Beta-ray treatment of malignant epithelial tumors of the conjunctiva

First clinical implementation of Yttrium-90 Disc Brachytherapy after FDA clearance

PURPOSE

Herein, we study if high-dose-rate (HDR) yttrium-90 (⁹⁰Y) brachytherapy could be utilized by medical physicists, radiation oncologists, and ophthalmic surgeons.

METHODS AND MATERIALS

Yttrium-90 (⁹⁰Y) beta-emitting brachytherapy sources received United States Food and Drug Administration clearance for episcleral treatment of ocular tumors and benign growths. Dose calibration traceable to the National Institute of Standards and Technology as well as treatment planning and target delineation methods were established. Single-use systems included a ⁹⁰Y-disc affixed within specialized, multifunction, handheld applicator. Low-dose-rate to high-dose-rate prescription conversions and depth-dose determinations were performed. Radiation safety was evaluated based on live exposure rates during assembly and surgeries. Clinical data for radiation safety, treatment tolerability, and local control was collected.

RESULTS

Practice parameters for the medical physicist, radiation oncologist, and ophthalmic surgeon were defined. Device sterilizations, calibrations, assemblies, surgical methods, and disposals were reproducible and effective. Treated tumors included iris melanoma, iridociliary melanoma, choroidal melanoma, and a locally invasive squamous carcinoma. Mean calculated ⁹⁰Y disc activity was 14.33 mCi (range 8.8-16.6), prescription dose 27.8 Gy (range 22-30), delivered to depth of 2.3 mm (range 1.6-2.6), at treatment durations of 420 s (7.0 min, range 219 s-773 s). Both insertion and removal were performed during one surgical session. After surgery, each disc-applicator- system was contained for decay in storage. Treatments were well-tolerated.

CONCLUSIONS

HDR ⁹⁰Y episcleral brachytherapy devices were created, implementation methods developed, and treatments performed on 6 patients. Treatments were single-surgery, rapid, and well-tolerated with short-term follow up.

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.

Clinical clues to the early diagnosis and management of ocular surface neoplasia following keratoplasty in xeroderma pigmentosa

The purpose of this report is to highlight the early clinical signs and management of ocular surface neoplasia following penetrating keratoplasty in xeroderma pigmentosa. A 14-year-old girl reported increased conjunctival hyperemia, tearing, photophobia in the right eye at 6 months after penetrating keratoplasty that worsened rapidly over the subsequent 2 weeks. Slit lamp examination showed increased vascularity, epithelial haze and raised whitish lesions at the graft-host junction. Alcohol keratoepithelectomy was performed for confirming the diagnosis. Histology of the sample revealed severe dysplasia. The lesion resolved after surface plaque brachytherapy. The graft clarity was restored and maintained until the last follow-up of 15 months following brachytherapy. Exacerbated symptoms and clinical signs of increased vascularisation and epithelial lesions should arouse the suspicion of ocular surface neoplasia in grafted eyes. Early diagnosis and management can salvage the graft clarity.

Gamma Knife Stereotactic Radiosurgery for Conjunctival Squamous Cell Carcinoma Invading the Anterior Orbit: A Case Series

Introduction

The aim of the study was to report our experience in the use of Gamma Knife Stereotactic Radiosurgery (GKSTRS) for conjunctival squamous cell carcinoma (SCC) invading the orbit, as an alternative to exenteration surgery.

Patients and Methods

Patients who had GKSTRS for conjunctival SCC invading the orbit but sparing the bone (AJCC eighth ed. T4a) with a minimum of 1-year follow-up were included. Treatment failure was defined as no decrease in tumour size 3 months post-treatment, or further growth during the follow-up period. Patients were followed up 3-monthly for 2 years and 6-monthly afterwards with a minimum of yearly MR Imaging of orbit.

Results

Six patients met the inclusion criteria. MR imaging was used to identify the extent of orbital involvement of SCC. Stereotactic radiosurgery utilizing the Leksell Gamma Knife® Perfexion was delivered in a single session in which patients received 18-20 Gy to the 45-50% isodose. The median follow-up was 29 months. Four patients responded to the treatment and had no evidence of recurrence at their most recent follow-up. The treatment failed in 2 patients, in 1 of whom the tumour was larger and extended deeper into the orbit. The other patient developed a recurrence away from the treated area at 9 months, suggesting a multifocal disease. Both patients had poorly differentiated SCC.

