domingo, 25 de noviembre de 2018

Eyelid Cancer Non-Surgical Treatments

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By Liji Thomas, MDReviewed by Afsaneh Khetrapal, BSc

Treatment of an eyelid cancer may be surgical, or via one of several non-surgical options. The decision as to which one to choose requires that several factors be taken into consideration, including:

Patient age
Previous medical history
Present state of health
Importance of cosmetic preservation
Tumor characteristics:
- Number of tumors
- Size of lesion
- Borders - well-defined or not
- Site of tumor
- History of previous radiation
- High or low-risk characteristics

In some patients, surgery may be ruled out for various reasons, or may not be sufficient. In these patients, the options available include:

Cryosurgery

This involves the use of extremely low temperatures to treat basal cell carcinomas with low-risk characteristics, such as a small diameter and a well-defined border. Its use in eyelid cancers is rare because of the higher rate of recurrence. It is useful as an adjuvant to surgical removal of sebaceous gland tumors which show epibulbar or pagetoid extension, because in such cases it may mean not having to perform orbital exenteration.

External Beam Radiation Therapy

This modality is used for various indications:

Preventing unsightly eye defects and minimizing the need for reconstruction
Removal of recurrent tumors
Removal of extensive tumors which present too technically challenging, or which cannot be adequately removed by surgery
Frail patients for whom surgical or other routes of non-surgical treatment are not suitable
It may be used to shrink the tumor for future surgical excision in sebaceous gland carcinoma (SGC). In general, it may help in treating SGC which has spread locally or into the orbital bone.

Radiation is used as the primary mode of therapy in a few basal cell carcinomas, such as for very large tumors, or for palliation of pain or other symptoms caused by such tumors. It is also offered as adjuvant therapy when the margin of excision is found positive, or when there is evidence of perineural invasion of the tumor.

Adverse Effects of Irradiation

These include:

Keratinization of the conjunctiva leading to dry eye
Eyelid atrophy
Necrosis of the irradiated skin
Loss of lashes
Telangiectasia of the lid
Ectropion
Cataract
Corneal damage

It does not yield a pathologic diagnosis as no tissue is obtained. Thus it does not determine the type of tumor present or confirm its complete removal. Irradiated tissues are prone to poor healing, making future treatment more difficult to treat in case the tumor recurs. The worst complications which occur in relation to radiation follow treatment of large upper eyelid tumors.

Topical Chemotherapy

This modality is used to treat low-risk basal cell carcinomas of the eyelid and in-situ squamous cell carcinoma (SCC), which is also called Bowen’s disease. The drug used is 5-fluoro uracil.

It is also tried for sebaceous gland carcinomas (SGC) of the eyelid with pagetoid invasion. Topical mitomycin C is usually used in this type of tumor. In any case, the patient needs to be followed up closely because of the possibility of persistent tumor when cells are deep under the skin.

Proton electron irradiation is not very useful.

Laser Surgery

This involves ablating the tumor tissue with the use of a beam of intensely focused collimated light energy. This is currently only used in the treatment of small tumors.

Systemic Chemotherapy

This treatment is used only rarely since the two commonest types of eyelid cancer do not spread to distant organs. The most aggressive tumor in this group is the SCC, and if metastasis occurs, systemic chemotherapy may be used to slow the growth of the tumor. Drugs used in such a case include:

Cisplatin
Doxorubicin
5-fluorouracil
Mitomycin C

Photodynamic Therapy

This uses the energy of light in combination with light-sensitizing medications to destroy superficial low-grade basal cell carcinomas.

Biologic Therapy

The use of biologic agents such as imiquimod is seen only in superficial basal cell carcinomas, but is still rare. Like topical chemotherapy, the patient requires subsequent monitoring for possible recurrences from buried tumor cells under the skin.

Targeted Therapy

This modality of treatment uses drugs such as vismodegib which target tumor cells by specific cell cycle antigens to disrupt tumor cell growth and division. It may help to treat some cases of advanced or metastatic basal cell tumors which are not suited to other conventional treatment options.