Conjunctival squamous cell neoplasia: the Liverpool Ocular Oncology Centre experience

Topical 5-fluorouracil 1% for moderate to extensive ocular surface squamous neoplasia in 73 consecutive patients: Primary versus secondary treatment

IMPORTANCE

Ocular surface squamous neoplasia (OSSN) is a spectrum of malignancies that generally includes conjunctival intraepithelial neoplasia (CIN) and squamous cell carcinoma (SCC). OSSN can be treated with topical therapies including interferon α-2b (IFN), mitomycin C (MMC), or 5-fluorouracil 1% (5FU). Recently, due to unavailability of IFN and toxicity associated with MMC, therapy has shifted towards 5FU.

OBJECTIVE

Herein, we compare the use of 5FU 1% as a primary versus (vs) secondary treatment regimen in eyes with moderate to extensive OSSN.

DESIGN SETTING AND PARTICIPANTS

Retrospective cohort study of 73 consecutive patients with unilateral moderate to extensive OSSN treated at a single tertiary ocular oncology center from 2016 to 2023. Mean follow up time was 478.2 days overall, with 283.0 days for primary 5FU group and 860.3 days for secondary 5FU group.

INTERVENTION

Topical 5FU 1% 4 times daily for 2 weeks with option for 2-weekly extension until tumor control, either as primary treatment or as secondary treatment to surgical resection, topical IFN or topical MMC, or cryotherapy.

MAIN OUTCOMES

Outcome measures included tumor response, need for additional surgery, complications, and visual outcomes.

RESULTS

A comparison (primary vs secondary treatment) revealed no difference in mean tumor basal dimension (19.6 vs 17.2 mm, P = 0.46), thickness (3.7 vs 3.4 mm, P = 0.64), or tumor extent (4.4 vs 4.5 clock hours, P = 0.92). The primary treatment group showed greater complete tumor control (77% vs 38%, P = 0.04). Multivariable analysis comparison (primary vs secondary treatment) showed primary treatment more likely to achieve complete tumor control (P = 0.01). There was no difference in the complication rate from 5FU treatment between the groups. There was no difference in visual outcome, and no tumor-related metastasis (0%) or death (0%).

CONCLUSION AND RELEVANCE

Topical 5FU 1% is efficacious and safe as a primary or secondary treatment for moderate to extensive OSSN. Tumors treated with primary 5FU 1% demonstrated more complete resolution. In patients with moderate to extensive OSSN, primary treatment with topical 5FU 1% may be warranted.

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.

Histopathology-guided management of ocular surface squamous neoplasia with corneal stromal or scleral invasion using ruthenium-106 plaque brachytherapy

BACKGROUND/AIM

To evaluate the safety and efficacy of ruthenium-106 (Ru-106) plaque brachytherapy in managing invasive ocular surface squamous neoplasia (OSSN).

METHODS

This is a retrospective, non-comparative, interventional case series of 42 eyes with OSSN with histopathologically-proven corneal stromal and/or scleral invasion that underwent Ru-106 plaque brachytherapy. Main outcome measures were tumour regression, eye salvage, final visual acuity, treatment complications and metastasis.

RESULTS

At presentation, the mean tumour basal diameter was 9.3 mm (range 5-26 mm) and thickness 3.1 mm (range 1.5-11 mm). Prior treatment included excision biopsy in two patients (5%), incision biopsy and topical interferon in one each (2%). Following excision with 4 mm clinically clear margins, corneal stromal and/or scleral invasion of OSSN was confirmed in all 42 cases, with the excised base showing invasive squamous cell carcinoma. A total dose of 5000 cGy over a mean duration of 19.7 hours (range 7-41 hours) was provided to an axial depth of 2 mm using Ru-106 surface plaque. Over a mean follow-up of 36.9 months (range 22.3-72 months), complete tumour regression was achieved in all eyes (100%). Two eyes (5%) showed conjunctival tumour growth remote from the site of prior treatment. Visual acuity was maintained at ≥20/200 in 35 eyes (83%), with a loss of >2 Snellen lines in 1 eye (2%). There was no evidence of regional lymph node or systemic metastasis.

CONCLUSION

Histopathology-guided use of Ru-106 surface plaque brachytherapy is a safe and an effective adjuvant therapy in the management of corneal stromal and/or scleral invasion of OSSN.

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.

Ocular surface squamous neoplasia at a tertiary eye facility, Southwestern Nigeria: a 10-year review

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is a low-grade malignancy arising from the squamous epithelium of the ocular surface AIM: To describe the clinical presentation, histological diagnoses, treatment, and outcome of treatment in patients with OSSN managed at a tertiary health facility.

METHODS

Medical records of all patients with OSSN managed using a standardized treatment protocol over a 10-year period were reviewed.

