Diffuse epibulbar squamous-cell epithelioma

Masquerade syndrome: An eye problem as a manifestation of a more sinister disease

A middle-aged man with cardiovascular risk factors, who suffered from a slight loss of unilateral vision for 6 months. After obtaining a diagnosis of diffuse choroiditis+papillitis within a probable masquerade syndrome, the patient was referred to outpatient Internal Medicine where this diagnosis was confirmed as an extended neoplastic disease.

Nodulo-Ulcerative Ocular Surface Squamous Neoplasia in 6 Patients: A Rare Presentation

PURPOSE

To describe clinical presentation and histopathological features of a nodulo-ulcerative variant of ocular surface squamous neoplasia (OSSN).

METHODS

Retrospective study.

RESULTS

Six patients were identified with a nodulo-ulcerative variant of OSSN. Mean age at presentation was 56 years. One patient was immunosuppressed because of human immunodeficiency virus infection. The initial misdiagnosis was necrotizing scleritis/sclerokeratitis (n = 4), intraepithelial neoplasia (n = 1), and chalazion (n = 1). The mean delay in diagnosis as OSSN was 6 months. The lesion involved bulbar conjunctiva in 5 patients and tarsal conjunctiva in 1 patient. The mean maximum tumor dimension was 16 mm, and the mean area of conjunctivoscleral/conjunctivotarsal necrosis was 8 mm. The primary treatment for nodulo-ulcerative OSSN included excisional biopsy (n = 2), plaque radiotherapy (n = 1), and orbital exenteration (n = 3). Tumor recurrence was noted in two patients necessitating orbital exenteration. At last follow-up, globe salvage could be achieved in only 1 case. Histopathology showed invasive conjunctival squamous cell carcinoma in all cases with lesions being well-differentiated (n = 4), moderately differentiated (n = 1), and with mucoepidermoid differentiation (n = 1). Underlying scleral/tarsal tumor infiltration was evident in all 6 (100%) cases. Intraocular tumor extension was evident in 3 cases infiltrating the iris (n = 2), ciliary body (n = 3), and choroid (n = 3). Orbital tumor extension was evident in 2 cases because of tumor recurrence. No metastasis or death was recorded at a mean follow-up of 26 months.

CONCLUSIONS

The nodulo-ulcerative variant of OSSN is rare and is most often misdiagnosed as necrotizing scleritis/sclerokeratitis causing a delay in the diagnosis. It is an aggressive lesion with increased occurrence of intraocular or orbital tumor extension.

Sclerokeratitis: an unusual presentation of squamous cell carcinoma of the conjunctiva

OBJECTIVE

To describe three cases of squamous cell carcinoma of the conjunctiva presenting with corneal and scleral inflammation, thinning, and perforation without any tumor formation.

DESIGN

Three case reports.

PARTICIPANTS

Three male subjects aged 76, 66, and 61 years.

INTERVENTION

The subjects had symptoms of external ocular inflammation with focal corneal or scleral thinning and inflammation, as well as interstitial keratitis in two cases. Initial diagnosis of sclerokeratitis with limbal thinning was made in all three in addition to a pterygium in case 2.

MAIN OUTCOME MEASURES

Diagnosis of the carcinoma was delayed for 2 to 24 months in two cases, whereas case 2 was diagnosed on excision of a pterygium from the involved area.

RESULTS

All subjects developed intraocular extension after further scleral thinning and perforation without tumefaction.

CONCLUSIONS

Squamous cell carcinoma of the conjunctiva may be seen without a distinct mass and can masquerade as sclerokeratitis, scleromalacia, or interstitial keratitis. It seems that diffuse growth with inflammation leads to thinning, necrosis, and perforation of the ocular wall with resultant intraocular spread. Squamous cell carcinoma should be considered in the differential diagnosis of corneal and scleral thinning, perforation, and inflammation of unknown cause, especially in the older male subject.

