Conjunctival Tumors: Review of Clinical Features, Risks, Biomarkers, and Outcomes--The 2017 J. Donald M. Gass Lecture

Artificial intelligence to enhance the diagnosis of ocular surface squamous neoplasia

To provide an artificial intelligence (AI) method using in vivo confocal microscopy (IVCM) to differentiate ocular surface squamous neoplasia (OSSN) from other lesions and compare the performance of well-known AI-related solutions. A dataset of 2,774 IVCM images, comprising OSSN and other ocular surface diseases was used to train three deep learning models: ResNet50V2, Yolov8x, and VGG19. These models were trained to identify OSSN-related lesions by recognizing specific visual features, including the "starry-sky" pattern, hyperkeratosis, mitotic figures and irregularly shaped epithelial cells. To mitigate class imbalance, a novel square-based data augmentation strategy was employed. Additionally, we implemented a few-shot learning model to enhance the precision of rare symptoms, such as mitosis. To enhance model interpretation, Shapley values and Uniform Manifold Approximation and Projection (UMAP) analysis were employed to explain decision-making processes. The AI models demonstrated high accuracy in distinguishing healthy tissues from pathological ones, achieving over 90% accuracy across all models. In our binary classification task, all AI models had accuracy above 97% (precision ≥ 98%, recall ≥ 85%, F1 score ≥ 92%). The model achieved lower accuracy in 4 class labeled classification. Aggregation of cell-level results provided the best performance with an F1 score of 100%. The models successfully identified patient-specific features in IVCM images, suggesting that these images can act as "fingerprints". Our AI model utilizing IVCM was able to classify OSSN with high accuracy. Moreover, cell-level classification results could be backpropagated to image-level and patient-level. The patient-specific information within IVCM images offers promise for personalized diagnostics and treatment monitoring in ocular oncology.

Primary Conjunctival Basal Cell Carcinoma Mimicking an Ocular Surface Squamous Neoplasia in a Young Adult Filipino: A Case Report and Literature Review

Objective: To describe the morphological and histopathological features of primary conjunctival basal cell carcinoma (BCC) in a young adult Filipino. Introduction: Malignant conjunctival tumors arise from different cells, the most common of which are squamous cell carcinomas (SCCs), (including ocular surface squamous neoplasia [OSSN]), melanomas, and lymphomas. Primary conjunctival BCC is rare and can mimic the clinical features of OSSN. Only seven reported cases were published. Most cases are in the 6th-8th decades of life, and we report the first case in a young adult male. Case Summary: A 37/M, HIV-seronegative, presenting with a 3-year history of enlarging fleshy, pedunculated mass on the right eye measuring 8.5 mm × 8.0 mm at the superonasal limbus encroaching on the cornea, with prominent feeder vessels. Whitish-to-grayish plaques were observed on the surface of the lesions. Wide excision of the mass using the no-touch technique was performed under local anesthesia. Four cycles of mitomycin C (0.02%) were administered as chemoadjuvant therapy. Histopathology showed basaloid cells with peripheral palisading, most consistent with BCC. Immunohistochemistry was positive for Bcl-2 and CD10 markers and negative for epithelial membrane antigen (EMA) and carcinoembryonic antigen (CEA), confirming conjunctival BCC. Eight weeks postoperatively, fibrovascular tissue proliferation was noted at the excision site. Anterior segment-optical coherence tomography (AS-OCT) revealed a thickened hyperreflective band that was continuous with the epithelium, indicating possible recurrence. Resection with rush frozen section revealed fibrotic tissue that was negative for tumor cells. The bare sclera was covered with conjunctival autograft. There was no recurrence of the lesion after 16 months of follow-up. Conclusion: Primary BCC of the conjunctiva is rarely encountered, especially in young individuals, mimicking squamous neoplasia both in morphology and histopathology. Therefore, this should be considered in the differential diagnosis of OSSN. Immunostaining is crucial in differentiating between the two conditions and confirming the diagnosis. In most cases, wide surgical excision is sufficient. In addition, adjuvant therapies may be beneficial in preventing tumor recurrence.

Chlamydia psittaci Screening of Animal Workers from Argentina Exposed to Carrier Birds

Different syndromes are involved in human psittacosis (flu-like syndrome, atypical pneumonia up to lacrimal gland lymphoma). Diagnostic methods include serology, culture, and PCR. The rate of Chlamydia psittaci (Cp) positive tests among exposed workers is still unknown. Our study aimed to assess the rate of positive tests among workers who have contact with carrier birds in natural reserves from Buenos Aires, Argentina. Secondary aims were to analyze risk factors linked to these outcomes and the occurrence of signs that suggest psittacosis. Nasopharyngeal swabs and serum pairs were collected from employees who had interacted with confirmed carrier birds. Those with detectable DNA of Cp and/or anti-Chlamydia spp. antibody baseline titer ≥ 160 mUI/ml, or at least quadruplicating, were considered positive. Activities performed with or near birds, personal protective equipment use, and previous chronic conditions were assessed. Possible Cp-related pathologies were evaluated during follow-up. A total of 63 exposed workers (71.4% men) with a median age of 35.7 years (IQR 26-39) were evaluated to detect 28.6% positives. Respiratory chronic conditions were the unique factor associated with positive tests (OR 5.2 [1.5-18.5] p < .05). Surprisingly, about a third of the workers resulted positive and all responded to medical treatment, none developing an acute atypical pneumonia syndrome associated with classical presentation of psittacosis. Active testing for early diagnosis and proper treatment in zoological workers exposed to carrier or potentially carrier birds is strongly suggested as part of zoonotic diseases preventive measures.

Case report: Clinical features and management outcomes of isolated corneal intraepithelial neoplasia

Purpose

To report clinical features and treatment outcome of three cases with isolated corneal intraepithelial neoplasia (CIN).

Methods

This case series presents 3 patients with isolated CIN. Data collected included, presenting signs and symptoms including vision, anterior segment examination, medical and surgical outcomes and signs and symptoms at lost post-treatment visit.

Results

Case 1 was a 45-year-old male who presented with an isolated grayish amoeboid corneal lesion which was excised with alcohol assisted epitheliectomy, he also received 6 cycles of topical mitomycin C (MMC) 0.02% and one injection of interferon alfa-2b with no recurrence during the 10-year follow-up period. Case 2 was 78-year-old male referred for a suspicious white corneal lesion which was completely excised, the patient also received 6 subconjunctival injections of interferon alpha-2b. However, the lesion recurred at 2.5-years post-treatment. Case 3 was a 63-year-old male patient who presented with an isolated corneal lesion that was excised using alcohol-assisted epitheliectomy, patient received four cycles of topical 5-fluorouracil with no recurrence at last follow-up visit at 6 months.

