radiation treatment of cancer of the eyelids · radiation treatment evaluates this method in the...

Brit. J. Ophthal. (1976) 6o, 794

Radiation treatment of cancer of the eyelids

M. LEDERMANFrom the Royal Marsden Hospital and Moorfields Eye Hospital, London

Eyelid cancers are not uncommon tumours and are

usually basal cell or more rarely squamous cell incharacter. Their importance lies in their specialsituation since unlike cancer arising elsewhere inthe skin they can by their natural progression or as

a consequence of the effects of treatment cause

impairment or even loss of vision. Although thesetumours are 'malignant', death of the patient rarelyresults from failure of local control, unless thedisease is very advanced or was mismanaged at theoutset. In the case of squamous cell cancer, deathmay occasionally result from metastatic spread.

It should be an obvious ethical maxim that no

patient should be submitted to a major surgicaloperation if an established and equally effectivealternative non-surgical procedure is available. Inthe case of skin cancer generally and the lids inparticular radiotherapy provides such an alternativesince its curative value has been firmly establishedduring the past 50 years. The reluctance of ophthal-mologists to advise the use of radiant energy

appears to relate to the calamities that first attendedits use by the pioneer ophthalmologists at thebeginning of this century. The story of their heritageof ocular disasters has been transmitted fromgeneration to generation ignoring the fact thatprogress in radiotherapy has been such that undermodern conditions most of the complications,particularly the more gruesomely destructive ones,

can largely be avoided. In view of this the present-

day tendency to submit patients suffering from lidneoplasms indiscriminately to simple excisional or

plastic surgical procedures without considering an

established altemative would seem unjustifiable.This report on a series of 896 patients (Table I)

seen at the Royal Marsden Hospital during theperiod 1945-70 describes some of the features ofthe natural history of lid cancer and by giving theresults, contraindications, and complications ofradiation treatment evaluates this method in thetreatment of lid cancer. The series is a relativelylarge one and the high proportion of 'previouslyuntreated' cases reflects the value of the long-standing liaison the Royal Marsden Hospital has

Address for reprints: M. Lederman, FRCR, Chairman, Divisionof Radiotherapy and Oncology, Royal Marsden Hospital, FulhamRoad, London SW3 6JJ

had with the main eye hospitals in London andalso it is to be hoped demonstrates the confidencethat many ophthalmologists have in radiotherapy.

Histological verification was obtained in 56z ofthe 630 cases of basal cell carcinoma. In most ofthe 68 cases lacking verification, a biopsy was takenbut this proved inadequate or was otherwiseunsatisfactory and by the time the report becameavailable the treatment had reached a stage whererepetition of the biopsy would have provided nouseful information.There is some doubt concerning the diagnosis of

one case of squamous carcinoma. The inclusion ofthe io per cent of patients who lack histologicalconfirmation can be excused because the clinicaldiagnosis of a basal cell carcinoma of the skin isusually easy and the response to radiation typical. Inany event this proportion of the cases is small enoughnot to vitiate the conclusions drawn from this study.Of the 689 previously untreated patients a num-

ber had had an excision biopsy before radiotherapy:some 8o patients had had an attempted primaryexcision but were promptly referred for post-operative radiotherapy because the pathologicalreport showed that removal had been incomplete.The recurrent cases comprise those patients

whose symptoms recurred after receiving someform of surgery or radiotherapy at other hospitals(I04 excisions; three excision and radiotherapy;five radiotherapy; five excision and plastic repair).These patients were referred to the Royal MarsdenHospital for treatment after frank recurrence 'hadtaken place. The patients seen and not treatedinclude those who were referred for an opinion,some who were advised to have surgery, and afew patients who refused treatment.

Table I Squamous and basal cell carcinomas ofeyelids and canthi, I945-70

Patients No.

Previously untreated cases 689Recurrent cases II7Cases seen and not treated go

Total 896

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Radiation treatment of cancer of the eyelids 795

Tables IIa, b show the regional distribution ofthe tumours in relation to their sex incidence. Thewell-known preponderance of tumours on thelower lid and inner canthus is well shown. Thebasal cell carcinomas are approximately io timesmore common than the squamous carcinomas butthe latter form a higher proportion of the tumoursof the upper lid and outer canthus. The sex ratiosare male/female: 1-23 for the basal cell carcinomasand 2-93 for the squamous carcinomas.Table III shows the age incidence illustrating the

fact that most of the patients are elderly.Table IV shows there is little of significance in

relation to site or sex: but in the basal cell carcino-mas there would appear to be a right-sided malepredominance while in females the inner canthuslesion was more common on the left side.

