Primary basal cell carcinoma of the caruncle with seeding to the conjunctiva
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- Østergaard, J., Boberg-Ans, J., Prause, J.U. et al. Graefe's Arch Clin Exp Ophthalmol (2005) 243: 615. doi:10.1007/s00417-004-1086-5
To report the clinical and histopathological characteristics of a patient with a primary basal cell carcinoma (BCC) of the caruncle with seeding of the tumour to the conjunctiva.
Surgical excision and histological examination.
A 60-year-old female presented with a lesion of the caruncle. Clinical examination revealed a pale lobulated tumour without skin involvement. Computer tomography scans showed orbital invasion. The tumour was excised. Three years later a small polypoid tumour developed in the inferior fornix of the same eye. Two and a half years later, the patient developed an orbital recurrence.
Microscopically, both neoplasms were composed of infiltrative islands of basaloid tumour cells, scattered mitoses and peripheral palisading consistent with the diagnosis of BCC.
This case describes a primary BCC of the caruncle with seeding to the conjunctiva.
Basal cell carcinoma (BCC) is the most common human malignancy and accounts for 90% of eyelid cancers . Primary BCC of mucous membranes is extremely rare  and the majority of BCCs of the conjunctiva are due to invasion from the periocular skin . Only two primary BCCs of the caruncle [8, 9] and four of the conjunctiva have been reported previously [1–3, 5].
This case report describes a patient who developed a primary BCC of the caruncle and later a conjunctival BCC in the same eye probably due to seeding from the caruncular lesion. Furthermore, the BCC of the caruncle showed orbital invasion.
Three years later, the patient was referred again because a polypoid tumour measuring 3 mm and located in the middle of the inferior fornix of the left eye had appeared. The lesion was excised, and histology showed it to be composed of infiltrative islands of basaloid tumour cells with peripheral palisading (Fig. 1c), consistent with a second BCC. The tumour was excised and tumour-free surgical margins were verified by means of microscopy.
Five-and-a-half years after the initial treatment, the patient developed horizontal diplopia caused by restriction in lateral motility. Renewed CT scans showed orbital recurrence at the location of the removed orbital extension of the caruncular BCC (Fig. 1d). The tumour was excised by anterior orbitotomy. Histology revealed a recurrence of the BCC with basaloid tumour cells located around nerves and vessels. The patient was referred to undergo supplementary orbital radiation therapy but shortly after finishing this she died unexpectedly from other causes.
BCC of the skin is overall the most common malignancy and is predominantly found in sun-exposed areas of elderly fair-skinned individuals . About 90% of the eyelid cancers are BCCs, of which the majority is located on the lower eyelid and medial canthus . BCC spreads by local invasion and, thus, BCC of the conjunctiva is most commonly found to originate from secondary invading BCCs . In a recent series of 2,455 conjunctival lesions, six of six BCCs were found to be secondary to a skin lesion .
Only two illustrated case reports on primary caruncular BCCs have previously been published [8, 9]. One of these was in a 74-year-old Australian male with a history of sun exposure and multiple malignant neoplasms of the skin . The lesion was a vascular multilobulated pink nodule . The second case was that of a German 24-year-old male who had worked outdoors for the last 8 years as a road construction worker . That lesion was a whitish nodule with a reddish centre and fine vessels surrounding the lesion . In the present case, malignancy was not suspected since the lesion presented as a cyst-like swelling of the caruncle. At the time of presentation, there were no signs of skin involvement, which supports the diagnosis of a primary BCC of the caruncle. The history of the patient contained no information of excessive sun exposure.
Summary of reports on primary basal cell carcinoma of the caruncle and conjunctiva
Age in years/gender
Growth of lesion (6 months)
Multilobulated nodule, vascularized, pink, 7×5 mm
Excision, 5-mm margins
Not stated (not stated)
Poon et al. (1997) 
Growth of lesion (3 months)
Nodule, vascularized, white, red center, 3×5 mm
No (14 months)
Meier et al. (1998) 
Growth of lesion, discomfort (weeks)
Lobulated, cyst like nodule, vascularized, pale, 3×4 mm
(1) Incomplete excision; (2) complete excision, cryosection control
Yes (51/2 years)
Growth of lesion (months)
Pedunculated nodule, fleshy 4 mm
No (2 months)
Aftab et al. (1973) 
Growth of lesion (6 months)
Pedunculated nodule, fleshy, lobulated surface, 2×11/2 in.
No (not stated)
Apte et al. (1975) 
Growth of lesion (4 months)
Multilobulated nodule, fleshy, yellow-pink, 4×3×2 mm
Excision, 2-mm margins
No (1 year)
Husain et al. (1993) 
Nodule, 6×6 mm
Enucleation, intraocular invasion
No (8 years)
Cable et al. (2000) 
The present conjunctival BCC may either be a de novo lesion or a recurrence caused by seeding from the caruncular BCC. The tumour developed in the same eye, at a location not exposed to actinic rays and within 3 years after primary treatment, which is a reasonable time frame for the development of a recurrence. We thus consider the conjunctival BCC a seeding from the primary caruncular BCC. Moreover, patients who have developed a periocular BCC once have an increased risk of developing multifocal BCC .
The existence of primary BCCs of mucous membranes has been controversial , but in contrast to other mucous membranes the conjunctiva and the caruncle are exposed to actinic rays. Based on the microscopic appearance, BCCs could originate from basal cells of the epithelium or infundibular cells of the hair follicles . Others believe that BCCs develop from pluripotent stem cells . The fact that the caruncle is skin derived, originating from the lower eyelid, and harbours adnexal elements such as hair and sebaceous glands might explain why BCCs occasionally develop at this site.
Finally, this case was complicated by orbital invasion and recurrence. BCC is the third most frequent invading orbital malignancy (10%), only next to choroidal malignant melanoma (55%) and squamous cell carcinoma (15%) . Orbital invasion by BCCs can be fatal due to intracranial extension . Although BCC most often is restricted to lateral growth, the tumour cells in the orbit in this case exhibited a perineural and perivascular growth pattern which could have facilitated the tumour to traverse the subcaruncular fatty tissue. This case illustrates the importance of accurate clinical diagnosis and careful primary surgery handling a possible malignant pericaruncular lesion.