Pick your poison
If I were able to choose which type of skin cancer (non-melanoma) I had to have on my eyelids, I would choose them in the following order:
1. Basal cell carcinoma (BCC). In general, BCC is a slow-growing tumor that doesn’t metastasize to other parts of the body; all of damage is done to the surrounding tissue as the tumor slowly expands. This growth can occur over decades. Not all BCCs are the same however: some are nodular (forming little growths that are easily identified) and usually are straightforward to remove and repair, provided they are not too advanced. However, others tend to grow outward much more subtly (morpheaform), and the true extent of tumor can be several times larger than what it appears clinically. These can be quite difficult to cure. All BCCs are bad news when they are located on the inner corner of the eyelids — in this location, they are harder to cure because they can sneak into the eye socket, or down along the tear duct into the nose. Unfortunately, I’ve had a handful of patients that I have cared for with this difficult subtype.
2. Squamous cell carcinoma (SCC). These are usually slow-growing, and they usually don’t metastasize, but they can. The big problem with SCCs is that they often grow along nerves in a way that is almost undetectable. So the true extent of the tumor can be much larger than it seems. When advanced, these tumors can sneak back into the eye socket and then back into the brain in an almost undetectable manner. They can grow rapidly in people who have weak immune systems, for example, those on powerful medications prescribed to prevent organ transplant rejections. However, when the tumors are small, in the central eyelid, and promptly dealt with, the cure rate is still quite good.
3. Sebaceous cell carcinoma. Sebaceous cell carcinoma accounts for less than 1% of eyelid skin cancers in Caucasians, but the mortality rate is 22%. There are three reasons that it is such a bad tumor: 1) it can look like chronic inflammation, leading to a delay in diagnosis; 2) it can grow over the entire surface of the eye in a single thin layer, undetected; and 3) it can metastasize. The old way to deal with this tumor was just to take everything out… the eyelids, the eyeball, the superficial eye socket tissue. And sometimes that is still the way to go. But in some patients, chemotherapy eye drops can be used, combined with lesser surgery. These drops (mitomycin C) are no picnic, either.
How I treat patients with these tumors
In general, after getting a biopsy confirming the diagnosis, I work in conjunction with a surgical dermatologist who uses the “Mohs” technique — they remove the tumor, leaving as much normal eyelid behind as possible. Sometimes we are surprised by the size of the tumor, and the dermatologist might have their work cut out for them. Afterwards, usually same day, I perform the reconstruction. There are many ways to reconstruct certain eyelid problems, but the basic principle is that that eyelid is like a ham and cheese sandwich: you need to reconstruct it, replacing the missing bread, ham, and cheese. Terrible analogy, but it’s what I use: you need to replace the outer lining of the eyelid, the inner “substance” of the eyelid, and the inner lining of the eyelid. And you can find suitable replacements for each of those tissues from many different sources.
Finally, a word about melanoma…
Melanoma is kind of different from these, in my mind. The very superficial melanomas can be cured by surgery alone, but once they get to a certain depth, the risk of metastasis is very high. I work with melanoma experts when I encounter patients with this type of tumor. To top it all off, dermatologists can’t reliably use the same “Mohs” technique for melanoma, which complicates their part of the treatment.