Topographical distributionIt is customary to divide the site of origin of lidtumours into upper and lower lid; inner and outer

Table hIa Basal cell carcinoma. Distributionaccording to site and sex (630 patients)

Site

Upper lidLower lidInner canthusOuter canthus

Total

Male

No. Percentage

45 12-9215 6i-876 21-812 3-5

348 I 00

Female Total

No. Percentage No. Percentage

29 10-3 74 1I1717I 6o-6 386 6I-377 27 3 153 24-35 i-8 17 2-7

282 100 630 100

Table IV Laterality by site and sex

Basal cellcarcinoma

Site

Upper lidLower lidInner canthusOuter canthus

Males

Left Right

i698366

29

II7406

Total I56 I92

Squamous cell carciUpper lidLower lidInner canthusOuter canthus

Total

Females

Left Right

II i885 8548 293 2

I47 134

noma8 8 I9 8 44 I 4I 5

22 22 9

2

4

6

Superior orbito- 1-polpebral sulcus

Inferior orbito- Cileary Tarsol 'Orbitalpolpebrol sulcus'-- J

Nasojugular fold---- -

Molor fold --

FIG. i Anatomical subdivisions of the lid

Table Ilb Squamous carcinoma. Distributionaccording to site and sex (59 patients)

Male Female Total

Site No. Percentage No. Percentage No. Percentage

Upper lid i6 36-4 3 20-0 I9 32.2Lower lid 17 38-6 8 53-3 25 42-3Inner canthus 5 11-4 4 26-7 9 15-3Outer canthus 6 13-6 - - 6 I0-2

Total 44 100 I5 100 59 I00

Table III Carcinomas of eyelids and canthi. Ageincidence of new cases

Basal cell Squamous cell

Male Female Male Female

Average ages(years) 6o-8 64-2 6ixo 65.5

Youngest 20 i8 34 49Oldest 87 94 87 88

canthus. However, in most early lid tumours it ispossible to be more precise with regard to theparticular part of the lid from which the tumourarises. In Fig. i the palpebral structures have beendivided into their anatomical components-that is,inner and outer canthus and ciliary, tarsal, andpalpebral parts for each lid. It has proved possibleto allocate some 8o per cent of tumours of the upperlid and go per cent of those of the lower lid to oneof these three sites of origin. For the more extensivetumours where the lid is involved for its wholeextent the term 'whole' has been used and for thevery advanced cases with involvement of the globeor orbit the term 'unclassifiable' has been employed.Table V shows the topographical distribution

according to the scheme outlined above. It can beseen that in both upper and lower lids the tarsalportion is most commonly affected but the ciliaryportion is affected three times as frequently in thelower lid than the upper; whereas in the upper lidthe orbital portion is affected nearly three timesas commonly as in the lower lid.The incidence of advanced tumours is also very



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796 British Journal of Ophthalmology

* f . . . j~~~~~~~~~~~~~~~~~~~~~~...

0~

FIG..2Loeldtmu.(a) 'c. b

FIG. 2 Lower lid tumours. (a) ciliary; (b) ciliary; (c) tarsal

FIG. 3 Lower lid tumours. (a) tarsal; (b) tarsal; (c) orbital

Table V Topographical subdivision (689 patients)

Site Basal cell Squamous cell

Upper lid No. Percentage No. PercentageCiliary I2 I6 5

Tarsal 32 43 5 25Orbital 21 28 5 25Whole 6 8 7 36Unclassifiable 3 4 5

Total 74 8o I9 20

Lower lidCiliaryTarsalOrbitalWholeUnclassifiable

Total

Inner canthusOuter canthus

Total

sii6x8943308

386

5317

630

3048I I

7

2

94

9573

8 32I5 6fI 4I 4

25 6

9 5

6 27

59

Total

No. PercentageI3 '437 4026 2713 144 5

93 100

124 30204 5044 IO3' 7

8 2

41I 100

162 IOO23 100

689

different in each lid. Nineteen per cent of theupper lid tumours are advanced (whole andunclassifiable) as opposed to 9 per cent in thelower lid. The reasons for this are possibly:

i. The greater incidence of ciliary lesions on thelower lid which are more likely to produceirritative symptoms.

2. The presence of epiphora if the lower punctumis involved.

3. On gazing directly at the eye the whole of

the lower lid is open to inspection by thepatient whereas to see the whole of the upperlid the affected eye has to be closed or the lidpulled down and inspection is therefore muchmore difficult.