Conclusion

GKSTRS is a potential alternative to orbital exenteration surgery for conjunctival SCC extending into the anterior orbit in a selected group of patients refusing orbital exenteration or has a second blind eye. Nevertheless, the disease is more likely to recur than with exenteration surgery, hence lifelong monitoring and low threshold for surgical intervention or retreatment is prudent.

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.

Superficial ocular malignancies treated with strontium-90 brachytherapy: long term outcomes

Purpose

The incidence of conjunctival malignancies is less than 1%. Though surgical excision remains the mainstay of treatment, the incidence of positive surgical margins and local recurrence rates are high, which is approximately up to 33% in negative margins and 56% in positive margins. Radiotherapy reduces the risk of recurrence in these cases. Brachytherapy using β emitters such as strontium-90 (⁹⁰Sr) is an ideal treatment technique for these tumors with the advantage of treating only a few millimeters of tissue while sparing the underlying normal eye. We report the long term outcomes in the form of local control and late sequelae of patients with conjunctival malignancies treated with ⁹⁰Sr applicator brachytherapy.

Material and methods

During 1999-2013, 13 patients with conjunctival tumors, treated using ⁹⁰Sr brachytherapy were analyzed. Brachytherapy was either in a post-operative adjuvant or in a recurrent setting. Local control (LC), disease free survival (DFS), overall survival (OS), and late sequelae were evaluated.

Results

The median age at presentation was 47 years (range: 11-71 years). Thirteen patients with 15 tumors were treated. The commonest histology was squamous cell carcinoma. The median dose was 44 Gy over 11 fractions. The median follow up of all the patients was 51 months (range: 3-139 months). The median follow up of patients with carcinoma only was 64 months with a LC and DFS of 90.9% at 5 years. None of the patients developed ≥ grade II Radiation Therapy Oncology Group (RTOG) acute toxicities. One patient developed a focal scar and another developed corneal opacification at the limbus. Vision was not impaired in any of the patients.

Conclusions

Strontium-90 brachytherapy used in early invasive conjunctival malignancies as an adjunct to surgery in primary and recurrent settings, results in optimal disease control and ocular functional outcomes.

The treatment of carcinoma in situ and squamous cell carcinoma of the conjunctiva with fractionated strontium-90 radiation in a population with a high prevalence of HIV

BACKGROUND

This study explores the safety and efficacy of strontium 90 (Sr-90) brachytherapy as the sole adjuvant therapy for carcinoma in situ (CIS) and squamous cell carcinoma (SCC) of the conjunctiva in a high HIV prevalent area.

METHODS

This is a retrospective case review of patients treated with 60 Gray Sr-90 brachytherapy in four divided doses after resection with a 2 mm margin and histological confirmation. Cryotherapy or alcohol debridement was not performed at the time of excision due to limited resources. Two plaque sizes, 8.5 mm and 18 mm, were used.

RESULTS

Sixty-nine patients were treated and had a median follow-up of 27 months (range 6-127). Thirty-three (47.8%) were HIV-positive. CIS was present in 40.6% and SCC in 59.4%. The surgical margins were positive in 39 (56.5%). Twenty patients (29.0%) were treated with the 18 mm plaque and 49 (71.0%) with the 8.5 mm plaque. Eight (11.6%) patients developed a recurrence at a median of 5 months (range 2-40). Recurrences only occurred in patients treated with the 8.5 mm plaque (p=0.094). There was no significant effect of HIV status, positive margins or staging on the number of recurrences. Treatment side effects were a dry eye in five patients which was successfully managed with topical lubricants, and induced astigmatism of 1 dioptre of cylinder in one patient.

CONCLUSIONS

Sr-90 brachytherapy is safe and effective in preventing recurrences in ocular surface squamous neoplasia in a high HIV prevalent setting. The 18 mm plaque size is superior to the 8.5 mm plaque size.

Conjunctival squamous cell neoplasia: the Liverpool Ocular Oncology Centre experience

PURPOSE

To report the outcome of patients with conjunctival squamous cell neoplasia (CSCN)--including conjunctival squamous cell carcinoma (SCC), conjunctival squamous intraepithelial neoplasia (C-SIN) and carcinoma in situ (CIS)-treated at the Liverpool Ocular Oncology Centre (LOOC).

