Basal cell carcinoma (BCC) is the most common form of skin cancer. It is slow growing and locally invasive. Risk factors include ultraviolet light exposure, increasing age, fair skin, immunosuppresion and familial conditions e.g. Gorlins Syndrome [1]. BCCs are commonly diagnosed in elderly populations but are still rarely diagnosed in youth [2]. We investigated the incidence, treatment and outcome of patients under 40 years of age with a histologically confirmed diagnosis of a periocular BCC.
A retrospective analysis of all patients that attended a ‘tumour clinic’ at the Edinburgh Princess Alexandra Eye Pavilion, over a 17-year period, was performed. Cases were identified from pathology diaries in which all patients that undergo a biopsy for suspected periocular malignancy are logged. This allowed us to identify all patients under the age of 40 that had a histologically confirmed BCC.1
Over the 17-year period 1068 biopsies were performed. Pathology results confirmed 720 of the biopsies were BCCs. We found 13 BCCs present in the under 40’s population with a mean length of follow up of 31 months (+/-21SD) (Table 1).
Table 1.
Characteristics of BCCs in the under 40’s
| Age (mean) | 33.8 years (+/- 4.1SD) |
|---|---|
| Sex | 6 Males, 7 Females |
| Pathology | 8 Nodular, 4 Morphoeic, 1 Basisquamous |
| Time from onset of signs to treatment (mean) | 2.7 years (+/-1.1SD) |
| Recurrence | 3 patients |
| Time to recurrence (mean) | 2.3 years (+/-0.6SD) |
We have shown a prevalence of periocular BCC’s in our under 40’s population of 1.8% which is in keeping with national data showing a BCC prevalence of 1.2% in patients aged 15–35 years [3].
Recurrence was defined as histologically confirmed BCC, arising at the site of previous surgery. A recurrence rate of 23.1% in our ‘under 40’s’ population is 12 times greater than our overall audited recurrence rate of 1.9%, with 17 year follow up, and the national average of <2%, with a five year follow up [2]. None of the recurrence cases had any underlying risk factors.
Margins of 2 mm are our standard practice. In one case of recurrent tumour, to preserve the lid margin, the surgical excision was less than 2 mm superiorly. Two of the three cases of recurrent tumour were noted to be morphoeic and in both cases the tumours were completely excised according to histology. Recurrence following histologically confirmed complete excision occurs in 1.3% of cases [3]. Our findings highlight the need for ongoing follow up irrespective of the histology report.
The time from onset of signs/symptoms to treatment was 2.7 years (+/-1.1SD) in our study population. We believe this demonstrates a significant diagnostic delay.
BCCs in under 40’s are rare; however the recurrence rate in this population is 12 times higher than our overall audited recurrence rate. This may reflect a higher proportion of morphoeic tumours, associated with an increased recurrence rate, or an intrinsically more aggressive disease. Given the significantly higher recurrence rate for patients under 40, we would recommend larger excision margins or excision with Moh’s micrographic technique and a prolonged follow up period.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Footnotes
This project was orally presented at the British Oculoplastics Society Meeting in Dublin June 2018.
References
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