Figs 2 to 6 illustrate the different topographicalsites. The differentiation between ciliary and tarsallesions is often difficult but in Fig. 2 it can be seenthat in early lesions the lashes provide a reasonablebaseline for identification. In the ciliary site thetumour is above the lashes or the lashes bisect itequally, whereas in the tarsal lesion the lash marginmay be free or if it is involved the bulk of the tumouris below this line. The separation between tarsaland orbital lesions rarely presents problems althoughwhen both parts of the lid are affected the bulk ofthe tumour is usually on one or other side of theorbitopalpebral sulcus. Loss of lashes in relation tothe tumour may occur with both tarsal and ciliarylesions, but usually the remaining lashes help inidentifying the level of origin of a given tumour.

Figs 7a, b (Mustarde' and Jones, I970) showschematically the direction and site of insertion ofthe main fasciculi of the orbicularis oculi muscle.

It is not too difficult to imagine the similaritybetween the distribution of these sphincteric fasciculiand the sites of origin of the overlying skin tumours.Equally the frequency with which the inner canthusand lower lid are involved seems to be reflected inthe manner and site of insertion of the musclefibres.



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FIG. 4 Upper lid tumours. (a) ciliary;(b) ciliary; (c) tarsal; (d) orbital

C'

C

That this should be so is within the bounds oflegitimate speculation since in other parts of thebody cancer tends to arise in relationship tosphincteric mechanisms (Lederman, I964). This isparticularly so in the case of the upper air and foodpassages where the direction taken by food andair on entering the body is controlled by a series ofstrategically situated complex sphincters. Cancerdoes not occur haphazardly in the upper air andfood passages but mainly at those sites of physio-

FIG. 5 Inner canthus.'.. .... ..-.; ...'':.'' (a) commissure free; (b) invasion oj

commissure; (c) invasion of upperlid; (d) invasion of lower lid

_L~~~~~A

logical activity corresponding to the sphinctericregions. It is suggested that a comparable relation-ship exists between the orbicularis oculi sphincterand the epithelial tumours arising from its integu-mentary covering.The occurrence of multiple lesions on the lid

which may be either synchronous or consecutive isanother feature characterizing sphincteric cancers.The multiple lesions illustrate the tendency thatexists towards 'cancerization' of the whole of a



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798 British Youirnal of Ophthalmology

....:: S n ' rFIG. 6 Outer canthus. (a) invasion of.> .: :jmlowerlid; (b) invasion of upper lid;A

..... s-.,, . ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...A B ~~~~~~~~~~~~~~~~~~~(c)invasion of canthus and lower lidextending down to the orbital part of

!;!1 ~~~~~~the lid; (d) invasion of canthus with~~~~~~~~~extension into the tarsal and orbi'talpart of the upper lid

. ~~~~~~~~~~~~~~~~~~......j.^. .. ..............................................J S ..S ... .. . C

given sphincteric mechanism. In this series therewere I9 patients with basal cell carcinoma whopresented with multiple lid tumours. Thirty-threepatients had multiple tumours involving lids andother parts of the skin, and 24 subsequentlydeveloped further skin tumours not necessarily ofthe lid.Among the squamous cancers three patients had

multiple lid tumours, four had multiple skincancers,Vand three later developed other skin tumours.

TNM classification (UICC, I974)

There is a special committee of the InternationalUnion against Cancer (UICC) (designated the FIG. 7(b) Insertions of the orbicularis oculi muscle.Committee on Clinical Stage Classification and (i) medial canthal tendon made up of superficial heads ofApplied Statistics) one of whose functions it is to pretarsal muscles; (2-2') Superciliaris and upper orbital

muscle; (3-3') preseptal muscles; (4) deep heads ofpretarsals; (5) lateral canthal tendon of pretarsal muscles;(6) lower orbital muscle (from Ophthalmic PlasticSurgery Up-to-Date, Lester T. Jo0nes)

extend the general technique of classification tocancer at all sites.Tumour classification is important and where

adopted internationally has the following advant-ages:

i.It provides a means of communication thattranscends language barriers.

1 ~~~~2.It assists in the evaluation and comparison oftreatment results.

3. It helps in the selection of treatment methods.FIG. 7(a) Orbicularis oculi muscle. (a-a') pretarsal part; 4. It aids prognosis.(b-b ) preseptal part; (c-c') orbital part Many cancer sites have been the subject of study



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by this Committee and international agreementhas been reached on some.

