Corneo-conjunctival carcinoma in Uganda

Demographics, clinical presentation and risk factors of ocular surface squamous neoplasia at a tertiary hospital, South Africa

AIMS

The aim of this study is to describe the demographic, presenting features and associated risk factors of ocular surface squamous neoplasia (OSSN) at a tertiary eye hospital in Johannesburg, South Africa.

METHODS

An interventional prospective study of patients presenting with conjunctival masses was conducted. An electronic questionnaire was completed to document demographic data, presenting history, and associated risk factors. A slit lamp examination and photos were used to document and describe the clinical features at presentation. Cases (OSSN) and controls (benign lesions) were determined by histology.

RESULTS

There were 130 cases and 45 controls. Median age was 44 years (IQR: 35-51) with an equal gender distribution in cases. The prevalence of HIV in cases was 74% and was strongly associated with OSSN (p < 0.001). Vascularisation, leukoplakia and pigmentation were clinical features that distinguished cases from controls. A fibrovascular morphology was strongly associated with a benign histology (p < 0.001), whereas leukoplakic and gelatinous morphologies were associated with OSSN. Conjunctival intra-epithelial neoplasia made up 82% of cases.

CONCLUSION

Our study describes a sample of OSSN that is young and has no gender predisposition. The majority of cases presented with CIN lesions, rather than SCC reported in other African countries. HIV was the most significant risk factor in this study population.

Promotor methylation in ocular surface squamous neoplasia development: epigenetics implications in molecular diagnosis

INTRODUCTION

Cancer is heavily influenced by epigenetic mechanisms that include DNA methylation, histone modifications, and non-coding RNA. A considerable proportion of human malignancies are believed to be associated with global DNA hypomethylation, with localized hypermethylation at promoters of certain genes.

AREA COVERED

The present review aims to emphasize on recent investigations on the epigenetic landscape of ocular surface squamous neoplasia, that could be targeted/explored using novel approaches such as personalized medicine.

EXPERT OPINION

While the former is thought to contribute to genomic instability, promoter-specific hypermethylation might facilitate tumorigenesis by silencing tumor suppressor genes. Ocular surface squamous neoplasia, the most prevalent type of ocular surface malignancy, is suggested to be affected by epigenetic mechanisms, as well. Although the exact role of epigenetics in ocular surface squamous neoplasia has mostly been unexplored, recent findings have greatly contributed to our understanding regarding this pathology of the eye.

Epidemiology and survival outcomes of patients with orbital region non-cutaneous squamous cell carcinoma: a population-based analysis

Background

Non-cutaneous squamous cell carcinoma (ncSCC) of the orbital region is very rare. Thus, its epidemiological characteristics and prognosis are poorly understood. The aim of the study was to assess the epidemiological characteristics and survival outcomes of ncSCC of the orbital region.

Methods

Incidence and demographic data on ncSCC of the orbital region were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and analyzed. The chi-square test was used to calculate the differences between groups. Univariate and multivariate Cox regression analyses were performed to determine the independent prognostic factors for disease-specific survival (DSS) and overall survival (OS).

Results

The overall incidence of ncSCC in the orbital region from 1975 to 2019 was 0.68/1,000,000, and the incidence showed an increasing trend during this period. A total of 1,265 patients with ncSCC of the orbital region (mean age, 65.3 years) were identified in the SEER database. Of these, 65.1% were aged ≥60 years, 87.4% were White, and 73.5% were male. The conjunctiva (74.5%) was the most common primary site, followed by the orbit (12.1%), lacrimal apparatus (10.8%), and overlapping lesion of the eye and adnexa (2.7%). Multivariate Cox regression analysis revealed that age, primary site, SEER summary stage, and surgery were independent prognostic factors for DSS, whereas age, sex, marital status, primary site, SEER summary stage, and surgery were independent prognostic factors for OS.

Conclusions

The incidence of ncSCC in the orbital region has increased over the past 40 years. It usually affects White people, men, and people aged ≥60 years, and its most common site is the conjunctiva. Orbital SCC has worse survival outcomes than SCC of other sites in the orbital region. Surgery is the independent protective treatment for ncSCC of the orbital region.

Conjunctival squamous cell carcinoma with massive apoptosis and immune cell infiltration: A case report

This case reports a rare case of conjunctival squamous cell carcinoma in China. The elderly (86-year-old) female patient was diagnosed and treated effectively after three times of diagnosis. During this period, she was misdiagnosed and ineffective treatment for many times. Therefore, we propose to make an integrated diagnosis based on histopathological diagnosis, combined with a variety of diagnostic methods including MRI and CDFI, supplemented by updated multiple immunohistochemically techniques, so as to achieve the purpose of accurate diagnosis.

Treatment challenges associated with a superiorly located bulbar conjunctival mass—case report and review of the literature

Purpose

This report describes a recurrent case of ocular surface squamous neoplasia in a middle-aged and immunocompetent patient.

