Ocular surface squamous neoplasia

A rare case of acantholytic squamous cell carcinoma presenting on non-sun exposed palpebral conjunctiva

Purpose

This report describes the clinical and histological characteristics and management of a keratinized lesion of the palpebral conjunctiva in a 59-year-old male. The lesion was identified as a rare acantholytic variant of squamous cell carcinoma that atypically arose from a non-sun exposed region of palpebral conjunctiva. Management was complete excision via Mohs surgery.

Observations

A 59-year-old male presented with ocular irritation and chronic foreign body sensation in the right eye. Exam revealed a keratinized lesion in the right lower tarsal conjunctiva, and an initial shave biopsy was non-diagnostic. 12 months later, the patient presented with similar symptoms and a larger, more irregular lesion for which histopathology of a tarsal-involving excisional biopsy was consistent with acantholytic squamous cell carcinoma with involved margins. The patient subsequently underwent complete excision via Mohs surgery and a secondary reconstruction.

Conclusions and importance

Acantholytic variants of squamous cell carcinoma are rare and are described as arising from areas with routine sun exposure. This case reports such a lesion arising from non-sun exposed tarsal conjunctiva, as identified by histopathology of a full-thickness excisional biopsy. The lesion was successfully managed with complete excision via Mohs surgery and secondary reconstruction. Given that this histologic variant may be more aggressive and have higher rates of recurrence than other forms of squamous cell carcinoma, this case highlights the importance of complete excisional biopsy and accurate histopathology of concerning periocular lesions and offers a template for management of similar lesions. The unique presenting location should bring awareness to consideration of this type of malignancy developing on palpebral conjunctiva.

The prevalence of human papillomavirus in ocular surface squamous neoplasia in HIV positive and negative patients in a South African population

PURPOSE

To assess the prevalence and subtypes of Human Papillomavirus (HPV) in Ocular Surface Squamous Neoplasia (OSSN) in Human Immunodeficiency Virus (HIV) positive and negative patients in South Africa.

BASIC PROCEDURES

This study was a single center retrospective cross-sectional study, conducted at Tygerberg Hospital, Western Cape, South Africa. We assessed 63 histopathologically confirmed OSSN formalin-fixed paraffin-embedded (FFPE) tissue blocks from 2015-2023. The presence of HPV was determined using the Hybrispot Direct Flow Chip Kit. Corresponding clinical data was retrieved from the National Health Laboratory Service (NHLS) central data warehouse.

MAIN FINDINGS

Of the confirmed OSSN samples, 66.7% tested positive for HPV (95% confidence interval [CI] 54-77.3%). Of the 42 HPV positive samples, 38 (90.5%) had one or more known genotypes detected and 4 had unknown genotypes. The most prevalent subtypes were HPV 11, 16 and 18 (found in 61.9%, 52.4% and 33.3% of HPV positive samples respectively). 88.9% of the lesions biopsied were from HIV positive patients, of whom 56.4% had a CD4 + count of < 200 cells/µL. A lower median CD4 + count was detected among HIV positive patients with invasive squamous cell carcinoma compared to those with moderate dysplasia (p < 0.0198).

CONCLUSIONS

There is a high prevalence of HPV in OSSN in South Africa. Certain subtypes namely, 11, 16, 18, 31, 33 and 35 may be more carcinogenic. HIV with HPV co-infection may be linked as a causative factor in the development of OSSN.

Personalized treatment concepts in extraocular cancer

Background

The periocular skin is neoplasms-prone to various benign and malignant. Periocular malignancies are more aggressive and challenging to cure and repair than those in other skin areas. In recent decades, immunotherapy has significantly advanced oncology, allowing the autoimmune system to target and destroy malignant cells. Skin malignancies, especially periocular tumors, are particularly sensitive to immunotherapy. This technique has dramatically impacted the successful treatment of challenging tumors.

Main text

Extraocular cancers, including eyelid (basal cell carcinoma, squamous cell carcinoma, melanoma, merkel cell carcinoma), conjunctival tumors (conjunctival melanoma, ocular surface squamous neoplasia) and other rare tumors, are unique and challenging clinical situations. Several genetic alterations associated with the pathogenesis of these diseases have been identified, and molecular mechanism are essential for the development of the immunotherapy agents, such as Hedgehog pathway inhibitors (vismodegib and sonidegib) for basal cell carcinoma, BRAF/MEK inhibitors (vemurafenib, dabrafenib, and encorafenib) for melanoma, and immune checkpoint inhibitors (Avelumab, pembrolizumab) for Merkel cell carcinoma.

Conclusions

The optimal treatment for periocular skin cancer depends on the type and size of the tumor and whether it involves orbital and adnexal structures. Adjuvant and neoadjuvant therapy with chemotherapy-targeted therapies and immune checkpoint inhibitors should be considered based on tumor type, tumor molecular profile, expected response rate, and candidacy for systemic treatment.