Conclusion

Isolated corneal intraepithelial neoplasia (CIN) is a rare entity with few reported cases in the literature. In this case series, we report long and short-term management outcomes of combined surgical and medical therapy for isolated CIN.

Combining Surgery, Radiotherapy, and Topical Chemotherapy to Prevent Primary Orbital Exenteration for Atypical Caruncular Melanoma: A Case Report

Introduction

This case report demonstrates the possibility of successful eye and vision-sparing therapy for caruncular melanoma.

Case Presentation

We present an atypical presentation of a caruncular melanoma. After excisional biopsy, residual flat conjunctival melanosis resolved using topical chemotherapy (5-fluorouracil), which was well tolerated. Relapse of the melanoma was treated with external beam radiotherapy, but the tumor grew despite treatment. Eighteen months after complete excision of the relapsed melanoma, the patient remains tumor-free while the eye and its function remain preserved.

Conclusion

This case report suggests that aggressive eye-sparing therapy for caruncular melanoma combining surgery, adjuvant topical chemotherapy, and external beam radiotherapy, can be an alternative for primary orbital exenteration.

Invasive Acantholytic Ocular Surface Squamous Neoplasia: A Rare Case

Ocular surface squamous neoplasia (OSSN) is a spectrum of intraepithelial and invasive neoplastic lesions of the conjunctiva and cornea. OSSN is a rare but potentially sight-threatening ocular malignancy that can be challenging to diagnose due to its clinical and histopathological resemblance to benign ocular surface lesions. However, OSSN can lead to significant ocular and systemic morbidity, including vision loss and metastasis. Various risk factors have been identified, including ultraviolet radiation exposure, human papillomavirus infection, and immunosuppression. The histopathological analysis of the lesion is of utmost importance in diagnosing and further managing squamous cell carcinoma. The acantholytic variant of squamous cell carcinoma is uncommon. Here, we present the case of a 69-year-old male who presented with an invasive mass of progressive growth on the left eyeball extending into the visual axis. The patient underwent extended enucleation, and a histopathological analysis demonstrated a rare acantholytic variant of squamous cell carcinoma.

Sublimation of Benign Conjunctival Nevi Using Plasma-Assisted Noninvasive Surgery: A Clinical Case Series

Background

Conjunctival nevi (CN) are common benign ocular tumors. Given their low risk of malignancy, surgical removal of nevi is primarily requested by patients. Herein, we introduce Atmospheric Low-temperature Plasma (ALTP) as a novel noninvasive method for the removal of CN.

Methods

A clinical case series was conducted from 2020 to 2021 at the Vision Health Ophthalmic Center in Tehran, Iran. CN in one of the eyes of seven patients was treated. In all patients, the benignity of CN was confirmed by ocular oncologists. The white handpiece of the Plexr device, which generates plasma with the lowest output, was used to apply plasma spots on the nevi. In addition, the Ocular Surface Disease Index (OSDI) questionnaire was completed by all patients before and six months after the treatment.

Results

In all patients, the nevi outside the limbus area completely disappeared. The mean size of pre- and post-operative nevi was 3.89×11.7 and 0.54×1.69 mm, respectively. Results of the OSDI questionnaire showed significantly lower scores after the surgery in all patients.

Conclusion

The ALTP method is a simple, cost-effective, and office-based surgery to remove CN safely and effectively.

Clinicopathologic Characteristics Associated with Prognosis in Ocular Extranodal Marginal Zone B Cell Lymphoma

Background and Objectives: Extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT) type is the most common subtype of the ocular adnexal lymphoma. Despite its excellent prognosis, some patients experience partial remission or progressive disease. We aimed to evaluate clinicopathologic differences in the treatment responder group by comparing complete remission (CR) and non-complete remission (non-CR). Materials and Methods: This study retrospectively reviewed 48 patients who were diagnosed with ocular adnexal MALT lymphoma at Ulsan University Hospital between March 2002 and August 2018. Patients who were followed up for less than 6 months were excluded. Histologic and clinical features were analyzed. The patients were divided into two groups: CR and non-CR. Results: Among the 48 patients, 33 achieved CR and 15 achieved non-CR during the median follow-up period of 40.00 months (range, 7-109 months). In univariable analysis, more patients tend to undergo treatment in the CR group, and post-radiotherapy (post-RT) SUVmax, PET and serum lactate dehydrogenase (LDH) levels were higher in the non-CR group (p = 0.043, p = 0.016, and p = 0.042, respectively). In a multivariable analysis, only application of treatment, including radiotherapy or chemotherapy with immunotherapy, was related to CR (odd ratio 7.301, 95% confidence interval 1.273-41.862, p = 0.026). In subgroup analysis according to the site of involvement, none of the variables were significant except for the post-RT SUVmax of PET and level of serum LDH in the non-conjunctiva group (p = 0.026, and p = 0.037, respectively). Seven (14.6%) patients had a recurrence, and those with a recurring site other than the primary site had a higher Ki-67 labeling index, although it was not statistically significant (9.56% vs. 18.00%, p = 0.095). Conclusions: Although belonging to the early stages, the non-CR rate was high in patients with high serum LDH levels, and recurred patients had higher Ki-67. Thus, considering active treatment is recommended in this group of patients.

Clinical profile of melanocytic lesions of the ocular surface in a Hispanic population

PURPOSE

To determine the prevalence, clinical characteristics, and demographic factors of melanocytic lesions of the ocular surface, such as racial melanosis, primarily acquired melanosis, conjunctival nevus, and conjunctival melanoma in a Hispanic population.

MATERIALS AND METHODS

A cross-sectional and observational study was undertaken in a tertiary referral ophthalmological center in northern Mexico from December 2020 to April 2021. All patients attending an ophthalmology specialty clinic were screened during their first visit in order to detect melanocytic lesions of the ocular surface. Demographic factors, clinical characteristics, and diagnosis and treatment were recorded.

RESULTS

227 patients were screened for melanocytic lesions. Melanocytic lesions were identified in 114 patients (50.2%). The prevalence of the different melanocytic lesions in the screened population was racial melanosis, 45.3%; primary acquired melanosis, 3.5%, and conjunctival nevus 1.3%. No conjunctival melanoma was identified in the screened population. Primary acquired melanosis was more common in the fifth to sixth decade of life and in females. Racial melanosis showed no gender predilection and was also more common in the fifth to sixth decade of life. Only 1 melanocytic lesion (a primary acquired melanosis) required medical treatment with excisional biopsy and cryotherapy.