METHODS

Patients treated between January 1993 and September 2011 were identified and categorised as having 'primary' or 'salvage' treatment, according to whether they had undergone a surgical procedure before referral to our centre. Invasive SCC was treated by excision with adjunctive ruthenium plaque radiotherapy. C-SIN or CIS was treated with topical 5-fluorouracil (5-FU), and in a few cases, cryotherapy.

RESULTS

Primary treatment was administered to 20 patients (16 males, four females). Mean age was 62 years (range, 33-85). Histological examination revealed C-SIN/CIS in ten patients and invasive SCC in nine. Median follow-up was 69 months (range, 34-168). Three patients required further topical chemotherapy for persistent/recurrent C-SIN. Salvage therapy was administered to 21 patients (15 males, six females). Mean age was 63 years (range, 26-82). Histology showed C-SIN/CIS in 11 patients and invasive SCC in ten. Median follow-up was 54.5 months (range, 36-120). At the close of this audit, there was no recurrence of invasive or metastatic disease in either the primary or salvage groups.

CONCLUSIONS

Our established protocol for treatment of CSCN has proven successful in local tumour control, and avoids ocular complications. We advocate adjunctive radiotherapy in patients with invasive SCC and chemotherapy in C-SIN/CIS. For improved patient outcome, prompt referral to a specialist centre is encouraged.

Clinical outcome of advanced squamous cell carcinoma of the conjunctiva

Background

To evaluate the outcome of surgical management of advanced squamous cell carcinoma (SCC) of the conjunctiva (American Joint Committee Cancer—classification >III) and the rate of recurrences after treatment during follow-up. Second, to investigate the incidence of orbital exenteration during follow-up.

Methods

Thirty-eight cases with SCC >grade T3 AJCC were retrospectively analysed at a University Eye Hospital Munich. Tumour stage, type of treatment, follow-up time, risk factors and—if present—recurrence were documented.

Results

The mean follow-up was 24.2 months (22.3–71 months). The most frequent surgical procedure was local tumour excision (n=25 patients, 71%). Orbital exenteration was performed in 10 patients (28%). Twenty patients (57%) did not show a progressive disease during follow-up. Of the patients with primary local excision, 13 (52%) had recurrence. Average time to recurrence for all treated patients was 24 months in the mean (minimum 4 months, maximum 68 months, SD, 22). Patients following orbital exenteration had recurrence of disease in 20% (n=2). None of the patients with primarily local tumour excision required an orbital exenteration.

Conclusion

Advanced-stage SCC can be treated surgically. An extensive surgical approach is sometimes inevitable. Patients with surgical excision of advanced-stage disease should be reviewed closely as recurrences may occur and even after more than 5 years. However, on early detection, most of these recurrences can be handled by local excision.

5-Fluorouracil for the treatment of intraepithelial neoplasia and squamous cell carcinoma of the conjunctiva, and cornea

Objective:

To evaluate the efficacy and risks of complications of pulse dosing of topical 5-fluorouracil (5-FU) in the treatment of corneal intraepithelial neoplasia (CIN), and conjunctival squamous cell carcinoma (SCC).

Design:

Prospective, noncomparative case series.

Participants:

Fifteen patients with histological evidence CIN or SCC of the conjunctiva and cornea were identified by tumor biopsy.

Methods:

All patients clinically evident of CIN, or SCC were evaluated, with maximum 30 months of follow-up were treated with pulsed dosing of 1% 5-FU. Treatment cycles were defined as four times per day for 4 days using the medication followed by 30 days without medication. The number of initial treatment was six cycles.

Results:

The mean age of the 15 patients was 50.8 years (range 25–78 years). Excision biopsy proved seven cases as CIN, and eight cases as locally invasive SCC. All patients remained disease free with a mean follow-up of 14.53 months (range 6–30 months). Additional chemotherapy was given after the initial treatment cycles, only for one case. 5-FU caused mild temporary local irritation, but no long-term intraocular or extra ocular complications.

Conclusions:

Adjuvant 1% topical 5-FU appears to be effective in the prevention of recurrence of conjunctival or corneal CIN and SCC after excision biopsy. Our results indicate that at least six cycles of topical 1% 5-FU is required to prevent local recurrence in the long term. It is well-tolerated and an effective method of treatment. No complications that would preclude use of our dose regimen were noted.

