Recurrent carcinoma in situ of the conjunctiva and cornea (Bowen's disease)

Long-term follow-up of conjunctival and corneal intraepithelial neoplasia treated with topical interferon alfa-2b

OBJECTIVE

To evaluate the long-term recurrence rate (>1 year) of conjunctival and corneal intraepithelial neoplasia (CIN) treated with topical interferon alfa-2b.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Twenty-eight eyes of 26 patients from 2 institutions, treated between April 1997 and June 2005, with CIN lesions utilized topical interferon alfa-2b drops 4 times daily until clinical resolution was achieved.

METHODS

Patients' charts and clinical photographs were reviewed, and data were analyzed.

MAIN OUTCOME MEASURES

All eyes were monitored for the possibility of recurrence with a minimum of 1-year follow-up from the time of documented clinical resolution.

RESULTS

Complete clinical resolution of the CIN lesions was achieved in 27 of the 28 eyes treated (96.4%). One of the 28 eyes treated (3.6%) had only a partial response to treatment. For the 27 eyes with complete response, resolution occurred after a median of 2.0 months (range, 10 days-15 months). Eyes were treated for a median of 3.2 months (range, 1-15). Median follow-up after clinical resolution (tumor-free period) was 42.4 months (range, 14-89). One eye of the 27 analyzed (3.7%) experienced a recurrence. Side effects of treatment were limited to mild conjunctival hyperemia and follicular conjunctivitis in 3 patients (12%). In all cases, there was total resolution of the side effects within 1 month after cessation of the medication.

CONCLUSIONS

In this group of patients with CIN lesions observed for >1 year, topical interferon alfa-2b was effective in treating lesions with minimal self-limited side effects.

Adjuvante topische Interferon-α-2b-Therapie bei epithelialen Tumoren der Augenoberfläche

PURPOSE

The aim of this study was to evaluate the role of topical interferon-alpha-2b in the adjuvant treatment of corneal and conjunctival tumors.

METHOD

In this noncomparative, prospective, interventional case series, five patients with histologically proven conjunctival intraepithelial neoplasia (CIN) after primary excision and amniotic membrane transplantation were treated with interferon (IFN)-alpha-2b eye drops five times daily over a period of 6 weeks (1 million IU/ml Intron A, Schering). An in situ hybridization technique was used to detect human papillomavirus (HPV) in all specimens. Frequent follow-up was undertaken clinically and photographically for evidence of tumor recurrence.

RESULTS

In the follow-up period (13.2+/-4,97 months) no clinical evidence of recurrence with only limited treatment side effects such as mild conjunctival hyperemia were recorded after 6 weeks of interferon. In one CIN specimen HPV 16/18 could be detected.

CONCLUSIONS

The combination of excisional biopsy and topical interferon-alpha-2b application seems to be an effective and safe treatment for conjunctival intraepithelial neoplasias. Therefore, we prefer this combined treatment to topical interferon-alpha-2b treatment alone, more destructive approaches such as radiation and cryotherapy, or treatment with antimetabolites such as 5-fluorouracil or mitomycin C.

Topical 0.002% Mitomycin C for the Treatment of Conjunctival-Corneal Intraepithelial Neoplasia and Squamous Cell Carcinoma

PURPOSE

To demonstrate the efficacy of topical 0.002% mitomycin C (MMC) as an adjunctive and alternative treatment in primary and recurrent conjunctival-corneal intraepithelial neoplasia (CCIN) and squamous cell carcinoma (SCC).

METHODS

The medical records of 7 patients with histopathologically confirmed CCIN and conjunctival SCC were retrospectively reviewed. All cases were treated with topical 0.002% MMC 4 times daily. The tumor size pre- and post-treatment, clinical response, and ocular complications were evaluated.

RESULTS

The mean age of the patients was 56 +/- 13.4 years. The most common presenting symptom was foreign body sensation (57.1%) with a mean duration of 2.3 +/- 3.8 months. Six patients had pathologically proven CCIN (85.7%) and 1 had SCC (14.3%). Before MMC treatment, 6 eyes (85.7%) had recurrences after surgical excision. The tumor-free period ranged from 2 to 19 months. Two patients had multiple recurrences. MMC 0.002% 4 times daily was applied for a period of 5.4 +/- 4.4 weeks (range, 2-14). All had complete tumor regression as observed clinically and confirmed by impression cytology. Side effects of MMC therapy included ocular irritation, mild conjunctival hyperemia, and punctate keratopathy. There were no serious complications detected. The mean follow-up time was 30.7 +/- 15 months (range, 2-52) with no evidence of clinical recurrence in any case.

CONCLUSIONS

Topical 0.002% MMC showed a favorable outcome as an adjunctive and alternative treatment of CCIN and SCC with regression of primary and recurrent tumors.