CONCLUSION

The prevalence of racial melanosis is remarkably high in the Hispanic population. While less prevalent, primary acquired melanosis is also present in a considerable percentage of Hispanic patients. Both melanocytic lesions exhibit demographic characteristics that match those previously reported in the medical literature.

Management of bilateral conjunctival squamous carcinoma following ocular cicatricial pemphigoid: A case report and review of literature

The purpose of this study is to report a case of bilateral highly locally invasive conjunctival squamous neoplasia in the clinical setting of ocular cicatricial pemphigoid (OCP), and to review the available literature about this rare association.

Case description: A man presented with chronic bilateral conjunctivitis and forniceal foreshortening. He had been previously diagnosed with OCP, and received proper therapy with systemic Dapsone and local steroids. After six months from treatment initiation, the patient complained of worsening symptoms and underwent two more biopsies, revealing a bilateral conjunctival squamous neoplasia. Conclusion: In rare cases, OCP can be associated with conjunctival squamous neoplasia. In case of suspected clinical modifications, it is important to make an early diagnosis by repeating several conjunctival biopsies or by performing less invasive diagnostic techniques (e.g. impression cytology of the ocular surface epithelium) to avoid unnecessary surgical damages.

Conjunctival Lesions: A 5-Year Basic Demographic Data and Clinicopathological Review in a Tertiary Eye Care Hospital

Background

Conjunctival lesions are common with a wide spectrum of benign, premalignant, and malignant lesions. Few histopathological studies have been conducted on conjunctival lesions with variable designs and results. Our aim in this study is to provide information on common conjunctival lesions seen in an ophthalmology tertiary care center in Saudi Arabia.

Methods

A retrospective, observational study of all consecutive conjunctival tissue specimens sent for histopathological assessment to the pathology department from 2015 to 2019 were analyzed. Clinical data were collected from medical records, and the histopathological slides were reviewed by a single pathologist.

Results

A total of 110 conjunctival specimens from 108 patients were included (mean age: 53 years, 67 males and 43 females). Bilateral involvement was mostly found in inflammatory lesions (40%). Most lesions were benign (91%), with a significantly longer duration of symptoms in malignant lesions (p = 0.036*). The clinical diagnosis matched the final histopathological diagnosis in 75.5% of the total specimens. The most frequent category of benign lesions was fibrodegenerative and proliferative lesions (53.6%), with a significantly higher prevalence among adult males (p < 0.001). Melanocytic lesions were more common in children (33.3%) than adults (9.8%), and the mean age of children was significantly lower (p = 0.013). The most frequent malignant lesion was ocular surface squamous neoplasia (50%), with equal prevalence among males and females. The overall outcome was favorable in 89.4% and unfavorable in 10.6%, mostly due to surgical complications, further progression of the lesion, or recurrence.

Conclusion

This study shows variability in the frequency of conjunctival lesions based on gender, age, geographical, racial, and environmental factors. There has been a shift in the gender-based prevalence of ocular squamous neoplasia over the last three decades, probably due to a change in lifestyle.

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.

Small but Challenging Conjunctival Melanoma: New Insights, Paradigms and Future Perspectives

Although its incidence has increased over the last decades, conjunctival melanoma (CM) remains a rare but challenging periocular malignancy. While there is currently no recognized standard of care, "no-touch" surgical excision followed by adjuvant treatments is usually recommended. Despite its small size, managing CM is challenging for clinicians. The first challenge is the high risk of tumour local recurrence that occurs in about one third of the patients. The management of locally advanced CM (≥T2) or multiple recurrences may require mutilating surgeries such as orbital exenteration (OE). The second challenge is the metastatic spread of CM that occurs in about one quarter of patients, regardless of whether complete surgical excision is performed or not. This highlights the infiltrative and highly aggressive behaviour of CM. Recently, attention has been directed towards the use of eye-sparing strategies to avoid OE. Initially, wide conservative surgeries followed by customized brachytherapy or radiotherapy have appeared as viable strategies. Nowadays, new biological insights into CM have revealed similarities with cutaneous melanoma. These new findings have allowed clinicians to reconsider the management of locally advanced CM with "medical" eye-sparing treatment as well as the management of metastatic spread. The aim of this review was to summarize the current and future perspectives of treatment for CM based on recent biological findings.

Recombinant Interferon Alpha-2b as Primary Treatment for Ocular Surface Squamous Neoplasia

Purpose

To investigate the effects of topical and perilesional interferon alpha-2b as primary treatment for ocular surface squamous neoplasia (OSSN).

Methods

In this prospective interventional case series, topical interferon alpha-2b (3 MIU/mL) was used as the initial treatment of OSSN, with perilesional interferon alpha-2b (3 MIU/mL) added based on clinical response. The primary outcome was complete tumor resolution. Spearman's rank correlation test was used to investigate the association of complete tumor resolution and time to resolution with baseline tumor characteristics and the American Joint Committee on Cancer (AJCC) classification for OSSN.

Results

Ninety-two patients (92 OSSN tumors) were included in the study. The total follow-up duration was 13.57 ± 2.14 months (median: 12, range: 3-23). The median basal tumor diameter was 4 mm (mean: 4.13 ± 1.37). Complete tumor resolution was achieved in 89 cases (96.73%), with a median time to complete tumor resolution of 5 months (mean: 4.64 ± 1.92). Complete tumor resolution was 57 of 57 in T1 (100%), 8 of 9 in T2 (88.88%), and 21 of 23 in T3 (91.30%). There were statistically significant correlations between AJCC classification and complete tumor resolution (Spearman's r = -0.22, P = 0.03) and maximal basal tumor diameter and the time to complete resolution (Spearman's r = 0.35, P = 0.001). There were no recurrences during the study follow-up period.

Conclusion

Topical interferon alpha-2b is effective and well tolerated as a primary treatment for OSSN, with a high rate of tumors responding completely to therapy.

