Recurrence Following Globe Sparing Excision for Basal Cell Carcinoma with Anterior Orbital Invasion

Abstract

Purpose: Globe-sparing excision for periocular basal cell carcinoma (BCC) with orbital invasion has evident benefits, but the ensuing morbidity and characteristics of recurrence are not well elucidated. This study aims to describe the extent of visual morbidity following globe-sparing excision, and the clinicoradiological characteristics of tumor recurrence. Methods: Multicentre retrospective case series. Results: Eight patients were identified for inclusion in this series. Time to recurrence following globe-sparing excision ranged from 3 to 12 years. Seven patients (87.5%) presented with recurrent disease originating from the medial canthus. Clinical features at presentation included contracture (n=4, 50.0%), upper lid ptosis (n=3, 37.5%), a palpable mass (n=2, 25.0%), and hypoesthesia (n=2, 25.0%). Radiologically, tumor recurrence was predominantly characterized by isointense signals on T1 and T2-weighted sequences (n=5, 62.5%) with moderate contrast enhancement. The most common histologic subtype in recurrent tumors was a mixed nodular and infiltrative growth pattern (n=5, 62.5%). Perineural invasion was a feature in four (50%) cases. Salvage therapy in the form of exenteration was performed in seven cases. Vismodegib and adjuvant radiotherapy were provided for one case with surgically unresectable tumor recurrence. Conclusions: Globe-sparing excision for invasive periocular BCC can be complicated by late recurrence that develops rapidly despite silent neuroimaging for years. Early clinical signs are subtle. High-risk features predictive of recurrence include medial canthus location, mixed histological subtypes, and perineural invasion. Patients with such characteristics require lifelong clinical and imaging surveillance following globe-sparing excision.

Advanced Periocular Basal Cell Carcinoma with Orbital Invasion: Update on Management and Treatment Advances

“…We have found a higher incidence of tumors located in the medial canthus (66.6%); similar to what has been reported in other works (56.2% in Leibovitch et al [8], 90% in Madge et al [9], 62.5% in González et al [6], and 87.5% in Tong et al [11]. Tumors located in this area and in the lateral canthal area present a greater propensity to recurrence and orbital invasion, as has also been indicated by other authors [8,25,[29][30][31], since the proximity of the skin to the periosteum in the medial and lateral canthal area is a factor that can predispose to orbital invasion.…”

“…Some authors [ 23 ] indicated years ago that an incomplete excision can contribute to the development of a more aggressive tumor, since the fibrosis caused by the scar can prevent malignant cells from migrating to the surface, therefore favoring its extension in depth, hindering its control, and delaying clinical detection of recurrence (Figures 3(a) , 5(d) , and 5(g) ). Previous recurrence is the main risk factor in subsequent recurrences, increasing by more than 50% after a third intervention [ 11 , 12 , 24 ]. Most of the cases with orbital invasion in our work were recurrent tumors (70.8%), due to incomplete excisions or previous nonsurgical treatments that prevented negative margins from being verified, as occurred in 82.3% (14/17) of them.…”

“…Clinical signs that suggest orbital invasion have been identified, such as limitation of ocular motility, displacement of the globe due to mass effect, eyelid immobility, fixation of the tumor to the orbital rim, and sensory changes [ 5 , 8 , 9 , 11 , 32 , 33 ]. We found, as the most frequent sign, a visible or palpable mass in 91.6% of the patients, similar to what was found by Madge et al [ 9 ] (90%) or by Leibovitch et al [ 8 ] (100%), and sometimes fixed to bone (10/24) (41.6%), in addition to eyelid retraction or immobility.…”

“…Another treatment, radiation therapy (RT), is less effective than surgery and carries considerable risk of ocular toxicity [ 8 , 13 , 14 ]. In select cases with anterior orbital invasion, conservative tumor excision preserving the eyeball, with or without adjuvant RT, has proven to be pathway a viable alternative [ 8 , 9 , 11 ].…”

“…It can often be clinically silent, which makes it necessary to be alert to high risk tumors [7]. Risk factors include multiple recurrences, large tumor size, positive surgical margins, aggressive histologic subtype (morpheiform/sclerosing, infltrative, basosquamous cell), location in the medial or lateral canthal area, advanced age of the patient and perineural invasion (PNI), present in less than 1% of cases [5,[8][9][10][11].…”