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Silvana Artioli Schellini
Dep. OFT/ORL/CCP - Faculdade de Medicina de Botucatu - UNESP
Botucatu São Paulo 18618-970
Received in September, 18th of 2003.
Approved by the Consultive Council and accepted for publication in March, 12th of 2004.
* Work done at "Faculdade de Medicina de Botucatu Unesp São Paulo".