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.

Clinical and Optical Coherence Tomography Comparison Between Ocular Surface Squamous Neoplasia and Squamous Metaplasia

PURPOSE

The purpose of this study was to compare the clinical characteristics and high-resolution optical coherence tomography (HR-OCT) findings between corneal squamous metaplasia and ocular surface squamous neoplasia (OSSN).

METHODS

A retrospective case-control study of 8 patients, 4 with histologically confirmed squamous metaplasia and 4 with histologically confirmed OSSN, who presented to the Miami Veterans Administration Medical Center and Bascom Palmer Eye Institute between 2016 and 2020 was performed. Clinical characteristics, HR-OCT findings, and pathology were evaluated and compared.

RESULTS

Four patients with squamous metaplasia and 4 with OSSN were evaluated. In the metaplasia group, 75% were male, 2 were White, and 2 were Black. In the OSSN group, all 4 were White males. All lesions were opalescent and occurred at the limbus; however, the borders were more smooth and rounded in the metaplastic lesions compared with OSSN. HR-OCT findings were indistinguishable between the 2 groups.

CONCLUSIONS

There is overlap in clinical characteristics and HR-OCT findings between corneal squamous metaplasia and OSSN, highlighting one limitation of HR-OCT. As such, if a corneal opacity has some but not all HR-OCT findings of OSSN, squamous metaplasia should also be considered. A biopsy may be indicated to further evaluate and guide treatment.

How Can We Diagnose Ocular Surface Squamous Neoplasia With Optical Coherence Tomography?

AIM

We aimed to evaluate the effectiveness of optical coherence tomography (OCT) in the differential diagnosis of anterior segment diseases such as ocular surface squamous neoplasia (OSSN) and pterygium.

METHODS

Patients who were pre-diagnosed with either OSSN (21) or pterygium (19) between January 2020 and November 2022 were included in this retrospective study. Anterior segment photographs and anterior segment optical coherence tomography (AS-OCT) measurements were obtained from each patient. Excisional or incisional biopsy materials underwent pathological evaluation.

RESULTS

Preoperative AS-OCT images of the patients with OSSN showed similarities with histopathological specimens. Both ocular and pathological specimens appeared to have a thicker epithelial layer with a distinct change from healthy to neoplastic epithelium. Preoperative AS-OCT images of individuals with pterygium were also comparable with histopathological samples. Both pathological and AS-OCT images of the pterygium patients showed a normal thickness epithelium and a thickened subepithelial layer under the epithelium. The mean epithelial thickness measured with AS-OCT in OSSN patients was found to be 295.3 ± 111.3 µm, while it was 80.7 ± 43.4 µm in pterygium patients. The difference was statistically significant (P<0.001). The receiver operating characteristic (ROC) curve analysis revealed a cut-off value of 97 µm for the differential diagnosis of OSSN from pterygium, with a sensitivity of 100% and specificity of 94.7%.

CONCLUSIONS

AS-OCT can be used as a noninvasive diagnostic tool for the evaluation of ocular surface lesions. Its ability to distinguish between OSSN and pterygium is demonstrated by the statistically significant difference in epithelial thickness and the significant morphological association with histopathological findings.

Ocular surface squamous neoplasia in Northern Thailand: a 16-year review

Purpose

To evaluate clinical characteristics, treatments, and outcomes in patients with ocular surface squamous neoplasia (OSSN) at a tertiary center in Northern Thailand.

Methods

Patients diagnosed with either corneal-conjunctival intraepithelial neoplasia (CIN) or squamous cell carcinoma (SCC) from May 2000 to December 2015, were recruited. The patients’ demographics, symptoms, clinical characteristics, cytopathology, treatments, and outcomes were reviewed.

Results

Overall 171 eyes from 168 patients, 92 eyes were CIN and 79 eyes were SCC. Males were affected in 65.5%. The mean age was 58.8 ± 16.8 (29–99) years. In most cases (60.3%), the tumors were located at the limbus. The most common clinical characteristic was papilliform appearance (46.2%). Human immunodeficiency virus (HIV) infection was found in 37 (22.0%) patients with a mean age of 40.5 ± 7.7 years. The treatments and outcomes were evaluated in 136 eyes whose main initial treatment was wide excision with adjunctive cryotherapy (47.8%), followed by topical mitomycin C (30.9%). The mean follow-up time after treatment was 20.8 ± 2.2 (3–110) months and the recurrence occurred in 18 eyes (13.2%) during the follow-up period. The mean recurrence-free time (months) for CIN was significantly longer than that of SCC (81.3 ± 10.0 [95%CI 61.5 – 101.1] vs 33.2 ± 4.6 [95%CI 24.0 – 42.3], p = 0.030). SCC was the only significant risk factor that influences the recurrence of the tumors with the adjusted hazard ratio of 5.69 (p = 0.005).

