Basal cell carcinoma BCC

BCCs account for approximately 90% of malignant eyelid tumours. Ultraviolet light

Box 6.3 Benign eyelid tumours


Benign lesions of the epidermis

Achrocordon (skin tag)

Seborrheic keratosis


Inverted follicular keratosis

Cutaneous horn


Benign lesions of the dermis



Capillary hemangioma

Pyogenic granuloma



Juvenile xanthogranuloma


Benign lesions of the adnexa

Tumours of sweat gland origin


Eccrine spiradenoma

Tumours of hair follicle origin



Tumours of sebaceous gland origin

Sebaceous gland hyperplasia

Sebaceous adenoma


Benign pigmentary lesions

Nevocellular nevi

Junction nevus

Compound nevus

Intradermal nevus

Congenital nevus

Blue nevus

Lentigo simplex

Lentigo senilis

exposure is an important aetiologic factor in the development of eyelid epithelial malignancies. This tumour is prevalent in fair-skinned people. The effects of sun exposure are cumulative, as reflected in the increasing incidence of the tumour with advancing age. BCC may, however, occur in younger patients, particularly those with a tumour diathesis such as the basal cell carcinoma syndrome.

In descending order of frequency, BCCs involve the following locations (Figure 6.2):

• Medial canthus

• Lateral canthus

BCCs have a variety of clinical appearances reflecting the various histopathologic patterns of the tumour. The most common presentation is a nodular pattern. The epithelial proliferation produces a solid pearly lesion contiguous with the surface epithelium. The superficial nature of telangiectatic vessels may predispose these lesions to spontaneous bleeding. With prolonged growth, central umbilication and ulceration will occur. The typical presentation is of a chronic, indurated, non-tender, raised, pearly, telangiectatic, well circumscribed lesion with an elevated surround and depressed crater-like centre (Figure 6.3).

Clinical varieties of BCCs

• Ulcerative

• Morphoeiform

The most commonly encountered morphologic patterns of basal cell carcinoma are the nodular and ulcerative forms. Nodular basal cell carcinomas may assume various clinical presentations such as papilloma (secondary to increased keratin production), a naevus (secondary to pigmentation), and a cyst (due to central tumour necrosis). The variety of clinical presentations of basal cell carcinoma accounts for the high incidence of misdiagnosis. Clinical awareness of the

Figure 6.3 Common nodular BCC with central umbilication and ulceration.

various presentations of the tumour minimises incorrect clinical diagnoses and management.

The morphoeiform lesion has clinically indistinct margins and has a tendency to deep invasion, especially at the medial canthus. Orbital invasion by a BCC is manifest clinically as a fixed, non-mobile tumour and/or a "frozen globe". Although BCCs "never" metastasize, approximately 130 cases of metastases have been described in the literature.

The most difficult BCCs (Figure 6.4) to manage are:

• Morphoeiform BCCs

• BCCs that are fixed to bone

• Medial canthal BCCs

• BCCs with orbital invasion

• Recurrent BCCs especially following radiotherapy.

BCCs have traditionally been regarded as relatively benign, rarely invasive tumours and as such have commonly been casually excised. This has been associated with a high incidence of recurrence, unnecessary morbidity, and occasionally avoidable mortality. A dedicated approach to tumour eradication is clearly essential in the management of these patients.

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