Topical 0.002% Mitomycin C for the Treatment of Conjunctival-Corneal Intraepithelial Neoplasia and Squamous Cell Carcinoma

PURPOSE

To demonstrate the efficacy of topical 0.002% mitomycin C (MMC) as an adjunctive and alternative treatment in primary and recurrent conjunctival-corneal intraepithelial neoplasia (CCIN) and squamous cell carcinoma (SCC).

METHODS

The medical records of 7 patients with histopathologically confirmed CCIN and conjunctival SCC were retrospectively reviewed. All cases were treated with topical 0.002% MMC 4 times daily. The tumor size pre- and post-treatment, clinical response, and ocular complications were evaluated.

RESULTS

The mean age of the patients was 56 +/- 13.4 years. The most common presenting symptom was foreign body sensation (57.1%) with a mean duration of 2.3 +/- 3.8 months. Six patients had pathologically proven CCIN (85.7%) and 1 had SCC (14.3%). Before MMC treatment, 6 eyes (85.7%) had recurrences after surgical excision. The tumor-free period ranged from 2 to 19 months. Two patients had multiple recurrences. MMC 0.002% 4 times daily was applied for a period of 5.4 +/- 4.4 weeks (range, 2-14). All had complete tumor regression as observed clinically and confirmed by impression cytology. Side effects of MMC therapy included ocular irritation, mild conjunctival hyperemia, and punctate keratopathy. There were no serious complications detected. The mean follow-up time was 30.7 +/- 15 months (range, 2-52) with no evidence of clinical recurrence in any case.

CONCLUSIONS

Topical 0.002% MMC showed a favorable outcome as an adjunctive and alternative treatment of CCIN and SCC with regression of primary and recurrent tumors.

[Association of malignant tumors of the conjunctiva and HIV infection in Kinshasa (D. R. Congo). First results]

BACKGROUND

Conjunctival carcinomas are tumors especially of the 6th/7th decades. They occur in Germany with a frequency of 1/20,000. For years it has been well known that in Africa the number of malignant tumors of the conjunctiva has been increasing. The reasons for that are not well known. HIV is a possible pathogenetic cofactor.

METHOD

A histological examination of 34 specimens was performed in Rostock on conjunctival tumors removed at the Ophthalmologic Department of the University of Kinshasa in 2001. The study included 23 female and 11 male patients aged 20-75 years (mean 42). All patients underwent serological investigation for HIV infection.

RESULTS

Of 34 patients 18 were HIV positive. Of the HIV-positive patients, six had a squamous cell carcinoma, seven a CIN (conjunctival intraepithelial neoplasia) I-III, and five a pinguecula. Of the HIV-negative patients, five showed a squamous cell carcinoma, eight a CIN I-III, one a pinguecula, one a sebaceous gland carcinoma, and one a papilloma. The average age of the HIV-positive patients with a squamous cell carcinoma was 41 years compared to the HIV-negative patients with 58 years.

CONCLUSIONS

There was no difference in frequency of conjunctival intraepithelial neoplasia between HIV-positive or HIV-negative patients. HIV-positive patients with a squamous cell carcinoma were on average 17 years younger. UV radiation is the main risk factor and HIV infection is a possible carcinogenic cofactor. Investigations on additional viral infections as possible pathogenetic factors and on changed tumor suppressor genes are needed.

Tear Function and Ocular Surface Changes with Topical Mitomycin (MMC) Treatment for Primary Corneal Intraepithelial Neoplasia

PURPOSE

To evaluate the tear function and ocular surface alterations in patients with primary CIN before and after treatment with topical mitomycin (MMC).

PATIENTS AND METHODS

We describe seven patients with unilateral CIN treated with 0.04% topical MMC three times daily until full eradication of the lesion. The patients underwent tear and ocular surface examinations including Cochet-Bonnet corneal sensitivity measurements, tear film break-up time (BUT), Schirmer test, and Rose-Bengal staining before, at the time of resolution of the CIN, and at the final follow-up. Conjunctival impression cytology was performed before treatment and at the last visit.