Conclusion

OSSN in Northern Thailand usually involved a limbal area and presented as a papilliform mass. HIV infection should be suspected in young patients. CIN had better outcomes after treatments than invasive SCC.

Update on the Management of Ocular Surface Squamous Neoplasia

Purpose of review

To review and update the latest findings in diagnosis and management of ocular surface squamous neoplasia (OSSN).

Recent findings

OSSN is the most common anterior segment neoplastic disease process. Several ocular surface imaging techniques have been developed for the early diagnosis and management of clinical and subclinical ocular surface squamous neoplasia, including high-resolution optical coherence tomography (HR-OCT), in vivo confocal microscopy, and ultrasound biomicroscopy. Treatment modalities include both surgical and medical management, with a recent trend towards primary and adjunctive pharmacotherapy.

Summary

There is increasing use of HR-OCT for the diagnosis and monitoring of clinical and subclinical OSSN lesions. Topical pharmacotherapy agents, including interferon α-2b, 5-fluorouracil, and mitomycin C, have demonstrable efficacy in the treatment of OSSN and their use may be dictated based upon tumor factors, patient factors, cost, and side effect profile. Both surgical excision and adjunctive topical medications have excellent success, with the favored treatment method trending towards topical pharmacotherapy as primary therapy.

Preliminary experience & rationale of primary allo Simple Limbal Epithelial Transplantation (SLET) following surgical excision of Ocular Surface Tumors

AIM

To report the preliminary outcomes and elucidate the possible rationale of alloSLET for primary ocular surface reconstruction following excision of extensive ocular surface tumors.

METHODS

Retrospective interventional case series with a minimum postoperative follow up of 1 year. AlloSLET was performed along with wide surgical excision and cryotherapy in 3 eyes.

RESULTS

Of the 2 eyes with extensive OSSN and one with an extensive pigmented lesion, there was no occurrence of symblepharon in all 3 eyes. No features suggestive of LSCD was noted in 2 eyes. In the child with xeroderma pigmentosum and OSSN, early peripheral vascularization was noted at 1 year of follow up with reduced vision secondary to amblyopia.

CONCLUSION

Primary alloSLET could be an alternative to primary autoSLET in eyes with extensive ocular surface tumors, commonly seen with ocular surface squamous neoplasia (OSSN) and pigmented lesions. This facilitates ocular surface reconstruction with reduced occurrence of symblepharon formation as well as limbal stem cell deficie4ncy (LSCD). It possibly, is the only option in eyes with OSSN with coexistent bilateral limbal insufficiency. It may obviate the need for autoSLET, primary or secondary in eyes with adequate residual limbus.

Migratory serpiginous corneal epitheliopathy (MSCE)- details of 4 cases

BACKGROUND AND OBJECTIVE

To describe four cases of recurrent, fleeting corneal epithelial lesion, migratory serpiginous corneal epitheliopathy (MSCE).

METHOD

Description of cases, histopathology and discussion of treatment outcome.

RESULTS

The study included 4 consecutive male patients; mean age was 21.25 years. Only one eye was affected. The common symptoms were irritation and tearing. Typical interpalpebral corneal lesion was a superficial greyish-white elevated corneal epithelium with stippled fluorescein staining in various geographic patterns. Corneal scrapings did not show any microorganisms and culture was negative; histopathology did not show corneal dysplasia. The lesions recurred within 1-3 weeks despite repeated scraping, application of a bandage contact lens, and a combination of topical antibiotics and lubricants. The recurrent lesion was of a different shape and eventually healed within 3-6 months without scarring.

CONCLUSION

We describe a possibly new entity, unilateral migratory serpiginous corneal epitheliopathy (MSCE) affecting young males, with inconspicuous inflammation. Etiology is not known and usually takes several months to heal after repeated epithelial debridement.

Use of High-Resolution Optical Coherence Tomography in the Surgical Management of Ocular Surface Squamous Neoplasia: A Pilot Study

PURPOSE

To evaluate whether high-resolution optical coherence tomography (HR-OCT) can detect histologic tumor margins of ocular surface squamous neoplasia (OSSN).

METHODS

Eight eyes of 8 patients with OSSN undergoing excision were studied prospectively. Immediately before surgery, the tumor was imaged using commercially available HR-OCT to identify the conjunctival margins of the neoplastic lesion. The tumor borders of the lesion determined by HR-OCT were mapped in relation to an anatomic reference point and transferred intraoperatively. The tumor was excised with 4-mm margins from the visible edge of the lesion with a "no-touch" technique. The specimens were sent for pathologic analysis and the histologic tumor margin was compared to the HR-OCT predicted tumor border.