Observations

The summary of clinical presentation, workup, and medical and surgical intervention are described, followed by a brief overview of the treatment challenges associated with superiorly located conjunctival lesions.

Conclusions

In cases where topical chemotherapeutic drops cannot penetrate the lesion, the location of conjunctival lesions can sometimes pose a challenge. Hence, injections in such cases might be preferred. However, histopathology still plays a significant role in achieving a definitive diagnosis.

Ocular surface squamous neoplasia: management and outcomes

Ocular surface squamous neoplasia (OSSN) is the most common ocular tumour with an incidence ranging from 0.03 to 1.9 per 100,000 persons/year. The diagnosis is made on clinical suspicion and confirmed with anterior-segment optical coherence tomography (AS-OCT), cytology, or histology. The purpose of this review is to provide an overview of the management options available for OSSN and review their success and recurrence rates. Surgery is the gold standard for the management of small OSSN lesions. With the increased use of less invasive diagnostic modalities such as AS-OCT and cytology, there has been a move to use topical therapies for the management of OSSN. The most commonly used agents are interferon-α2b (IFN), mitomycin-C (MMC) and 5-fluorouracil (5FU). They have been shown to have similar resolution and recurrence rates but differ in cost and side effect profile. IFN has the lowest side effect profile, but is also the most expensive, whereas MMC has the greatest surface toxicity and is priced midway between the three. 5FU is the cheapest of the three topical agents with less surface toxicity than MMC. Radiotherapy is mostly employed as adjuvant therapy. Newer novel therapies are available but have not been widely adopted as mainstream therapy due to cost and lack of clinical evidence. OSSN has the benefit of many management options. No single modality has been shown to superior and some patients will need the use of combination therapy to achieve an optimal clinical outcome.

Proton beam radiotherapy of locally advanced or recurrent conjunctival squamous cell carcinoma: experience of the CATANA Centre

Aim:

Conjunctival squamous cell carcinoma (SCC) is a rare tumour of the ocular region and microscopic radical surgical is difficult. There are no single guidelines for therapeutic management and the role of radiation therapy is not clearly defined although conventionally photon or electron beams are used. Proton beam radiotherapy (PBRT) is a new option for a conservative approach and allows good sparing of the organs at risk.

Materials and methods:

After surgical resection, we collected 15 cases treated at our institution with PBRT. The dose delivered was between 48 and 60 Gy relative biological effectiveness (RBE), with fractions of 12–15 Gy RBE.

Results:

After an average period of 48 months, the patients achieved excellent disease control (overall survival and disease-free survival: 86·6%), with minimal acute and late toxicity.

Findings:

In this work, we present our experience on the use of PBRT technique in SCC treatment. A larger sample of patients is needed to draw conclusions about the impact of this treatment on disease recurrence and overall survival.

Delay along the care-seeking journey of patients with ocular surface squamous neoplasia in Kenya

Background

In Africa, accessing eye health services is a major challenge. Ocular surface squamous neoplasia (OSSN) is a substantial ocular health problem in Africa related to solar UV light exposure and HIV infection among other risk factors. The disease causes visual loss and even death in advanced cases. This study was conducted to assess referral pathway and treatment delay for patients with OSSN in Kenya.

Methods

Adults with conjunctival lesions presenting to four eye centres were asked about their occupations, when they noticed the growth, health facilities visited in seeking care, cost of consultation, surgery, medicines and histopathology and dates at each step. The time-to-presentation was divided into quartiles and correlates analysed using ordinal logistic regression.

Results

We evaluated 158 first-time presenters with OSSN. Most were women (102 [65%]), living with HIV (78/110 tested [71%]), with low to medium income (127 [80%]). Most of the HIV patients (49/78 [63%]) were in antiretroviral care programs. About half (88/158, [56%]) presented directly to the study centres while the rest were referred. Indirect presenters sought care earlier than direct presenters (median 2.0 months vs 5.5 months) and travelled a shorter distance to the first health facility (median 20 km vs 30 km) but had surgery later (median 12.5 months vs 5.5 months). Visits beyond the first health facility for indirect presenters markedly increased delay (median 7.3, 29.0, 37.9, and 32.0 months for 1–4 facilities, respectively). Delay was associated with number of health facilities visited (adjusted ordered OR = 9.12; 95%CI 2.83–29.4, p < 0.001) and being female (adjusted ordered OR = 2.42; 95%CI 1.32–4.44, p = 0.004). At the time of presentation at the study centres for surgery the median tumour diameter in both directly and indirectly presenting patients was 6 mm (p = 0.52) and the histological spectrum of OSSN was similar between the groups (p = 0.87).

Conclusions

Referral delays definitive treatment for OSSN. Women were more likely to experience delay. Despite regular contact with the health system for those with known HIV infection, delays occurred. Early detection and referral of OSSN in the HIV service might reduce delays, but reassuringly delay did not give rise to a larger proportion with more advanced grade of OSSN.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2428-4) contains supplementary material, which is available to authorized users.

