The primary treatment for most eyelid tumors involves surgical excision or other forms of surgical removal. The type of surgical procedure chosen depends upon:
- The type of cancer (squamous cell carcinomas require a larger margin of excision and possibly adjuvant therapy, compared to basal cell carcinomas)
- The tumor characteristics:
- Primary or recurrent nature of the tumor
This type of resection involves the complete removal of the tumor with a margin of healthy tissue. The size of the margin may be anywhere between 3-15 mm – this depends upon the grade of the tumor and its associated risk factors. Small tumors with a low risk of recurrence, metastasis or local spread are suitable for local resection with a margin.
This is often the only treatment needed except in the case of a melanoma. If the excisional biopsy successfully removes the whole of the tumor, as seen by the intact margins, no further therapy is needed. It is usually performed on an outpatient basis but may be done in a hospital, under local anesthesia. Once the tumor is removed, it is sent for histopathologic examination. Wound closure or eyelid reconstruction may be necessary depending upon the size of the defect. The scar usually fades with time.
This procedure is also called Mohs micrographic surgery. It produces the highest rates of cure among all surgical procedures. It is usually done under local anesthetic, on an outpatient basis.
Its indications include:
- Aggressive tumors
- Large tumors
- Recurrent tumors or those which are likely to recur
- Tumors occurring after radiation
- Tumors in immunosuppressed patients
- Tumors with ill-defined borders
- Invasion of bone or cartilage
Here, the tumor is removed with a thin surrounding layer of tissue. The wound is temporarily bandaged while the surgeon marks the sample for further orientation. Then the surgeon visits the histopathology laboratory for a full tissue examination under the microscope to make sure the margin is free of cancer. The sample is mapped to the eyelid so that the location of any tumor cells found can be accurately achieved and deeper excision performed at that site alone.
This is repeated as needed until the margins are confirmed to be free of tumor cells. This technique conserves the maximum amount of healthy tissue but ensures that all cancerous tissue is removed. However, this procedure is not performed at all centers. Wound closure may be by primary or secondary intention, or may require reconstruction.
Side Effects of Surgical or Mohs Excision
These are uncommon but may occur either early or late. Some may be permanent.
- Pain: surgery may injure one or more nerves to the eyelids and may cause nerve pain. This may appear later and may be slow to resolve. It is controlled with pain medication.
- Edema of the treated area: this may happen if the area is extremely thin, and is more likely if the wound was closed by a graft or a skin flap.
- Bleeding: while mild blood discharge is normal, it should not exceed the normal.
- Infection: wound infection may occur despite the use of antibiotics. Signs of infections include erythema, pus, foul-smell, swelling or tenderness in the area and fever.
- Scarring: this is common but usually transient.
Curettage and Electrodissection
This surgery uses heat to ablate cancerous tumor tissue while sealing off blood vessels. Following this, the dead tissue is scraped away. It is sometimes used to remove small (less than 2 cm) basal cell carcinomas near the surface, or in situ squamous cell carcinomas. It is usually not used for eyelid tumors because of the lack of tissue diagnosis following an ablative procedure, and the high recurrence risk.
It is done under local anesthetic, and without significant disfigurement.
This involves removal of all the structures within the socket of the eye, and is usually recommended when a tumor of the eyelid spreads locally.
Lymph Node Removal
This is intended to cut off the spread of tumor cells through the lymph nodes. If a cervical node alone is enlarged it will be dissected out and examined for the presence of cancer. Other nodes that may be involved include the axillary, inguinal, iliac and cervical nodes. This is more important with Sebaceous gland carcinoma (SCC) and Merkel cell carcinomas (MCC).
Side effects include lymphedema of the upper limb due to damage of the normal lymphatic drainage from this part of the body. This is both prolonged and uncomfortable.
Surgical techniques of reconstruction aim to restore normal appearance to the eyelids. They may use a skin graft, or a flap tunneled under the skin to the eyelid, to close a large wound or when the remaining skin is too denuded.
Reviewed by Afsaneh Khetrapal BSc (Hons)