Basal cell carcinoma is the most common form of skin cancer, and fortunately with early diagnosis and treatment basal cell carcinoma of the eyelid has a great outlook and is seldom fatal. Treatment is necessary. It is ideal to have care by a coordinated team of specialists who can each help you to manage optimal treatment. With multiple treatment options available, how do you know which is right for you to pursue? This will depend on your individual situations and insight from your doctor. Educating yourself on your condition and treatment options is also of great value.
In the vast majority of situations, treatment is surgical and starts with a diagnosis that requires a biopsy of a nonhealing growth of the skin. This can be performed by a dermatologist, plastic surgeon, or facial plastic surgeon. When the growth is on the eyelid, you may be referred to an oculoplastic surgeon for this biopsy. Many lesions can be directly excised with excellent outcomes. Then the basal cell carcinoma involved important structures of the face, Mohs’ cancer surgery is the preferred method of excising the skin cancer because it has a high cure rate and preserves the most uninvolved skin. This makes for better preservation of form and function following reconstructive surgery. Depending on the complexity of the reconstruction, the wound might be repaired by the Mohs’ surgeon or it might require the specialized surgical skill of the oculoplastic surgeon, facial plastic surgeon, or general plastic surgeon depending on the precise nature of the defect. Cure rates following successful Mohs’ surgery can exceed 95%.
There are some novel non-surgical treatments under study for treating basal cell carcinoma, including hedgehog pathway drug and Imiquimod, which are promising medical developments but we still need to further study and better understand them in order to develop their best medical application.
Hedgehog Pathway Drug
The hedgehog signaling pathway is active in human embryogenesis and plays a key role in proper growth and development during our earliest stages; but in adults this pathway is inactive. Researchers have found that the signaling pathway is active in certain tumors where it promotes a micro-environment that favors tumor growth. Sporadic mutations in the active hedgehog pathway appear to account for the majority of spontaneously occurring basal cell, ovarian, colon, and pancreatic carcinomas.
This pathway can be suppressed, which provides hope for a new cure for basal cell carcinoma. GDC-0449 is a drug that is active in suppressing this pathway, and it is currently under development from Genetech. Treatment with this drug appears to provide promise for advanced forms of basal cell carcinoma that are beyond surgical cure with eyelid or orbit surgery. As with many medical drugs, there are associated side effects, and clinical evaluations are still in progress to help us learn more about this new approach. Since we have already found that GDC-0449 can induce a temporary regression in advanced basal cell carcinoma, it may offer the possibility of prolonging survival in the most advanced cases.
Imiquimod, also known under the trade name Aldara, is an immune response modifier that was approved by the FDA for dermatological use in 1997. It has been used to treat a variety of superficial skin malignancies including basal cell carcinoma, squamous cell carcinoma, superficial malignant melanomas, and genital warts. Researchers and doctors still do not completely understand the actual mechanism of how this drug functions, and ongoing studies are working to answer these questions. Treatment with Imiquimod involves applying the treatment to the affected skin to provide an anti-proliferative effect on these skin cancers. Unfortunately, side effects of the drug can cause skin breakdown, ulceration, crusting, and blisters. However, these symptoms are only temporary and the skin heals remarkably well once the medication is stopped. The rates of cure for this method are less than that of Mohs cancer surgery, but the Imiquimod is a good alternative for diffuse superficial skin cancers and actinic keratosis, which is a precursor of squamous cell carcinoma.
While these treatments are under investigation, more traditional treatment methods remain effective and appropriate for many basal cell carcinomas. These include Mohs surgery, simple excision, cryotherapy, and radiation therapy:
Mohs cancer surgery with reconstruction continues to be the gold standard for treating basal cell carcinoma of the eyelids. This treatment option, named after general surgeon Frederic Mohs who developed the life-saving medical procedure, involves a team approach and microscopic examination of the excised tissue. This method has a very high cure rate and preserves the most amount of normal eyelid tissue. Immediately following the removal of the skin cancer, your eyelid reconstruction should be performed.
Surgeons have found that a simple escision is very effective for localized basal cell carcinoma. By taking a margin of normal tissue around the lesion, it is possible to completely excise the skin cancer. Mohs surgery usually incorporates this approach into a comprehensive treatment.
Cryotherapy is a method that freezes the basal cell carcinoma with liquid nitrogen. This method can be effective for small lesions but requires monitoring of the treated area due to the risk of reoccurrence. This approach is considered on a case-by-case basis and is something to discuss with your doctor to find out whether you are a candidate.
Radiation therapy is effective, but it is associated with reoccurrences and can cause local tissue damage to the surrounding tissue. However, for select circumstances and individuals, this can be an appropriate treatment option.
All of the treatment methods outlined here should be considered on an individual basis with an experienced doctor who will help you receive the best treatment for you. For many people, eyelid surgery is an important part of treatment for basal cell carcinoma, which is why an eye plastic surgeon often plays a very important role in your recovery.
