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Corneal Invasion by Basal Cell Carcinoma

Mechel, Elzbieta M.D.*; Tran, Ann Q. M.D.; North, Victoria S. M.D.; Kazim, Michael M.D.

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Ophthalmic Plastic and Reconstructive Surgery: March/April 2022 - Volume 38 - Issue 2 - p e63
doi: 10.1097/IOP.0000000000002036
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CASE PRESENTATION

A 68-year-old man suffered with a basal cell carcinoma of the right lower eyelid, with features of the morpheaform and nodular types, treated by report with clear margins on Mohs resection and primary closure. Nine years later, an invasive recurrence involved the lateral canthus and lacrimal gland, producing restrictive strabismus. There was no radiographic evidence of orbital invasion. A Mohs resection, clearing the skin and conjunctiva, resulted in an 80% upper and 90% lower eyelid defect, exposing the anterior zygoma and the lateral 180° conjunctival defect (Fig. 1A). However, the region of the lacrimal gland was not cleared by Mohs surgery, and at the time of reconstruction, an intraoperative frozen section of the lacrimal gland demonstrated myoepithelial cells concerning for malignancy, prompting complete resection of the gland. The surrounding orbital fat and soft tissue were histologically clear of tumor. The lower eyelid was reconstructed with a hard palate graft and a myocutaneous advancement cheek flap anchored to the orbital rim. The upper eyelid was reconstructed with advancement of the remnant levator aponeurosis, Müller muscle, and conjunctiva, surfaced with a postauricular skin graft. Postoperatively, a PROSE lens (BostonSight, Boston, MA) was employed to maintain corneal integrity. One year later, the patient developed a second recurrence, treated with vismodegib, which produced clinical and radiographic tumor control but drug intolerance prompted its discontinuation. Eight months later, a third recurrence required re-excision of the tumor, which involved the lateral conjunctiva and extended to the anterior orbit. The area was repaired with a buccal mucosal graft. Globe preservation precluded achieving tumor-free margins. Postoperatively, the patient received 6 cycles of cemiplimab, which failed to suspend tumor progression. He was subsequently treated with sonidegib for a total of 11 months, which also failed to control the tumor, producing a palpable mass in the lower lid, cicatricial ectropion, and an adduction deficit (Fig. 1B). Neuroimaging demonstrated soft-tissue hyperintensity indicative of persistent tumor of the eyelid (lateral canthal infiltration indicated by the arrow) also involving the globe (Fig. 1C). The patient ultimately underwent orbital exenteration. Final pathology revealed invasive basal cell carcinoma, with corneal infiltration (Fig. 1D, E).

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FIG. 1.:
Mohs resection of the initial recurrence of basal cell carcinoma resulted in an 80% upper eyelid defect and 90% lower eyelid defect (A). Following subsequent recurrences and prior to exenteration, a palpable mass was evident in the lower eyelid causing a cicatricial ectropion (B). Neuroimaging revealed lateral canthal infiltration of tumor, as indicated by the arrow (C). Histopathology of the exenteration specimen demonstrated basal cell carcinoma invading the corneal surface (hematoxylin and eosin stain 60× and 600×) (D, E).
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