Update on the Management of Ocular Surface Squamous Neoplasia

Squamous Cell Carcinomas in Horses: An Update of the Aetiopathogenesis and Treatment Options

Squamous cell carcinomas are a very common tumor type in horses, and are found in a variety of dermatologic and non-dermatologic locations. Metastasis is common, even at the first presentation of the disease, and a full staging workup is therefore strongly recommended to direct treatment and assist with prognostication. Wide surgical excision remains the treatment of choice in most cases, but recurrence is common, and adjunctive therapy may be indicated to improve the long-term prognosis.

Chronic inflammation as a proposed risk factor for ocular surface squamous neoplasia

PURPOSE

Chronic inflammation is a predisposing factor for metaplastic changes and ultimately dysplasia. We describe cases of OSSN occurring in the setting of chronic ocular surface inflammation.

METHODS

Sixteen eyes from 14 individuals were included from one ocular oncology clinic between 2010 and 2023. Patients presented with ocular surface squamous neoplasia (OSSN) in the setting of chronic inflammation. The diagnosis of OSSN was made using anterior segment high-resolution optical coherence tomography (HR-OCT) and confirmed by histopathological analysis in all cases.

RESULTS

Median age on presentation was 61 [IQR 47.5-69.2] years. Eleven (86%) individuals were male and five (36%) identified as White Hispanic. Ten eyes were referred with ocular surface diagnoses including pannus (n = 4), scarring (n = 3), pterygium (n = 2), and herpetic keratitis (n = 1). Only six eyes were referred as possible neoplasia. All individuals had a history of ocular surface inflammation. The most common inflammatory conditions were ocular rosacea (seven individuals) and atopic keratoconjunctivitis (AKC) (five individuals). Two individuals were found to have bilateral OSSN, one in the setting of ocular rosacea and the other in the setting of AKC. All 16 eyes from 14 individuals were suspected to have OSSN based on HR-OCT findings which guided the location of the incisional biopsies that subsequently confirmed histopathological diagnosis in all cases.

CONCLUSION

OSSN may arise in the setting of chronic inflammation on the ocular surface. Identification of the tumor can be challenging in these cases, and HR-OCT can be a key diagnostic tool in detecting OSSN.

Toluidine blue 1% eye drop versus optical coherence tomography for margin delimitation of ocular surface squamous neoplasia

PURPOSE

To compare the use of toluidine blue 1% eye drops with anterior segment optical coherence tomography (OCT) for the determination of tumour margins in patients with ocular surface squamous neoplasia (OSSN).

METHODS

The study was conducted from July 2020 to June 2021 at the Ocular Oncology department at the Federal University of São Paulo, Brazil. Slit-lamp photographs after toluidine blue staining and OCT of the anterior segment were taken on the same day from patients with OSSN. Photographs and OCT images were analyzed quantitatively using the software ImageJ and IMAGEnet®, respectively. The agreement between techniques was evaluated qualitatively through the Bland-Altman graph and quantitatively through intraclass correlation (ICC).

RESULTS

A total of 21 participants (71.43% males) with a clinical diagnosis of OSSN were included in the study. The average + SD diameter along the chosen axes was 4.43 ± 2.08 mm with OCT of 4.37 ± 2.03 mm with toluidine blue, a difference not statistically significant (p = 0.2891). The Bland-Altman analysis indicated a good qualitative agreement between the methods, with all cases inserted within the limits of agreement from -0.3217 to 0.4268. The ICC quantitative analysis showed an almost perfect agreement of 99.57% (95%CI: 98.96-99.83%; p < 0.001).

CONCLUSIONS

Our findings showed that OCT and toluidine eye drops are equivalent in determining margins for tumour measurements, which is particularly relevant in low-income settings where anterior segment OCT is not available. The use of toluidine blue 1% could be an useful alternative to quantify the size of the tumour, help to monitor tumour growth, and outline margins for surgical planning.

Molecular and epigenetic mechanisms governing ocular surface squamous neoplasia: opportunities for diagnostics

INTRODUCTION

Ocular surface squamous neoplasia (OSSN) is the most common ocular malignancy; the pathophysiology is influenced by molecular, genetic, and epigenetic mechanisms. The incidence of OSSN is associated with the anatomy and physiology of the ocular surface, limbal stem cell configuration, limbal vulnerability, cancer stem cells, dysplasia, neoplasia, angiogenesis, invasion, and metastasis. The key etiological factors involved are human papillomavirus (HPV), human immunodeficiency virus (HIV), immunosuppression, p53 tumor suppressor gene, hypovitaminosis A, and failure of Deoxyribonucleic acid (DNA) repair mechanisms.