RESULTS

Mean age of the 8 patients was 67 ± 9.9 years. Seven were male, 7 were white, and, ethnically, 3 were Hispanic. All 8 tumors were bulbar and in the exposure zone. Seven tumors were limbal. Corneal extension was present in 5. Mean tumor area was 17.5 ± 11.1 mm². Clinically, 2 of the tumors were leukoplakic, 1 papillomatous, and 3 gelatinous. A conjunctival tumor margin identified with the HR-OCT coincided with the pathologically confirmed margin mark in all eyes.

CONCLUSIONS

HR-OCT has the potential to predict histologic tumor margins in OSSN. Optical identification of tumor margins could potentially decrease the incidence of residual positive margins and minimize healthy tissue removal. Advances in HR-OCT technology and integration into a microscope for "real-time" imaging are needed to further improve this technique. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Update on pharmacotherapy for ocular surface squamous neoplasia

The most frequently encountered non-pigmented tumor of the ocular surface is ocular surface squamous neoplasia (OSSN). Over the past two decades, the pharmacological management of OSSN has grown, with topical 5-fluorouracil, mitomycin, and interferon alpha 2b all being successfully used to treat this disease. Other agents, such as anti-vascular endothelial growth factor (VEGF), retinoic acid, cidofovir and Aloe vera, have less frequently been used in the treatment of OSSN. This review will discuss these pharmacologic agents, summarizing available data and presenting the approach to the treatment of these tumors.

The effect of topical voriconazole on conjunctiva in rats as revealed by histopathology and immunohistochemistry

The aim of this study was to evaluate the effects of topical voriconazole with histopathological and immunohistochemical analysis of the conjunctiva in rats. Twenty-eight Sprague Dawley rats were divided into four groups as two study (S1, S2) and two control (C1, C2). Voriconazole was instilled four times daily to S1, S2 rats. Physiologic saline (0.9%) was instilled four times daily in C1 and C2 rats. S1 and C1 were followed in a dark room; S2 and C2 were held in a room with sunlight. Impression cytology was performed at 0, 15, 30, 45 and 60th d after instillations. After 2 months of treatment conjunctival tissue was removed for histological and immunohistochemical analysis. In impression cytology evaluation, there was no difference between S1 and S2. At 60 d the difference between S1 and C1 was significant. In other comparisons, there was no difference between S1 and C1, C2. The scores of S2 was higher than C1 and C2 for all comparisons except 15th day scores of S2 and C2. In study groups, epithelial and gland degeneration were higher in S2, but inflammation scores were similar. The comparison of immunreactivity of ERK, TGFβ and E-cadherin were different in the study groups than the control groups for all comparisons. In conclusion, voriconazole has side effects due to phototoxicity including squamous cell carcinoma. Clinicians should particularly be careful with the long-term use of topical voriconazole and should follow-up patients strictly in terms of ocular surface alterations.

A prospective study of the incidence, associations and outcomes of ocular surface squamous neoplasia in the United Kingdom

PURPOSE

To describe the incidence, associations and outcomes of ocular surface squamous neoplasia (OSSN) in the United Kingdom.

METHODS

Prospective, observational study of every new case of OSSN reported via the British Ophthalmological Surveillance Unit reporting scheme over a 12-month period. Cases were followed up for 12 months.

RESULTS

The reported incidence of OSSN was 0.53 cases/million/year (conjunctival intraepithelial neoplasia: 0.43 cases/million/year; squamous cell carcinoma: 0.08 cases/million/year). Eighty-five per cent of affected patients were male, 97% were Caucasian, and the mean age at presentation was 67.9 (±12.8) years. Information on potential underlying risk factors was frequently unknown. The most commonly affected sites were the limbus and the nasal and temporal bulbar conjunctivae. Most patients presented with a visual acuity of 6/9 or better, without symptoms of pain or visual loss. Excision (with or without additional treatment) was the most common first-line treatment and interferon (with or without additional treatment) was the most common second-line treatment, although management varied widely. Complications of treatment were rare but occasionally severe. Recurrence within 12 months of follow-up occurred in at least 6% of patients.

CONCLUSION

Although subject to reporting bias, these data suggest that there has not been a significant change in the incidence of OSSN in the United Kingdom, or its demographic profile, since 1996. The broad range of management approaches identified in this study reflect a lack of consensus as to the optimal referral and treatment pathways.

Primary limbal stem cell transplantation in the surgical management of extensive ocular surface squamous neoplasia involving the limbus

Purpose

To determine the role of primary limbal stem cell transplantation (LSCT) in managing extensive ocular surface squamous neoplasia (OSSN) with more than 3 quadrants of limbal involvement to prevent manifestations of limbal stem cell deficiency.