A classification for skin cancer has been recom-

mended by the Committee and is meant to beapplicable to tumours of the eyelids. In practice itsimplementation is difficult since it is dependent on

tumour measurements and the dimensions it selects(2 and 5 cm) as a fbasis for classification are notreadily relevant to the average lid tumour, Table VI.

In this series of cases the precise dimensions ofthe tumour were not routinely recorded since thesite and extent of the lid involvement was expressedin topographical terms so as to indicate the manner

and direction of tumour spread. However, some

idea of the size of the tumour can be obtained fromthe maximum dimension of the field size used intreatment (this usually included a minimum marginof 5 mm of apparently normal skin surrounding thelesion) (Halman and Britten, I960). Tables VIIa, bshow the distribution of the basal cell and squamouscell carcinomata according to the field sizes usedin treatment. The tumour of 3 cm or less wouldpresumably correspond to the Ti group, the 3 to 3-9

Table VIIa Basal cell carcinoma: new cases

Field size

Site

Upper lid (no.)Percentage

Lower lid (no.)Percentage

Inner canthus (no.)Percentage

Outer canthus (no.)Percentage

Total (no.)Percentage

<3 3-3*9 >4cm cm cm

2838.4'3936-29663-25

29.4

26842-8

3243.8I6643-24026-38

47-I

24639'2

13

17.87920-6i6IO-54

23 5

I 12i8-o

Total sizeunknown

73IOO-O384I00-0I 52

100I017

IOO-O

626100I0

Note: 4 cases with unrecorded field size excluded

Table VIIb Squamous cell carcinoma: new cases

Field size

Table VI TNM classification applicable totumours of the skin of the eyelid (UICC, I974)

T-Primary tumourTIS Pre-invasive carcinoma (carcinoma in situ).To No primary tumour present.Ti Tumour 2 cm or less in its largest dimension,

strictly superficial or exophytic.T2 Tumour more than 2 cm but not more than

5 cm in its largest dimension or with minimalinfiltration of the dermis, irrespective of size.

T3 Tumour more than 5 cm in its largest dimen-sion or with deep infiltration of the dermis,irrespective of size.

T4 Tumour involving other structures such ascartilage, muscle, or bone.

N-Regional lymph nodesThe clinician may record whether palpable nodes areconsidered to contain growth or not.No No palpable nodes.Ni Movable homolateral nodes.

Nia Nodes not considered to contain growth.Nib Nodes considered to contain growth.

N2 Movable contralateral or bilateral nodes.N2a Nodes not considered to contain growth.N2b Nodes considered to contain growth.

N3 Fixed nodes.

M-Distant metastasesMo No evidence of distant matastases.Mi Distant metastases present including lymph

nodes beyond the region in which the primarytumour is situated or satellite nodules morethan 5 cm from the border of the primarytumour.

Site < 3 3-3 9 > 4 Total sizecm cm cm unknown

Upper lid 7 2 10 I9Lower lid 10 15 25Inner canthus 3 4 2 9Outer canthus - 2 3 5

Total (no.)Percentage

20 23 15 5834*5 39-6 25-9 I00-0

Not: I case with unrecorded field size excluded

group to T2, and greater than 4 cm to T3 and T4.There were only three Ni cases in the squamousgroup.

Results of treatment

In assessing the results obtained in the treatmentof basal cell carcinomas the five-year survival ratecustomarily adopted as a measure of success forcancer generally is applicable with certain reserva-tions since in the head and neck basal cell carcino-mata do not metastasize and even if untreated thepatient may survive many years. A simpler andmore acceptable parameter for assessing thesuccess or failure of treatment is to base this on therecurrence-free rate. Tables VIIIa, b show this forbasal cell carcinoma of the different sites. Onlytwo patients actually died of uncontrolled disease,although in three other cases the cause of deathwas unknown.A recurrence-free rate of at least go per cent or



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8oo British Journal of Ophthalmology

Table VIlla Basal cell carcinoma. Recurrence-freerates (all sites and all patients)

Lower lid (all sites) Inner canthus

Initially at risk = 386 Initially at risk = I53

Recurrence-free Recurrence-free

Years Percentage Years PercentageI1 97.3 I 94.72 95'9 2 93-23 95*3 3 91I74 95 0 4 90-85 94*3

IO 93 7-10 None >4 None

Table VlIIb Basal cell carcinoma

All patients: upper lid (all sites)