Efficacy of a training programme designed to teach cervical smear screeners to identify ocular surface squamous neoplasia using conjunctival impression cytology

Ocular surface squamous neoplasia (OSSN) is a recently proposed term introduced to encompass both intraepithelial neoplasia and invasive squamous cell carcinoma of the conjunctiva and cornea. A teaching programme incorporating a manual, slide sets, and an evaluation test was developed. The aim was to teach experienced cervical smear screeners to evaluate ocular surface specimens collected by conjunctival impression cytology, with a minimum of individual tuition. The use of the manual was well accepted and half of the original six candidates were able to master the new skill adequately within 8 h. It was considered that the differences between the cytology of OSSN and the equivalent lesions of the uterine cervix are sufficient to prevent some experienced screeners acquiring these skills rapidly.

Ocular surface squamous neoplasia

Ocular surface squamous neoplasia presents as a spectrum from simple dysplasia to carcinoma in situ to invasive squamous cell carcinoma involving the conjunctiva as well as the cornea. It is a distinct clinical entity, although it has been known by a variety of different names throughout the literature. Most commonly it arises in the limbal region, occurring particularly in elderly males who have lived in geographic areas exposed to high levels of ultraviolet-B radiation. Symptoms range from none to severe pain and visual loss. The development of preoperative diagnostic techniques, such as impression cytology, are of value in clinical decision making and follow-up management. Simple excision with adequate margins is currently the best established form of treatment despite trials of other modalities. The course of this disease may be evanescent, but is more frequently slowly progressive and may require exenteration and occasionally may lead to death.

Conjunctival intraepithelial and invasive squamous cell carcinomas treated with strontium-90

Twenty-seven patients with malignant epithelial tumors of the conjunctiva were treated between 1967 and 1987. Histological diagnosis was intraepithelial epithelioma in 15 cases (56%) and squamous cell carcinoma in 12 (44%). All patients were treated with a strontium-90 source on cup-shaped applicators of different sizes according to the extension of the tumor. Surface dose ranged from 60 Gy in a single treatment to 140 Gy in 7 fractions, depending on the thickness of the lesion. Fifteen patients were previously untreated, 7 were irradiated after some type of surgical treatment and 5 were treated for recurrence after multiple surgical excisions. Follow-up period ranged from 2 to 15 years. No patient died of his tumor. There were four local recurrences, three of them in patients with intraepithelial carcinoma. Two of the recurrences were salvaged with a new beta-ray treatment and the other two with enucleation. Since 1981, standard policy was to irradiate the entire conjunctiva in patients with diagnosis of intraepithelial epithelioma. Five patients developed cataracts. Considering the high primary control rate and minimal morbidity, strontium irradiation should be considered as a first-choice treatment for conjunctival tumors.

Metastatic squamous cell carcinoma of the conjunctiva

Metastasis from carcinoma of the conjunctiva is said to be rare. The authors have reviewed the clinical and histopathologic findings of squamous cell carcinoma of the conjunctiva in ten patients from Saudi Arabia in whom distant metastasis developed. There were six men and four women who ranged in age from 45 to 75 years (mean, 61 years). The initial site of metastasis included the parotid gland, submandibular and submaxillary glands, preauricular, cervical lymph nodes, lungs, and bone. Squamous cell carcinoma of the conjunctiva appears to follow a more aggressive course in Saudi Arabia than elsewhere, which appears to be related to delay in management.

Conjunctival and corneal intraepithelial and invasive neoplasia

The histopathologic findings and clinical records of 98 patients with conjunctival and corneal intraepithelial neoplasia (CIN) and 22 patients with invasive neoplasia were studied. Pathologic material was evaluated for cell type, degree of dysplasia, margins of excision, and change in pattern with recurrence. Clinical records were reviewed for demographic features, presenting symptoms, clinical appearance, therapy, and subsequent course. Recurrences occurred in 23 patients with CIN and 9 patients with invasive neoplasia. Intraocular or orbital extensions or both occurred in four patients and metastatic disease in two patients. The cell type, clinical appearance, and degree of dysplasia did not correlate with recurrence; involvement of the margins of the initial excision was an important prognostic sign for recurrence.