Structural Protein Analysis of Driver Gene Mutations in Conjunctival Melanoma

In recent years, there has been tremendous enthusiasm with respect to detailing the genetic basis of many neoplasms, including conjunctival melanoma (CM). We aim to analyze five proteins associated with CM, namely BRAF, NRAS, c-KIT, NF1, and PTEN. We evaluated each protein for its intrinsically disordered protein regions (IDPRs) and its protein-protein interactions (PPI) with the Predictor of Natural Disordered Protein Regions (PONDR^®) and the Search Tool for the Retrieval of Interacting Genes (STRING^®). Our PONDR^® analysis found high levels of IDPRs in all five proteins with mutations linked to CM. The highest levels of IDPRs were in BRAF (45.95%), followed by PTEN (31.76%), NF1 (22.19%), c-KIT (21.82%), and NRAS (14.81%). Our STRING analysis found that each of these five proteins had more predicted interactions then expected (p-value < 1.0 × 10⁻¹⁶). Our analysis demonstrates that the mutations linked to CM likely affected IDPRs and possibly altered their highly complex PPIs. Quantifying IDPRs in BRAF, NRAS, c-KIT, NF1, and PTEN and understanding these protein regions are important processes as IDPRs can be possible drug targets for novel targeted therapies for treating CM.

Ocular surface angiography: from neovessels to neoplasia

The ocular surface vascular system plays a key role in corneal and conjunctival inflammatory, infectious and neoplastic pathology. Angiographic vessel analysis using intravenous dyes and optical coherence tomography technology allow both the quantitative and functional assessment of conjunctival vasculature and corneal neovessels. Based on a thorough understanding of vascular alterations in ocular surface disease, angiographic assessment facilitates the clinical management of corneal neovascularisation, the grading of ocular surface inflammation and the identification of tumour angiogenesis in dysplastic or malignant lesions. This review summarises key aspects of the clinical application of corneal and conjunctival angiography as presented at the 2021 virtual Bowman Club meeting.

Synchronous eyelid oncocytoma and conjunctival intraepithelial neoplasia

Oncocytoma of the eyelid is a rare neoplasm. Oncocytoma associated with an ocular surface squamous neoplasm, namely conjunctival intraepithelial neoplasia, is very hard to find in the literature. Herein we report a case of a 53-year-old male who presented with a swelling in the right lower lid over the last 6 years, along with a growth in the conjunctiva of the same eye for the last 2 years and encroaching upon the cornea for the last 4 months. Excision biopsy of the lower lid mass showed histopathological features consistent with oncocytoma. The conjunctival tissue revealed conjunctival intraepithelial neoplasia 3 (severe dysplasia). This case documents a rare synchronous dual ocular neoplasia, a very unlikely coexistence of oncocytoma with conjunctival intraepithelial neoplasia.

Single-Fraction Adjuvant Electronic Brachytherapy after Resection of Conjunctival Carcinoma

Simple Summary

A centralized distribution of specialized oncologic facilities is a widely repeated situation in many latitudes around the globe, limiting the patient’s access options to specialized treatments. Strategies to alleviate the overpassed attention capacities in low- and middle-income countries, such as Peru, have driven the attention of practitioners towards hypofractionated treatments. In order to shorten treatment times and hospital visits, treating ocular conjunctival carcinoma with a single-fraction electronic brachytherapy approach arises as a novel option, which further increases the current therapeutic arsenal against this entity. We aim to report the clinical findings of this treatment modality, in terms of feasibility, oncological outcomes and toxicity profile, while opening a new possibility of diminishing patient- and health care-related financial impact.

Abstract

A retrospective study was performed to assess the outcomes of a single-fraction adjuvant electronic brachytherapy (e-BT) approach for patients with squamous cell conjunctival carcinoma (SCCC). Forty-seven patients with T1–T3 SCCC were included. All patients underwent surgery followed by a single-fraction adjuvant e-BT with a porTable 50-kV device. Depending on margins, e-BT doses ranged between 18 to 22 Gy prescribed at 2 mm depth, resembling equivalent doses in 2 Gy (EQD2) per fraction of 46–66 Gy (α/β ratio of 8–10 Gy and a relative biological effect (RBE) of 1.3). The median age was 69 (29–87) years. Most tumors were T1 (40.4%) or T2 (57.5%) with a median size of 7 mm (1.5–20). Margins were positive in 40.4% of cases. The median time from surgery to e-BT was nine weeks (0–37). After a median follow-up of 24 (17–40) months, recurrence occurred in only two patients (6 and 7 months after e-BT), yielding a median disease-free survival (DFS) of 24 (6–40) months and DFS at two years of 95.7%. Acute grade 2 conjunctivitis occurred in 25.5%. E-BT is a safe and effective for SCCC treatment, with clinical and logistic advantages compared to classical methods. Longer follow-up and prospective assessment are warranted.

Cost-effective treatment of ocular surface squamous neoplasia for an undocumented and uninsured New York City patient: a case report

Background

New York City has a heterogeneous population with many undocumented and uninsured immigrants from equatorial areas who have a higher incidence of ocular surface squamous neoplasia. To the best of our knowledge, this is the first documented selection of this cost-effective treatment of ocular surface squamous neoplasia (the use of absolute ethanol along the corneal margin, primary excision, double freeze-thaw cryopexy, and primary conjunctival closure) for an undocumented and uninsured New York City patient.

Case presentation

A 35-year-old man from Ecuador presented to a New York City emergency department due to worsening discomfort of a long-standing left eye pterygium. A slit-lamp examination of the left eye demonstrated a nasally located conjunctival mass measuring 6 × 8 mm extending onto the cornea (3 mm superiorly and 6 mm inferiorly on the cornea). Histological diagnosis confirmed squamous cell carcinoma in situ arising from the pterygium. Surgical excision with adjunctive absolute alcohol with additive double freeze-thaw cryopexy was performed. Our patient has remained free of tumor recurrence at year 2 postoperative visit.

Conclusions

Our case highlights the need to choose a cost-effective treatment for ocular surface squamous neoplasia in an at-risk population among undocumented and uninsured patients. Areas in the world with similar types of populations or treatment challenges may need to consider this approach as a primary treatment option.

Observation of angiographic dye leakage in ocular surface squamous neoplasia

Purpose

The clinical diagnosis of ocular surface squamous neoplasia is challenging, mostly requiring excisional biopsy. Human tumor angiogenesis is characterized by abnormal vessel architecture and transvascular hyperpermeability. This case report describes features of fluorescein and indocyanine green angiography in a case of conjunctival intraepithelial neoplasia.

Observations

Color photography, optical coherence tomography, fluorescein and indocyanine green angiography were performed in a patient with suspected conjunctival intraepithelial neoplasia before excisional biopsy and histologic confirmation of clinical diagnosis. Fluorescein dye showed extensive early extravascular dye leakage within the limits of the lesion. Indocyanine green dye displayed corneal terminal vessel bulbs with early leakage after 70 seconds and showed diffuse intralesional dye leakage after 7 minutes.