74 initially at riskNo recurrences in a maximum period ofobservation of I5 years

All patients: outer canthus

17 initially at riskI recurrence only-within I year

more establishes the value of radiation treatmentsince unless the sample is small or case selection, or

more commonly, dubious statistical manipulationhas taken place, there is no cancer site in the bodyhowever early the lesion where a Ioo per cent cure

rate is achieved.In the case of the squamous carcinomas with their

potentialities for metastasis a different mode ofpresentation of results is necessary. To emphasizethe greater gravity of these lesions even whenaffecting the skin, the recurrence-free rate, thecrude survival rates, and the incidence of lymphnode metastases are given in Tables IX and X.One-third of the patients died within five years

but of these only three succumbed to their cancer

and in four cases the cause of death was unknown:the remaining deaths were due to intercurrentdisease.

Complications

In the 22 years between the publication of Textbookof Ophthalmology, vol. V (Duke-Elder, 1952) andSystem of Ophthalmology, vol. XIII (Duke-Elder,1974) Duke-Elder's views on the relative roles ofradiotherapy and surgery in the treatment of eyelidtumours underwent a profound change. In 1I952

Duke-Elder stated that excision should be the ruleand radiation the exception' whereas in I974 heconsidered that 'excision or radiotherapy . . . areprobably equally effective ... when efficientlycarried out'.

In common with Haye, Jammet, and Dollfus(I965) Duke-Elder emphasizes that the fear ofradiation complications is often the main reasonfor preferring surgery to radiotherapy. There islittle doubt that were it possible to establish thatlid tumours could be treated by radiotherapy withan acceptable minimum of complications a formid-able case could then be made for its preferential use.Table XI lists the complications encountered in

this series of cases. Three complications are notspecially listed:

Telangiectasia with or without depigmentation (I2per cent)The radiotherapist's attitude towards telan-giectasia should parallel that taken by the surgeontowards postoperative scars. There is no guaran-tee that any scar whether surgical or radiationalwill always be cosmetically acceptable althoughmuch can be done technically by both the surgeonand the radiotherapist towards achieving asatisfactory non-disfiguring scar.

Table IX Squamous cell carcinoma. Survival rateby site

Patients at 5-yearrisk 5 years survivaland followed- Alive 5 (percentage)

Site up years

Upper lid i8 I2 67Lower lid 23 i8 78Inner canthus 6 2Outer canthus 4 2

Total 51 34 67

Table X Recurrence-free rate for all sites. Lymphnode involvements (59 patients)

InvolvedNot

Site involved Initially Later Total

Upper lid i6 2 I I9Lower lid 25 - 25Inner canthus 8 - I 9Outer canthus 4 2 6

Total 53 4 2 59

In nine previously treated cases, two had nodes involved laterRecurrence-free percentage: I year (87 5 per cent)No recurrences observed beyond I year



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Radiation treatment of cancer of the eyelids 8oi

FIG. 8 (a) Extenisive carcinoma oflower lid before treatment

FIG. 8(b) After treatment showinglid deformity

Lid deformity (7 per cent)As many of the patients are elderly they have anatural tendency to laxness of the lower lid oreven ectropion. If already existing this can beaggravated by radiotherapy. Alternatively, whena lid has been infiltrated by neoplasm for its wholethickness healing after radiation will be ac-companied by fibrosis and when the tarsal plateis affected a contraction deformity will ensue.This type of deformity, usually ectropion, almostexclusively affects the lower lid. In the case ofthe upper lid, infiltration and destruction of thetarsal plate tend after successful radiation treat-ment to result in a coloboma rather than in acicatricial deformity, Figs 8, 9, ioa, b.

Epiphora ( io per cent)The possible occurrence of postradiation epiphora

is frequently advanced as an argument againstthe use of radiotherapy. However, the obliterationor loss of the upper punctum occasions noproblem: only when the lower punctum andcanaliculus are stenosed or destroyed mayepiphora occur. Mustarde and Jones (1970) indiscussing the reconstructive surgery of themedial canthus point out that it is possible toremove the lacrimal passages completely withoutepiphora. After such an event epiphora will occuronly in the presence of conditions giving rise toexcessive tear formation. These are listed asbeing high wind, undue exposure of the con-junctiva, and in particular ectropion and alsoinflammatory conditions involving the lid margin,conjunctiva, cornea, or lacrimal sac.These observations are supported by the events

after radiation obliteration of the lacrimal passages.Only a small proportion of the patients in this



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FIG. g(a) Extensivetumour of left lowerlid with invasion offornix and destructionof tarsal plate

