Ocular surface squamous neoplasia: analysis based on the 8th American Joint Committee on Cancer classification

Novel automated non-invasive detection of ocular surface squamous neoplasia using artificial intelligence

Ocular surface squamous neoplasia (OSSN) is a common eye surface tumour, characterized by the growth of abnormal cells on the ocular surface. OSSN includes invasive squamous cell carcinoma (SCC), in which tumour cells penetrate the basement membrane and infiltrate the stroma, as well as non-invasive conjunctival intraepithelial neoplasia, dysplasia, and SCC in-situ thereby presenting a challenge in early detection and diagnosis. Early identification and precise demarcation of the OSSN border leads to straightforward and curative treatments, such as topical medicines, whereas advanced invasive lesions may need orbital exenteration, which carries a risk of death. Artificial intelligence (AI) has emerged as a promising tool in the field of eye care and holds potential for its application in OSSN management. AI algorithms trained on large datasets can analyze ocular surface images to identify suspicious lesions associated with OSSN, aiding ophthalmologists in early detection and diagnosis. AI can also track and monitor lesion progression over time, providing objective measurements to guide treatment decisions. Furthermore, AI can assist in treatment planning by offering personalized recommendations based on patient data and predicting the treatment response. This manuscript highlights the role of AI in OSSN, specifically focusing on its contributions in early detection and diagnosis, assessment of lesion progression, treatment planning, telemedicine and remote monitoring, and research and data analysis.

Clinicopathological Correlates of Ocular Surface Squamous Neoplasia

Introduction

This study examined the distribution of histopathological disease severity amongst a cohort of patients treated for clinically suspected ocular surface squamous neoplasia and evaluated the relationship between various patient and clinical factors and the severity of pathological grade as well as treatment outcomes.

Methods

A retrospective cohort study of demographic and clinicopathological factors of 150 patients clinically diagnosed with suspected ocular surface squamous neoplasia who underwent excision of lesion with histopathological diagnosis.

Results

The study included 125 cases; the mean age at diagnosis was 64 years (SD = 11.26). 74% of cases were histologically confirmed as ocular surface squamous neoplasia. Pathological distribution was conjunctival intraepithelial neoplasia I (13.6%), conjunctival intraepithelial neoplasia II (16.8%), conjunctival intraepithelial neoplasia III (21.6%), carcinoma in situ (21.6%), and squamous cell carcinoma (2.4%). Lesion appearance was leukoplakic (18%), gelatinous (15%), dysplastic (11%), vascular (6%), papilliform (2%), nodular (2%). Lesion location was nasal (43%), temporal (42%), and superior or inferior (14%). Recurrence occurred in 7 cases (5.6%). A significant association was found between presence of leukoplakia and pathological grade (p = 0.05).

Conclusions

Ocular surface squamous neoplasia is most frequently diagnosed in conjunctival intraepithelial neoplasia III and carcinoma in situ stages, and treatment outcomes are usually favourable.

Ocular surface squamous neoplasia with orbital tumour extension: risk factors and outcomes

PURPOSE

To describe the risk factors, clinical features, histopathology, treatment, and outcomes of patients with orbital tumour extension of ocular surface squamous neoplasia (OSSN).

METHODS

Retrospective study of 51 patients with orbital tumour extension (cases) and 360 patients without orbital extension (controls).

