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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 3  |  Page : 205-207

Cryotherapy for a morpheaform basal cell carcinoma: A 5-year follow-up


1 Eye Microsurgery and Laser Centre, Thiruvalla, Kerala, India
2 Department of Ocular Pathology, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Web Publication2-May-2017

Correspondence Address:
Amita Verghese
Eye Microsurgery and Laser Centre, International Complex, Thiruvalla - 689 101, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_24_17

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  Abstract 

The purpose of this article is to highlight that cryotherapy is an effective, noninvasive, and simple treatment modality for basal cell carcinoma of the eyelid, especially if the tumor size is small. Cryotherapy is not recommended for basal cell carcinomas of the morphea type; however, the treatment was successful in this patient of ours. We present here a case of morpheaform basal cell carcinoma of the lower eyelid which improved after cryosurgery and showed complete resolution at 5-year follow-up.

Keywords: Basal cell carcinoma, cryotherapy, eyelid, morpheaform


How to cite this article:
Verghese A, Joseph V, Biswas J. Cryotherapy for a morpheaform basal cell carcinoma: A 5-year follow-up. Kerala J Ophthalmol 2016;28:205-7

How to cite this URL:
Verghese A, Joseph V, Biswas J. Cryotherapy for a morpheaform basal cell carcinoma: A 5-year follow-up. Kerala J Ophthalmol [serial online] 2016 [cited 2020 Apr 1];28:205-7. Available from: http://www.kjophthal.com/text.asp?2016/28/3/205/205424


  Introduction Top


There are several histological presentations of basal cell carcinoma, of which the morpheaform is usually the most aggressive variety. Cryotherapy is a simple, cost-effective procedure used for small-sized, well-defined basal cell carcinomas with excellent results.[1]

Recommended treatment for the morphea type of basal cell carcinoma is a wide surgical excision.[2] Tuppurainen treated four cases of morpheaform basal cell carcinoma of the eyelid and periocular region by cryotherapy with a 50% recurrence rate.[3] We present here a case of morpheaform basal cell carcinoma who completely recovered with cryosurgery at 5-year follow-up.


  Case Report Top


In 2010, a 43-year-old male presented with a history of painless swelling on the left lower eyelid which he had noticed for the past 6 months. He had itching over the region for which he was applying steroid eye ointment, but there was no symptomatic relief.

On examination, his best-corrected visual acuity was 6/6; N6 in both eyes and rest of the ocular examination was within normal limits. There was a flat indurated lesion on the lower lid of the left eye involving the central 15 mm length of the lid margin with a width of 5 mm and a distinct border. It did not involve the fornix, there was no fixation to periosteum, and there was no loss of sensation over the area [Figure 1]a. General and systemic examinations were within normal limits including the absence of regional lymphadenopathy.
Figure 1: (a) Pretreatment photograph at presentation on January 1, 2010, showing a 15 mm lesion at margin of the lower lid. (b) Appearance of the lesion site after the first sitting of cryosurgery (January 11, 2010). (c) After the second sitting of cryosurgery (January 25, 2010). (d) At 5-year follow-up - normal appearance of lid margin (February 27, 2015)

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An excision biopsy was performed and the sample was sent for histopathological examination. It was diagnosed as basal cell carcinoma. The patient was counseled to undergo either a surgical excision or cryosurgery of which he opted for the latter. At the first sitting of cryosurgery, a second biopsy was performed and he was sent to an ocular pathologist for an expert opinion. It was reported as morpheaform basal cell carcinoma involving healthy margins [Figure 2]. After 2 weeks of the cryosurgery, the patient showed improvement; therefore, a second sitting of cryosurgery was performed. After the second sitting of cryosurgery, the patient was referred to undergo surgical excision at a center with facility for frozen section control. However, he returned at the end of 1 month with the lesion considerably reduced in size to 4 mm × 2 mm, therefore a third cryosurgery was performed. Subsequently, he was lost to follow-up. He came to our center 5 years later in February 2015 with a completely healed lesion and normal-looking lid [Figure 1]b,[Figure 1]c,[Figure 1]d.
Figure 2: Microphotograph showing peripheral palisading with fibrotic and inflammatory cells in the intervening stroma and underlying fibers containing tumor cells. Margins are involved (H and E, x 200)

