Skin Cancers of the Eyelid

What is a skin cancer of the eyelid

Australia has the highest rate of skin cancer in the world. This is because most common skin cancers are caused by sun-exposure. Skin cancers can occur anywhere on the body, but are most commonly found on parts of the body which are exposed to the sun. This includes the face and the eyelids. About 10% of all skin cancers of the body occur in the eyelids.

There are many different types of eyelid cancers, but the 3 most common ones that occur in the skin of the eyelid are the:

• Basal cell carcinomas (BCC or Rodent ulcer)
• Squamous cell carcinoma (SCC)
• Melanoma

The BCC is, by far, the most common skin cancer of the eyelid. SCC and melanomas are rare in the eyelid.

What causes eyelid skin cancers

SUN EXPOSURE (UV light) is the main risk factor for eyelid skin cancers. People who have spent a lot of time in the sun during their lives are most at risk. People who are fair-skinned are also most at risk.

Other rare factors that may put a person at risk of skin cancer of the eyelid include previous radiation therapy, immunosuppression therapy for other cancers, and certain genetic syndromes.

How do I know I have an eyelid tumour

Eyelid skin cancers can prevent in many different shapes and sizes and colours on the eyelid, which is why it is important to always seek medical attention if you see any changes in your eyelids.

BCC skin cancers will most often present as a new lump on the eyelid. This lump is often round, and red/pink in colour. It may have a central ulcer, and may bleed or itch at times. It does not usually have any pigment (darkening) to it. Less commonly, the BCC will present as a thickening of the skin of the eyelid, which may be mistaken for a scar or a non-cancerous skin condition.

SCC skin cancers may also present as a lump or a general thickening, and are difficult to tell apart from BCC unless a biopsy is done.

Melanomas most often present as a pigmented (dark) lump on the eyelid (like a mole), which changes rapidly in size and colour with time.

It is important to remember that:

• Eyelid skin cancers are usually painless.
• They do not usually affect the vision, and do not cause pain or redness in the eye itself until the advanced stages of cancer.
• BCCs grow very slowly, and may be neglected (by the patient) for many months or even years before they are properly diagnosed

As with any skin cancer on the body, the earlier an eyelid skin cancer is diagnosed and treated, the better the chances for cure.

How is an eyelid skin cancer diagnosed

An eyelid skin cancer can often be diagnosed based on its appearance in the eyelid. But many surgeons (including Dr Then) also prefer to do a biopsy of any eyelid lesion to confirm that it is a skin cancer, and which skin cancer it is.

An eyelid biopsy is usually performed in the office rooms, under local anaesthetic. Dr Then will inject a small amount of local anaesthetic under the skin where the abnormal area is, and use either a blade or a special instrument to sample part of the abnormal area. This is then sent to the pathology laboratory for assessment. Results are usually available within 1 week, and Dr Then will see you at that time to discuss the results.

If the biopsy confirms that there is an eyelid skin cancer present, then more surgery will be required to completely remove the cancer from the eyelid.

How is an eyelid skin cancer treated

SURGERY:
The main treatment of eyelid skin cancers is surgery. The aim of surgery is to completely remove all skin cancer, to reduce the risk of it coming back again in the future. The type of surgery that is chosen will depend on the type of skin cancer, the size and shape, its location in the eyelid, and whether it is primary (first-time) cancer or recurrent cancer.

There are 2 parts to any eyelid surgery for skin cancer. The first part is to completely remove the cancer from the eyelid. The second part is to reconstruct (put back together) the eyelid so that it looks and functions as normally as possible.

If the skin cancer is small, then it may be possible to remove and reconstruct it in one session, as day surgery.

However, in the eyelid, where there is very little tissue to spare, and where it is vital that all skin cancer is removed, there are other specialised techniques used. These include:

1. MOH’s surgery
2. Frozen section control surgery

What is MOH’s surgery

MOH’s surgery is a highly specialised form of treatment for skin cancers, and is especially useful for eyelid skin cancers. In MOH’s surgery, the skin cancer is examined under the microscope at the same time as it is excised, to ensure that ALL of the skin cancer is removed. At the same time, it preserves as much precious normal tissue in the eyelid.