Conclusions

Increased fluorescein and early indocyanine green dye leakage can be used to confirm active angiogenesis already in early stages of dysplastic ocular surface squamous neoplasia. Late leakage of indocyanine green dye may be due to chronic transvascular hyperpermeability within intrinsic tumor vessels. The leakage behaviour of intravenous dyes has the potential to serve as a diagnostic indicator of active growth in dysplastic ocular surface neoplastic lesions.

Conjunctival melanoma with orbital invasion and liver metastasis managed with systemic immune checkpoint inhibitor therapy

A 60-year-old Caucasian female was referred for biopsy-proven amelanotic orbito-conjunctival melanoma. Map biopsies revealed residual invasive melanoma on the deep tarsal margin at the site of previous surgery. Repeat excisions were required after recurrence was detected following 3 months and 7 months. Positron emission tomography scan detected liver metastasis and additional orbito-conjunctival melanoma recurrence. Biomarker testing showed NRAS mutation without BRAF or c-KIT mutations and without PD-L1 expression. Systemic checkpoint inhibitor therapy was initiated with regression of both the orbito-conjunctival melanoma and liver metastasis. Invasive, non resectable orbito-conjunctival melanoma with liver metastasis can demonstrate a response to systemic checkpoint inhibitor therapy.

Observational study of ocular surface squamous neoplasia: Risk factors, diagnosis, management and outcomes at a tertiary eye hospital in South Africa

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is the most common ocular surface tumour. Diagnosis and management have traditionally been by excision biopsy. Recently there has been success with the use of topical chemo or immunotherapy, which has resulted in a move from invasive diagnosis by histology to an array of non-invasive diagnostic tests.

METHODS

This observational study aims to describe the characteristics of patients with OSSN at St John Eye Hospital in Johannesburg, South Africa. Non-invasive diagnostic tests (impression cytology, anterior segment-OCT, methylene blue staining) will be compared to the gold standard, histology. Treatment success, recurrence and adverse events will be documented between three treatment options that include: surgical excision, topical 5-Fluorouracil (5FU) chemotherapy, and topical 5FU with retinoic acid therapy.

DISCUSSION

There is a trend to the use of less invasive diagnosis and management for OSSN. Minimally invasive diagnostic tests include cytology, anterior-segment OCT and methylene blue staining. The study will compare these to the gold standard histology, thereby providing evidence for their use in clinical practice. Interferon alpha 2b is commonly used as immunotherapy for OSSN. The cost of this medication is prohibitive to its adoption in a developing country. We therefore decided to use 5FU as the chemotherapeutic agent of choice in this study. The success, adverse events and recurrence rates with this agent may provide additional evidence for its use in the management of OSSN. Overall, if diagnosis and management can be implemented with good success in the outpatient environment, care can be improved for this condition in a developing country.

Whole exome profiling and mutational analysis of Ocular Surface Squamous Neoplasia

PURPOSE

To determine genetic mutational profiles in patients with Ocular Surface Squamous Neoplasia (OSSN) using whole exome sequencing.

METHODS

Prospective, case-series study. Patient recruitment was conducted in a single tertiary referral center from April to September 2017. Specimens were obtained by incisional biopsies of tumors from ten eyes with histopathologic confirmation of OSSN. DNA whole exome sequencing and mutation analysis were performed.

RESULTS

Ten patients with clinically-diagnosed OSSN underwent DNA whole exome sequencing analysis. Deleterious mutations in 305 genes known to drive tumor development and progression were found. These mutations centered around two main pathways: DNA repair/cell cycle and development/growth. All ten samples had at least one mutation in a DNA repair/cell cycle gene and all but one sample had one in a development/growth gene. The most common mutation was found in TP53 and HGF (both present in 50% of cases) and mutually exclusive mutations were found in BRCA1 and BRCA2 (50% of cases). Mutations in APC, MSH6, PDGFRA, and PTCH1 were found in 40% of cases. Global mutation analysis identified ultraviolet induced radiation as the only mutational signature present in the dataset.

CONCLUSIONS

Mutations found in samples from patients with OSSN are mainly induced by ultraviolet radiation and occur within two main pathways related to DNA repair/cell cycle and development/growth. There are many clinically available drugs and several others being evaluated in clinical trials that target the genes found mutated in this study, offering new therapeutic options for OSSN.

Extra-Nodal Marginal Zone Lymphoma (MZL) of MALT CD20+ of the Ocular Adnexa: Case Report

Even though rare in the orbital region, lymphomas are reported as the third most common malignancies of the conjunctiva, following squamous cell carcinoma and melanoma. It is estimated that more than 95% lymphomas in periocular tissues are B cell in origin. We present a case of extra-nodal marginal zone lymphoma (MZL) of MALT type of the ocular adnexa, successfully treated with chemoimmunotherapy R-CVP.

Extranodal Ocular Adnexal Marginal Zone Lymphoma in a Ten-Year-Old Child

A 10-year-old girl was brought to the clinic with the complaint of a salmon-colored conjunctival lesion for 1 month. With the aid of histopathological evaluation and other tests, extranodal ocular adnexal marginal zone lymphoma was diagnosed. The patient was graded as T1bN0M0 according to AJCC and Stage 1 according to Ann Arbor classification. She was treated with external radiotherapy at 1.8 Gy/day for 17 days for a total dose of 36 Gy. She is in remission for 26 months and still being followed up.

Survey of 138 Conjunctival Tumors in the Dominican Republic

PURPOSE

To report the frequency of conjunctival tumors in the Dominican Republic.

METHODS

Retrospective noninterventional case series. One hundred thirty-eight consecutive patients with a conjunctival mass evaluated at two tertiary referral centers from 2010 to 2018. Main outcome measures were frequency of tumors by diagnosis and distribution of tumors relative to patients' age and gender.

RESULTS

The mean age at presentation was 41.2 years (median, 42 years; range 10 days - 91 years). There were 83 male patients (60%) and 55 female patients (40%). The three most common specific diagnoses were junctional, compound, and subepithelial naevi (47 [34%]), squamous cell carcinoma (SCC) (26 [19%]) and conjunctival squamous intraepithelial neoplasia (CIN) (17 [12%]). The mean age at detection was 36.5 years for non-malignant tumors and 56.3 years for malignant tumors (p < .001), with a mean difference of 19.8 years at time of diagnosis (95% CI, 10.7-28.8). Benign tumors were more common in children and young adults; malignant and premalignant tumors were more common in mid and older adults (p = .009). Malignant tumors were more common in males (73%) than in females (27%) (p = .04).

CONCLUSION

In the Dominican Republic, conjunctival tumors are benign (63%), premalignant (13%) and malignant (24%). Malignant tumors are more common in older adults and men.