Methods

A multi-center, comparative, and interventional clinical study of cases and historical controls was done. Patients with a limbal mass suggestive of OSSN involving more than 3 quadrants of limbus (> 9 clock hours) and no local, regional or systemic metastasis, who underwent primary surgical excision with or without adjuvant chemotherapy and had a minimum follow-up of 12 months were included in this study. Two historical controls underwent tumor excision with only amniotic membrane grafting. Three cases underwent tumor excision along with LSCT in the form of conjunctival limbal autograft (CLAG) or simple limbal epithelial transplant (SLET).

Results

None of the eyes had any recurrences of OSSN during the follow-up period. Cases with primary LSCT with tumor excision showed better ocular surface stability in the long term.

Conclusion

Concomitant LSCT either in the form of CLAG or SLET appears to provide better long-term outcomes and is advocated while excision of extensive OSSN involving the limbus.

Lack of relationship between cigarette smoking and alcohol use with dysplasia grade in ocular surface squamous neoplasia

Objective

To evaluate smoking and alcohol use as risk factors for higher-grade dysplasia in a population of patients with histopathologically proven ocular surface squamous neoplasia.

Materials and methods

This is a retrospective chart review of data extracted from a database comprising demographic information and medical diagnosis information based on International Classification of Disease codes. Outcome measures were analyzed using the Wilcoxon two-sided test, a non-parametric t-test.

Results

Database review yielded 35 patients with ocular surface squamous neoplasia lesions proven by histopathologic analysis. The mean age was 64.51 years with SD 17.54 years. Patients were 28.57% female and 71.43% male. Nearly all patients were White (88.57%), and 5.71% were African American, 2.86% Hispanic, and 2.86% Other. There was no significant difference in dysplasia grade between smokers and non-smokers (P=0.7044), those who used alcohol vs did not use alcohol (P=0.2470), those who used tobacco and alcohol vs those who did not (P=0.5117), and those who used either tobacco or alcohol vs those who did not (P=0.8259).

Conclusion

No statistically significant relationship was found between high-grade dysplasia and cigarette smoking, alcohol use, or both cigarette smoking and alcohol use.

Conjunctival Squamous Cell Neoplasia Associated With Ocular Cicatricial Pemphigoid

The purpose of this study was to describe a possible causal relationship between ocular cicatricial pemphigoid (OCP) and ocular surface squamous neoplasia. Two middle-aged female patients with already diagnosed OCP were studied in regard to the subsequent onset of conjunctival squamous neoplasia. Their clinical histories, ocular examinations, clinical photographs, and results of biopsies and any ancillary immunofluorescent laboratory evaluation studies were carefully reviewed. One patient had a preinvasive squamous dysplasia and the other an invasive squamous cell carcinoma, both in the unequivocal setting of OCP with bilateral conjunctivitis, symblephara, and forniceal foreshortening. The patients had been receiving intensive immunotherapy consisting of some combination of corticosteroids, rituximab, and interferon alpha. Both patients had a positive immunofluorescent study demonstrating immunoreactants at the level of the epithelial basement membrane. Each patient had 2 earlier negative immunofluorescent studies before a third was positive. While rare, there is 1 previous report of an association between OCP and conjunctival squamous neoplasia. The current report provides more data supporting the proposal that this conjunction is more than a random event. Repeat immunofluorescent studies after an initial negative result in a patient with strong clinical signs of OCP are imperative due to the frequency of false negative studies in the context of clinically persuasive disease.

Infiltrative Intraocular Conjunctival Squamous Cell Carcinoma after Local Resection and Brachytherapy: Clinical and Pathological Findings

A pseudophakic 70-year-old man presented to the clinic with a slow-growing conjunctival mass in the left eye. He was diagnosed with a conjunctival exophytic lesion suspicious of invasive conjunctival squamous cell carcinoma (CSCC). Excisional biopsy showed a well-differentiated CSCC with positive margins and the patient underwent adjuvant brachytherapy. Six weeks later, examination of the anterior segment revealed cells in the anterior chamber and a neurotrophic corneal ulcer with corneal perforation. Considering the high suspicion of intraocular invasion of CSCC, the left eye was enucleated. Histopathologic findings showed scarring of the ciliary body with fibrosis temporally. Nasally, the sclera showed a lobular infiltration of well-differentiated squamous carcinoma. The central cornea exhibited a large ulcer with perforation and infiltrating squamous cells adhering to the posterior surface. To our knowledge, this is the first documented case of an intraocular diffuse recurrence of CSCC after resection and adjuvant brachytherapy, with clinicopathologic correlation of radiation effects on the ocular tissues.

Interferon alpha-2a as alternative treatment for conjunctival squamous cell carcinoma

CASE REPORT

A 35 year-old male patient with a history of HIV infection characterized by progressive tumour growth in bulbar conjunctiva of the left eye, corresponding to conjunctival squamous cell carcinoma that responded to treatment with interferon alpha-2a.