RESULTS

The mean pretreatment corneal sensitivity was 30.3 +/- 7.4 mm and improved to 55 +/- 5 mm at the final visit (P < 0.05). There were no aqueous-deficient eyes. The BUT values and Rose-Bengal staining scores also showed significant improvement at the last follow-up compared with the pretreatment values (P < 0.05). Initial impression cytology specimens showed goblet cell loss, higher grades of squamous metaplasia, areas of isolated keratinized, binucleated, and actively mitotic disfigured epithelial cells in all patients. The mean goblet cell density and squamous metaplasia grade were observed to improve significantly at the last visit (P < 0.05). MMC-induced cytologic changes were seen to persist long after cessation of treatment in some patients. All eyes remained free of recurrence and complications during the follow-up period.

CONCLUSION

We found 0.04% topical MMC treatment tid until full eradication to be effective in the management of CIN. The ocular surface disease of CIN was characterized by disturbance of tear film stability, goblet cell loss, and increased squamous metaplasia in all patients. Impression cytology proved useful in attaining the diagnosis of CIN, evaluating the effect of treatment, and showing MMC-related long-term changes on the ocular surface.

Excision and cryosurgery in the treatment of conjunctival malignant epithelial tumours

PURPOSE

To evaluate the long-term results of combined treatment with excision and cryosurgery for malignant epithelial tumours of the conjunctiva.

METHODS

We retrospectively reviewed the medical records of patients diagnosed with conjunctival malignant epithelial tumours and treated with excision and cryosurgery between 1980 and 1998. The demographic features of the patients, characteristics of the tumours, and the peculiarities of the recurrences were recorded. The SPSS V 9.05 computed program was used for the statistical analysis of the results. Kaplan-Meier plots were used to determine the recurrence-free survival, and the logrank test was used to compare the recurrences according to histological classification.

RESULTS

A total of 55 subjects (57 eyes), 19 female and 36 male, were included in the study. Their ages ranged between 15 and 82 years (mean 55+/-14 years). Histological diagnosis was conjunctival intraepithelial neoplasia (CIN) in 26 (46%) and invasive squamous cell carcinoma (SCC) of the conjunctiva in 31 eyes (54%). All eyes were treated with excision and cryosurgery with nitrous oxide probe. During the follow-up period of 6 months to 15 years, seven (12.3%) recurrences were observed. The success rate for patients with CIN and invasive SCC was 88.5 and 87.1%, respectively. There was no difference for recurrence rates between CIN and invasive SCC groups according to logrank test (P=0.68).

CONCLUSIONS

Over the long-term follow-up, cryosurgery following excision is a successful method in the treatment of conjunctival intraepithelial tumours and invasive squamous cell carcinoma of conjunctiva with favourable outcome and minimal complications.

Mitomycin C therapy for conjunctival-corneal intraepithelial neoplasia

PURPOSE

To evaluate the efficacy and safety of topical mitomycin C (MMC) for conjunctival-corneal intraepithelial neoplasia (CCIN).

METHODS

One patient with primary CCIN received seven applications for 3 minutes of mitomycin C 0.02%, for 2 weeks, on alternative days. The size of the CCIN before and after the treatment and ophthalmic mitomycin C related complications were evaluated.

RESULTS

The lesion started to regress during the second month after the last application of mitomycin C, and by the third month it disappeared completely. The patient remains disease free after 36 months follow up. The complications of mitomycin C included a mild tearing and a slight conjunctival hyperemia that resolved 7 days after the end of the therapy.

CONCLUSION

Multiple applications of mitomycin C could be an effective treatment for selected cases of CCIN.

Chemotherapy for eye cancer

Chemotherapy has been used to treat a multitude of eye cancers. We attempted to review the role of chemotherapy in the treatment of ocular, adnexal, and orbital malignancies by conducting an extensive search of the medical literature. Unfortunately, the published reports typically contain few patients with limited follow-up, precluding definitive recommendations. For most eye cancers, multicenter trials will offer the potential to gather the numbers of patients required to determine the clinical utility of chemotherapy.

5-Fluorouracil for the treatment of intraepithelial neoplasia of the conjunctiva and cornea

OBJECTIVE

To evaluate the efficacy of pulse dosing of topical 5-fluorouracil (5-FU) in the treatment of conjunctival and corneal intraepithelial neoplasia.

DESIGN

Prospective, noncomparative case series.

PARTICIPANTS

Seven patients with histologic evidence of intraepithelial neoplasia were identified by conjunctival biopsy or tumor excision.

METHODS

Seven patients with a minimum of 7 months of follow-up were treated with pulsed dosing of 1% 5-FU. Topical 1% 5-FU was administered four times daily for 2 to 4 days for each cycle. The number of initial treatment cycles was two to six, with the time between cycles being 30 to 45 days.