Conjunctival pigmented lesion: Clinicopathological analysis of 85 cases in Korean population

To evaluate histopathological characteristics of conjunctival pigmented lesions and analyze clinical features related to histologic classification in Asian population, we analyzed medical records, anterior segment photographs, and histological specimen of 85 eyes who had undergone biopsy for pigmented conjunctival lesions at Seoul National University Hospital between 1999 and 2018. Compound nevus was the most common type of conjunctival pigmented lesions (67.1%), followed by conjunctival melanocytic intraepithelial neoplasia (primary acquired melanosis)(11.8%), subepithelial nevus (8.2%), and malignant melanoma (MM)(7.1%). Patients with compound nevus were younger than those with non-compound nevus (22.1 ± 17.0 vs 39.9 ± 18.8 years, p < 0.001), while patients with MM were older than those without melanoma (55.7 ± 18.2 vs 25.8 ± 18.0 years, p = 0.001). The lesion in compound nevus tended to be more frequently located on the temporal conjunctiva than that in the non-compound nevus group (54.4% vs 32.1%, p = 0.053), and feeder vessels were associated with most of compound nevus (98.2% vs 78.6% of non-compound nevus, p = 0.005). The lesion in MM was larger, involved multiple quadrants, and had extrabulbar location than lesions without melanoma (p < 0.001, p < 0.001, and p = 0.002, respectively). Together, the results would help clinicians to distinguish benign conjunctival pigmentations from malignant counterparts in clinical practice without biopsy.

[Conjunctival malignancies]

Conjunctival malignancies are rare. However, some of these tumors are among the most aggressive malignancies in ophthalmology and require radical forms of therapy that may lead to blindness or loss of the ipsilateral eye and tumor-associated death. The most relevant primary conjunctival malignancies for oncologists are squamous cell carcinoma, malignant melanoma and malignant lymphoma. Surgical therapy is the primary treatment for squamous cell carcinoma and malignant melanoma. An adjuvant therapy in the form of topical chemotherapy or radiation is necessary in most cases. The isolated malignant lymphoma of the conjunctiva is biopsied excisionally if possible. However, if an incisional biopsy was unavoidable, additional irradiation should be performed; malignant lymphoma generally responds very well to relatively low irradiation doses with a good prognosis quad vitam. More aggressive forms, such as diffuse large cell B‑cell lymphoma or mantle cell lymphoma, must also be treated systemically at an early stage.

Xeroderma Pigmentosum: Ocular Findings in an Isolated Brazilian Group with an Identified Genetic Cluster

Purpose

Xeroderma pigmentosum (XP) is a rare autosomal recessive genetic disorder characterized by increased susceptibility to UV radiation- (UVR-) induced skin pigmentation, skin cancers, ocular surface disease, and, in some patients, sunburn and neurological degeneration. Eight different genes are affected, and the prevalence of the disease differs across the world. The present study describes the main ophthalmologic features and symptoms in patients with XP in this case series.

Methods

Patients were examined consecutively at the University Hospital of the Federal University of Goias between January 2016 and June 2018. All patients underwent ophthalmologic examination and were asked about their ophthalmological history and the presence of ocular symptoms.

Results

Twenty-one patients with genetic confirmation were evaluated. The genetic variants XPV and XPC were detected in the patients. The most prevalent findings include eyelid changes, observed in 80.9% of the patients, and ocular surface changes as punctate keratopathy, occurring in 16 patients (76.2%), corneal neovascularization, and corneal opacities. Six patients (28.5%) presented corneoconjunctival tumor. More than half of patients had previous history of treatment of ocular neoplasia. Ocular burning was the most reported symptom.

Conclusions

The ocular characteristics identified in this study corroborate the existing literature, mainly related to the surface. Concerning the XP variant and the gravity of ocular signs, XPC has earlier and more severe symptoms than XPV. Due to their relative rarity, publications of XP cases are important to understand the possible damages caused by the disease in the eyes and surrounding area.

PD-L1/PD1 Expression, Composition of Tumor-Associated Immune Infiltrate, and HPV Status in Conjunctival Squamous Cell Carcinoma

Purpose

Conjunctival squamous cell carcinoma (SCC), a type of ocular surface neoplasia, is primarily treated by surgical resection and topical immuno- or chemotherapy. Metastatic disease may be treated with systemic chemo- or immunotherapy, albeit with variable response. The purpose of this study was to determine whether immune checkpoint blockade might be considered in the management of conjunctival SCC.

Methods

In this retrospective study, we evaluated tumor programmed death-ligand 1 (PD-L1) expression, high-risk human papillomavirus (HPV) status, and immunohistochemical expression of cluster of differentiation 3 (CD3), cluster of differentiation 8 (CD8), and programmed death 1 (PD1) in tumor-associated immune infiltrate in a series of 31 conjunctival SCCs.

Results

PD-L1 expression in ≥1% of tumor cells was noted in 14 conjunctival SCCs (47%) and was more prevalent in invasive than in situ SCC and among tumors with higher American Joint Committee on Cancer (AJCC) T category (≥T3 versus ≤T2). The density of CD3-positive T cells was higher in primary than recurrent tumors and higher in invasive than in situ tumors. Density of CD3-positive and CD8-positive T cells was higher in higher AJCC stage tumors. Density of CD8-positive T cells was higher in HPV-positive than HPV-negative tumors. PD-L1 expression correlated with a higher density of CD3-, CD8-, and PD1-positive cells in the tumor-associated immune infiltrate but not with HPV status.

Conclusions

Our findings demonstrate that PD-L1 is expressed in almost half of conjunctival SCCs. The density of tumor-associated immune cells correlated with invasive SCC, stage, and HPV status in conjunctival SCC. Our findings support further studies to establish the potential application of immune checkpoint blockade in the management of conjunctival SCC.

Factors affecting recurrence after surgical treatment in cases with ocular surface squamous neoplasia

AIM

To evaluate the risk factors leading to recurrence in patients with ocular surface squamous neoplasia (OSSN).

METHODS

The records of 112 patients with OSSN who underwent treatment and follow-up between February 1999 and August 2018 were reviewed retrospectively.