About Dr. Steinsapir
Dr. Steinsapir is a much sought after oculofacial surgeon. He is an innovator in minimally invasive cosmetic and reconstructive procedures and has invented new methods for treating with BOTOX, Fillers and cutting edge facial surgery. He specializes in high precision eyelid surgery and is a leader in correcting prior facial and eyelid surgery, including prior cancer reconstruction. He attended medical school at the UCLA and completed ophthalmology residency at The University of Chicago. He is multiple fellowship trained including three years of fellowship training in oculofacial plastic surgery at UCLA, and a two year cosmetic surgery fellowship in Rancho Mirage. He is widely published and lectures to other surgeons nationally and internationally. He is an associate clinical professor of Ophthalmic Plastic and Reconstructive Surgery at the Jules Stein Eye Institute at UCLA. His private practice is located in West Los Angeles, immediately serving the Los Angeles and Bevery Hills communities. Additionally, individuals from all over the country and the world regularly come to Los Angeles for this expert care.
Skin cancer is very common and for the most part is the result of chronic sun exposure. The three most common forms of skin cancer include basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. By far the most common one is basal cell carcinoma. This type of skin cancer is seldom fatal; however, it can cause extensive local destruction and if neglected, it can cause enough damage that leads to life threatening complications. Fortunately, diagnosed early, it can be treated successfully with a variety of methods. However, when it involves the eyelid, the challenge is to completely excise the cancer, yet preserve as much of the eyelid structure and function as possible. Mohs’ cancer surgery for basal cell carcinoma of the eyelid, has become the preferred method for accomplishing this task. This specialized surgical technique, developed by general surgeon Frederic Mohs at the University of Wisconsin, has a very high cure rate for skin cancers like basal cell carcinoma and others. This surgery focuses on the microscopic examination of the excised tissue, and it has radically changed how eyelid cancers are managed.
Basal cell carcinoma is the skin cancer that most commonly affects the eyelids, and the lower eyelid is most commonly affected. Skin cancer has the potential to disfigure the eyelids, and often does. When the eyelid is affected by skin cancer, the primary goal is of course to remove the immediate threat of the cancer before it spreads or worsens. Early intervention improves your chances of being cured, and in all cases surgical excision is key to eliminating or at least controlling the cancer. Of the different types of skin cancers that affect the eyes, basal cell carcinoma is unlikely to spread or metastasize to a distant site, but it does damage local tissue without treatment.
The Importance of Definitive Treatment
The best eyelid skin cancer treatment involves an expert team of physicians. The traditional method is to have an eye plastic or general plastic surgeon remove the cancers, then have a pathologist examine the edges of the removed tissue through frozen sections. This method has a high success rate, but there is another team approach with even better eyelid cancer prognosis. In this method, a dermatologist surgeon who specializes in Mohs cancer treatment excises the tumor or cancer and an oculoplastic surgeon like Dr. Steinsapir reconstructs the eyelid. This team physician approach enables you to receive the best, most specialized treatment for each component of your surgery. We typically see at least the following three benefits with this process:
- Although both have very good outlooks, the Mohs surgery success rate is much higher than frozen section control.
- Mohs surgery reconstruction preserves more of healthy surrounding tissue. Since the eyelids and tearducts are crucial to the function of our eyes, and because their arrangement is a key part of our aesthetic appearance, conserving as much tissue as possible improves both functionality and aesthetics.
- Mohs surgery recovery time is faster because the least amount of normal tissue is removed when the skin cancer is excised.
Reconstructive Surgery after Cancer
Reconstructive eyelid surgery benefits many people who may not initially be aware that their results can be improved. Often the closure performed at the time of surgery may be the best compromise at the time, the operating physician does not specialize in eyelid reconstruction, or the reconstruction needs to occur in multiple stages. Benefiting from additional reconstructive surgeries after your cancer is initially removed in no way reflects poorly on the first surgeon. Given the nature of cancer, the first concern is always to eliminate it, and this often presents obstacles to your functional and aesthetic needs. Your doctor made decisions based on the dangers you faced and likely chose the best option. If only one surgeon performed your procedure, you may have had a great specialist in skin cancer removal who did not specialize in eyelid reconstruction. If your cancer is gone, your first surgeon clearly did a commendable job.
However, this does not mean that you can’t seek a new opinion on whether you’ll benefit from further eyelid reconstruction. Some may fear that they’ll appear vain or ungrateful if they’re dissatisfied with the face cancer has left them. This is not the case. You have survived cancer, and it is fair and understandable that you want to feel, look, and function at your best. It’s important to understand the healing stages of cancer surgery when considering reconstructive options; while we don’t want to downplay the benefits of a great initial closure, we also recognize that different options open up at each stage during and after healing. In time, the body repairs the microcirculation in the operated area, enabling deficiencies to be reassessed and corrected or improved with revisional surgery.
Make Us a Part of Your Healing Experience
Often a fresh perspective can vastly improve a situation that previously seemed to have very few options. Dr. Steinsapir, a Los Angeles oculoplastic surgeon, customizes eyelid reconstruction on an individual basis by combining scientifically proven methods with his artistic vision and extensive experience. He frequently collaborates with other specialized physicians to deliver the best Mohs treatment possible. Many also find that after surgery, a second opinion from Dr. Steinsapir is very helpful. Dr. Steinsapir’s attitude is both positive and realistic; he commends the skill and importance of doctors who do wonderful work in treating skin cancer, and to this he brings his personal specialization in eyelid reconstruction. A team approach is often the best way to meet all your needs in a complex medical situation. We invite you to a personal consultation with Dr. Steinsapir to find out how he can be a vital member of your treatment team. Contact us today to find out how Mohs surgery or reconstruction can be a part of your treatment plan.