MAIN OUTCOME MEASURES

The presence or absence of clinically evident intraepithelial neoplasia was evaluated after each treatment interval. Patients were also monitored for adverse reactions to the use of topical 5-FU.

RESULTS

Four patients remain disease free with a mean follow-up of 18.5 months (range, 7-36 months) with no additional treatment after the initial treatment cycles (mean, 3.75 cycles; range, 2-5 cycles). Three patients had recurrence of disease after the initial treatment cycles. Two patients were treated with additional cycles for recurrent disease (six cycles in one patient and five cycles in the other patient) and are free of disease at 20 and 21 months after treatment, respectively. One patient had persistent disease despite treatment with topical 5-FU and was treated with topical mitomycin C with resolution of the disease without recurrence for 16.5 months. No adverse reactions to pulse dose treatment with topical 5-FU were noted.

CONCLUSIONS

Pulsed dosing with 1% topical 5-FU for the treatment of conjunctival and corneal intraepithelial neoplasia, alone or as an adjunct to excision of bulky disease, is a well-tolerated and effective method of treatment.

Treatment of conjunctival squamous cell carcinoma with topical 5-fluorouracil

AIM

To evaluate the efficacy of topical 5-fluorouracil (5-FU) alone, without concurrent surgery or radiotherapy, for the treatment of conjunctival squamous cell carcinoma.

METHODS

Eight patients affected by conjunctival squamous cell carcinoma (three recurrent cases, three incompletely excised, and two untreated cases) were treated with 1% 5-FU eye drops. Topical 1% 5-FU was administered four times daily for 4 weeks (one course). Clinical examination (biomicroscopy and photography) and morphological evaluation of conjunctival cytological specimens were used to monitor the efficacy of local chemotherapy, side effects, and recurrences.

RESULTS

All patients showed clinical regression of conjunctival carcinoma after topical 1% 5-FU treatment. Neoplastic conjunctiva was completely replaced by normal epithelium within 3 months. Mean follow up was 27 months. One patient needed two courses of local chemotherapy for recurrent disease. An acute transient toxic keratoconjunctivitis was observed in all treated cases; it was easily controlled with topical therapy. No long term side effects were found.

CONCLUSIONS

Topical 1% 5-FU is effective in the treatment of recurrent, incompletely excised, and selected untreated conjunctival squamous cell carcinomas. Topical 1% 5-FU has no major complications. This study suggests that topical conjunctival chemotherapy with 1% 5-FU may be useful, at least as adjunctive therapy, in the treatment of conjunctival squamous cell carcinoma.

Conjunctival melanoma

Conjunctival melanoma is an uncommon tumor that is likely to recur and carries an overall mortality rate of approximately 30%. The seemingly unpredictable and enigmatic character of this entity has initiated much debate over the past decades regarding the etiology, histogenesis, prognosis, and preferred management. This review outlines the historical perspective; incidence and demographics; etiologic factors; histogenesis; cytogenetic findings; clinical characteristics; histopathologic and ultrastructural features; differential diagnoses; classifications; management of primary, recurrent, and systemic disease; survival after conjunctival melanoma; and diverse factors of potential prognostic significance. Finally, a brief outlook on present and future research objectives is provided.

Late recurrences and the necessity for long-term follow-up in corneal and conjunctival intraepithelial neoplasia

PURPOSE

The purpose of the study was to elucidate the natural history of corneal-conjunctival intraepithelial neoplasia (CIN) and suggest treatment and follow-up guidelines.

METHODS

The records of all histologically proven cases of CIN at the Royal Victorian Eye and Ear Hospital between 1979 and 1994 were reviewed.

RESULTS

Seventy-nine eyes of 76 patients had a pathologic diagnosis of CIN and were observed for up to 15 years. The lesion recurred in 31 eyes (39%) overall. There was no statistical difference shown in the likelihood of recurrence based on histologic classification. Complete excision was attempted in each case. In 18 eyes, dysplastic cells were evident at the excision margin. Ten (56%) of these tumors recurred, compared to a 33% recurrence rate in completely excised lesions. The time to the first recurrence ranged from 33.0 days to 11.5 years between the first and second surgeries, with 11 lesions recurring after more than 4 years. Incompletely excised lesions reappeared more rapidly (average, 2.5 years) than did those with clear surgical margins (average, 3.8 years). Seven cases progressed to invasive squamous cell carcinoma and four cases led to blindness or removal of the eye.