Risk factors for ocular surface squamous neoplasia in Kenya: a case-control study

OBJECTIVE

To determine modifiable risk factors of ocular surface squamous neoplasia (OSSN) in Kenya using disease-free controls.

METHODS

Adults with conjunctival lesions were recruited at four eye care centres in Kenya and underwent excision biopsy. An equal number of controls having surgery for conditions not affecting the conjunctiva and unrelated to ultraviolet light were group-matched to cases by age group, sex and eye care centre. Associations of risk factors with OSSN were evaluated using multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs). Continuous variables were compared using the t-test or the Wilcoxon-Mann-Whitney U-test depending on their distribution.

RESULTS

A total of 131 cases and 131 controls were recruited. About two-thirds of participants were female, and the mean age of cases and controls was 42.1 years and 43.3 years, respectively. Risk factors for OSSN were HIV infection without antiretroviral therapy (ART) use (OR = 48.42; 95% CI: 7.73-303.31) and with ART use (OR = 19.16; 95% CI: 6.60-55.57), longer duration of exposure to the sun in the main occupation (6.9 h/day vs. 4.6 h/day, OR = 1.24; 95% CI: 1.10-1.40) and a history of allergic conjunctivitis (OR = 74.61; 95% CI: 8.08-688.91). Wearing hats was protective (OR = 0.22; 95% CI: 0.07-0.63).

CONCLUSION

Measures to prevent and control HIV, reduce sun exposure such as wearing hats and control allergic conjunctivitis are recommended.

Viral-associated malignancies in Africa: are viruses 'infectious traces' or 'dominant drivers'?

Since the discovery of Epstein-Barr virus (EBV) the first human virus associated with cancer in 1964, the number of human malignancies associated with viruses has grown. A review of cancer incidence reveals substantial variation in the incidence of such cancers around the world. In some parts of Africa, the majority of cancers are caused by infectious agents. However, there remain huge challenges in measuring the burden of cancer, especially in sub-Saharan Africa. Despite this limitation, it is clear that viral-associated malignancies are key drivers of cancer incidence rates in Africa. Prevention is available through vaccination for some but development of vaccines for others remains an important the goal.

Topical fluorouracil after surgery for ocular surface squamous neoplasia in Kenya: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is an aggressive eye tumour particularly affecting people with HIV in Africa. Primary treatment is surgical excision; however, tumour recurrence is common. We assessed the effect of fluorouracil 1% eye drops after surgery on recurrence.

METHODS

We did this multicentre, randomised, placebo-controlled trial in four centres in Kenya. We enrolled patients with histologically proven OSSN aged at least 18 years. After standard surgical excision, participants were randomly allocated to receive either topical fluorouracil 1% or placebo four times a day for 4 weeks. Randomisation was stratified by surgeon, and participants and trial personnel were masked to assignment. Patients were followed up at 1 month, 3 months, 6 months, and 12 months. The primary outcome was clinical recurrence (supported by histological assessment where available) by 1 year, and analysed by intention to treat. The sample size was recalculated because events were more common than anticipated, and trial enrolment was stopped early. The trial was registered with Pan-African Clinical Trials Registry (PACTR201207000396219).

FINDINGS

Between August, 2012, and July, 2014, we assigned 49 participants to fluorouracil and 49 to placebo. Four participants were lost to follow-up. Recurrences occurred in five (11%) of 47 patients in the fluorouracil group and 17 (36%) of 47 in the placebo group (odds ratio 0·21, 95% CI 0·07-0·63; p=0·01). Adjusting for passive smoking and antiretroviral therapy had little effect (odds ratio 0·23; 95% CI 0·07-0·75; p=0·02). Adverse effects occurred more commonly in the fluorouracil group, although they were transient and mild. Ocular discomfort occurred in 43 of 49 patients in the fluorouracil group versus 36 of 49 in the placebo group, epiphora occurred in 24 versus five, and eyelid skin inflammation occurred in seven versus none.

INTERPRETATION

Topical fluorouracil after surgery substantially reduced recurrence of OSSN, was well-tolerated, and its use recommended.

FUNDING

British Council for Prevention of Blindness and the Wellcome Trust.

Solar ultraviolet radiation in Africa: a systematic review and critical evaluation of the health risks and use of photoprotection

The majority of the African continent experiences high solar UVB radiation throughout the year. The adverse consequences of this on the health of populations living in Africa are reviewed.

[Prognosis of primary malignant tumors of the conjunctiva]

PURPOSE

To discuss possible factors that could influence the prognosis of primary malignant conjunctival tumors.

PATIENTS AND METHODS

We retrospectively analyzed medical records of 79 patients followed for primary malignant conjunctival tumors between January 1997 and July 2011.