RESULTS

Eighty-six patients comprising 44 (51.2%) males and mean age of 48.2 ± 15.8 years were studied. The most common presentation was a fleshy growth in the eye in all patients, and 43 (50.0%) patients tested positive to human immunodeficiency virus. The right eye was affected in 44 (51.2%) patients with no bilateral tumors, and the medial limbus was involved in 28 (32.6%) patients. Morphologically, 40 (46.5%) patients had gelatinous growth, 24 (27.9%) patients were in T_is category while 30 (34.9%) patients were in T₄ category. Twenty-eight (32.6%) patients received complete course of adjuvant topical mitomycin C (0.04%) while nine (10.5%) patients completed adjuvant systemic chemotherapy and external beam radiation. Overall, 61 (70.9%) patients had no tumor recurrence, seven (8.1%) patients had recurrent tumor, while the status of 18 (20.9%) patients was not known.

CONCLUSION

OSSN occurs more commonly in younger age group in our studied population and is strongly associated with HIV seropositivity. Intraoperative cryotherapy in patients with carcinoma in situ and intraoperative cryotherapy with adjuvant topical mitomycin C in those with invasive SCC that is limited to the ocular surface are associated with low tumor recurrence.

Racial and socioeconomic disparities in ocular surface squamous neoplasia: a National Cancer Database analysis

Purpose: A retrospective population-based study to investigate racial and socioeconomic disparities in patients diagnosed with ocular surface squamous neoplasia (OSSN).Methods: To explore racial disparity, we selected OSSN patients with known age, insurance, gender and zip code-level income and education from the National Cancer Database (NCDB). Comparisons of clinical and socioeconomic variables stratified by race were made with the chi-square or Mann-Whitney tests. Survival outcome was examined a Cox regression model.Results: Of the 2,402 identified patients from 2004 to 2015, 117 were black. Unadjusted differences were found between groups in regard to age, histology, insurance, income, and education. Black patients in comparison to white patients were younger (mean age: 62 years vs. 70 years; p < .001), represented a higher proportion of Medicaid use (10.3% vs. 3.2%; p < .001) or uninsured (10.3% vs. 2.7%; p < .001), and were more likely to reside in areas of low educational attainment (32.5% vs. 16.1% of whites; p < .001). Multivariate analysis found significantly higher risk of death in patients who were male (HR: 1.66, 95% CI 1.37-2.01) or black (HR: 1.57, 95% CI 1.03-2.38).Conclusion: Disparities in socioeconomic factors were observed in black patients with OSSN. OSSN occurred earlier in blacks, who were also socioeconomically disadvantaged and faced higher risk of death.

Ocular surface squamous neoplasia: outcomes following primary excision with 2 mm margin and cryotherapy

PURPOSE

To assess margins and the rate of local recurrence of ocular surface squamous neoplasia after excision with a 2 mm margin and cryotherapy at a single ophthalmic oncology center.

OUTCOME MEASURES

(1) Conjunctival margin were assessed as positive, negative, or indeterminate margins. (2) Feasibility of repair without a graft. (3) Local recurrence.

METHODS

Retrospective chart review of histologically proven conjunctival intraepithelial neoplasia and invasive squamous cell carcinoma cases that underwent excision with a 2 mm margin and cryotherapy.

RESULTS

Eighty cases met inclusion criteria for the quantitative analysis. The margin was positive in six cases (7.5%), four of which were treated with post-op topical immunotherapy/chemotherapy. Of the six positive margin cases, there was one recurrence which occurred in the patient who did not receive post-op topical adjuvant therapy, however resolved after starting topical treatment. Conjunctival repair without use of a graft was feasible in 74 (93%) cases with a mean basal diameter of 6.4 mm. Total number of local recurrence was seen in three cases (4%), which were successfully treated with adjuvant topical treatment (one positive margin case, one indeterminate margin case) or repeat resection followed by episcleral plaque brachytherapy (one negative margin case).

CONCLUSION

Excision with 2 mm margin of OSSN is not associated with high rates of positive surgical margins. Even those with positive margins, when treated with adjuvant topical therapy did not develop recurrence. While achieving low rates of local recurrence, the conjunctiva is conserved, thereby minimizing the need for amniotic membrane or free conjunctival grafts for conjunctival repair.

Combining Brachytherapy and Cryotherapy as Adjuvant Therapy for Squamous Cell Carcinoma of the Conjunctiva: Literature Review and Case Reports

Background

Separately, cryotherapy and brachytherapy have shown promising results when adjuvating the excision of squamous cell carcinoma of the conjunctiva (SCCC). The aim of this paper is to assess the combined effect in terms of complications and recurrence rate.

