British3JournalofOphthalmology, 1992,76, 195-197 ORIGINAL ARTICLES The treatment of periocular basal cell carcinomas by radiotherapy J M Rodriguez, G P Deutsch Abstract Experience in the treatment of periocular basal cell carcinoma is described. Excellent local control rates and minimal morbidity have been achieved in a series of 128 tumours occurring in 127 patients with a minimum 3 year follow- up. The role of radiotherapy in the management of skin cancer is well established,' but the manage- ment of basal cell carcinoma of the eyelid is controversial. There is a reluctance among some ophthalmologists to refer patients for radio- therapy because of the fear of serious complica- tions and a high failure rate. This is undoubtedly due to the calamities attendant on the use of radiotherapy in the early part of this century. An analysis of a series of 127 patients treated by a standard 5-day course of outpatient superficial radiotherapy reveals a 100% local control rate with a minimum 3-year follow-up. The minor complication rate was low and there were no serious complications. The cosmetic result was generally good and probably better than surgery could have achieved, particularly when lid recon- struction would have been required for larger lesions. A review of the literature indicates comparable results. Radiotherapy provides a safe simple outpatient alternative to surgery. Anaesthesia and highly skilled reconstructive surgery can be avoided in an often elderly group of patients. Table I Basal cell carcinoma. Distribution of 128 lesions in 127 patients Site Number Percentage Upper lid 1 <1 Lowerlid 79 61-8 Medial canthus 36 28-1 Lateral canthus 12 9 3 Total 128 100 0 Table 2 Basal carcinomas of eyelids and canthi. Age incidence of cases Average age 62-5 Youngest 40 Oldest 94 52 of 127 patients (40 6%) were older than 75 years Table 3 Size of lesion by largest diameter Size <1cm 1cm 1-5cm 2-0cm 2-5cm >3 0cm Number 40 37 24 19 7 1 of lesions protected with a lead internal eyeshield (Figs 1 and 2). The majority of lesions were 2-0 cm or less in diameter and ideally suited to this particular treatment schedule. Lesions more than 3 0 cm would require more protracted treatment courses in order to achieve the best tumour control with acceptable morbidity. Table 4 shows how our Department of Radiotherapy and Oncology, Royal Sussex County Hospital, Brighton J M Rodriguez G P Deutsch Correspondence to: J M Rodriguez. Accepted for publication 29 August 1991 Materials and methods We report on a series of 127 patients referred to the Sussex Radiotherapy and Oncology Centre, Royal Sussex County Hospital, Brighton between 1974 and 1988. One hundred patients were previously untreated, eight had histologi- cally incomplete excisions, and 19 had frank post-surgical recurrences. The diagnosis was not considered in doubt by the referring clinician or radiotherapist in the eight remaining cases. Table 1 shows the regional distribution of the tumours and Table 2 the age distribution. Table 3 shows the size distribution of the lesions. All our patients were treated with a standard fractionation regimen and each lesion was treated with a dose of 3400 cGy given in five consecutive daily fractions of 680 cGy using a 90 keV beam. A minimum margin of 0-5 cm around the visible lesion was employed and the underlying eye was Figure I Showing treatment set-up and shielding of contralateral eye when irradiating a lesion at the medial canthus. 195 on September 11, 2020 by guest. Protected by copyright. http://bjo.bmj.com/ Br J Ophthalmol: first published as 10.1136/bjo.76.4.195 on 1 April 1992. Downloaded from
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British3JournalofOphthalmology, 1992,76, 195-197
ORIGINAL ARTICLES
The treatment of periocular basal cell carcinomas byradiotherapy
J M Rodriguez, G P Deutsch
AbstractExperience in the treatment ofperiocular basalcell carcinoma is described. Excellent localcontrol rates and minimal morbidity have beenachieved in a series of 128 tumours occurringin 127 patients with a minimum 3 year follow-up.
The role of radiotherapy in the management ofskin cancer is well established,' but the manage-ment of basal cell carcinoma of the eyelid iscontroversial. There is a reluctance among someophthalmologists to refer patients for radio-therapy because of the fear of serious complica-tions and a high failure rate. This is undoubtedlydue to the calamities attendant on the use ofradiotherapy in the early part of this century. Ananalysis of a series of 127 patients treated by astandard 5-day course of outpatient superficialradiotherapy reveals a 100% local control ratewith a minimum 3-year follow-up. The minorcomplication rate was low and there were noserious complications. The cosmetic result wasgenerally good and probably better than surgerycould have achieved, particularly when lid recon-struction would have been required for largerlesions. A review of the literature indicatescomparable results. Radiotherapy provides asafe simple outpatient alternative to surgery.Anaesthesia and highly skilled reconstructivesurgery can be avoided in an often elderly groupof patients.