RESULTS

The mean age at the time of diagnosis was 61.1 years; male/female ratio was 2.59. The mean tumor size was 13.9 mm. The histological type was invasive squamous cell carcinoma in 43 cases (54.4%), epithelial dysplasia in 11 cases (13.9%), carcinoma in situ in 7 cases, conjunctival malignant melanoma in 5 cases, conjunctival lymphoma in 4 cases and other rare tumors in 9 cases. We performed an excisional biopsy with a safety margin in 89.8% of cases, associated with cryotherapy in 46.6% of cases. Enucleation was performed in two cases and orbital exenteration in 5 cases. We noted tumor recurrence in 33.3% of patients after an average period of 9.5 months. Radiation therapy was indicated in 44 cases (55.7%). The mean follow-up of our patients was 42 months. Tumor recurrences were statistically associated with a history of xeroderma pigmentosum (P=0.012), a diagnostic delay more than 11 months (P=0.001), caruncular location (P=0.004), tumor size greater than 10mm (P=0.044), scleral extension (P=0.011), initial treatment limited to excisional biopsy (P=0.033) and histopathologic involvement of the margin of the tumor resection (P=0.008).

CONCLUSION

A better understanding of the prognostic factors of primary malignant conjunctival tumors is essential for management and may improve the prognosis of these tumors.

The treatment of carcinoma in situ and squamous cell carcinoma of the conjunctiva with fractionated strontium-90 radiation in a population with a high prevalence of HIV

BACKGROUND

This study explores the safety and efficacy of strontium 90 (Sr-90) brachytherapy as the sole adjuvant therapy for carcinoma in situ (CIS) and squamous cell carcinoma (SCC) of the conjunctiva in a high HIV prevalent area.

METHODS

This is a retrospective case review of patients treated with 60 Gray Sr-90 brachytherapy in four divided doses after resection with a 2 mm margin and histological confirmation. Cryotherapy or alcohol debridement was not performed at the time of excision due to limited resources. Two plaque sizes, 8.5 mm and 18 mm, were used.

RESULTS

Sixty-nine patients were treated and had a median follow-up of 27 months (range 6-127). Thirty-three (47.8%) were HIV-positive. CIS was present in 40.6% and SCC in 59.4%. The surgical margins were positive in 39 (56.5%). Twenty patients (29.0%) were treated with the 18 mm plaque and 49 (71.0%) with the 8.5 mm plaque. Eight (11.6%) patients developed a recurrence at a median of 5 months (range 2-40). Recurrences only occurred in patients treated with the 8.5 mm plaque (p=0.094). There was no significant effect of HIV status, positive margins or staging on the number of recurrences. Treatment side effects were a dry eye in five patients which was successfully managed with topical lubricants, and induced astigmatism of 1 dioptre of cylinder in one patient.

CONCLUSIONS

Sr-90 brachytherapy is safe and effective in preventing recurrences in ocular surface squamous neoplasia in a high HIV prevalent setting. The 18 mm plaque size is superior to the 8.5 mm plaque size.

Pathophysiology of ocular surface squamous neoplasia

The incidence of ocular surface squamous neoplasia (OSSN) is strongly associated with solar ultraviolet (UV) radiation, HIV and human papilloma virus (HPV). Africa has the highest incidence rates in the world. Most lesions occur at the limbus within the interpalpebral fissure particularly the nasal sector. The nasal limbus receives the highest intensity of sunlight. Limbal epithelial crypts are concentrated nasally and contain niches of limbal epithelial stem cells in the basal layer. It is possible that these are the progenitor cells in OSSN. OSSN arises in the basal epithelial cells spreading towards the surface which resembles the movement of corneo-limbal stem cell progeny before it later invades through the basement membrane below. UV radiation damages DNA producing pyrimidine dimers in the DNA chain. Specific CC → TT base pair dimer transformations of the p53 tumour-suppressor gene occur in OSSN allowing cells with damaged DNA past the G1-S cell cycle checkpoint. UV radiation also causes local and systemic photoimmunosuppression and reactivates latent viruses such as HPV. The E7 proteins of HPV promote proliferation of infected epithelial cells via the retinoblastoma gene while E6 proteins prevent the p53 tumour suppressor gene from effecting cell-cycle arrest of DNA-damaged and infected cells. Immunosuppression from UV radiation, HIV and vitamin A deficiency impairs tumour immune surveillance allowing survival of aberrant cells. Tumour growth and metastases are enhanced by; telomerase reactivation which increases the number of cell divisions a cell can undergo; vascular endothelial growth factor for angiogenesis and matrix metalloproteinases (MMPs) that destroy the intercellular matrix between cells. Despite these potential triggers, the disease is usually unilateral. It is unclear how HPV reaches the conjunctiva.

Diagnosing ocular surface squamous neoplasia in East Africa: case-control study of clinical and in vivo confocal microscopy assessment

OBJECTIVE

To examine the reliability of clinical examination and in vivo confocal microscopy (IVCM) in distinguishing ocular surface squamous neoplasia (OSSN) from benign conjunctival lesions.

DESIGN

Case-control study.

PARTICIPANTS

Sixty individuals with conjunctival lesions (OSSN and benign) and 60 age-matched controls with normal conjunctiva presenting to Kilimanjaro Christian Medical Centre, Moshi, Tanzania.