DISCUSSION

Interferon alpha-2b has been used at conjunctival level as a topical immunomodulator treatment, with complete remission of epithelial neoplasms being observed. However, there have not been any previous publications on the use of interferon alpha-2a, which differs from interferon alpha-2b in a single amino acid, for the treatment of conjunctival squamous cell carcinoma.

Concomitant Simple Limbal Epithelial Transplantation After Surgical Excision of Ocular Surface Squamous Neoplasia

PURPOSE

To compare the surgical outcomes of ocular surface squamous neoplasia (OSSN) following wide excisional biopsy with and without primary simple limbal epithelial transplantation (p-SLET).

DESIGN

Nonrandomized clinical study with historical controls.

METHODS

setting: Single-institutional study.

PATIENTS

Eight patients who underwent wide excisional biopsy of OSSN without p-SLET (historical controls) and 7 patients with p-SLET (cases).

INTERVENTION

Wide excisional biopsy, p-SLET.

MAIN OUTCOME MEASURES

Limbal stem cell deficiency (LSCD).

RESULTS

The tumor features of cases vs historical controls, including mean number of limbal clock hours affected by OSSN (6 vs 4; P = .12), mean tumor basal dimension (13 mm vs 8 mm; P = .11), and mean number of clock hours of corneoscleral limbal dissection owing to wide tumor excision (8 vs 7; P = .12), were comparable. The occurrence of partial LSCD in historical controls vs cases was 75% vs 0% (P = .007) at a mean follow-up period of 12 months in both groups. Of these 6 historical controls that developed LSCD, pannus was noted in 1 (13%) and pseudopterygium extending onto the cornea in 5 (63%) patients. The mean number of clock hours of LSCD was 3 (median, 2; range, 2-6) in these historical controls. The mean time interval between surgical excision of OSSN and onset of LSCD was 8 weeks (median, 6 weeks; range, 6-12 weeks).

CONCLUSION

Corneoscleral limbal dissection of ≥6 clock hours during wide excision of OSSN can cause LSCD. Concomitant p-SLET after surgical excision of OSSN prevents LSCD in cases requiring extensive corneoscleral limbal dissection.

Altered gene expression in conjunctival squamous cell carcinoma

Conjunctival squamous cell carcinoma is a malignancy of the ocular surface. The molecular drivers responsible for the development and progression of this disease are not well understood. We therefore compared the transcriptional profiles of eight snap-frozen conjunctival squamous cell carcinomas and one in situ lesion with normal conjunctival specimens in order to identify diagnostic markers or therapeutic targets. RNA was analyzed using oligonucleotide microarrays, and a wide range of transcripts with altered expression identified, including many dysregulated in carcinomas arising at other sites. Among the upregulated genes, we observed more than 30-fold induction of the matrix metalloproteinases, MMP-9 and MMP-11, as well as a prominent increase in the mRNA level of a calcium-binding protein important for the intracellular calcium signaling, S100A2, which was induced over 20-fold in the tumor cohort. Clusterin was the most downregulated gene, with an approximately 180-fold reduction in the mRNA expression. These alterations were all confirmed by qPCR in the samples used for initial microarray analysis. In addition, immunohistochemical analysis confirmed the overexpression of MMP-11 and S100A2, as well as reductions in clusterin, in several independent in situ carcinomas of conjunctiva. These data identify a number of alterations, including upregulation of MMP-9, MMP-11, and S100A2, as well as downregulation of clusterin, associated with epithelial tumorigenesis in the ocular surface.

Recurrence of Ocular Surface Squamous Neoplasia Treated With Excisional Biopsy and Cryotherapy

PURPOSE

To evaluate the recurrence rate of ocular surface squamous neoplasias (OSSN) after excision and cryotherapy in an academic cornea practice and to determine factors associated with recurrence.

DESIGN

Retrospective interventional case series.

METHODS

All cases of OSSN from 1998 through 2013 that were treated with excisional biopsy and adjunctive cryotherapy were retrospectively reviewed. Clinical characteristics upon presentation including size of lesion, location, and atypical features were noted. All recurrences of OSSN after excision and cryotherapy were noted and categorized in relation to clinical characteristics, pathologic grade, and margin involvement.

RESULTS

Forty-three cases of OSSN from 42 patients were analyzed with a median follow-up of 29 months. A total of 32.6% of subjects had dysplasia and 67.4% had squamous cell carcinoma (SCC). A total of 83.7% of subjects had both corneal and conjunctival involvement while 16.3% had conjunctival involvement only. Overall, 3 recurrences were observed, all of which had margin involvement; nonetheless, the majority of incompletely excised OSSN (25/28) showed no recurrence. The recurrence rate at 6 months was 2.3%. Recurrence at 1 year, 2 years, and 5 years remained stable at 7.1%.