FIG. g(b) Aftertreatment

series (IO per cent) developed a troublesomeepiphora and these were usually patients with adegree of lid deformity or some other local cause ofreflex increase of tears.This ability of the eye to accommodate itself to

loss of the lacrimal passages means that attemptsto maintain the patency of the punctum during orafter radiotherapy, by irrigation, intermittentdilatation, the insertion of various kinds of dilatoror operation are unnecessary. Efforts should ratherbe directed to ensuring that every cause of irritationthat might give rise to a reflex increase in tearproduction should be sought and eliminated.There is one factor that operates to the advantage

of the patient with postradiation as opposed topostsurgical epiphora and that is that in manycases the epiphora appears to be self-limiting,tending to subside spontaneously within a year oftreatment. The reason for this fortunate event isthat radiation not only produces stenosis of thepunctum but also destroys some of the secretoryglands of the lid and conjunctiva so that there is areduction in the total quantity of tears produced.At some point the impaired secretory mechanismand the damaged drainage system enter into

compensatory equilibrium and the patient's eye nolonger weeps.

OTIIER COMPLICATIONS, Table XIKeratinization of the conjunctival mucosa occurredin 5 6 per cent of cases. When this affected thelower lid problems could be avoided by regularremoval of the keratin plaque and most patientscan be taught to do this themselves. In the upperlid the keratin plaque is a potential menace to thecornea and a contact lens may be required to avoidcorneal damage. Fortunately in recent yearskeratinization is less likely because of modificationsin radiation technique whereby intense reactionsare avoided.

Lid necrosis has occurred in patients withmoderately atrophic skin changes or those withsurgical scars. As a rule these necroses seem tooccur in summer after exposure to an intense andunaccustomed degree of sunlight. The avoidanceof bad scars, warning the patients against direct

B-i ~~~~~~~.

FIG. 10 (a) Extensive tumour of upper lid withdestruction of part of the tarsal plate; (b) after treatmentshowing lid coloboma

...-- .. 'k. ...t,so..11.5

.A

Bs'

.14. .A.

4,:. ...



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Radiation treatment of canicer of the eyelids 803

FIG. II (a) Postoperative recurrence in scar before radiotherapy; (b) after radiotherapy; (c) skin necrosis afterexposure to excessive sunlight

Table XI Incidence of complications

Complication

Lid necrosisKeratinizationCorneal ulceration

or opacityCorneal abrasion or

keratitisCataractEye removed

Basal cell

No. Percentage

i8 2-9

35 5-6

IO I-6

1353

2-1

o 80-5

Squamous cell

No. Percentage

43

I

I

Any complication 84 I3-3 IO i6

Total 630 59

exposure of the lids to intense sunlight, and theuse of barrier creams all help. These sunlight-induced necroses heal readily with the applicationof a corticosteroid ointment once the solar-exposurefactor is removed.The corneal complications encountered were

not due to direct irradiation of the cornea since innearly all cases complete shielding of the cornea

was achieved. Most of the comeal complicationswere due to exposure or irritation from secondarychanges in the lid. The radiation cataracts occurredin patients treated by gamma radiation, usually inthe form of a radon seed implant. In no case wasit found necessary to deal with the cataractsurgically. Of the three cases where the eye was

lost, in two the eye was removed before the patientwas referred for radiotherapy and in the third case

a useless eye was removed because of involvementby uncontrolled disease.

Prevention of complicationsGENERAL MEASURES

Patients undergoing the irradiation of a lid tumourinevitably develop a radiation reaction in thetreated area. While this lid reaction ultimately

subsides and is generally followed by few compli-cations, the related bulbar conjunctiva and thecornea may, as already noted, be secondarilyaffected even though total protection of these tissuesagainst irradiation has been provided. In additionmany of the patients in the age groups concernedhave incidental ocular problems requiring skilledcare while the patient is undergoing radiotherapy.Because of this there is imperative need for ophthal-mological control and care of the patient duringtreatment and the ophthalmologist has a vital partto play in any radiation unit dealing with thesecases if unnecessary complications are to beavoided.