AREAS COVERED

This special report is a focussed attempt to understand the molecular mechanism, genetic and epigenetic mechanism, and diagnostic modalities for OSSN.

EXPERT OPINION

While these mechanisms contribute to genome instability, promoter-specific hypermethylation might facilitate and promote tumor formation by silencing tumor suppressor genes. OSSN understanding has improved with increased literature available on various genetic, molecular, and epigenetic mechanisms, although the exact genetic and epigenetic mechanisms still need to be elucidated. It is important to note that the molecular mechanisms of OSSN can vary among individuals, and further research is required to elucidate the underlying processes fully. Understanding these mechanisms is crucial for the development of targeted therapies and improved management of OSSN.

Yes-associated protein-1 overexpression in ocular surface squamous neoplasia; a potential diagnostic marker and therapeutic target

Yes-associated protein-1 (YAP-1) is a Hippo system transcription factor, which serves as an oncogene in squamous cell carcinoma, and several solid tumors when the Hippo pathway is dysregulated. Yet, the activity of YAP-1 in ocular surface squamous neoplasia (OSSN) has not been determined. Here, we investigate the relationship between YAP-1 overexpression and OSSN. Using a cross-sectional study design, we recruited 227 OSSN patients from the University Teaching Hospitals in Lusaka, Zambia. Immunohistochemistry was used to assess YAP-1 protein overexpression in tumor tissue relative to surrounding benign squamous epithelium. OSSN patient samples (preinvasive, n = 62, 27% and invasive, n = 165, 73%) were studied. One hundred forty-nine invasive tumors contained adjacent preinvasive tissue, bringing the total number of preinvasive lesions examined to 211 (62 + 149). There was adjacent benign squamous epithelium in 50.2% (114/227) of OSSN samples. Nuclear YAP- 1 was significantly overexpressed in preinvasive (Fisher's (F): p <.0001, Monte Carlo (MC): p <.0001) and invasive (F: p <.0001, MC: p <.0001) OSSN in comparison to adjacent benign squamous epithelium when analyzed for basal keratinocyte positive count, staining intensity, expression pattern, and Immunostaining intensity-distribution index. YAP-1 expression did not differ between preinvasive and invasive OSSN (p >.05), keratinizing and non- keratinizing cancer (p >.05), or between T1/T2 and T3/T4 stages in invasive tumors (p >.05). However, grade 2 and 3 tumors had significantly stronger nucleus YAP-1 overexpression intensity than grade 1 tumors (F: p = .0078, MC: p = .0489). By immunohistochemistry, we identified significant overexpression (upregulation of YAP-1 protein expression) in preinvasive and invasive OSSN lesions compared to neighboring benign squamous epithelium. YAP-1 expression was significantly higher in poorly and moderately differentiated invasive squamous cancer than in well-differentiated carcinomas. Overexpression of YAP-1 within the margin of preinvasive and invasive OSSN, but not in the neighboring normal epithelium, indicates that it plays a role in the development and progression of OSSN.

Medical treatment for ocular surface squamous neoplasia

Ocular surface squamous neoplasia (OSSN) is the most common non-melanocytic tumour of the ocular surface. Surgical excision with wide margins using the "no-touch" method was originally the most popular treatment for OSSN. However, in the past two decades, the use of topical medications for OSSN treatment has gained a reputation amongst ophthalmologists for being an effective alternative to surgical excision. Furthermore, technological advancements, such as those seen in high-resolution optical coherence tomography (HR-OCT) for the anterior segment, have facilitated the diagnosis and monitoring of OSSN. When selecting a topical agent, interferon alpha-2b (IFNα-2b) and 5-fluorouracil (5-FU) are two of the gentlest medications used for OSSN and are often considered first line therapies due to their high-resolution rates and mild side effect profiles. Mitomycin C (MMC), on the other hand, has a highly toxic profile; therefore, while effective, in our hands it is considered as a second-line treatment for OSSN if the other modalities fail. In addition, newer and less studied agents, such as immune checkpoint inhibitors, retinoic acid, aloe vera, and anti-vascular endothelial growth factor have anti-neoplastic properties and have shown potential for the treatment of OSSN. We enclose an updated literature review of medical treatments for OSSN.