RESULTS

Totally 67 patients (59.8%) were male and 45 patients (40.2%) were female. The mean age at presentation was 63.7y (range 22-87y). Partial lamellar scleroconjunctivectomy (PLSC) was performed in 105 (93.7%) cases and enucleation was performed in 7 (6.3%) cases due to bulbus invasion as the first step treatment. Treatments used in addition to PLSC included cryotherapy in 78 eyes (74.3%), alcohol epitheliectomy in 57 eyes (54.3%) for presence of corneal involvement, and amniotic membrane transplantation in 17 eyes (16.2%) for ocular surface reconstruction. Topical mitomycin C was used in 10 patients (9.5%) and strontium-90 (Str-90) treatment in 4 (3.8%) patients because surgical margins were tumor positive at the histopathological examination. Postoperative histopathologic diagnoses were squamous cell carcinoma (52 cases), carcinoma in situ (44 cases), moderate conjunctival intraepithelial neoplasia (11 cases), and mild conjunctiva intraepithelial neoplasia (5 cases). At a mean follow-up of 20.1mo, tumor recurrence was observed in 21 (18.8%) cases. The rate of recurrence was found to be lower in cases that underwent supplemental cryotherapy compared to those that did not (P<0.001). There was no metastasis in any case.

CONCLUSION

In our series, the recurrence rate is 18.8% and overall globe salvage rate is 90.2% for OSSN at relatively short-term follow-up.

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.

Classification, diagnosis, and management of conjunctival lymphoma

Lymphoma is a malignant lymphoproliferative tumor that can involve the conjunctiva. Approximately 5-15% of all extranodal lymphomas are found in the ocular adnexal region, with approximately 25% of those involving the conjunctiva. Ninety-eight percent of conjunctival lymphomas arise from B-lymphocytes. The most common subtype of conjunctival lymphoma is extranodal marginal zone lymphoma (80%), followed by follicular lymphoma (8%), diffuse large B-cell lymphoma (3%) and mantle cell lymphoma (3%). Natural killer and T cells (NK/T) are rare causes of lymphoma. While most conjunctival lymphomas are localized to the ocular adnexa at the time of presentation, systemic examination and management are of key importance in the long-term care of the patient. This review outlines the classification, etiology, presentation, diagnosis, and management of conjunctival lymphoma. The novel use of high resolution optical coherence tomography, both as a diagnostic tool and as a means for ongoing evaluation during treatment, is illustrated. Treatment options discussed include external beam radiation, chemotherapy, immunotherapy, antibiotic therapy, and combination regimens. Future investigation of the etiology and pathogenesis of conjunctival lymphoma is expected to reveal opportunities for innovative and individualized therapeutic agents. Collaboration between multiple disciplines is key in the advancement of the field.

Vitamin D receptor gene polymorphisms in ocular surface squamous cell neoplasms

PURPOSE

To investigate vitamin D receptor polymorphisms in ocular surface squamous cell neoplasm and to evaluate the relationship between the identified polymorphisms and susceptibility to ocular surface squamous cell neoplasm and the clinical course.

MATERIALS AND METHODS

A totala of 70 patients with ocular surface squamous cell neoplasm (study group) and 75 healthy age and gender-matched individuals (control group) were included in the study. Vitamin D receptor FokI and BsmI polymorphisms were examined. The relationships between histopathological diagnosis, recurrence rates, tumor stage, and identified polymorphisms were investigated.

RESULTS

Histopathologically, 43 of the cases were squamous cell carcinoma and 27 of the cases were conjunctival intraepithelial neoplasia. The frequency of FokI (FF, Ff, ff) and BsmI (BB, Bb, bb) polymorphism genotype of vitamin D receptor gene were similar in the groups. The frequency of polymorphism (heterozygous or homozygous) for BsmI (Bb and bb) was significantly higher (p = 0.046) in the study group, while no difference was found between the groups in terms of polymorphic carriers (heterozygous or homozygous) for FokI. There was no correlation between tumor stage, recurrence-polymorphism frequency, and patient age-polymorphism frequency.

CONCLUSION

It is known that active vitamin D inhibits the growth of cancer cells by binding to vitamin D receptor with regulation of genes responsible for cell proliferation. The presence of BsmI polymorphism in vitamin D receptor, in particular bb genotype and b allele, appears to be associated with the susceptibility of ocular surface squamous cell neoplasm. BsmI gene polymorphisms of vitamin D receptor might play an effective role in the formation, progression, and in the course of ocular surface squamous cell neoplasm.

Conjunctival dysbiosis in mucosa-associated lymphoid tissue lymphoma

To investigate the conjunctival microbiota and the association between the development of conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma and dysbiosis, DNA samples were collected from 25 conjunctival MALT lymphoma patients and 25 healthy controls. To compare the microbiota, samples were collected from the following four body locations: conjunctiva, meibomian gland, periocular skin and hand. Extracted DNA was analyzed by 16S rRNA sequences, and libraries were sequenced on an Illumina MiSeq sequencer. The differences in bacteria were characterized by using principal coordinate analysis of metagenomics data, and the differences in bacterial compositions were evaluated by linear discriminant analysis effect size. The conjunctival microbiota of MALT lymphoma patients was compositionally different from that of healthy controls. For the conjunctival MALT lymphoma patients, alterations in the microbial composition were detected, and a remarkable change was detected at the conjunctiva. Detailed analysis showed that a specific population of the microbiota, the genus Delftia, was significantly more abundant in conjunctival MALT lymphoma patients, and the genera Bacteroides and Clostridium were less abundant in the MALT lymphoma patients. A specific microbiota on the ocular surface in conjunctival MALT lymphoma patients was detected, and dysbiosis may play an important role in the pathophysiology of conjunctival MALT lymphoma.

Detection of Malignancy in Ocular Surface Lesions by Inverse Spectroscopic Optical Coherence Tomography and Two-Photon Autofluorescence

Purpose

Advanced imaging is increasingly important in the diagnosis of ocular surface malignancy. Inverse spectroscopic optical coherence tomography (ISOCT) and two-photon autofluorescence microscopy (2P-AF) are emerging techniques capable of quantifying ultrastructural and metabolic changes, respectively. We aimed to detect malignancy in ocular surface lesions using ISOCT and 2P-AF.

Methods

Portions of excised specimens from patients undergoing conjunctival biopsy at Boston Medical Center were imaged by ISOCT and/or 2P-AF, and submitted for histologic diagnosis. Lesions were categorized as malignant, premalignant (with dysplasia) or benign. ISOCT and 2P-AF findings were compared between categories.

Results

Fourteen specimens from 13 patients were collected. The IS-OCT marker D was 2.2-fold higher in combined malignant and premalignant (4.27 ± 0.28, n = 3) versus benign (1.92 ± 0.26, n = 11) lesions (P = 9 × 10⁻⁴). ISOCT markers μ_s and μ_b were not significantly different. By 2P-AF, the redox ratio was 0.24-fold lower in premalignant (0.11 ± 0.004, n = 2) versus benign (0.45 ± 0.04, n = 9) lesions (P = 1.08 × 10⁻⁵).