CONCLUSIONS

Excision with cryotherapy is an effective treatment for the majority of OSSN cases, even among cases with pathologic evidence of tumor at the margin, with an overall recurrence rate of 7.1% at 1 year, 2 years, and 5 years.

Topical interferon alpha-2b for treatment of noninvasive ocular surface squamous neoplasia with 360° limbal involvement

PURPOSE

To report the results of topical interferon alpha-2b (IFNα2b) for the treatment of ocular surface squamous neoplasia (OSSN) with 360° limbal involvement.

METHODS

In a prospective observational study, five patients with biopsy proven primary or recurrent OSSN with 360° limbal involvement received topical IFNα2b (3 million IU/ml, 4 times daily) and were followed from 8 to 12 months. Outcome measures included resolution of the lesion, relief of symptoms, systemic and ocular side effects, and recurrence rate.

RESULTS

Five patients including 4 primary OSSNs and one recurrent OSSN received topical interferon alpha-2b. The mean age was 60.2 (range: 52-73) years and mean follow up duration was 10.2 months. Clinical resolution of the tumor occurred in all cases 2 months after initiation of treatment and no patient developed ocular or systemic complications. No recurrence of OSSN developed during the follow up period.

CONCLUSION

Topical recombinant IFNα2b appears to be an effective alternative treatment for OSSN with 360° limbal involvement. This approach precludes the high risk of limbal stem cell deficiency which results from surgical excision or topical chemotherapeutic agents.

Identification of multiple DNA copy number alterations including frequent 8p11.22 amplification in conjunctival squamous cell carcinoma

PURPOSE

Little is known about the molecular alterations that drive formation and growth of conjunctival squamous cell carcinoma (cSCC). We therefore sought to identify genetic changes that could be used as diagnostic markers or therapeutic targets.

METHODS

The DNA extracted from 10 snap-frozen cSCC tumor specimens and 2 in situ carcinomas was analyzed using array-based comparative genomic hybridization (aCGH), and further examined with NanoString and quantitative PCR.

RESULTS

The number of regions of DNA loss ranged from 1 to 23 per tumor, whereas gains and amplifications ranged from 1 to 15 per tumor. Most large regions of chromosomal gain and loss were confirmed by NanoString karyotype analysis. The commonest alteration was amplification of 8p11.22 in 9 tumors (75%), and quantitative PCR analysis revealed 100-fold or greater overexpression of ADAM3A mRNA from 8p11.22 locus. In addition, recurring losses were observed at 14q13.2 and 22q11.23, both lost in 5 (42%) of the 12 tumors, and at 12p13.31, lost in 4 (33%) of the 12 samples. Of the eight loci associated with the DNA damage repair syndrome xeroderma pigmentosum, three showed loss of at least one allele in our aCGH analysis, including XPA (9q22.33, one tumor), XPE/DDB2 (11p11.2, one tumor) and XPG/ERCC5 (13q33.1, three tumors).

CONCLUSIONS

Conjunctival SCC contains a range of chromosomal alterations potentially important in tumor formation and growth. Amplification of 8p11.22 and overexpression of ADAM3A suggests a potential role for this protease. Our findings also suggest that defects in DNA repair loci are important in sporadic cSCC.

Quantitative histopathological assessment of ocular surface squamous neoplasia using digital image analysis

The aim of this retrospective pilot study was to evaluate the Aperio nuclear V9 algorithm as an image analysis tool to observe the histopathological changes of ocular surface squamous neoplasia (OSSN). A histopathological assessment, including the Ki-67 proliferative index (PI) of immunohistochemically-stained tumor conjunctiva (TC) and healthy conjunctiva (HC) tissues, was performed in six cases of OSSN. The Aperio V9 algorithm was applied to digital images of the tissue specimens to count the Ki-67 PI and to measure the nuclear area indices. This digital algorithm was validated using stereological and visual analysis methods. The visual scoring of Ki-67 PI ranged from 22 to 60% (mean, 38.5%), and from 5 to 20% (mean 9.5%) in TC and HC tissue, respectively. The computer-aided analysis, using the Aperio nuclear V9 algorithm, revealed that the Ki-67 PI ranged from 21.5 to 43.5% (mean, 33.6%), and from 1.9 to 21.0% (mean, 11.8%) in the TC and HC tissue, respectively. The stereological method demonstrated that the Ki-67 PI ranged from 30.1 to 51.5% (mean, 41.0%), and from 3.2 to 30.1% (mean, 15.1%) in the TC and HC tissues, respectively. The strongest association in the collinearity of regression analysis was observed between the Aperio nuclear V9 algorithm/stereological models in the TC tissue (r²=0.7; P=0.04) and the HC tissue (r²=0.7; P=0.03), and the visual/stereological models in the TC tissue (r²=0.7; P=0.04) and the visual/Aperio nuclear V9 algorithm models in the HC tissue (r²=0.7; P=0.04). A weak and statistically insignificant association was identified between the visual/Aperio nuclear V9 algorithm analysis in the TC tissue (r²=0.4; P=0.2) and the visual/stereological models in the HC tissue (r²=0.5; P=0.13). No significant difference was observed between the nuclear area of the TC (mean, 36.5 μm²) and HC (mean, 35.7 μm²; P=0.88) tissues. It was concluded that the Aperio nuclear V9 algorithm is a useful tool for the reliable analysis of histopathological changes of OSSN. The results of this computer-aided algorithm correlate strongly with the stereological method when assessing the Ki-67 PI.