METHODS

Participants were examined and photographed, and IVCM was performed. Patients with conjunctival lesions were offered excisional biopsy with histopathology and a human immunodeficiency virus (HIV) test. The IVCM images were read masked to the clinical appearance and pathology results. Images were graded for several specific features and given an overall categorization (normal, benign, or malignant). A group of 8 ophthalmologists were shown photographs of conjunctival lesions and asked to independently classify as OSSN or benign.

MAIN OUTCOME MEASURES

Comparison of the histopathology diagnosis with the clinical and IVCM diagnosis.

RESULTS

Fifty-two cases underwent excisional biopsy with histopathology; 34 were on the OSSN spectrum, 17 were benign, and 1 was lymphoma. The cases and controls had comparable demographic profiles. Human immunodeficiency syndrome infection was more common in OSSN compared with benign cases (58.8% vs. 5.6%; odds ratio, 24.3, 95% confidence interval [CI], 2.8-204; P = 0.003). Clinically, OSSN lesions more frequently exhibited feeder vessels and tended to have more leukoplakia and a gelatinous appearance. Overall, the ophthalmologists showed moderate agreement with the histology result (average kappa = 0.51; 95% CI, 0.36-0.64). The masked grading of IVCM images reliably distinguished normal conjunctiva. However, IVCM was unable to reliably distinguish between benign lesions and OSSN because of an overlap in their appearance (kappa = 0.44; 95% CI, 0.32-0.57). No single feature was significantly more frequent in OSSN compared with benign lesions. The sensitivity and specificity of IVCM for distinguishing OSSN from benign conjunctival lesions were 38.5% and 66.7%, respectively.

CONCLUSIONS

In East Africa, conjunctival pathology is relatively common and can present significant diagnostic challenges for the clinician. In this study, neither clinical examination nor IVCM was found to reliably distinguish OSSN from benign conjunctival pathology because of an overlap in the features of these groups. Therefore, IVCM cannot currently replace histopathology, and management decisions should continue to rely on careful clinical assessment supported by histopathology as indicated.

Epidemiology of ocular surface squamous neoplasia in Africa

OBJECTIVES

To describe the epidemiology and an aetiological model of ocular surface squamous neoplasia (OSSN) in Africa.

METHODS

Systematic and non-systematic review methods were used. Incidence was obtained from the International Agency for Research on Cancer. We searched PubMed, EMBASE, Web of Science and the reference lists of articles retrieved. Meta-analyses were conducted using a fixed-effects model for HIV and cigarette smoking and random effects for human papilloma virus (HPV).

RESULTS

The incidence of OSSN is highest in the Southern Hemisphere (16° South), with the highest age-standardised rate (ASR) reported from Zimbabwe (3.4 and 3.0 cases/year/100 000 population for males and females, respectively). The mean ASR worldwide is 0.18 and 0.08 cases/year/100 000 among males and females, respectively. The risk increases with exposure to direct daylight (2-4 h, OR = 1.7, 95% CI: 1.2-2.4 and ≥5 h OR = 1.8, 95% CI: 1.1-3.1) and outdoor occupations (OR = 1.7, 95% CI: 1.1-2.6). Meta-analysis also shows a strong association with HIV (6 studies: OR = 6.17, 95% CI: 4.83-7.89) and HPV (7 studies: OR = 2.64, 95% CI: 1.27-5.49) but not cigarette smoking (2 studies: OR = 1.40, 95% CI: 0.94-2.09). The effect of atopy, xeroderma pigmentosa and vitamin A deficiency is unclear.

CONCLUSIONS

Africa has the highest incidence of OSSN in the world, where males and females are equally affected, unlike other continents where male disease predominates. African women probably have increased risk due to their higher prevalence of HIV and HPV infections. As the survival of HIV-infected people increases, and given no evidence that anti-retroviral therapy (ART) reduces the risk of OSSN, the incidence of OSSN may increase in coming years.

Ocular surface neoplasias and human immunodeficiency virus infection

PURPOSE OF REVIEW

Ocular surface malignancy is a serious complication in HIV infection, but can often result in successful treatment if diagnosed appropriately. In the literature, most reviews focus on information for the ophthalmic community. Here, we provide a review of the literature with the pertinent information for the nonophthalmologist, as they are the first point of contact for most HIV patients.

RECENT FINDINGS

Ocular surface squamous neoplasia (OSSN) is the most common nonpigmented ocular surface malignancy. It can be treated well with surgery or topical chemotherapy, the newest method of treatment. When presenting in young patients, a high percentage have been found to be HIV positive. Kaposi's sarcoma is an AIDS-defining malignancy and critical to diagnose. It cannot be cured, but treatment is effective for keeping it controlled. Conjunctival lymphoma can be recognized with the salmon patch appearance. External beam radiation, systemic chemotherapy, and intralesional injections are the mainstays of treatment.

SUMMARY

Ocular surface malignancy manifests significantly in the HIV population. OSSN, Kaposi's sarcoma and conjuctival lymphoma all have different clinical presentations. The capacity of the managing physician to recognize these tumours and refer to an ophthalmologist is essential for appropriate treatment.