CONCLUSIONS

This study suggests that excision margin at the time of surgery is the most important factor in predicting recurrence. The slow growth of the recurrent lesions combined with the ever-present malignant potential leads the authors to suggest that all patients with a history of CIN warrant annual follow-up for the remainder of their lives.

Topical 5-fluorouracil in treating epithelial neoplasia of the conjunctiva and cornea

PURPOSES

To evaluate the efficacy of topical 5-fluorouracil (5-FU) in treating conjunctival and corneal epithelial neoplasia.

METHODS

Three patients underwent surgical excision of bulky disease followed by topical 1% 5-FU in artificial tear base for 2 to 3 weeks or until epithelial separation occurred. An additional three patients underwent treatment with topical 1% 5-FU alone.

RESULTS

Minimum follow-up was 6 months. In one patient with conjunctival in situ carcinoma and no detectable normal conjunctiva, who had normal findings on conjunctival histologic examination after application of topical 5-FU, a focus of invasive disease requiring orbital exenteration. One patient had a favorable response to 5-FU therapy but required a repeat excision for control of bulky disease. Four patients have remained disease-free for 10, 13, 18, and 30 months after topical 5-FU therapy.

CONCLUSION

With its potential selective toxicity on dysplastic epithelium, topical 5-FU shows promise as an adjunctive treatment for managing conjunctival and corneal epithelial neoplasia.

Ocular surface squamous neoplasia

Ocular surface squamous neoplasia presents as a spectrum from simple dysplasia to carcinoma in situ to invasive squamous cell carcinoma involving the conjunctiva as well as the cornea. It is a distinct clinical entity, although it has been known by a variety of different names throughout the literature. Most commonly it arises in the limbal region, occurring particularly in elderly males who have lived in geographic areas exposed to high levels of ultraviolet-B radiation. Symptoms range from none to severe pain and visual loss. The development of preoperative diagnostic techniques, such as impression cytology, are of value in clinical decision making and follow-up management. Simple excision with adequate margins is currently the best established form of treatment despite trials of other modalities. The course of this disease may be evanescent, but is more frequently slowly progressive and may require exenteration and occasionally may lead to death.

Conjunctival intraepithelial and invasive squamous cell carcinomas treated with strontium-90

Twenty-seven patients with malignant epithelial tumors of the conjunctiva were treated between 1967 and 1987. Histological diagnosis was intraepithelial epithelioma in 15 cases (56%) and squamous cell carcinoma in 12 (44%). All patients were treated with a strontium-90 source on cup-shaped applicators of different sizes according to the extension of the tumor. Surface dose ranged from 60 Gy in a single treatment to 140 Gy in 7 fractions, depending on the thickness of the lesion. Fifteen patients were previously untreated, 7 were irradiated after some type of surgical treatment and 5 were treated for recurrence after multiple surgical excisions. Follow-up period ranged from 2 to 15 years. No patient died of his tumor. There were four local recurrences, three of them in patients with intraepithelial carcinoma. Two of the recurrences were salvaged with a new beta-ray treatment and the other two with enucleation. Since 1981, standard policy was to irradiate the entire conjunctiva in patients with diagnosis of intraepithelial epithelioma. Five patients developed cataracts. Considering the high primary control rate and minimal morbidity, strontium irradiation should be considered as a first-choice treatment for conjunctival tumors.

Long-term results of cryotherapy on malignant epithelial tumors of the conjunctiva

We studied the results of combined treatment with excision and cryotherapy with the nitrous oxide probe in 22 eyes of 20 patients with intraepithelial tumors or squamous cell carcinomas of the conjunctiva. Patients were followed up for five to 12 years. Only two recurrences (9%) were seen, both of which occurred within the first two years. Over the long term, excision combined with cryotherapy decreased the recurrence rate of intraepithelial tumors and squamous cell carcinomas of the conjunctiva.

Clinical and therapeutical considerations on a case of conjunctival melanoma

The authors report a case of limbal conjunctival melanoma treated in a conservative manner. The choice of such a therapy was based not only on clinical examinations and review of literature, but also and mainly on the intraoperative histological examination that showed no involvement of the conjunctival deeper layers.