RESULTS

Of 1,653 patients with OSSN, orbital tumour extension was noted in 51 (3%) cases. The risk factors for orbital tumour extension included outdoor occupation (p < 0.03; Odds ratio (OR) = 1.96), Human Immunodeficiency Virus (HIV) infection (p < 0.0001; OR = 5.81), prolonged duration of symptoms (p = 0.01; OR = 1.02), tumour bilaterality (p = 0.02; OR = 2.92), forniceal and tarsal conjunctival involvement, diffuse tumour (p < 0.0001; OR = 9.13), inferior quadrantic location (p < 0.0001; OR = 7.51), increased tumour thickness (p = 0.04; OR = 1.59), higher % of ocular surface involvement (p = 0.002; OR = 1.12), nodular (p = 0.002; OR = 2.61) and nodulo-ulcerative (p < 0.0001; OR = 11.05) tumour morphology, poorly differentiated tumours (p = 0.006; OR = 4.23); invasive squamous cell carcinoma (SCC) (p < 0.0001; OR = 29.76), spindle cell and mucoepidermoid variant (p = 0.02; OR = 16.94) tumours. At a mean follow-up period of 27 months, tumour recurrence in the socket was noted in 1 (2%), locoregional lymph node metastasis (LNM) in 15 (29%) patients, and nine (18%) patients died due to systemic metastasis (SM). T4 tumour at presentation was a risk factor for LNM (p = 0.01; Hazard ratio (HR) = 5.60) and SM (p = 0.0003; HR = 5.09).

CONCLUSION

Orbital extension of OSSN is rare. Outdoor occupation, HIV infection, larger and thicker tumours in the inferior quadrant with forniceal and/or tarsal conjunctival involvement with nodular or noduloulcerative morphology, poor tumour differentiation, SCC, spindle cell and mucoepidermoid variants on histopathology are at increased risk for orbital tumour extension.

Exploring the Risk Factors of Conjunctival Squamous Cell Carcinoma and Establishing a Prognostic Model: Retrospective Study

Objective

Exploring the risk factors of conjunctival squamous cell carcinoma (CSCC) and establishing a prognostic model.

Methods

Information on patients with CSCC was extracted from the SEER database, conducting a retrospective study. 650 patients with CSCC were finally included in the model. Descriptive analysis was performed by Chi-square test and T-test. The risk factors of CSCC were explored by COX multivariate analysis, and the corresponding prognostic model was established as a result.

Results

The all-cause mortality rate of CSCC was 38.3%, and the risk factors were age (HR = 1.077), sex (HR = 0.691), grade (HR = 7.857), laterality (HR = 1.403), N (HR = 7.195), M (HR = 0.217), and surgery (HR = 1.618), all P < 0.05. The new model had C index and area under curve ROC (AUC) value greater than 0.7. Calibration curve, Net Reclassification Index (NRI), Integrated Discrimination Improvement (IDI), and Decision Curve Analysis (DCA) indicate the new model has better predictive performance than the American Joint Committee on Cancer (AJCC-TNM).

Conclusions

Compared with the clinical guidance of AJCC (TNM) for patients with CSCC, the established model exhibits good performance and can provide guidance for clinical decision-making.

Clinicopathological characteristics of ocular surface squamous neoplasia: a 10-year review form a referral tertiary centre in Nigeria

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is a heterogeneous group of proliferative squamous lesions on the ocular surface with varying biologic behaviours. This study aims to report the clinical profile and pathological characteristics of cases of OSSN seen at a tertiary referral centre in North West Nigeria.

METHODS

A retrospective review of all cases of OSSN diagnosed over a 10-year period was done.

RESULTS

OSSN accounted for 68 out of 91 ocular surface lesions affecting twice as many males as females and a peak incidence in the 30-39 years age group. They frequently presented as higher-grade and higher-stage lesions with invasive squamous cell carcinoma being the most frequently diagnosed OSSN. They also frequently showed an association with HIV infection and a relatively long duration of symptoms before presentation.

CONCLUSION

OSSN occurs in a relatively young age group in our environment. Certain clinical and epidemiological features appear to predict the occurrence of higher-grade lesions, and this may help in the clinical prediction of likely pathologic grade and/or biologic behaviour of these lesions.

Metastatic conjunctival squamous cell carcinoma: a study of 5 patients

PURPOSE

To describe the risk factors, clinical features, management, and outcomes in patients with metastatic conjunctival squamous cell carcinoma (mcSCC).

METHODS

Retrospective comparative study.