Summary

We describe 2 patients suffering from SCCC, and we review the current literature on adjuvant cryotherapy and brachytherapy. Both patients, one of whom suffered from recurrent SCCC, underwent surgical excision followed by combined cryotherapy and brachytherapy. Cryotherapy was performed using a retinal cryoprobe, and 2 rounds each of 5 s with N₂O as a cryogen were applied. Brachytherapy was performed using a ruthenium-106 plaque, delivering a dosage of 100 Gy at 2-mm depth.

Key Messages

By reviewing the current literature and describing 2 case reports, this paper illustrates the use of combined cryotherapy and brachytherapy after surgical excision of SCCC. The current literature presents promising results of each treatment, and the 2 cases showed promising results by combining the 2 adjuvant therapies showing no signs of recurrence or complications during a follow-up period of 26 and 38 months.

Liquid Biopsy for Solid Ophthalmic Malignancies: An Updated Review and Perspectives

Simple Summary

To date, there is no treatment for metastatic uveal melanoma. Identifying its metastatic spread is essential. Liquid biopsy can identify patients at risk of metastatic spread early. Here, we aim to summarize the current knowledge of liquid biopsy in ophthalmic malignant tumors, including uveal melanoma. Our objective is to establish the current state of liquid biopsy in the ophthalmic field, as well as its perspectives and limitations.

Abstract

Tissue biopsy is considered the gold standard when establishing a diagnosis of cancer. However, tissue biopsies of intraocular ophthalmic malignancies are hard to collect and are thought to be associated with a non-negligible risk of extraocular dissemination. Recently, the liquid biopsy (LB) has emerged as a viable, non-invasive, repeatable, and promising way of obtaining a diagnosis, prognosis, and theragnosis of patients with solid tumors. LB refers to blood, as well as any human liquid. The natural history of uveal melanoma (UM) and retinoblastoma (RB) are radically opposed. On the one hand, UM is known to disseminate through the bloodstream, and is, therefore, more accessible to systemic venous liquid biopsy. On the other hand, RB rarely disseminates hematogenous, and is, therefore, more accessible to local liquid biopsy by performing an anterior chamber puncture. In this review, we summarize the current knowledge concerning LB in UM, RB, conjunctival tumors, and choroidal metastases. We also develop the current limitations encountered, as well as the perspectives.

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.

Clinical Management of Squamous Cell Carcinoma of the Conjunctiva

Patient: Female, 33-year-old

Final Diagnosis: Conjunctival squamous cell carcinoma

Symptoms: Tumorous lesion on the nasal bulbar conjunctiva • red eye

Medication: —

Clinical Procedure: The conjunctival tumor was excised. The histopathological diagnosis suggested a conjunctival squamous cell carcinoma. A treatment with topical MMC was admistered

Specialty: Ophthalmology

Management Issues in Conjunctival Tumours: Ocular Surface Squamous Neoplasia

Ocular surface squamous neoplasia is the most common tumour of the ocular surface. It is a spectrum of disease from intraepithelial dysplasia to invasive squamous cell carcinoma. Recent years have seen an increase in the use of topical chemotherapeutic agents to treat this condition, often as primary treatment without full-thickness biopsy. This practical approach provides a critical appraisal of the evidence base with the goal being to aid the clinician in the management of these patients.

Ocular surface squamous neoplasia with intraocular tumour extension: a study of 23 patients

PURPOSE

To describe the clinical features, histopathology and treatment of ocular surface squamous neoplasia (OSSN) with intraocular tumour extension.

METHODS

Retrospective study of 23 patients.

RESULTS

The mean age at presentation of OSSN with intraocular tumour extension was 48 years. Mass (52%) and pain with redness (30%) were the most common presenting complaints. The mean duration of symptoms was 9 months. History of human immunodeficiency virus (HIV) infection was present in eight (35%) patients and one (4%) had xeroderma pigmentosum. History of prior tumour excision was noted in 16 (70%) patients. The mean basal diameter was 17 mm and the mean tumour thickness was 4 mm. Fifteen (65%) tumours had a nodulo-ulcerative tumour pattern at the time of detection of intraocular extension of OSSN. Anterior chamber cells and flare was noted in five (24%) cases and two (9%) patients had secondary glaucoma. Ultrasound biomicroscopy (UBM) (n = 11) revealed blunting of anterior chamber in three (27%) cases and uveal thickening in seven (67%) cases. Over the course of follow-up, extended enucleation (n = 6; 26%) or orbital exenteration (n = 17; 74%) was required for tumour control. At a mean follow-up period of 18 months, locoregional lymph node metastasis was seen in two (9%) patients, and one patient died with systemic metastasis. On histopathology, ciliary body was involved in all (100%) cases.

CONCLUSION

Multiple tumour recurrences with history of prior tumour excision and nodulo-ulcerative tumour pattern are commonly associated with intraocular tumour extension of OSSN. UBM is a useful tool to detect intraocular extension of OSSN.

