Painless Lesion Interferes With Man’s Vision

For years, this 80-year-old man has had a lesion on his right upper eyelid. It has slowly grown, though it causes no pain or other symptoms, and is now interfering with his lateral vision. This is what prompts him to seek evaluation.

His primary care providers over the years have seen the lesion. All have assured him of its benignancy.

In the distant past, the patient had a great deal of overexposure to the sun. Several skin cancers have been removed from his face.

At this time, he is residing in a rehab center, where he is recovering from a stroke. With his daughter’s assistance, the patient, who is not ambulatory and is a bit confused, is able to understand what is happening.

EXAMINATION
The lesion is a well-defined, 5 mm x 1.1–cm pearly plaque located on the lateral portion of his left upper eyelid, within 2 to 3 mm of the lateral palpebral margin. It is seen in the context of heavily sun-damaged type II facial skin.

A shave biopsy indicates the lesion is a basal cell carcinoma (BCC).

DISCUSSION
BCCs, though rarely fatal, can be associated with a great deal of morbidity. This case highlights several issues regarding the diagnosis and treatment of nonmelanoma skin cancers (eg, basal or squamous cell carcinoma)—not the least of which is the delayed diagnosis. In this instance, the delay is unlikely to harm the patient; however, that is not always the case. If this BCC had been a bit more aggressive, it could have invaded the periocular structures, which might have necessitated extensive surgery and possibly postoperative radiation.

Fortunately, this particular BCC was exceptionally slow to grow, to the extent that doing nothing was a serious consideration. If the patient had been older and/or less capable of cooperating with the surgical process, taking no action might have been the best choice.

But his BCC had grown, and he was able to state his preference (as did the family) to have it surgically removed. As of this writing, he has been scheduled for an appointment with a Mohs surgeon, who is likely to remove the lesion with margins. If the sample tests negative for residual cancer, the patient may not require further treatment. (Given the lesion’s location, the surgical wound does not even require closure, since they usually heal nicely by secondary intention.)

If microscopic examination reveals that the cancer extends into the eyelid itself, the patient will probably be referred to an oculoplastic surgeon for definitive excision and repair, which can be complex and difficult.

While the initial biopsy identified the lesion as a BCC, other items in the differential include seborrheic keratosis and even sebaceous carcinoma (an unusual diagnosis, but one common in patients this age). Squamous cell carcinoma and wart were also possibilities.

TAKE-HOME LEARNING POINTS
• Changing lesions require investigation, usually in the form of a simple shave biopsy.

• Patients with a history of skin cancer tend to develop additional skin cancers.

• Not all basal cell carcinomas are aggressive. Some are remarkably slow-growing.

• For nonaggressive basal cell carcinomas in patients who are unable to cooperate with treatment decisions, consider doing nothing.

• The eyelid is a favorite location for an unusual type of skin cancer: sebaceous carcinoma.

For years, this 80-year-old man has had a lesion on his right upper eyelid. It has slowly grown, though it causes no pain or other symptoms, and is now interfering with his lateral vision. This is what prompts him to seek evaluation.

His primary care providers over the years have seen the lesion. All have assured him of its benignancy.

In the distant past, the patient had a great deal of overexposure to the sun. Several skin cancers have been removed from his face.

At this time, he is residing in a rehab center, where he is recovering from a stroke. With his daughter’s assistance, the patient, who is not ambulatory and is a bit confused, is able to understand what is happening.

EXAMINATION
The lesion is a well-defined, 5 mm x 1.1–cm pearly plaque located on the lateral portion of his left upper eyelid, within 2 to 3 mm of the lateral palpebral margin. It is seen in the context of heavily sun-damaged type II facial skin.

A shave biopsy indicates the lesion is a basal cell carcinoma (BCC).

DISCUSSION
BCCs, though rarely fatal, can be associated with a great deal of morbidity. This case highlights several issues regarding the diagnosis and treatment of nonmelanoma skin cancers (eg, basal or squamous cell carcinoma)—not the least of which is the delayed diagnosis. In this instance, the delay is unlikely to harm the patient; however, that is not always the case. If this BCC had been a bit more aggressive, it could have invaded the periocular structures, which might have necessitated extensive surgery and possibly postoperative radiation.