RESULTS

Of the 1192 cases with ocular surface squamous neoplasia during the study period, 654 (55%) patients were biopsied and 223 (19%) had invasive squamous cell carcinoma (cSCC). Of these 223 patients with cSCC, locoregional metastasis developed in 4 (2%) and distant metastasis in 1 (0.4%) patient. Mean age at diagnosis of OSSN was 48 years (median, 40 years; range 35-74 years). Tumors belonged to T2 (n = 2; 40%) and T4a (n = 3; 60%) at presentation. Primary treatment modalities included topical and subconjunctival interferon α 2B immunotherapy (n = 2; 40%), extended enucleation (n = 1; 20%) and orbital exenteration (n = 2; 40%). Metastases were noted after a mean period of 22 months of onset of primary tumor (median, 18 months; range 2-46 months). Death from metastatic disease occurred in all patients over a mean follow-up period of 21 months (median, 11 months; range 1-46 months). Bivariate regression analysis revealed smoking (p = 0.037, Odds Ratio (OR) = 0.13), tumor thickness ≥ 5 mm (p = 0.015, OR = 17.78), orbital invasion (p = 0.018, OR = 1.00), and poor histopathological differentiation (p = 0.031, OR = 10.44) to be significant risk factors for mcSCC.

CONCLUSION

Metastatic disease in cSCC is rare and risk factors for metastasis include smoking, thicker tumors, orbital tumor extension, and poor tumor differentiation. mcSCC is associated with high mortality.

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.

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.

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.

Diagnosis and staging of ocular surface squamous neoplasia

Background: Ocular surface squamous neoplasia (OSSN) is the most common ocular tumour. The diagnosis of OSSN is based on clinical suspicion and confirmed by various diagnostic modalities, of which histology is the gold standard. With the move to less invasive management options such as topical chemo- or immunotherapy, less invasive diagnostic options have come to the fore.Aim: The purpose of this article was to review the current staging and diagnostic modalities for OSSN with a focus on less invasive modalities.Method: A literature review was performed for publications on ocular surface neoplasia and diagnostic modalities.Results: Histology is the gold standard for diagnosing OSSN. Cytology has been shown to be a simple, repeatable and minimally invasive diagnostic modality, which also allows for additional testing such as polymerase chain reaction. Anterior segment optical coherence tomography provides a non-contact method of evaluating the ocular surface, with OSSN showing a thickened hyper-reflective epithelium, abrupt transition zone and demarcation line. Vital dyes are used less commonly with high sensitivity, but lower specificity for OSSN. Finally, confocal microscopy provides en-face images of the ocular surface, with OSSN showing a classic ‘starry night’ appearance.Conclusion: Histology remains the gold standard for diagnosis; however, with the increasing use of topical therapy for OSSN, there has been an increase in the uptake of less invasive diagnostic modalities.

Epidemiology of invasive ocular surface squamous neoplasia in Canada during 1992-2010

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is the most common non-pigmented ocular surface malignancy. It is classified as invasive OSNN (IOSSN) when the underlying stroma are infiltrated by dysplastic squamous epithelial cells through the basement membrane. Here, we present the descriptive epidemiology and geographical distribution of IOSSN in Canada.

METHODS

We determined the incidence and geographical distribution of IOSSN cases diagnosed between 1992 and 2010 using two independent population-based cancer registries: the Canadian Cancer Registry and Le Registre Québécois du Cancer.

RESULTS

The mean annual age-standardised incidence rate (WHO 2000-2025) of IOSSN for 1992-2010 was 0.45 cases per million individuals per year with an average annual percent increase in incidence of 4.5%. IOSSN localisation to the conjunctiva was documented in at least 57% of the reported cases. IOSSN exhibited a male predilection ratio of 3.3:1.0 with a mean age at diagnosis of 69 years. Incidence rates of IOSSN across Canadian provinces and cities showed no significant differences from the crude national average.

CONCLUSIONS

Our results, particularly concerning IOSSN patient age and male predilection, corroborate with data reported from the USA. Additional studies are needed to determine whether the observed increase in incidence rate over the study period (1992-2010) is significant.

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.