Superficial radiotherapy as a treatment alternative for recurrent conjunctival squamous cell carcinoma: a case study

This case study discusses the use of superficial radiotherapy (SXRT) in the treatment of recurrent conjunctival squamous cell carcinoma (SCC). Conjunctival SCC is often an aggressive cancer, with surgery the current standard of care. There is currently limited literature on alternative treatment options to treat conjunctival SCC recurrences that enable ocular function preservation. Furthermore, the use of SXRT in this setting is not well-reported. Technical feasibility, practical limitations and potential side effects of SXRT (in comparison to other treatment options) are discussed in this case study. This case describes a 62 years old male with limited treatment options following multiple recurrences of conjunctival SCC. He was prescribed a therapeutic SXRT dose of 48.4 Gy in 22 fractions (5 fractions/week). At 6-month follow-up, there was no evidence of residual or recurrent disease, or any significant objective or patient reported treatment induced side effects. This case study provides preliminary evidence for the potential application of SXRT for conjunctival SCC. The benefits reported in this case study warrant further investigation of the applicability of SXRT in a larger patient cohort, with the potential to provide patients with a less invasive treatment alternative for recurrent conjunctival SCC.

Ruthenium brachytherapy for intraocular growth of a conjunctival squamous cell carcinoma: a case report

The aim of this study is to report the use of ruthenium brachytherapy as an adjunctive treatment in the management of an intraocular extension of the conjunctival squamous cell carcinoma (SCC).

In 2013, a 73-year-old man presented with a tumor blocking the angle and infiltrating corneal endothelium. The patient was treated with iridectomy, and after one month, ruthenium brachytherapy was applied. 4.5 years post-irradiation, the treated eye is painless, and no recurrence was noted.

We advocate the use of ruthenium brachytherapy as an eye salvage treatment with an intraocular extension of conjunctival SCC.

Pharmacotherapy and Immunotherapy of Conjunctival Tumors

Conjunctiva and cornea tumors represent a large spectrum of conditions ranging from benign lesions to aggressive and life-threatening malignancies. Topical pharmacotherapies and immunotherapies have recently acquired a relevant role in the management of conjunctival tumors and, in the past 2 decades, there has been a shift from surgery alone toward the use of these agents, both as a sole therapy or as adjunct to surgery (before or after surgery). The 3 main agents that have been used for topical medical treatment of conjunctival tumors are mitomycin-C, 5-fluorouracil, and interferon-α2b. Advantages of topical pharmacotherapies and immunotherapies include the ability to treat the entire ocular surface and prevention of surgical side effects and complications. The aim of this review is to summarize the current use of topical pharmacotherapy and immunotherapy in the management of conjunctival tumors.

Topical 5-Fluorouracil 1% as Primary Treatment for Ocular Surface Squamous Neoplasia

PURPOSE

To determine the efficacy of topical 5-fluorouracil 1% (5-FU) as a primary treatment of ocular surface squamous neoplasia (OSSN).

DESIGN

Retrospective study.

PARTICIPANTS

Topical 5-FU was used as primary therapy in 44 patients with OSSN.

METHODS

5-Fluorouracil 1% administered topically 4 times daily for 1 week followed by a drug holiday of 3 weeks. Patients were identified through a pharmacy database. Patients were excluded if 5-FU was used as adjuvant therapy, if they did not complete therapy, or if they were still actively receiving treatment for OSSN at the time of last follow-up.

MAIN OUTCOME MEASURES

The primary outcome measures were the frequency of complete resolution with topical 5-FU treatment and the rate of OSSN recurrence.

RESULTS

Of the 44 patients identified, 32 were men and 12 were women. The mean age was 68 years. Complete resolution of OSSN was noted in 82% of patients (36/44); 18% (8/44) were considered treatment nonresponders. Patients were treated with a median of 4 cycles (range, 2-9 cycles). Nasal location was the only risk factor identified for nonresponse to therapy (P = 0.04). The median follow-up after resolution was 10 months (range, 2-77 months). In the 36 patients who showed complete resolution, 4 experienced tumor recurrence. Recurrence rates at 1 and 2 years were 6% and 15%, respectively, using Kaplan-Meier survival analysis. At least 1 side effect from the medication was reported by 61% of patients (21/44), but only 1 patient discontinued the medication because of intolerance. The most common side effect was pain (n = 17; 39%), followed by tearing (n = 10; 23%), photophobia (n = 6; 14%), itching (n = 4; 9%), swelling (n = 2; 5%), and infection (n = 1; 2%). No long-term complications were reported.

CONCLUSIONS

5-Fluorouracil is effective and well tolerated as a primary treatment for OSSN, with 82% of tumors responding completely to therapy.