This is actually a bit of an odd story. A while back, my grown-up son decided to get the small lump on his lower eyelid checked out. His doc really didn’t think it was much of anything but decided to remove it. Luckily, he sent the specimen to pathology. It turned out to be a skin cancer – a basal cell carcinoma to be exact.
Fast forward, one year later
Fast forward, about a year later, I find a teensy tiny lump on my lower lid. Even though it seemed unlikely that my son and I would both have basal cell cancers of the lower lid, I decided to get it checked out.
The dermatologist I went to was sure it was just a cyst. She took a scalpel and cut it off. However, she did not send the specimen to pathology. In retrospect, this was a mistake.
Four or five months later, the little lump returned so I went back to her. Again, she didn’t think it was much of anything (an indication of how benign these things look), but she agreed to send me to the ophthalmologist for a second opinion.
What did the pathologist find?
Initially, the ophthalmologist couldn’t see the lesion even with a slit lamp. But once I pointed it out, he also thought it was just a cyst and, therefore, no big deal.
He tried to drain it with a hypodermic needle but was unable to extract any fluid. So he said, “I can take it off and send it to pathology if you like.” I agreed. He numbed it up and cut it out. It healed beautifully in a few days—no visible scar.
Well, guess what? The pathology report returned a basal cell carcinoma. The biopsy made the diagnosis.
Too weird…Like son, like mother?
What are some general characteristics of eyelid cancers?
Eyelid cancers can be difficult to recognize because they tend to grow inward. They often grow under the skin for years before finally appearing on the surface. Even when the cancer appears on the surface of the lid, its appearance may not suggest cancer.
More than 10% of people later proven to have cancer of the eyelid, initially reported only “altered appearance” of the lid, a red spot, or ingrown lashes. Luckily, most people present with a more typical “warning sign,” such as a lump or a sore that doesn’t heal.
Forty-four percent of eyelid cancers, in one study, occurred on the lower eyelid with another 20% in the area of the medial canthus (see graphic below).
Why types of skin cancers appear on the eyelid?
The eyelid area is a common site for skin cancers. In fact, eyelid cancers account for about 5-10% of all skin cancers. Most non-melanoma skin cancers have low rates of spread (metastasis). But when they occur around the eye, they can wreak havoc because the skin is thin in this area. The tumor can, therefore, affect nearby tissues, such as the bony orbit or nasal cavities.
Non-melanoma skin cancers of the eyelid
Basal cell carcinoma (BCC) is the most common type of skin cancer that occurs on the eyelid. In non-Asian countries, it accounts for 85–95% of all eyelid cancers. Most cases involve the lower eyelid and inner canthus. It usually occurs in adults and almost always as a solitary lesion. It is usually painless but can be accompanied by the loss of lashes.
The most common type of basal cell carcinoma is called nodular. It appears as a raised, firm, pearly nodule. If you look closely you may see small spidery blood vessels on its surface (telangiectasia). These lesions can ulcerate as they grow larger.
Basal cell carcinomas are unlikely to metastasize (spread to lymph nodes or distant organs). However, they can spread locally and cause significant damage to the eyelid and surrounding structures. Also, they can recur in the same area or nearby if the entire tumor is not removed. The margins of the excised tumor must be clear of cancer. Prolonged exposure to ultraviolet (UV) light is the most important risk factor.
Squamous cell carcinoma (SCC) is a relatively uncommon cause of eyelid cancer comprising only 5% of all eyelid cancers. However, it is more aggressive than BCC. It can spread to nearby lymph nodes and other parts of the body.
SCCs mainly affect older fair-skinned people. As is true with basal cell lid cancers, one of the main risk factors is exposure to UV light. Further, it may arise from pre-existing skin lesions, such as:
- actinic keratosis
- xeroderma pigmentosa
- carcinoma in situ
- following radiotherapy
Surgical removal is the primary treatment for this type of eye cancer. Radiation therapy or other treatments may be used in addition to surgery if a large area is affected or if the tumor cannot be fully removed.
Sebaceous carcinoma (cancer of the oil glands) is a rare type of eye cancer that affects the meibomian glands of the eyelids, conjunctiva or other ocular surface structures. These glands normally produce the oily layer of the tear film, the liquid layer that covers the eye.
It can be mistaken for a stye (a non-cancerous lesion of the eyelid that is also called a chalazion). If a stye does not heal with medical treatment or surgical drainage, it should be biopsied.
Treatment requires surgical removal. The defect in the eyelid can be reconstructed afterward using various techniques depending on the size and location of the tumor. Sometimes topical chemotherapy is used after the surgical area has healed.
Melanoma skin cancers of the eyelid
Melanoma is a potentially life-threatening type of skin cancer. Luckily, it accounts for only about 1% of eyelid cancers. This type of cancer can affect the eyelid skin or the conjunctiva (the tissue that covers the white part of the eye).
Like SCCs, this cancer occurs primarily in older fair-skinned individuals. It may occur de novo or it may evolve out of an existing pigmented lesion that grows and changes its shape and color.
It is very aggressive and may present with early metastasis in the nearby lymph nodes that drain an eyelid or conjunctival melanoma. Sentinel lymph node biopsy can help stage melanomas of the eyelid and conjunctiva.
MOHS Surgery is the treatment of choice for non-melanoma skin cancers
Although many people will have eyelid lumps and bumps removed by standard surgery, the treatment of choice for basal cell and squamous cell carcinomas is MOHS Micrographic Surgery (microscopically controlled surgery). This is because it can best preserve the complex and delicate structures around the eye.
The procedure is done in stages by specially trained surgeons in an outpatient surgical suite with laboratory facilities. A small layer of tissue is resected and examined under the microscope to see if there is any suggestion that cancer cells may still be in the skin. If so, the surgeon removes another small layer of tissue from the area where the malignant cells remain. The procedure is continued until all evidence of the cancer is removed.
Because it is done in stages, with careful dissection and examination, the amount of tissue removed is the smallest amount possible that allows for complete resection of the cancer. Cosmetic results are usually quite good.
Recurrence after standard surgery or radiation treatment is between 5-30% but falls to 2% or less after MOHS surgery.
Preventing eyelid cancers
A major contributor to eyelid cancers, as is true of all other skin cancers, is UV radiation (both UVA and UVB). Prescription eyeglasses and sunglasses with UV protection are important prevention measures.
So is the application of sunscreen. Be careful though, as anyone who has ever gotten sunscreen in their eyes knows that this can be irritating at best and painful at worst.
The bottom line
If you find a lump, bump, red spot, or sore that won’t heal in the eyelid area, you should make an appointment with a dermatologist or ophthalmologist.
If they say, “no big deal,” ask them to cut it off anyway. Be sure to tell the doctor that you want it sent to pathology.
Is this overreacting? I don’t think so. Eyelid cancers are tricky, risky, and, for the most part, completely curable if caught early and treated appropriately.
Originally published on October 19, 2011, this post was updated by the author on 5/7/17 and again on 4/22/2020.
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