Table I Basal cell carcinoma. Distribution of128 lesions in127 patients
protected with a lead internal eyeshield (Figs 1and 2).The majority of lesions were 2-0 cm or less in
diameter and ideally suited to this particulartreatment schedule. Lesions more than 3 0 cmwould require more protracted treatment coursesin order to achieve the best tumour control withacceptable morbidity. Table 4 shows how our
Department ofRadiotherapy andOncology, Royal SussexCounty Hospital,BrightonJM RodriguezG P DeutschCorrespondence to:J M Rodriguez.Accepted for publication29 August 1991
Materials and methodsWe report on a series of 127 patients referred tothe Sussex Radiotherapy and Oncology Centre,Royal Sussex County Hospital, Brightonbetween 1974 and 1988. One hundred patientswere previously untreated, eight had histologi-cally incomplete excisions, and 19 had frankpost-surgical recurrences. The diagnosis was notconsidered in doubt by the referring clinician orradiotherapist in the eight remaining cases.
Table 1 shows the regional distribution of thetumours and Table 2 the age distribution. Table3 shows the size distribution of the lesions.
All our patients were treated with a standardfractionation regimen and each lesion was treatedwith a dose of 3400 cGy given in five consecutivedaily fractions of680 cGy using a 90 keV beam. Aminimum margin of 0-5 cm around the visiblelesion was employed and the underlying eye was
Figure I Showing treatment set-up and shielding ofcontralateral eye when irradiating a lesion at the medialcanthus.
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local control and recurrence-free rates comparewith other radiotherapy series. Figure 3 illus-trates a typical pre- and post-treatment result.
ComplicationsIn 1948 Duke-Elder and Parsons stated that, foreyelid tumours, excision should be the rule andradiation the exception,5 however, by 1974 theseviews had profoundly altered and they con-sidered6 that 'excision or radiotherapy areprobably equally effective when efficientlycarried out.' It is undoubtedly the fearofradiationcomplications that is the main reason for prefer-ring surgery to radiation therapy. In our seriescomplications of treatment have been minimaland are listed in Table 5.Moderate skin changes and epilation are
viewed as equivalent to a surgical scar and are notconsidered as complications. Ectropion is oftenpresent before treatment and epiphora is fre-quently seen at presentation with lesions of themedial canthus. Two of our patients developedcanalicular stenoses following treatment oflesions involving the lower punctum and cana-liculus which would have required excision ofthese structures had surgery been undertaken.Mustarde78 has stated that in reconstructivesurgery of the medial canthus it is possible toremove the lacrimal passages completely withoutepiphora, which is only likely to occur in thepresence of conditions causing excessive tearformation such as a high wind, excessiveexposure of the conjunctiva, and inflammatoryconditions involving the lid margin, conjunctiva,cornea or lacrimal sac. Keratinisation of the
Table 4 Local control
No ofrecurrences NEDNo Treatment controlled by 4years or
Series irradiated failures re-irradiation longer
Brighton 128 0 93/93(100%)
Hahnemann2 444 20 2 426/444(95 9%)
RMH' 630 39 590/630(94*3%)
PMH4 1062 53 1009/1062(95%)
RMH=Royal Marsden Hospital.PMH=Princess Margaret Hospital, Toronto.
Fig 3B
Figure 3 Tumour before radiotherapy (A) and aftertreatment (B) showing excellent tumour response and goodcosmetic result.
tarsal conjunctiva occurred in 7% of cases. It ispotentially a much greater problem when thecentre of the upper lid is affected as the keratinplaque may abrade the cornea and patients mayrequire a haptic contact lens to protect thecornea.
Despite the above list of potential complica-tions the results from radiotherapy are excellentboth in terms of tumour control and cosmeticresult as shown in Table 6.
Prevention of complicationsPatients who have an eyelid tumour irradiatedinvariably develop a radiation reaction in thetreated area. While this reaction ultimatelysubsides the related bulbar conjunctiva and thecornea may be affected despite the presence of alead contact lens during treatment. Antibiotic
The treatment ofperiocular basal cell carcinomas by radiotherapy
Table 7 Surgical series
No Frozen Recurrence Localtreated section rate control
Doxanas" 165 39 0 100%7/126 94 5%
Payne etal"2 273 0 42/199 79%at 6/12
Collin' 261 0 3/176 after 95-8%primary surgery 6
deadChalfin' 53 53 0 100%Frank'° 165 165 3 97-8%
eyedrops are routinely employed to avoid anyinfection, particularly in those cases where aninternal eyeshield has been employed.
DiscussionThe results of treatment in our series reveal no
recurrences thus far in a group of patients whohave been treated in identical fashion withmeticulous attention to the treatment set-up. Forsmall lesions of TI category, of which there were101 in our series, we would argue that radio-therapy is the treatment of choice. However it isalso this group78 who are suitable for an opera-tion not requiring major plastic reconstruction.However our remaining patients, many ofwhomwere elderly, would have required plastic recon-
structive procedures with all that that entails interms of availability of the requisite surgicalskills and the surgical risks to the elderly frailpatient.