CONTRAINDICATIONS TO RADIOTHERAPY

The misuse of radiotherapy is understandable sinceit is a non-operative procedure readily available andeasily applied. However, if complications are to beeliminated or reduced in frequency then theradiotherapist must be on his guard not to beenticed into treating a patient in circumstanceswhere complications are inevitable or when treat-ment is accompanied by a high risk of postradiationdamage. In these circumstances it is clearly betterfor the patient to submit to alternative, non-radiational methods. If no alternative is availableor if available would entail removal of the eye thenthe radiation risks may be accepted as the lesserof two evils but this should be done only after a fulldiscussion with both the patient and his doctors.The following may be accepted as contra-

indications to radiotherapy:

Recurrence after previous treatmentRecurrent cases, whether the previous treatmentbe surgical or radiotherapeutic, should in principlebe surgically treated if possible. If surgery isimpractical then radiotherapy can be used, againwith a good prospect of controlling the neoplasmbut at an increased risk of a cosmetically unwelcomecicatrix and an added risk of radionecrosis. In thisseries of cases 3-8 per cent of the previously



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untreated patients were referred for surgery afterradiotherapy either because of incomplete tumourregression or frank recurrence.

Disease involving the mid-third of the upper lid

Lesions in this situation are readily curable byradiotherapy but in the event of undesirablemucosal changes such as keratinization, secondarydamage to the cornea is highly probable. Thisrestriction on the use of radiotherapy in upper lidtumours applies only to small tumours centrallysituated which would be amenable to simpleexcision and closure by direct approximation. If anupper lid tumour is sufficiently extensive to requirea complicated reconstruction radiotherapy becomesa desirable alternative, since not only are the resultsexcellent but there is always a good chance thatkeratinization may be avoided and even if it doesoccur and proves troublesome a contact lensprovides a remedy. A sense of proportion has tobe preserved in connexion with the risks of keratini-zation and no patient, particularly if elderly,should be persuaded to undergo a complicated andserious operation on the physiologically importantupper lid unless some overriding reason other thanthe possibility of postradiation mucosal keratiniza-tion exists.

The presence of a damaged cornea

When the lid tumour is related to a cornea that isalready abnormal or damaged in some way thenas any subsequent postradiation lid changes mayadd further injury to the already damaged corneasurgery should be considered.

Skin changesIn outdoor workers or light-skinned patients, whoalready have solar skin changes, irradiation shouldbe avoided especially if the patient lives in a tropicalor subtropical climate.

Bone invasion

Radiotherapy is rarely successful in eradicating atumour which has invaded bone. The advancedrodent ulcer accompanied by orbital bone invasionis best treated by a preliminary course of radiationfollowed by radical surgery.

A very small lesion remote from the canthus and lidmarginsRadiotherapy should be avoided in cases in whicha biopsy excision would adequately remove thetumour.

TECHNICAL MEASURES

The technical steps the radiotherapist can taketowards reducing the complications affecting thelids, conjunctiva, and the eye relate to the selectionof apparatus and the dose and time factors of thetreatment. Unwelcome cosmetic sequelae are morelikely where radiation energies of 6o kV or less areused and ocular complications are more likely whengamma-ray sources are implanted near the eye.The intensity of the radiation reaction, the

incidence of mucosal keratinization, and the cos-metic quality of the radiation scar can all befavourably influenced by attention to the fractiona-tion of the dose and the length of the overalltreatment time.

PROTECTIVE DEVICES (Lederman and Jones, I966)The normal eye and the unaffected parts of the lidsshould be completely shielded. It is important toavoid trauma and sepsis when inserting the protec-tive lead eye shields or spatulae. Even when thelids, eye, and orbital contents are involved bydisease it is still possible to protect the cornea andthe intraocular structures deep to it. To do this theradiation field has to be delineated by a light beamand an indirect method of shielding is employedwherein a lead absorber is placed in the beam ofradiation so that the part of the eye that has to beprotected is brought within the shadow producedby the interposed absorbing material.

This indirect method of shielding is of greatvalue not only in the presence of orbital invasionbut whenever the lids or fornices are deformed ordestroyed and the direct insertion of a lead protectivedevice proves impossible or potentially traumaticto the eye.

ANCILLARY PROCEDURES

The use of a haptic contact lens as a means ofprotecting the cornea against damage from second-ary changes in the lids has proved of great value.The two chief indications are:

i. When tumours of the upper lid requireradiation treatment and the risks of keratiniza-tion have to be guarded against.

2. When both upper and lower lids, particularlythe lid margins, require treatment.

The risk of undesirable postradiation changes inthe lids with secondary damage to the cornea isdirectly proportional to the length of lid margintreated. In these two instances the contact lens ismade and fitted before treatment and worn through-out treatment and the period of reaction. If thereaction settles down without any serious lidsequelae the lens can be abandoned: otherwise its



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permanent use may be necessary. In order to preventexposure keratitis with secondary keratinization oropacification of the cornea the patient with a seriouspostradiation lower lid deformity should beconsidered for plastic surgical correction of thedeformity before signs of corneal exposure becomeapparent.

