Primary Basal Cell Carcinoma of

the Limbal Conjunctiva

Syed E. Husain, MD,l James R. Patrinely, MD,I·2 Lorenz E. Zimmerman, MD,3

Ramon L. Font, MDI

Background: The authors describe a 66-year-old man with primary basal cell car-
cinoma of the conjunctiva. He presented with a fleshy nodular conjunctival lesion of 4
months' duration, located at the nasal limbus of the left eye. No associated cutaneous
lesions were present.
Results: The lesion was completely excised, and results of histopathologic ex-
amination showed a primary basal cell carcinoma of the conjunctiva.
Conclusion: This report provides clinicopathologic evidence that primary basal cell
carcinoma can rarely occur in the conjunctiva. The authors summarize two well-docu-
mented previously reported cases of this unusual lesion.
Ophthalmology 1993; 100: 1720-1722

Primary epithelial carcinoma of the conjunctiva is un- cutaneous or visceral malignancies. He had worked as a con-
common. It may arise from a papilloma, intraepithelial struction worker for the last 20 years with a prolonged and fre-
epithelioma, pre-existing leukoplakia, or spontaneous quent exposure to sunlight. There was no family history of skin
metaplasia. l The overwhelming majority of invasive ep- cancer.
The lesion was located at the nasal limbus of the left eye. It
ithelial tumors of the conjunctiva are squamous cell car-
was a 4 X 3 X 2-mm fleshy, multilobulated, yellowish-pink,
cinomas. 2 Most basal cell carcinomas of the conjunctiva non ulcerated mobile lesion (Fig I). Fine vessels surrounded and
described in the ophthalmic literature are cutaneous in penetrated the lesion with minimal surrounding hyperemia or
origin and secondarily involve the conjunctiva. None of inflammation. The lesion was not associated with dellen or other
the previously reported cases of basal cell carcinoma of corneal changes. The preoperative clinical diagnosis was atypical
the conjunctiva have included clinical photographs of the conjunctival papilloma. The lesion was excised under local
lesions. 3,4 Primary basal cell carcinoma involving mucous anesthesia with a 2-mm tumor-free margin. The bare sclera was
membranes has not been described in modern dermato- allowed to heal by secondary intention. Results of follow-up
pathology or ophthalmic pathology textbooks. 5,6 examination showed no evidence of recurrence I year after sur-
gical excision.
Histopathologic Findings. Results of histopathologic
Case Report examination showed a basal cell carcinoma (Fig 2). The lesion
was composed of invasive epithelial lobules ofbasaloid cells sur-
A 66-year-old man had a 4-month history of a slowly enlarging rounded by bands of connective tissue. The tumor contained
conjunctival lesion in his left eye. The patient had no other prior closely packed polyhedral basaloid cells with round basophilic
nuclei and a small amount of cytoplasm. Some of the islands
of tumor cells were connected to the conjunctival epithelium
Originally received: March 22, 1993. (Fig 2). The cells at the periphery of the tumor lobules were
Manuscript accepted: April 12, 1993. columnar and exhibited nuclear palisading (Fig 2). Some of the
I Department of Ophthalmology, Cullen Eye Institute, Baylor College tumor lobules exhibited areas of squamoid differentiation. Mild
of Medicine, Houston. mitotic activity was present. The stroma contained moderate
2 Division of Plastic Surgery, Baylor College of Medicine, Houston. lymphoplasmacytic infiltrates.
3 Armed Forces Institute of Pathology, Washington, DC.

Supported in part by the Retina Research Foundation and the Lions

Eye Bank, Houston, Texas, and in part by an unrestricted grant to Baylor
College of Medicine from Research to Prevent Blindness Inc, New York, Discussion
New York.
Reprint requests to James R. Patrinely, MD, Baylor College of Medicine, Primary basal cell carcinoma of mucosal surfaces, partic-
Cullen Eye Institute, 650 I Fannin, NC-200, Houston, TX 77030. ularly the conjunctiva, is extremely rare. Many authors

1720
 Husain et al . Primary Basal Cell Carcinoma

Figure 1. Clinical appearance

of the tumor involving the
nasal limbus of the left eye.
The lesion is a lobulated, yel-
lowish-pink, non-ulcerated
nodule surrounded by prom-
inent vessels.