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Surgical procedure

Nitrous oxide gas as a freezing agent along with the Appasamy Cryo Surgical Unit with a probe diameter of 2.5 mm was used for the procedure. The freezing temperature obtained at the tip was −80°C. The local area was infiltrated with 2% lignocaine hydrochloride, and 4% lignocaine drops were instilled in the conjunctival cul-de-sac. A lid spatula was used on the conjunctival side to lift the lid away from the globe and to allow the probe to press onto it for the maximum effect. Three cycles of fast freezing and slow thawing were applied around the tumor including a safety zone of 3 mm around it. The application time was 60 s. Overlapping areas were used as a safety factor.


  Discussion Top


The aim of treatment for basal cell carcinoma is to completely cure patients with tumor because treatment of recurrences could be difficult.[1] Cryotherapy is a simple, cost-effective procedure which has minimal side effects and excellent cosmetic results.[4],[5] The eyelid structures including the lid margin, tarsal plate, basal membranes of the epithelium, vessel walls, and the lacrimal passages are not damaged due to the procedure.[5] Tissue destruction is caused by rapid freezing leading to sudden loss of heat and vascular stasis and cell death. It selectively destroys epithelial components while preserving the mesenchymal tissue which helps in tissue regeneration and healing takes place with minimal tissue contracture.[2],[6]

It is recommended for well-defined lid of 10 mm or less in size, but Pasquali has found it effective even in tumors as large as 25 mm.[1],[5] It can also be used to reduce the size of large eyelid tumors before surgical excision, especially in debilitated old patients or those with systemic comorbidities, in lesions involving the lacrimal system, and patients who refuse surgery.[5],[7]

Buschmann used the contact cryoprobe technique to treat basal cell carcinomas of the eyelid and reported a recurrence rate of 5.1%, at 5-year follow-up.[5]

Side effects of cryosurgery include permanent destruction of eyelashes which is more significant or the upper lid as compared to lower, overgrowth of conjunctiva onto the lid margin and transient hyper- or hypo-pigmentation of the skin, and rarely scaring especially in the medial canthal area.[1]

In guidelines for basal cell carcinoma treatment, cryotherapy is not recommended as a treatment modality for morpheaform basal cell carcinoma.[1] However, in our patient, cryosurgery for morpheaform tumor was effective as seen at the 5-year follow-up of the patient. The lid margin continuity and skin color were normal, and the patient was asymptomatic [Figure 1]d.


  Conclusion Top


This is an isolated case report with a favorable outcome which does not provide evidence-based conformation for the efficacy of cryotherapy for well-defined, small-sized morphea-type basal cell carcinoma lesions; however, it does provide an alternate nonsurgical treatment method in selected patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lindgren G, Larko O. Cryosurgery for eyelid basal cell carcinomas: A practical guide. In: Pasquali P, editor. Cryosurgery: A Practical Manual. New York, Dordrecht London: Springer-Verlag Berlin Heidelberg; 2015. p. 238-42.  Back to cited text no. 1
    
2.
Telfer NR, Colver GB, Morton CA; British Association of Dermatologists. Guidelines for the management of basal cell carcinoma. Br J Dermatol 2008;159:35-48.  Back to cited text no. 2
    
3.
Tuppurainen K. Cryotherapy for eyelid and periocular basal cell carcinomas: Outcome in 166 cases over an 8-year period. Graefes Arch Clin Exp Ophthalmol 1995;233:205-8.  Back to cited text no. 3
    
4.
Fraunfelder FT, Zacarian SA, Wingfield DL, Limmer BL. Results of cryotherapy for eyelid malignancies. Am J Ophthalmol 1984;97:184-8.  Back to cited text no. 4
    
5.
Buschmann W. A reappraisal of cryosurgery for eyelid basal cell carcinomas. Br J Ophthalmol 2002;86:453-7.  Back to cited text no. 5
    
6.
Kaur S, Thami GP, Kanwar AJ. Basal cell carcinoma – Treatment with cryosurgery. Indian J Dermatol Venereol Leprol 2003;69:188-90.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Govind A, Lamba PA. Cryo surgery for lid tumors. Indian J Ophthalmol 1988;36:165-7.  Back to cited text no. 7
[PUBMED]  [Full text]  


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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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