The advantages of MOH’s surgery over other surgical techniques are

• Gives the highest cure rates for eyelid skin cancers.
• Preserves as much normal tissue as possible around the eyelid.

There are 2 surgeons involved in MOH’s surgery of the eyelids. The MOH’s surgeon (who removed the cancer) and the Oculoplastic surgeon (who reconstructs the eyelid after the cancer has been removed completely)

1.MOH’s surgeon. This is usually a dermatologist surgeon. They will remove the eyelid skin cancer under local anaesthetic. Once removed, the tumour is divided and marked with special colours to allow the edges of it to be examined under the microscope. This is called mapping. If the MOH’s surgeon sees that tumour is still present in any part of the specimen, the patient will be brought back into theatre for further removal of tumour, and this specimen is again mapped and examined under the microscope. This process is repeated until the surgeon is satisfied that all tumour has been removed. This may mean several trips back to the operating theatre during the day, although most tumours are removed within 1-2 sessions.

Once the tumour is completely removed, an eyepad is placed over the defect that remains in the eyelid, and the patient returns to see the Oculoplastic surgeon for reconstruction of the eyelid. This usually happens 1-2 days later.

2.Oculoplastic surgeon (Dr Then). The oculoplastic surgeon is responsible for reconstructing the eyelid. The surgical technique used to reconstruct the eyelid will depend on many factors, including the size and location of the defect, and whether any vital structures (such as the tear ducts) are involved. Dr Then will discuss this with you prior to the reconstruction being performed. Reconstructive surgery is usually day surgery, and usually performed under local anaesthetic. However, larger and more complex defects may be more comfortably reconstructed under general anaesthetic.

The aims of reconstructive surgery are:

• To achieve an eyelid that looks normal
• To achieve an eyelid that functions normally, and in particular allows full closure of the eyelids to protect the eye

When is MOH’s surgery required

Not all patients with eyelid skin cancers require MOH’s surgery. MOH’s surgery is generally used for eyelid tumours that:

• Are large
• Are not well-defined
• Are close to vital structures in the eyelid (such as the tear ducts)
• Are recurrent (have been removed before and have come back)
• Are at the inner or outer corners of the eyelids

Moh’s surgery is time-consuming, demanding and exhausting for the patient. It is therefore not suitable for all patients.

What is frozen section control surgery

This is also a very good technique used to ensure that an eyelid tumour is completely removed. This can usually be performed by one surgeon (usually an oculoplastic surgeon) and in one sitting on the same day.

In this technique, the tumour is removed, and the patient’s eye is padded and they wait comfortably in a waiting room. The tumour specimen is sent to a pathologist on-site, who will examine the specimen under the microscope and tell the surgeon whether the tumour has been completely removed. This examination can be done quickly (within 1 hour). Once the pathologist confirms that all tumour has been removed, the patient is brought back into theatre and reconstruction is performed.

This is a more commonly used technique, is less demanding for the patient, and also achieves high cure rate for skin cancers of the eyelids.

Are there non-surgical techniques to treat eyelid skin cancers

Yes, there are. These include:

• Radiotherapy
• Cryotherapy (freezing)
• Skin Creams (eg Aldara, Efudex)

However, the cure rates with these are not as good as with surgery. They are generally reserved for patients in whom surgery is contraindicated (elderly, frail, very unwell patients), or in patients with very early, very superficial skin cancers.

Will the eyelid skin cancer come back after treatment

The aim of any treatment is to completely remove any tumour cells from the skin. Tumour cells left behind may lead to recurrence of the cancer, which can occur months to years down the track. Recurrent tumours may grow slowly under the skin, and be difficult to diagnose under the scar of the first surgery or treatment. Recurrent skin cancers also tend to be more aggressive and more difficult to treat.

Fortunately, the rate of recurrence of eyelid skin cancers is low, if the tumour is removed properly the first time. However, no technique can guarantee 0% recurrence. Moh’s surgery, which has the highest cure rates, still had recurrence rates of approximately 2%.

It is therefore important that any patient with any eyelid tumour is monitored regularly after any surgery. Dr Then will usually see you frequently in the first year, and then less frequently after that, to check your eyelids for any tumour recurrence. This is usually for a total period of 5 years for most eyelid skin cancers.