Prevalence of undiagnosed HIV infection in patients with ocular surface squamous neoplasia in a tertiary center in Karnataka, South India

PURPOSE

To evaluate the prevalence of undiagnosed and asymptomatic human immunodeficiency virus (HIV) infection in patients with ocular surface squamous neoplasia (OSSN) in a referral hospital in Karnataka, South India.

METHODS

A consecutive series of patients presenting with OSSN were evaluated in an academic center during January 2009 to June 2010. A detailed history was obtained and physical examination in 25 consecutive patients with OSSN was performed. Twenty-three patients (88%) agreed to undergo serological HIV testing. Of these, 2 were excluded from the current study because they had xeroderma pigmentosa, a known predisposing factor for OSSN.

RESULTS

Of the 21 patients, 6 (29%) patients were HIV positive. None of the patients had previous HIV testing. The median age of presentation among HIV-positive patients was 36 years, whereas it was 54 years among HIV-negative patients. The mean CD4 count in HIV-positive patients was 133 cells per mm, and all patients were started on antiretroviral treatment.

CONCLUSIONS

The conjunctival tumor may be the primary and the only apparent manifestation of HIV in patients presenting with OSSN, and the ophthalmologist needs to be aware of this association.

Ocular surface squamous neoplasia in patients with HIV infection in sub-Saharan Africa

PURPOSE OF REVIEW

Ocular surface squamous neoplasia (OSSN) in sub-Saharan countries is an aggressive tumor that affects younger patients and appears to be increasing in incidence. There are data to suggest the association of this disease with solar radiation exposure, HIV, and human papilloma virus (HPV). This trend possibly reflects the association of the high incidence of HIV, concomitant high incidence of exposure to HPV, and the solar radiation exposure that people in this region of the world receive. We undertook a PubMed search with the terms 'ocular surface squamous neoplasia', 'conjunctival carcinoma', 'HIV' and 'HPV', and 'sub-Saharan/Africa' to ascertain the scope of the problem and to review the available data, with an emphasis on publications of 2009 and the first quarter of 2010.

RECENT FINDINGS

There is increasing evidence of a significant association between HIV seropositivity and OSSN. The role of HPV as contributing to the cause of OSSN is being investigated.

SUMMARY

Patients with conjunctival cancer in sub-Saharan Africa are typically younger and more than 50% have underlying HIV infection. Initial presentation can be asymptomatic; however, many of these patients have advanced disease before they seek medical help and OSSN appears to have a more aggressive clinical course in sub-Saharan Africa. Treatment in Africa is primarily surgical. Chemotherapy and antiviral agents have been used. A diagnosis of OSSN in younger patients in sub-Saharan Africa should prompt HIV serotesting.

A case-control study of ocular surface squamous neoplasia (OSSN) in Uganda

HIV increases the risk of OSSN. Here we investigate other factors in a case-control study from Uganda with 318 cases (48 CIN I, 66 CIN II, 81 CIN III and 123 with invasive disease) and 762 controls. Initial analyses were stratified by HIV serostatus (204 cases and 202 controls were HIV seropositive), but since findings were similar in infected and uninfected people, the combined results are presented here. The risk of OSSN increased with increasing time spent in direct sunlight (p(trend) = 0.003, adjusted for age, sex, residential district and HIV serostatus): compared to those who reported spending up to 1 hr a day in direct sunlight, the risk was 1.7 (95% Confidence Interval [CI] 1.2-2.4) in those reporting 2-4-hr exposure and 1.8 (95% CI 1.1-3.1) in those reporting 5+ hr. The risk was also increased among people reporting a previous injury to the affected eye (OR 2.4, 95% CI 1.2-4.5). Pinguecula in the nasal quadrant of the unaffected eye were evident on clinical examination for 98% of cases (293/300) and for 91% of the same quadrant in the right eye (246/271) of controls (OR = 6.4, 95% CI 2.5-16.1). We confirm associations with exposure to solar ultraviolet radiation and with the presence of pinguecula and report a role for previous ocular trauma in the aetiology of OSSN. We did not identify any additional factors that point to an underlying infectious cause, although this is an area of on-going research.

Multiple oncogenic viruses identified in Ocular surface squamous neoplasia in HIV-1 patients

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is a rare cancer that has increased in incidence with the HIV pandemic in Africa. The underlying cause of this cancer in HIV-infected patients from Botswana is not well defined.

RESULTS

Tissues were obtained from 28 OSSN and 8 pterygia patients. The tissues analyzed from OSSN patients were 83% positive for EBV, 75% were HPV positive, 70% were KSHV positive, 75% were HSV-1/2 positive, and 61% were CMV positive by PCR. Tissues from pterygium patients were 88% positive for EBV, 75% were HPV positive, 50% were KSHV positive, and 60% were CMV positive. None of the patients were JC or BK positive. In situ hybridization and immunohistochemistry analyses further identified HPV, EBV, and KSHV in a subset of the tissue samples.