Conjunctival squamous cell carcinoma: prognostic factors for the recurrence and metastasis and clinicopathological characteristics at an oncological hospital in Peru

BACKGROUND/AIMS

Conjunctival squamous cell carcinoma (CSCC) is the most frequent malignant tumour of the conjunctiva, with scarce recurrence and infrequent metastasis. The purpose of this study is to describe the clinical and pathological characteristics of this neoplasm and to identify the prognostic factors for recurrence and metastasis in a cancer hospital in Peru.

MATERIALS AND METHOD

A longitudinal, retrospective study of 176 consecutive patients diagnosed with SCC of the conjunctiva. Sociodemographic and clinical characteristics were evaluated. In addition, Kaplan-Meier curves were performed, and Cox regression was used to determine prognostic factors for recurrence and metastasis over time.

RESULT

Only 12.5% presented tumour size ≤5 mm. The highest proportion according to the histopathological type was the well-differentiated infiltrative forms (40.9%), and according to tumour, node, metastases (TNM), stage T3 was the most frequent (31.3%). The most performed initial treatment was orbital exenteration (38.6%). The proportion of recurrence was 6.8% and 8.0% for metastasis. The annual survival rate was 7% and the annual metastasis rate was 6%; for recurrence after 5 years, the survival rate was 11% and the metastasis rate was 14%. No prognostic factor evaluated was significant.

CONCLUSION

This is the most extensive patient study in Latin America with CSCC, with a high proportion of advanced histopathological grade, TNM stages, and radical treatments such as exenteration. Recurrence rates on average are similar to other reported studies, and it describes the rates of metastasis that have been poorly described in the literature.

Pyogenic granuloma associated with conjunctival epithelial neoplasia: report of nine cases

Aims

To systematically describe the clinical and histopathological features of a case series of conjunctival carcinomatous lesions underlying as—and also masquerading—pyogenic granuloma.

Methods

Nine cases of conjunctival carcinomatous lesions underlying a pyogenic granuloma (which were clinically predominant) were retrospectively identified. Patients’ records were analysed for demographic data, clinical appearance and the postoperative course. Formalin-fixed paraffin-embedded specimens were routinely processed and stained with H&E and periodic acid-Schiff. Immunohistochemical stains for cytokeratin were performed in selected cases.

Results

All nine tumours were located in the conjunctiva (bulbar, tarsal, limbal conjunctiva) of patients between 44 and 80 years. The lesions exhibited clinical features of pyogenic granuloma which dominated the clinical appearance. Additional features comprised a papillomatous appearance of the adjacent conjunctiva, a more whitish aspect of the lesion and a history of squamous cell carcinoma (SCC) respectively surgery for other entities. Histopathological analysis revealed a carcinomatous lesion (conjunctival intraepithelial neoplasia or SCC) at the base of a classic pyogenic granuloma in all nine cases. Surgical removal (R0 resection) was performed. Three cases received adjuvant mitomycin C or interferon α2b treatment. Two lesions locally recurred within 2 years after initial presentation.

Conclusion

Carcinomatous lesions may be accompanied by a pyogenic granuloma which may dominate the clinical pictures. As the tumour is usually located at the base of the lesion, a complete surgical excision followed by histopathological analysis is mandatory for each lesion appearing as conjunctival pyogenic granuloma.

Clinical Management of Ocular Surface Squamous Neoplasia: A Review of the Current Evidence

Ocular surface squamous neoplasia (OSSN) is the most common non-pigmented malignancy of the ocular surface and is represented in a wide range of histologic diagnoses, ranging from mild epithelial dysplasia to invasive squamous carcinoma. Although surgical excision is still the gold standard for OSSN treatment, interest in conservative medical approaches is steadily growing. We have reviewed all of the literature on OSSN published in English in the MEDLINE database up to May 2018, using the keywords “ocular surface squamous neoplasia,” “squamous conjunctival carcinoma,” and “conjunctival carcinoma in situ,” with the aim to provide a comprehensive review of the most recent evidence on this distinct clinical entity.