Table 7 records some of the major surgicalseries. In three of these frozen section control ofthe margins was undertaken adding considerablyto the duration of the procedure. In Collin'sseries9 71 2% of patients had either a flap or a
graft procedure, yet 96% of the lesions were Tiby stage and eminently suitable for local radio-therapy; Frank,'0 in her series employing frozensection control, used flaps or grafts in more than50% ofcases. The results ofboth radiotherapeuticand surgical treatment are similar but, in view ofthe complexity of the surgical procedures thathave to be employed even for small radiocurabletumours, we would submit that radiotherapywhen performed with meticulous attention to thetumour margins and with every care taken tominimise morbidity is the treatment of choice forthe majority of basal cell carcinomas of theeyelid, though surgery has an important role inthe management of upper eyelid lesions andextensive tumours at the medial canthus whosedeep margins may be assessable only at surgery.These tumours if they recur may spread deeplyinto the orbit and sinuses necessitating exentera-tion for cure.'4 The patients' interests are bestsafeguarded by ensuring close collaborationbetween ophthalmologists, plastic surgeons,radiotherapists, and dermatologists so thattherapeutic approaches based on a partisanapproach are avoided if possible. Each tumourmust be judged on its merits and the mostappropriate modality for each patient carefullydecided.
Recurrence after previous radiotherapy
should be treated surgically as the risk ofradiationnecrosis is excessive. However Lafontan et al'5 16using interstitial radiotherapy techniques havesuccessfully treated radiation failures, but thistechnique is not readily available and requiresconsiderable expertise.The rare lesion in the middle third of the
upper eyelid constitutes a relative contraindica-tion to radiation due to the probable risk of tarsalkeratinisation and the risk of corneal damage andwe do not routinely irradiate these lesions.However ifa lesion on the upper lid is sufficientlylarge to require an extensive plastic procedurethen radiotherapy becomes an attractive alterna-tive, as keratinisation does not invariably ensueand a contact lens may suffice to protect thecornea adequately. Ifthe eyelid tumour is relatedto a damaged or abnormal cornea the risk offurther damage to the cornea from irradiationchanges in the eyelid should lead one to considersurgery as the favoured treatment. The advancedbasal cell carcinoma with bone involvement israrely eradicated by radiotherapy and is besttreated by a course of radical radiotherapyfollowed by radical surgery.
ConclusionOur data show meticulously planned superficialradiotherapy to be a highly effective treatmentfor periocular basal cell carcinoma with excellentcontrol rates and minimal morbidity in oftenelderly patients. We do not dismiss surgery butregard surgery and radiotherapy as complemen-tary modalities.
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2 Brady LW, Binnick SA, Fitzpatrick PJ. Skin cancer. In: PerezCA, Brady LW, eds. Pninciples and practice of radiationoncology. Philadelphia: Lippincott, 1987: chapter 18, 386-9.
3 Lederman M. Radiation treatment of cancer of the eyelids.BrJ Ophthalmol 1976; 60: 794-805.
4 Fitzpatrick PJ, Thompson GA, Easterbrook WM, Gallie BL,Payne DG. Basal and squamous carcinoma of the eyelids andtheir treatment by radiotherapy. Int J Radiat Oncol BiolPhvs 1984; 10: 449-54.
5 Duke-Elder S, Parsons JH. Diseases of the eye. 11th Edition.Edinburgh: Churchill-Livingstone, 1948: 645-6.
7 Mustarde JC. Major reconstruction of the eyelids: functionaland aesthetic considerations. Clin Plast Surg 1981; 8:227-36.
8 Mustarde JC. Repair and reconstruction in the orbital region; apractical guide. 2nd Edition. Edinburgh: Churchill Living-stone, 1980: 44-8 chapter 3.
9 Collin JRO. Basal cell carcinoma in the eyelid region.BrJ3 Ophthalmol 1976; 60: 806-9.
10 Frank HJ. Frozen section control of excision of eyelid basalcell carcinomas: 81/2 years' experience. Br J Ophthalmol1989; 73: 328-31.
11 Doxanas MT, Green WR, Iliff G. Factors in the successfulmanagement of basal cell carcinoma of the eyelids.AmJrOphthalmol 1981;91: 726-36.
12 Payne JW, Duke JR, Butner R, Eifrig DE. Basal cellcarcinoma of the eyelids. A long term follow-up study. ArchOphthalmol 1969; 81: 553-8.
13 Chalfin J, Putterman AM. Frozen section control in thesurgery of basal cell carcinoma of the eyelids.AmJ7 Ophthalmol 1979; 87: 802-9.
14 Rodriguez-Sains RS, Robins P, Smith B, Bosniak SL. Radio-therapy of periocular basal cell carcinomas: recurrence ratesand treatment with special attention to the medial canthus.BrJ3 Ophthalmol 1988; 72: 134-8.
15 de-Lafontan B, Daly N, Bachaud J-M, Martinez M. Curie-therapy of palpebral epithelioma with iridium-192. Methodand results apropos of 192 cases treated at the ClaudiusRegaud Centre.I Fr Opthamol 1986; 9: 471-9.
16 Daly N-J, de-Lafontan B, Combes P-F. Results of thetreatment of 165 lid carcinomas by iridium wire implants.Intj Radiat Oncol Biol Phys 1984; 10: 455-9.
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