Corneal epithelial dysplasia after trifluridine use

Prolonged topical trifluridine treatment of herpes simplex keratitis in three elderly patients produced slightly raised dysplastic corneal epithelial lesions. The involved epithelium had a ground-glass appearance and exhibited opaque cells, edema, and spindle-shaped surface cells. Histopathology demonstrated severe cellular atypism, loss of cell polarity, dyskeratosis, parakeratosis, and a few mitotic figures. The pathological change was apparently intraepithelial. After scraping, the edema and opaque cells in the regenerated epithelium gradually disappeared in 3-4 months on cessation of trifluridine therapy. In one patient recurrence of dendritic keratitis, 5 weeks after scraping, was treated by topical bromovinyldeoxyuridine eye drops. Since severe epithelial dysplasia may represent a precancerous condition, prolonged use of trifluridine should be avoided.

Unilateral central corneal epithelial dysplasia

A unilateral, apparently nonfamilial disease process affecting the interpalpebral portion of the corneal epithelium is reported. The patient, a 62-year-old man, was in good general health; he had no disease of the skin or mucous membranes and no history of trauma. Severe intermittent discomfort of the left eye had been present for several months. Corneal epithelial scrapings were performed on two occasions with a one-year interval, the condition having recurred during the intervening months. Material from both biopsy specimens showed dysplasia of the epithelium with foci of acantholysis and dyskeratosis and features of apoptosis. Transmission electron microscopic findings included intracytoplasmic desmosomes, conspicuous thickened tonofibrils, irregular convoluted cytoplasmic membranes, and dyskeratotic bodies.

Preinvasive carcinoma of the cornea and conjunctiva

Greyish-white spots, varying in size, caused diagnostic problems in 2 patients with pre-invasive corneal carcinoma. Keratectomy specimens permitting light and electron microscopy indicated that the smaller spots predominating in one patient correlated with epithelial microcysts and vacuoles, while areas of parakeratosis accounted for the macroscopic white patches found in the other. A variety of ultrastructural abnormalities, including excessive basement membrane fibrillogenesis, were present in both cases.

Masquerade syndrome

A 52-year-old man experienced chronic blepharoconjunctivitis of the right eye of the three years' duration that was unresponsive to medications. Conjunctival cytologic examinations suggested carcinoma and this was confirmed. However, only a full-thickness eyelid biopsy established that the tumor was a sebaceous carcinoma. We discuss the importance of considering this condition in all cases of unilateral, persistent, or recurrent eyelid inflammation resistant to the usual therapy; the diagnostic value of conjunctival scrapings and full-thickness lid biopsy; and the necessity of interpretation of the biopsy material by a pathologist experienced with, and alerted to look for, this neoplasm. Early recognition of sebaceous carcinoma followed by prompt adequate therapy should improve the survival of patients with this rare but malignant tumor.

Beta-ray treatment of malignant epithelial tumors of the conjunctiva

Fifteen patients with malignant epithelial tumors of the conjunctiva were treated with beta-ray ocular applicators filled with radioactive strontium and yttrium (90Sr/90Y). Histologic examination confirmed the diagnosis. There were ten squamous cell carcinomas, four carcinomas in situ, and one case of epidermidalization. In one patient, who may have received an insufficient dose, recurrence led to enucleation. Radiogenic complications-secondary glaucoma and corneal degeneration-caused visual loss in two other patients. All of the other tumors disappeared completely without seriously affecting the eyes. Beta-ray irradiation with 90Sr/90Y applicators was effective if a sufficient dose (15,000 to 18,000 rads) was applied to the tumor surface and if the height of the tumor did not exceed 5 mm.