Ocular Surface Squamous Neoplasia

Even though ocular surface squamous neoplasia (OSSN) has been recognized for well over a century, the past decade has witnessed advances that have helped rewrite many of the paradigms for the diagnosis and management of these lesions. OSSN occurs predominantly in the elderly for whom they are the third most common oculoorbital tumors after melanoma and lymphoma. In addition to advanced age and male sex, other major risk factors linked to its pathogenesis are ultraviolet light, cigarette smoking, and the human papilloma virus. Although the latter has been linked to OSSN for nearly 4 decades, its identification and role in the pathogenesis of these tumors has been elucidated recently and is addressed in detail in this review. Newer techniques of impression cytology represent a noninvasive and reliable method of diagnosing OSSN and monitoring treated cases. The efficacy of chemotherapeutic agents such as mitomycin C and 5-fluorouracil have been proven in the recent past, making them a clear alternative to the time-tested treatment of surgical excision and cryotherapy. Early reports on the efficacy of topical Iterferon alpha 2b indicate significant promise in providing another alternative for the treatment of some of these neoplasms. These advances thus represent a minimally invasive and highly successful approach to the diagnosis and treatment of OSSN.

Regression of presumed primary conjunctival and corneal intraepithelial neoplasia with topical interferon alpha-2b

PURPOSE

To evaluate topical interferon alpha-2b (IFNalpha2b) as a lone therapy in the treatment of primary conjunctival and corneal intraepithelial neoplasia (CIN).

METHODS

Noncomparative, prospective, interventional case series. Seven patients from three institutions, treated between February and October 1999, with presumed primary CIN lesions (clinically diagnosed by corneal specialists) were given topical IFNalpha2b drops (1 million units/mL) four to six times daily. Follow-up was performed biweekly until there was complete clinical resolution of the presumed CIN lesions. Patients were to continue topical IFNalpha2b drops for 1 month after clinical resolution. Patient charts and clinical photographs were reviewed, and data were analyzed.

RESULTS

All seven eyes had complete resolution of the presumed CIN lesions after an average of 77.0 +/- 59.2 days (range, 28-188 days). Average posttreatment follow up was 12.4 +/- 2.5 months (range, 9-16 months). No patients were lost to follow-up. No recurrences have yet been seen. Side effects of treatment were limited to mild conjunctival hyperemia and follicular conjunctivitis in four (57.1%) eyes. In all cases, there was total resolution of conjunctival hyperemia and follicular changes within 1 month after cessation of the medication, without additional treatment.

CONCLUSIONS

Topical IFNalpha2b alone may be an effective treatment of primary CIN. It appears to be a safe alternative to radiation, intralesional IFNalpha2b injection, and surgical excision with cryotherapy. Larger population studies with longer follow-up are recommended to better assess the risk of recurrence and other possible adverse effects.

Guidelines for management of Bowen's disease. British Association of Dermatologists

These guidelines for management of Bowen's disease have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Late recurrences and the necessity for long-term follow-up in corneal and conjunctival intraepithelial neoplasia

PURPOSE

The purpose of the study was to elucidate the natural history of corneal-conjunctival intraepithelial neoplasia (CIN) and suggest treatment and follow-up guidelines.

METHODS

The records of all histologically proven cases of CIN at the Royal Victorian Eye and Ear Hospital between 1979 and 1994 were reviewed.

RESULTS

Seventy-nine eyes of 76 patients had a pathologic diagnosis of CIN and were observed for up to 15 years. The lesion recurred in 31 eyes (39%) overall. There was no statistical difference shown in the likelihood of recurrence based on histologic classification. Complete excision was attempted in each case. In 18 eyes, dysplastic cells were evident at the excision margin. Ten (56%) of these tumors recurred, compared to a 33% recurrence rate in completely excised lesions. The time to the first recurrence ranged from 33.0 days to 11.5 years between the first and second surgeries, with 11 lesions recurring after more than 4 years. Incompletely excised lesions reappeared more rapidly (average, 2.5 years) than did those with clear surgical margins (average, 3.8 years). Seven cases progressed to invasive squamous cell carcinoma and four cases led to blindness or removal of the eye.

CONCLUSIONS

This study suggests that excision margin at the time of surgery is the most important factor in predicting recurrence. The slow growth of the recurrent lesions combined with the ever-present malignant potential leads the authors to suggest that all patients with a history of CIN warrant annual follow-up for the remainder of their lives.

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.

Adjunctive radiotherapy with strontium-90 in the treatment of conjunctival squamous cell carcinoma