Conclusions

Conjunctival lesions with higher malignant potential had higher D and lower redox ratios. Higher D can correlate with ultrastructural changes associated with malignancy, similar to what has been seen in cancers of the gut mucosa. Lower redox ratios can suggest the presence of the Warburg effect, which is associated with tumorigenesis.

Translational Relevance

IS-OCT and 2P-AF can potentially be applied to the detection of malignancy or malignant potential in ocular surface lesions. ISOCT allows for the detection of nanoscale ultrastructural changes that are not resolvable by conventional OCT.

Conjunctival Melanoma in Childhood and Adolescence: A Systematic Review

Background

Conjunctival melanoma is rare in adults and rarer in children. We systematically reviewed the presentation, diagnostic and management strategies as well as outcomes for conjunctival melanoma in children and adolescents.

Methods

The following databases were searched: Medline, Embase, Web of Science and Scopus for cases of conjunctival melanoma occurring in children and adolescents < 18 years of age.

Results

Seventeen studies with 32 patients (18 males) were identified. The median age at presentation was 11 years (range 4-18 years). Most patients were white. Most patients presented with a conjunctival mass or naevus with a recent history of growth or change. Excision biopsy provided diagnosis and management for all cases. Adjuvant chemotherapy and radiotherapy were also used. One patient had metastatic disease at diagnosis and 3 developed metastatic disease (range 1-10 months). Two patients died from disease and one was alive with metastatic disease. Two patients had disease recurrence. Outcomes were observed to be better where diagnosis was made earlier and "no-touch" excision biopsy was performed in an appropriate specialist setting.

Conclusions

Conjunctival melanoma occurs rarely in children and adolescents. Surgery is the mainstay of management. The prognosis is guarded in metastatic disease due to the small sample size and limited follow-up.

Immunoglobulin Heavy Chain Gene Rearrangement Studies in the Diagnosis of a Paediatric Conjunctival Lesion

We present a case whereby standard immunohistochemistry and flow cytometry studies for a conjunctival biopsy were unable to reliably differentiate between the two distinct pathological processes of benign reactive lymphoid hyperplasia from conjunctival lymphoma. A tissue diagnosis was only able to be conclusively attained after the application of immunoglobulin heavy chain rearrangement studies to the specimen. This is unusual and to our knowledge has not been previously expressed in the literature. Hence, the use of these further molecular studies may have great potential clinical implications in helping resolve such diagnostic dilemmas.

Programmed Cell Death 1 Ligand 1 and Programmed Cell Death 1 Ligand 2 Are Expressed in Conjunctival Invasive Squamous Cell Carcinoma: Therapeutic Implications

PURPOSE

Novel cancer immunotherapies, called immune checkpoint inhibitors, have demonstrated clinical efficacy in the treatment of squamous cell carcinomas of the head and neck. Tissue expression of programmed cell death 1 ligand 1 (PD-L1) and programmed cell death 1 ligand 2 (PD-L2) has been shown to predict tumor response to these drugs. We examine the expression of prognostic immune biomarkers, PD-L1 and PD-L2, in invasive ocular surface squamous neoplasia.

DESIGN

Retrospective case series.

METHODS

Eighteen cases of ocular surface or ocular adnexal invasive squamous cell carcinomas were identified in pathology case files of the Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary and at the Wills Eye Hospital accessioned between January 1, 2014 and January 1, 2017. Immunohistochemical staining for PD-L1, PD-L2, CD8, and p16 was performed and graded in a standardized fashion.

RESULTS

PD-L1 and PD-L2 were expressed on tumor cells to varying degrees, and also on some stromal cells and endothelial cells. Stromal and endothelial cell expression was also seen in control conjunctival specimens. Tumor expression of PD-L1 and PD-L2 was present on the cell membranes. All 18 (100%) of the tumors expressed PD-L1: 7 (39%) expressed a high level, 3 (17%) expressed a medium level, and 8 (44%) expressed a low level. Only 9 (50%) tumors expressed PD-L2 and it was at a low level. The expression of PD-L1 in tumor cells correlated with the presence of CD8-positive cytotoxic T lymphocytes among tumor cells (P < .01) and with the presence of CD8-positive cells in the surrounding stroma (P = .04).

CONCLUSIONS

A subset of ocular invasive conjunctival squamous carcinomas express high levels of PD-L1 and CD8 and therefore may respond therapeutically to immune checkpoint inhibition.

Clinical characteristics, HIV status, and molecular biomarkers in squamous cell carcinoma of the conjunctiva in Ghana

BACKGROUND AND AIMS

Conjunctival squamous cell carcinoma (CSCC) varies in incidence geographically from 0 to 1 case per 100 000 per year globally. Additionally, the incidence of CSCC is known to increase 49% for every 10° decrease in latitude. Since the onset of the AIDS epidemic, there has been a trend of increasing incidence of CSCC in Africa, and despite relatively stable levels of ultraviolet (UV) exposure, there is an observed 12 times greater risk of developing CSCC when individuals are infected with HIV. In this study, we aim to analyze the clinical characteristics and biomarkers of CSCC in Ghana.

METHODS

In this study, a registry review of patients from January 2011 to May 2016 with CSCC at Komfo-Anokye Teaching Hospital in Kumasi, Ghana, was performed (n = 64). Tumor blocks of the CSCC were analyzed for the expression of various biomarkers.

RESULTS

In this study, the median age of onset of CSCC is 46.5 years old (range of 20-90 y old). Fifty one and a half percent (n = 33) of the cohort is female. There is a low rate of smoking and alcohol use in our CSCC cohort. Thirty-nine percent (n = 12) of Ghanaian men with CSCC are HIV-, while only 12% (n = 4) of women are HIV-. Fifteen patients had metastasis to lymph nodes or other tissues, and we observed a statistically significant relationship between HIV infection and metastasis (P = 0.027, chi-squared test). We observed no statistically significant relationship between known prognostic CSCC biomarkers and HIV status, age, or tumor stage.

CONCLUSION

Better characterization of CSCC could have a profound impact on the prevention, early identification, and treatment of CSCC in Africa. A retrospective chart analysis and collection of tumor samples can be challenging in this region due to methods of record keeping and stigma attached to clinical data such as HIV testing and smoking and alcohol use. As a result, in this study, data were often incomplete leading to inconclusive results and analysis that should be interpreted with caution. Future studies should consider a prospective study design that gathers clinical data in a standardized format and ensures fresh tissue from CSCC tumors.