CONCLUSION

We identified the known oncogenic viruses HPV, KSHV, and EBV in OSSN and pterygia tissues. The presence of these tumor viruses in OSSN suggests that they may contribute to the development of this malignancy in the HIV population. Further studies are necessary to characterize the molecular mechanisms associated with viral antigens and their potential role in the development of OSSN.

[The influence of the HIV pandemic on the incidence of malignant ocular tumours in Southern Malawi (Blantyre)]

BACKGROUND

The HIV pandemic in Southeast Africa is a challenge to the poorly staffed and poorly financed health systems of the affected countries. A dramatic increase of HIV-associated ocular malignancies has been observed in Malawi. This study investigated the frequency of malignant ocular tumours at the only eye hospital in the south of Malawi.

METHODS

A retrospective analysis of all patients who underwent removal of conjunctival growth suspicious for malignancy was performed for the period from 1989 to 2006. In addition a consecutive group of 49 patients with malignant ocular tumours was offered an HIV test.

RESULTS

The number of patients undergoing surgery for suspected ocular surface squamous neoplasia (OSSN) increased from 32 cases in 1989 to 467 in 2006. Of the patients with malignant ocular tumours, 80% (39 of 49) had OSSN, and 76% of the patients with OSSN were HIV positive.

CONCLUSIONS

OSSN has become the most frequent malignant ocular tumour in the south of Malawi. The incidence of OSSN seems to have increased dramatically from 1989 to 2006--in parallel to increasing HIV infection rates.

No evidence for a pathogenic role of human papillomavirus infection in ocular surface squamous neoplasia in Germany

PURPOSE

The etiology of ocular surface squamous neoplasia is unknown. Possible etiologic factors are physical and/or viral damage by human papillomavirus (HPV), especially in Sub-saharian populations. This study focused on the presence of human papillomavirus in ocular surface squamous neoplasia in comparison to pterygia and normal conjunctiva.

METHODS

Thirty-one consecutive samples of ocular surface squamous neoplasia from a single institution (24 conjunctival intraepithelial neoplasias of various grades and 7 invasive conjunctival squamous cell carcinomas) were analyzed for evidence of HPV infection by immunohistochemistry and multiplex polymerase chain reaction (PCR). The results were compared to 11 samples of pterygia and 5 of normal conjunctiva.

RESULTS

Twenty-one (68%) of 31 ocular surface squamous neoplasia showed solar elastosis, while all cases analyzed were negative for HPV. Six (19%) of 31 ocular surface squamous neoplasia specimens demonstrated overexpression of p53 with a lack of p21 upregulation indicating a functional tumor suppressor gene p53 (TP53) mutation. Carcinomas presented a dysbalance between proliferation and apoptosis possibly contributing to tissue transformation and tumor growth.

CONCLUSIONS

In our study, exposition to ultraviolet (UV) appears to be an important risk factor for the development of ocular surface squamous neoplasia, while HPV infection was not detected. TP53 mutations were also rare but may play a role in the progression from conjunctival intraepithelial neoplasia to invasive carcinoma in a subset of cases.

Human papillomavirus infection and squamous cell carcinoma of the conjunctiva

Background:

Squamous cell carcinoma of the conjunctiva (SCCC) is associated with HIV-related immunosuppression, but human papillomavirus virus (HPV) is also suspected to have a role. We carried out a case–control study to assess the role of cutaneous and mucosal HPV types in SCCC, conjunctival dysplasia, and their combination (SCCC/dysplasia) in Uganda.

Methods:

We compared HPV prevalence in frozen biopsies from 94 SCCC cases (79 of whom were found to be HIV-positive), 39 dysplasia cases (34 HIV-positive), and 285 hospital controls (128 HIV-positive) having other eye conditions that required surgery. Highly sensitive PCR assays that detect 75 HPV types were used. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed, adjusting for, or stratifying by age, sex, and HIV status.

Results:

Cutaneous HPV types were detected in 45% of SCCC cases, 41% of dysplasia cases and 11% of controls. Human papillomavirus virus 5 and 8 were the most common types in SCCC, and most often occurred in combination with other types. Associations were observed between SCCC/dysplasia and detection of both single (OR=2.3; 1.2–4.4) and multiple (OR=18.3; 6.2–54.4) cutaneous HPV types, and were chiefly based on findings in HIV-positive patients. Cutaneous HPV infections were rarely observed among HIV-negative patients and the association with SCCC/dysplasia was not significant (OR=2.4; 0.6–9.6) among them. Squamous cell carcinoma of the conjunctiva/dysplasia risk and mucosal HPV types were not associated in either HIV-positive or HIV-negative patients.

Conclusions:

We detected cutaneous HPV types in nearly half of SCCC/dysplasia cases and often multiple types (HPV5 and 8 being most common). The role of HIV (confounder or strong enhancer of cutaneous HPV carcinogenicity) is still uncertain.

