Should Neck Nodes Be Treated in Eyelid Tumors: Unmet Need of Nodal Irradiation

Abstract

Surgery with adjuvant radiation forms the cornerstone of management. Treatment of neck nodes has remained debatable. We analyzed our database and extracted data of 35 patients with eyelid tumors who underwent treatment at our center between 2006 and 2013. Median age was 55 years (range 30 to 85) with male to female predisposition of 1.05:1. Median duration of symptoms was 12 months. Upper eyelid tumors were 48.5% (17) and lower eyelid tumors were 51.4% (18). Amongst histology sebaceous cell carcinoma 54.2% (19), basal cell carcinoma 22.8% (8), squamous cell carcinoma 11.4% (4), 2.8% (1) each of mucoepidermoid carcinoma, malignant melanoma, adenocarcinoma, poorly differentiated carcinoma. Most commonly performed imaging modality was contrast-enhanced computed tomography of orbit (CECT) 71.4% (25), followed by positron emission tomography 8.5% (3), magnetic resonance imaging 2.85% (1). Staging was according to TNM was stage 0 2.85% (1) IA 22.8% (8), IB 2.85% (1), IC 11.4% (4), II 5.7% (2), IIIA 28.57% (10), IIIB 17.1% (6) IIIC 8.5% (3). In management 91.4% ( 32) underwent surgery, 5.7 % (2) received palliative radiation therapy (RT), 2.857% ( 1) radical RT. Amongst 32 who underwent surgery patients 59.37% (19) received adjuvant RT. Out of 32, 50% (16) underwent exentration and 75% (12) had neck dissection of which 41.6% (5) were type 1, 41.6% (5) were type 3, and 16.65 (2) were type 2. Of 12 patients with neck dissection 66.6% (8) had intra-parotid lymph node group involved, 16.6% (2) in level Ib, 8.3% (1) in level II. Most commonly sebaceous cell carcinoma was associated with positive lymph nodes 75% (9), 8.3% (1) by squamous and malignant melanoma. RT was performed with electrons with corneal tungsten shield in 88% (22) and by photons in 12% (3). Postoperative dose employed was 60 Gray in 30 fractions over 6 weeks. Short term toxicity due to radiation was conjunctivitis in 20% (5), dryness of eyes 20% (5), dermatitis 16% (4). Of 33 patients treated with radical intent, 48.48% (16) had recurrence of which most common histology to recur was sebaceous cell carcinoma 56.255 (9), squamous 12.5% (2). 56.25% (9) with recurrence did not receive postoperative RT (all had local recurrence), 43.75% (7) had recurrence after RT mostly recurred in nodal region 57.1% (4). Salvage therapy most commonly employed was surgery 56.25% (9), followed by RT 43.75% (7). 25% (4) had re-recurrence salvaged with surgery and postoperative radiation. Median duration of follow-up was 24 months with 71.42% (25) with no evidence of disease and 28.57% (10) with progressive disease at last follow-up. Neck dissection and elective neck irradiation should be considered in certain histology like sebaceous and squamous especially if T stage >T3.