Mesoporous Silica Nanoparticles Coated with Carboxymethyl Chitosan for 5-Fluorouracil Ocular Delivery: Characterization, In Vitro and In Vivo Studies

This study investigates the development of topically applied non-invasive amino-functionalized silica nanoparticles (AMSN) and O-Carboxymethyl chitosan-coated AMSN (AMSN-CMC) for ocular delivery of 5-Fluorouracil (5-FU). Particle characterization was performed by the DLS technique (Zeta-Sizer), and structural morphology was examined by SEM and TEM. The drug encapsulation and loading were determined by the indirect method using HPLC. Physicochemical characterizations were performed by NMR, TGA, FTIR, and PXRD. In vitro release was conducted through a dialysis membrane in PBS (pH 7.4) using modified Vertical Franz diffusion cells. The mucoadhesion ability of the prepared nanoparticles was tested using the particle method by evaluating the change in zeta potential. The transcorneal permeabilities of 5-FU from AMNS-FU and AMSN-CMC-FU gel formulations were estimated through excised goat cornea and compared to that of 5-FU gel formulation. Eye irritation and ocular pharmacokinetic studies from gel formulations were evaluated in rabbit eyes. The optimum formulation of AMSN-CMC-FU was found to be nanoparticles with a particle size of 249.4 nm with a polydispersity of 0.429, encapsulation efficiency of 25.8 ± 5.8%, and drug loading capacity of 5.2 ± 1.2%. NMR spectra confirmed the coating of AMSN with the CMC layer. In addition, TGA, FTIR, and PXRD confirmed the drug loading inside the AMSN-CMC. Release profiles showed 100% of the drug was released from the 5-FU gel within 4 h, while AMSN-FU gel released 20.8% of the drug and AMSN-CMC-FU gel released around 55.6% after 4 h. AMSN-CMC-FU initially exhibited a 2.45-fold increase in transcorneal flux and apparent permeation of 5-FU compared to 5-FU gel, indicating a better corneal permeation. Higher bioavailability of AMSN-FU and AMSN-CMC-FU gel formulations was found compared to 5-FU gel in the ocular pharmacokinetic study with superior pharmacokinetics parameters of AMSN-CMC-FU gel. AMSN-CMC-FU showed 1.52- and 6.14-fold higher AUC0-inf in comparison to AMSN-FU and 5-FU gel, respectively. AMSN-CMC-FU gel and AMSN-FU gel were "minimally irritating" to rabbit eyes but showed minimal eye irritation potency in comparison to the 5 FU gel. Thus, the 5-FU loaded in AMSN-CMC gel could be used as a topical formulation for the treatment of ocular cancer.

Squamous cell carcinoma of the conjunctiva. Case report

Introduction

The prevalence of squamous cell carcinoma of the eyeball is low, and this is a rare condition. There are multiple therapeutic strategies for the treatment and depend on the degree of local involvement and extension of the tumor which, in turn, will have an impact on the patient's prognosis.

Presentation of case

We present a case of a patient with a mass of progressive growth on the left eyeball whit vision damage. The biopsy showed a squamous cell carcinoma of the conjunctiva, and imaging studies showed orbital invasion cT4bN0cM0, so surgery was indicated. The surgery was done with macroscopic margins of 5 mm. After resection, a radial free flap reconstruction was performed. Adjuvant treatment with radiotherapy was performed without complications. After six months, the patient manifested an improvement in his quality of life, and there is no evidence of relapse.

Discussion

The prevalence of squamous cell carcinoma of the conjunctiva is low. The most important risk factor is exposure to UV rays. Most are derived from conjunctival intraepithelial neoplasms. There are topical management protocols with chemotherapeutic agents and in patients with ocular or orbital invasion, enucleation and exanteration are the treatments of choice.

Conclusion

The squamous cell carcinoma of the conjunctive is rare. The management in the locally advanced tumors is surgical. The use of a radial free flap reconstruction is one of the reconstructive strategies to take into account, and the knowledge of additional strategies required to control the disease is important to ensure an optimal treatment.

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Squamous cell carcinoma is the most frequent tumor of the eyeball.

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The most important risk factor is the exposure to UV rays (damage in repairing DNA).

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There are topical management protocols with multiple chemotherapeutic agents.

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In patients with ocular or orbital invasion, the surgery is the GOLD standard of care.

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Adjuvant therapies are useful tools in the oncological management of these patients.