Genital and cutaneous human papillomavirus (HPV) types in relation to conjunctival squamous cell neoplasia: a case-control study in Uganda

BACKGROUND

We investigated the role of infection with genital and cutaneous human papillomavirus types (HPV) in the aetiology of ocular surface squamous neoplasia (which includes both conjunctival intraepithelial neoplasia (CIN) and carcinoma) using data and biological material collected as part of a case-control study in Uganda.

RESULTS

Among 81 cases, the prevalence of genital and cutaneous HPV types in tumour tissue did not differ significantly by histological grade of the lesion. The prevalence of genital HPV types did not differ significantly between cases and controls (both 38%; Odds ratio [OR] 1.0, 95% confidence interval [CI] 0.4-2.7, p = 1.0). The prevalence of cutaneous HPV types was 22% (18/81) among cases and 3% (1/29) among controls (OR 8.0, 95% CI 1.0-169, p = 0.04).

CONCLUSION

We find no evidence of an association between genital HPV types and ocular surface squamous neoplasia. The prevalence of cutaneous HPV was significantly higher among cases as compared to controls. Although consistent with results from two other case-control studies, the relatively low prevalence of cutaneous HPV types among cases (which does not differ by histological grade of tumour) indicates that there remains considerable uncertainty about a role for cutaneous HPV in the aetiology of this tumour.

Ocular complications of HIV infection in sub-Sahara Africa

This article reviews the magnitude and spectrum of ocular complications of HIV infection in sub-Sahara Africa. A literature search was done using PubMed, Google, and UpToDate and by talking to ophthalmologists and HIV experts working in the region. Ocular complications of HIV infection, mostly retinal, are seen in 29% to 71% of patients. Cytomegalovirus retinitis affects 0% to 16.5% of HIV-infected patients and is treated successfully with intravitreal ganciclovir in South Africa and Botswana. Ocular surface squamous neoplasia is seen in 4% to 7.8% of persons with HIV (a 5%-6% increase in Uganda and Tanzania), and recurrence after surgery occurs in 3.2% to 31.2%. In Zimbabwe, 45% of meningitis in adults is cryptococcal, and cryptococcal meningitis is the third leading cause of death in HIV patients in rural Uganda. In Rwanda, 9% of patients with cryptococcal meningitis developed visual loss and sixth nerve palsy. Thus, HIV infection leads to significant ocular morbidity in sub-Sahara Africa.

Topical interferon or surgical excision for the management of primary ocular surface squamous neoplasia

OBJECTIVE

To describe the successful treatment and long-term outcomes of primary ocular surface squamous neoplasia (OSSN) with topical interferon alfa-2b or surgical excision.

DESIGN

Retrospective, comparative, interventional case series.

PARTICIPANTS

Twenty-nine consecutive patients with OSSN never before treated.

INTERVENTION

Patients with primary OSSN chose topical interferon alfa-2b or excision with wide surgical margins, with crossover to surgery in those interferon-treated patients whose OSSN failed to regress within 2 months after beginning therapy.

MAIN OUTCOME MEASURES

Successful resolution of clinical disease at 2 months after topical interferon treatment and time to recurrence after either topical interferon or surgical excision.

RESULTS

Of 29 patients with primary OSSN, 15 elected topical interferon and 14 chose surgical excision. Two patients in the interferon group subsequently underwent surgical excision for apparent lack of response to interferon. No patient in either group developed a recurrence during the study period (disease-free follow-up: interferon group, mean, 35.6 months [95% confidence interval, 21.9-49.3]; surgery group, mean, 35.6 months [22.9-48.3]).

CONCLUSIONS

Both topical interferon alfa-2b and aggressive surgical excision appear to be effective for primary OSSN.

Human transcriptome subtraction by using short sequence tags to search for tumor viruses in conjunctival carcinoma

Digital transcript subtraction (DTS) was developed to subtract in silico known human sequences from expression library data sets, leaving candidate nonhuman sequences for further analysis. This approach requires precise discrimination between human and nonhuman cDNA sequences. Database comparisons show high likelihood that small viral sequences can be successfully distinguished from human sequences. DTS analysis of 9,026 20-bp tags from an expression library of BCBL-1 cells infected with Kaposi's sarcoma-associated herpesvirus (KSHV) resolved all but three candidate sequences. Two of these sequences belonged to KSHV transcripts, and the third belonged to an unannotated human expression sequence tag. Overall, 0.24% of transcripts from this cell line were of viral origin. DTS analysis of 241,122 expression tags from three squamous cell conjunctival carcinomas revealed that only 21 sequences did not align with sequences from human databases. All 21 candidates amplify human transcripts and have secondary evidence for being of human origin. This analysis shows that it is unlikely that distinguishable viral transcripts are present in conjunctival carcinomas at 20 transcripts per million or higher, which is the equivalent of approximately 4 transcripts per cell. DTS is a simple screening method to discover novel viral nucleic acids. It provides, for the first time, quantitative evidence against some classes of viral etiology when no viral transcripts are found, thereby reducing the uncertainty involved in new pathogen discovery.