Fortunately, this particular BCC was exceptionally slow to grow, to the extent that doing nothing was a serious consideration. If the patient had been older and/or less capable of cooperating with the surgical process, taking no action might have been the best choice.

But his BCC had grown, and he was able to state his preference (as did the family) to have it surgically removed. As of this writing, he has been scheduled for an appointment with a Mohs surgeon, who is likely to remove the lesion with margins. If the sample tests negative for residual cancer, the patient may not require further treatment. (Given the lesion’s location, the surgical wound does not even require closure, since they usually heal nicely by secondary intention.)

If microscopic examination reveals that the cancer extends into the eyelid itself, the patient will probably be referred to an oculoplastic surgeon for definitive excision and repair, which can be complex and difficult.

While the initial biopsy identified the lesion as a BCC, other items in the differential include seborrheic keratosis and even sebaceous carcinoma (an unusual diagnosis, but one common in patients this age). Squamous cell carcinoma and wart were also possibilities.

TAKE-HOME LEARNING POINTS
• Changing lesions require investigation, usually in the form of a simple shave biopsy.

• Patients with a history of skin cancer tend to develop additional skin cancers.

• Not all basal cell carcinomas are aggressive. Some are remarkably slow-growing.

• For nonaggressive basal cell carcinomas in patients who are unable to cooperate with treatment decisions, consider doing nothing.

• The eyelid is a favorite location for an unusual type of skin cancer: sebaceous carcinoma.

For years, this 80-year-old man has had a lesion on his right upper eyelid. It has slowly grown, though it causes no pain or other symptoms, and is now interfering with his lateral vision. This is what prompts him to seek evaluation.

His primary care providers over the years have seen the lesion. All have assured him of its benignancy.

In the distant past, the patient had a great deal of overexposure to the sun. Several skin cancers have been removed from his face.

At this time, he is residing in a rehab center, where he is recovering from a stroke. With his daughter’s assistance, the patient, who is not ambulatory and is a bit confused, is able to understand what is happening.

EXAMINATION
The lesion is a well-defined, 5 mm x 1.1–cm pearly plaque located on the lateral portion of his left upper eyelid, within 2 to 3 mm of the lateral palpebral margin. It is seen in the context of heavily sun-damaged type II facial skin.

A shave biopsy indicates the lesion is a basal cell carcinoma (BCC).

DISCUSSION
BCCs, though rarely fatal, can be associated with a great deal of morbidity. This case highlights several issues regarding the diagnosis and treatment of nonmelanoma skin cancers (eg, basal or squamous cell carcinoma)—not the least of which is the delayed diagnosis. In this instance, the delay is unlikely to harm the patient; however, that is not always the case. If this BCC had been a bit more aggressive, it could have invaded the periocular structures, which might have necessitated extensive surgery and possibly postoperative radiation.

Fortunately, this particular BCC was exceptionally slow to grow, to the extent that doing nothing was a serious consideration. If the patient had been older and/or less capable of cooperating with the surgical process, taking no action might have been the best choice.

But his BCC had grown, and he was able to state his preference (as did the family) to have it surgically removed. As of this writing, he has been scheduled for an appointment with a Mohs surgeon, who is likely to remove the lesion with margins. If the sample tests negative for residual cancer, the patient may not require further treatment. (Given the lesion’s location, the surgical wound does not even require closure, since they usually heal nicely by secondary intention.)

If microscopic examination reveals that the cancer extends into the eyelid itself, the patient will probably be referred to an oculoplastic surgeon for definitive excision and repair, which can be complex and difficult.

While the initial biopsy identified the lesion as a BCC, other items in the differential include seborrheic keratosis and even sebaceous carcinoma (an unusual diagnosis, but one common in patients this age). Squamous cell carcinoma and wart were also possibilities.

TAKE-HOME LEARNING POINTS
• Changing lesions require investigation, usually in the form of a simple shave biopsy.

• Patients with a history of skin cancer tend to develop additional skin cancers.

• Not all basal cell carcinomas are aggressive. Some are remarkably slow-growing.

• For nonaggressive basal cell carcinomas in patients who are unable to cooperate with treatment decisions, consider doing nothing.

• The eyelid is a favorite location for an unusual type of skin cancer: sebaceous carcinoma.