doubt the occurrence of basal cell carcinoma on the mu- Ash and Wilder9 described one tumor that was interpreted
cous membranes. 5- 7 Basal cell carcinoma occurs almost as a basal cell carcinoma. Later, in a more comprehensive
exclusively on hair-bearing skin, especially on the face report based on 1120 patients with epibulbar tumors,
due to chronic exposure to sunlight. It accounts for 85% Ash lO listed 53 as having basal cell carcinoma, more than
to 95% of all malignant epithelial tumors of the eyelid. 8 half of which involved the canthi or palpebral conjunctiva.
In a series of93 epithelial tumors of the corneal/limbal He further suggested that most of these tumors probably
region on file at the Armed Forces Institute of Pathology, represented conjunctival involvement secondary to pri-

Figure 2. The histopathologic

photograph of the lesion
shows an invasive basal cell
carcinoma. The epithelial
lobules, some of which are
connected to the conjunctival
epithelium, disclose periph-
eral palisading of the nuclei
(hematoxylin -eosin; original
magnification, X68).

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 Ophthalmology Volume 100, Number 11, November 1993

Table 1. Clinical Summary of Reported Cases of Primary Conjunctival Basal Cell Carcinoma
Age Follow-up
Reference (yrs) Location Clinical Appearance Information
Aftab and Percival3 (1973) 82 Interpalpebral conjunctiva Pedunculated, fleshy, mobile No recurrence 2 mos
between plica and without vascular core
limbus
Apte et al4 (1975) 69 Interpalpebral conjunctiva Pedunculated, mobile, Not stated
between plica and lobulated surface with
limbus irregular margins
Husain et al (1993 current study) 66 Nasal limbal conjunctiva Nodular, mobile, lobulated, No recurrence 12
fleshy, and slightly mos
vascular

mary cutaneous basal cell carcinomas. Ash, however, de- In summary, primary conjunctival basal cell carcinoma
scribed three basal cell carcinomas located at the limbus, is a rare but distinct entity. These lesions usually occur
1 on the cornea and 17 involving the bulbar conjunctiva. 10 in the actinically exposed interpalpebral conjunctiva near
None of these tumors was illustrated, and no specific dis- the nasal limbus. They tend to occur in older individuals,
cussion of basal cell carcinoma of the conjunctiva was are often asymptomatic, and present as fleshy, mildly vas-
provided. The question of whether any of the 53 epibulbar cular, mobile, nodular lesions with minimal surrounding
basal cell carcinomas were considered primary conjunc- inflammation or ulceration. Wide surgical excision ap-
tival tumors was not addressed. These authors also made pears curative.
no comment regarding the origin of basal cell carcinoma
from mucous membranes. References
In 1973, Aftab and Perciyal3 described an 82-year-old
man who had a pedunculated lesion of the nasal inter- J. Reese AB. Tumors of the Eye, 2nd ed. New York: Hoeber,
palpebral conjunctiva located between the plica and the 1963;23-6.
limbus. Clinically, the lesion was thought to be a papil- 2. Jakobiec FA, Rootman J, Jones IS. Secondary and metastatic
loma but histopathologically it proved to be a basal cell tumors of the orbit. In: Tasman W, Jaeger EA, eds. Duane's
Clinical Ophthalmology, rev. ed. Philadelphia: JB Lippin-
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a basal cell carcinoma of the conjunctiva in a 69-year-old 3. Aftab M, Percival SPB. Basal cell carcinoma of the con-
woman. This lesion also was located in the interpalpebral junctiva. Br J Ophthalmol 1973;57:836-7.
region between the limbus and the plica. As in our case, 4. Apte PV, Talib VH, Patil SD. Basal cell carcinoma of con-
this lesion was described as fleshy, pedunculated, and mo- junctiva. Indian J Ophthalmol 1975;23:33-4.
bile with a lobulated surface and irregular margins. 5. Spencer WH, Zimmerman LE. Conjunctiva. In: Spencer
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by Aftab and Percival 3 and Apte et al 4 had occurred in 3rd ed. Vol 1. Philadelphia: WB Saunders, 1985; chap. 2.
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In addition, it is noteworthy that although the epithelia Book, 1991 ;481.
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distinct difference in the frequency of the occurrence of 8. Kwitko ML, Boniuk M, Zimmerman LE. Eyelid tumors
primary basal cell carcinoma on these surfaces. Although with reference to lesions confused with squamous cell car-
the exact origin of the tumor is still debatable, most au- cinoma. I. Incidence and errors in diagnosis. Arch Ophthal-
thors believe basal cell carcinoma is derived from the basal mol 1963;69:693-7.
cells of the pilosebaceous structures. They further em- 9. Ash JE, Wilder He. Epithelial tumors of the limbus. Am J
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10. Ash JE. Epibulbar tumors. Am J Ophthalmol 1950;33: 1203-
tures, are never the primary sites. 11.12 Because the caruncle 19.
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