Medical history:

- Bilateral Glaucoma;

- Arthritis of the lumbar spine;

- L5-S1 herniated disc with L3-L4 and L4-L5 disc protrusions and lumbar canal stenosis;

- Arterial hypertension pharmacologically treated with Ladip 6 mg and Normothen 4 mg.

Case History:

The patient reports the appearance of skin lesions at the internal orbital canthus of the right eye, approximately 2/3 months ago.

At the beginning of February 2008, she had a check-up with an ophthalmologist; the specialist recommended the lesion to be examined by a oncology specialist.

The patient was examined by an oncologist towards the end of February, and an excision of the neoformation was recommended.

On March 12, 2008, at the plastic surgery unit she underwent the resection of the suspected basocellular carcinoma with a diameter of 15 x 7 mm from the internal orbital canthus of the right eye.

A histological examination confirmed the diagnosis of infiltrating basocellular carcinoma, with uninvolved margins. The macroscopic description reads as follows: “A diamond shaped piece of skin measuring 2.2 x 0.8 with penetration point indicating the upper apex and with 2 points indicating the edge of the eyelids. Towards the upper apex, an irregular area was noted, partially appearing ‘dug out’, with a maximum diameter of 0.6 cm. Inclined on the external surface. Full sample included”.

The patient currently states that she feels healthy, and has no disturbances relating to the pathology specified.

Questions:

1) Any risk of local or distance relapse?

2) Are there any further treatments that can be carried out in addition to surgery to reduce the risk of such relapse?

3) What is the expected prognosis?

4) Any centres of excellence in Italy?

Second MEDICAL OPINION Report

Thank you for the referral of the medical information on Ms. ___________. I had the opportunity to review the document and to write the following second opinion, at the request of Medical Opinion.

A) Reconstruction of the case history:

This is a 72 yr old woman. Approximately in January 2008 she noticed a new "skin lesion" at the internal orbital cantus of the right eye.

On March 12, 2008 she underwent at the plastic surgery unit an excision of a suspected basocellular carcinoma from the internal orbital cantus of the right eye measuring 15 x 7 mm.

The full description of the histological examination was not submitted to me. I understand that it confirmed the diagnosis of an infiltrating basocellular carcinoma and that the margins of the resection were not involved. The resected specimen measured 22 x 8 mm.

B) Questions and answers:

1. Any risk of local or distant relapse?
2. Are there any further treatments that can be carried out in addition to surgery to reduce the risk of such relapse?

Most cases of basocellular (basal cell) carcinoma are characterized by persistently localized and very slow growing behaviour. Local relapse can occur if the tumour is not completely excised including at the microscopic level. Since I have not received the full report of the MICROscopic evaluation I strongly recommend that this will be re-examined: if the tumour excision is indeed with safe margins there is no risk of local recurrence.

The MICROscopic evaluation should investigate the possibility that the tumour contains malignant squamous cells. This second component exists within about 10% of basocellular tumours, and it may be responsible for regional lymph node metastases and also for metastases to lung or bone. However, it is very rare to encounter distant metastases from basocellular carcinoma and in any case no adjuvant treatment is recommended for preventing this unusual possibility.

3. What is the expected prognosis?

If the MICROscopic examination of the resected specimen confirms both free margins all around the tumour and the absence of any squamous cell component, there is an excellent prognosis.

Still, another point to be considered with this regard is that basocellular carcinomas which originate in sun exposed areas of the skin, like the case of Ms _______, are considered "radiation induced tumours". Her skin has manifested its capacity to develop "skin tumours" and she should stay under regular follow up by a dermatologist in order to rule out separate/ additional tumours, mainly in all areas of the skin which have been heavily exposed to the sun all along her life, especially in her childhood.

4. Any centres of excellence in Italy?

At the present time, if there is confirmation of radical removal of the tumour at the MICROscopic level, there is no need of any centre of excellence. The follow up should be conducted by a senior dermatologist.

In the case of any change in the operated area a biopsy should be considered.

At the present time I am not aware of any specific centre in Italy with higher excellence over other centres. Usually every large centre of ophthalmology cooperates with a plastic surgeon, used to operate on the eye related structures including the inner cantus and the eyelids.

If and when a local recurrence is suspected and it becomes necessary to perform a confirmatory biopsy, the patient should seek a centre where such a surgeon practices as an integral member in the ophthalmologic team.

However, if a repeated operation is considered in the future for the rare condition of local recurrence, this should be discussed in a multidisciplinary setup versus the alternative option of "contact irradiation" which sometimes can offer a less traumatic solution.

I very much hope that Ms. ___________ is already a cured patient.

However, if I can be of any further help to you, please contact me through Medical Opinion.

Sincerely,

Dr. ____________

Senior oncologist

and Consultant in Oncology