Squamous cell carcinoma of the ocular conjunctiva is a relatively rare malignancy which is attended by a high rate of local recurrence following simple surgical excision. To date, the management of conjunctival squamous cell cancer has been controversial. From 1950 to 1985, 146 consecutive patients with superficial conjunctival squamous cell cancer were treated at the Queensland Radium Institute. All patients were treated by simple surgical excision of the visible conjunctival lesion followed by adjunctive radiotherapy. Of 140 patients with histologically confirmed squamous cell cancer, 123 were treated with a strontium-90 source, 10 with a radon "ring," and 7 with superficial X ray therapy. Standard policy since 1960 has been to deliver an incident dose of 30 Gy in a single fraction within the first 48 post-operative hours to the surgical bed using a strontium-90 source on a stand-off eye applicator. This report will largely focus on the 123 patients who were treated with a strontium-90 source, of whom 107 received 30 Gy, 14 received 40 Gy (pre 1960) and one patient each received 20 and 25 Gy incident dose. Of 131 evaluable patients, there were only 3 who developed local recurrence. All 3 local recurrences developed in elderly men who had presented with extensive superficial primary tumors. Two of the three recurrences occurred in the two patients who were treated with doses less than 30 Gy. Both early and late radiation-induced complications following ablative surgery and treatment with strontium-90 were very uncommon. Three patients developed unsightly conjunctival telangiectasia, 2 patients developed a persistent scleral ulcer and 2 patients developed clinically significant cataracts. This negligible degree of treatment-related side effects contrasts with the experience of 10 patients who had previously been treated with a radon ring, 8 of whom developed serious complications, although none developed local recurrence. On the basis of our excellent local control rates with minimal morbidity we would continue to advocate the use of simple surgical excision followed by 30 Gy beta radiation from a strontium-90 source as the definitive treatment for superficial conjunctival squamous cell cancer.

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.

Mucoepidermoid carcinoma of the conjunctiva with intraocular invasion

A 70-year-old man developed intraocular invasion from a recurrent tumor of the nasal perilimbal conjunctiva of the right eye six months after the original tumor had been resected. Examination of the enucleated right globe disclosed massive invasion of the nasal one-half of the anterior segment by a mucoepidermoid carcinoma of the conjunctiva. The neoplasm demonstrated mainly epidermoid features, including the production of a substantial amount of intraocular keratin. However, a segment of tumor along and within the iris stroma showed almost exclusively mucus-secretory features with a mucinous material within individual tumor cells and cysts lined by tumor cells. The original biopsy specimen demonstrated only the epidermoid and not the mucoid component of the carcinoma. Mucoepidermoid carcinoma of the conjunctiva appears to be more locally aggressive than conventional squamous cell carcinoma as is characterized by its tendency for early recurrence associated with a high incidence of intraocular and orbital invasion.

The management of lid and conjunctival malignancies

Adnexal tumors are relatively rare in a general eye practice, and the most important component in their management is early recognition. The clear differentiation between stimulating lesions and lid or conjunctival tumors can be difficult. Any recurrent lid inflammation, chronic lid ulcer, chronic unilateral keratoconjunctivitis, or a suspicious pigmented conjunctival lesion should be biopsied. The choice of treatment in lid and conjunctival tumors is partially dependent on the available surgical expertise. Lid tumors can be treated with either surgery (using frozen section control), radiation, or cryotherapy. Conjunctival tumors should first be biopsied, then treated with surgery or radiation. Exenteration is rarely indicated in the management of conjunctival tumors. A metastatic evaluation should precede possible exenteration, especially if this procedure is planned because of a recurrent or large conjunctival melanoma.

The use of strontium-90 in the treatment of carcinoma in situ of the conjunctiva

Four patients with carcinoma in situ were treated with strontium-90 beta ray application. The dose used was 4,500 rads after surgical removal or with small recurrent tumor and 7,000 rads for primary treatment. All patients were disease-free at follow-up periods of 48 to 320 months after treatment. One patient required superficial x-ray treatment for recurrent disease. No serious complications developed with the treatment and no progressive cataracts have occurred.

[Electron-microscopic findings in Bowen's disease of the conjunctiva (author's transl)]

The conjunctival tumors of eleven patients were histologically diagnosed as an intraepithelial squamous cell carcinoma Bowen's disease. All characteristic intraepithelial changes were manifest. Microinvasion, secondary dyskeratosia, dyskeratotic keratinisation, individual cell keratinization, and loss of intercellular desmosomes were clearly evident in the electron microscope. Virus-like organisms were not observed.

Pigmented squamous cell carcinoma of cornea and conjunctiva: A light microscopic, histochemical, and ultrastructural study

A light microscopic, histochemical, and ultrastructural study was performed on tissue obtained from a pigmented squamous cell carcinoma of the cornea and conjunctiva. To the best of our knowledge this is the first time that one of these rare pigmented squamous cell carcinomas of the ocular mucous membrane has been described in detail. The occurrence of this neoplasm, which needs to be differentiated from other pigmented lesions, and particularly epibulbar melanomas, underscores the fact that all pigmented tumors are not melanomas. The study revealed that melanin granules, which accounted for the pigmentation of the neoplasm, were present in variable numbers in neoplastic squamous cells, Langerhans cells, macrophages, and stellate cells identified as melanocytes with mature melanosomes. Premelanosomes were not observed in any of these cells types. Current concepts concerning the common association of Langerhans cells with their characteristic intracytoplasmic "Birbeck granules" and melanocytes are discussed.

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.

Urea in the treatment of epibulbar malignancies

Eight patients with epibulbar malignancies of the eyes were sucessfully treated with urea. One of them presented a malignant melanoma, one a tumour of Kaposi's disease, and six had squamous cell carcinomas. At least four out of these eight patients would have required enucleation of the globe or exenteration of the orbit as an alternative to urea therapy.