Discussion

It is believed that the results obtained in thisseries of cases, even accepting the incidence andthe nature of the complications, would justify andsupport the continued advocacy of radiotherapy asthe treatment of choice for malignant lid tumours.

It is difficult to determine the part that surgeryshould play in the treatment of these tumours sincea survey of the surgical literature, particularlypublications emanating from plastic surgical sources,are devoted almost exclusively to detailed accountsof surgical techniques. Any prolonged acquaintancewith the treatment of malignant disease willdemonstrate that cancer is no respecter of surgicalexpertise and for any given surgical procedure forlid cancer to be acceptable careful objectiveevaluation is necessary. If the rigid standardsadopted by radiotherapists are to be followed it isessential that the description of any given operationbe accompanied by its contraindications, compli-cations, and the success rate achieved over at leasta five-year period of observation. Nevertheless itmust be accepted that in spite of the reliable resultsand obvious advantages of radiotherapy some casesare better treated by surgery particularly thosecontraindicating radiotherapy.Any further scope for surgery should, assuming

the patient is fit for operation, depend on thetumour size and situation and hence the simplicityor complexity of the operation needed.

If the size of tumour in this series (Tables VIIa,b) is taken as representative it will be seen that ofthe basal cell carcinomas approximately one-thirdof the lid tumours and two-thirds of the innercanthus tumours would fall into category Ti ofthe UICC system of classification. This means that

allowing for a 5 mm margin of normal tissue thesetumours were 2 cm or less in diameter and there-fore presumably suitable for an operation notrequiring plastic lid reconstruction (Mustarde andJones, 1970). It should be noted that it is preciselythese early cases that give the best results andfewest complications with radiation treatment.However, the remaining patients, namely themajority, would require excision and lid reconstruc-tion with all that that entails by way of availabilityof the requisite surgical skills, the surgical risks forthe elderly patient, to which must be added theeconomic disadvantages of surgical as opposed toradiotherapeutic treatment.As neither surgery nor radiotherapy is a specific

remedy for cancer, debate on their respectivemerits can prove endless. Effort can most profitablybe expended on determining their relative spheresof usefulness in a complementary rather than acompetitive sense. Until such time as more evidenceconcerning the true scope and value of surgery,particularly when associated with plastic lid re-construction becomes available the patient's interestscan best be safeguarded by ensuring collaborationbetween surgeon, radiotherapist, and dermatologistso that therapeutic decisions based on a partisanapproach are avoided if possible.

I thank the many ophthalmologists who by sending theircases have made this study possible. I wish to single outin particular the members of the staff of the MoorfieldsEye Hospital, City Road and High Holborn, and theRoyal Eye Hospital. I am especially indebted to mycolleagues at the Royal Marsden Hospital, Mr Shapland,Mr Wybar, and Mr Mallet, and to Mr Ruben of theHigh Holborn branch of Moorfields for dealing withthe contact lens problems. I also thank Mr P. Payne,Director of the South Metropolitan Cancer Registry,for providing me with the statistical tables, and MissPegus and Mrs Potucek of the Medical Art and Photo-graphic Departments of the Royal Marsden Hospitalfor the tables and illustrations. The editors of OphthalmicPlastic Surgery Up-to-Date kindly gave permission toreproduce Figs 2 and 3 on page 4 of that book.Dr B. Lewinsky, now at the Letterman Hospital,

San Francisco, kindly helped with analysing the clinicalmaterial.

References

DUKE-ELDER, S. (1952) 'Textbook of Ophthalmology', vol. V. Kimpton, London(1974) 'System-of Ophthalmology', vol. XIII, pt i. Kimpton, London

HALMAN, K., and BRITTEN, M. (I960) Brit. Y. Ophthal., 52, 43HAYE, C., JAMMET, H., and DOLLFUS, M., (I965) 'L'Oeil et les Radiations', vol. II. Masson, ParisLEDERMAN, M. (I964) J. Laryng., 78, i8i

, and JONES, C. (I966) 'Textbook of Radiotherapy', ed. G. Fletcher. Lea & Febiger, PhiladelphiaMUSTARDE, j., and JONES, L. T. (1970) 'Ophthalmic Plastic Surgery Up-to-Date'. Aesculapius, AlabamaUIcc (I974) TNM Classification of Malignant Tumours. International Union Against Cancer, Geneva



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