Amniotic membrane transplantation in surgical management of ocular surface squamous neoplasias: long-term results

OBJECTIVE

To evaluate the long-term efficacy of amniotic membrane transplantation for ocular surface reconstruction in the surgical management of ocular surface squamous neoplasia (OSSN).

METHODS

OSSN in 21 patients (7 female, 14 male patients) was managed with excisional biopsy, cryotherapy, corneal epitheliectomy with absolute alcohol application when the cornea is involved, lamellar sclerectomy and adjunctional absolute alcohol application to the base when episclera is involved, and ocular surface reconstruction with cryopreserved amniotic membrane transplantation. Tumor control and complications were evaluated.

RESULTS

The mean age of the patients was 62.42 ± 20.9 (range, 16-84). The average diameter of the base of the tumors was 13.1 ± 4.8 (range, 9-21) mm and complete removal was achieved in all cases as revealed histopathologically. Ocular surface healing was achieved in all cases. At the postoperative period, limbal stem cell deficiency in three eyes and mild symblepharon in one eye were detected. In a mean follow-up of 30.95 ± 18.8 (range, 13-75) months, no recurrence was detected.

CONCLUSION

For large or multifocal conjunctival tumors, the reconstruction of ocular surface and fornix is challenging. The amniotic-membrane use to repair conjunctival defects larger than 10 mm is a safe and effective technique with minimal complications allowing surgeons to make large enough excisions.

Risk factors for ocular surface squamous neoplasia recurrence after treatment with topical mitomycin C and interferon alpha-2b

PURPOSE

To determine the rate of recurrence and associated risk factors after the use of mitomycin C (MMC), interferon alpha-2b, or both for management of noninvasive ocular surface squamous neoplasia (OSSN).

DESIGN

Retrospective, noncomparative, interventional case series.

METHODS

Clinical practice setting of 135 patients treated consecutively with topical MMC (0.4 mg/mL), interferon alpha-2b (1 million units/mL), or both for OSSN observed for clinical recurrence.

RESULTS

Clinical recurrences were diagnosed in 19 (14.1%) of 135 eyes after topical treatment. The mean time to recurrence was 17.2 months (range, 4 to 61 months), with 14 eyes (73.7%) recurring within a 2-year period. There was no greater risk of recurrence identified for variables including lesion size, lesion location, gender, age, treatment type, or treatment duration. Post hoc log-rank pairwise comparisons revealed that lesions initially treated using surgery alone had significantly reduced time to recurrence (21.1 ± 5.6 months) compared with previous topical treatment with MMC (with or without surgery; 29.6 ± 4.7 months; P = .04) and primary OSSN (23.2 ± 1.8 months; P = .09).

CONCLUSIONS

Topical MMC and interferon alpha-2b are an effective treatment method for a wide range of noninvasive OSSNs. Topical therapy avoids the morbidity of excisional surgery with equivalent or reduced recurrence rates and should be considered as primary therapy.

In situ carcinoma of the conjunctiva: surgical excision associated with cryotherapy

Background

Although frequently underdiagnosed, squamous cell carcinoma is the most commonly observed malignancy of the conjunctiva. Multiple different treatments have been proposed to date. The purpose of this paper is to report our experience in the treatment of In situ carcinoma of the conjunctiva by surgical excision associated with cryotherapy.

Methods

Four eyes in four consecutive patients (two men and two women) of average age 53.2 (range 39–71) years at the time of diagnosis of ocular surface squamous neoplasia were treated by simple surgical excision and cryotherapy of the resulting surgical bed margins. In all cases, the diagnosis of in situ carcinoma was confirmed histopathologically.

Results

On histopathology, the edges of the surgical specimens were free of malignant cells in three of four patients. All patients showed excellent evolution without recurrence. Mean follow-up was 6.5 (range 2–14) years.

Conclusion

In situ carcinoma of the conjunctiva may be simply and successfully treated with surgical excision and cryotherapy.

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.