Adjunctive radiotherapy with strontium-90 in the treatment of conjunctival squamous cell carcinoma

Squamous cell carcinoma of the ocular conjunctiva is a relatively rare malignancy which is attended by a high rate of local recurrence following simple surgical excision. To date, the management of conjunctival squamous cell cancer has been controversial. From 1950 to 1985, 146 consecutive patients with superficial conjunctival squamous cell cancer were treated at the Queensland Radium Institute. All patients were treated by simple surgical excision of the visible conjunctival lesion followed by adjunctive radiotherapy. Of 140 patients with histologically confirmed squamous cell cancer, 123 were treated with a strontium-90 source, 10 with a radon "ring," and 7 with superficial X ray therapy. Standard policy since 1960 has been to deliver an incident dose of 30 Gy in a single fraction within the first 48 post-operative hours to the surgical bed using a strontium-90 source on a stand-off eye applicator. This report will largely focus on the 123 patients who were treated with a strontium-90 source, of whom 107 received 30 Gy, 14 received 40 Gy (pre 1960) and one patient each received 20 and 25 Gy incident dose. Of 131 evaluable patients, there were only 3 who developed local recurrence. All 3 local recurrences developed in elderly men who had presented with extensive superficial primary tumors. Two of the three recurrences occurred in the two patients who were treated with doses less than 30 Gy. Both early and late radiation-induced complications following ablative surgery and treatment with strontium-90 were very uncommon. Three patients developed unsightly conjunctival telangiectasia, 2 patients developed a persistent scleral ulcer and 2 patients developed clinically significant cataracts. This negligible degree of treatment-related side effects contrasts with the experience of 10 patients who had previously been treated with a radon ring, 8 of whom developed serious complications, although none developed local recurrence. On the basis of our excellent local control rates with minimal morbidity we would continue to advocate the use of simple surgical excision followed by 30 Gy beta radiation from a strontium-90 source as the definitive treatment for superficial conjunctival squamous cell cancer.

Squamous cell carcinoma of the conjunctiva: case presentation and treatment

A case of the rare condition of invasive squamous cell carcinoma of the conjunctiva is presented. The plan for surgical excision of the area involved, determined by results of frozen section biopsies, is outlined. The methods of treatment of other authors are briefly reviewed, including this method (from Fraunfelder) of combined excision and cryotherapy.

Topical application of 5-fluorouracil in premalignant lesions of cornea, conjunctiva and eyelid

Local application of 5-Fluorouracil was practised on 5 patients. In 3 patients with multiple premalignant oculo-cutaneous lesions, two of whom had also premalignant epibulbar lesions, local 5% 5-Fu cream and/or 1% 5-Fu eyedrops were applied. In 2 other patients who had only premalignant lesions on the cornea and conjunctiva, 1% 5-Fu eyedrops were used only. In animal experiments 1% 5-Fu was not found to cause any damage to normal corneal and conjunctival epithelium. The frequency of the applications and the duration of the treatment were dependent on the location and extent of the lesions. Except for easily treatable lesions, caused by the separation of the tumour epithelium, no complications of local 5-Fu treatment were seen. The visual acuity improved in all 4 patients in whom the cornea was affected. In these premalignant conditions the diagnosis and assessment of the therapy were based on exfoliative cytology and biopsies.

Conjunctival and corneal intraepithelial and invasive neoplasia

The histopathologic findings and clinical records of 98 patients with conjunctival and corneal intraepithelial neoplasia (CIN) and 22 patients with invasive neoplasia were studied. Pathologic material was evaluated for cell type, degree of dysplasia, margins of excision, and change in pattern with recurrence. Clinical records were reviewed for demographic features, presenting symptoms, clinical appearance, therapy, and subsequent course. Recurrences occurred in 23 patients with CIN and 9 patients with invasive neoplasia. Intraocular or orbital extensions or both occurred in four patients and metastatic disease in two patients. The cell type, clinical appearance, and degree of dysplasia did not correlate with recurrence; involvement of the margins of the initial excision was an important prognostic sign for recurrence.

Management of intraepithelial conjunctival tumors and squamous cell carcinomas

We compared the effects of excision, extensive freezing with a liquid nitrogen spray, and combined therapy with excision and superficial freezing with a liquid nitrogen probe on intraepithelial conjunctival tumors. After follow-up periods of at least 36 months, excision and extensive freezing produced recurrence rates similar to those previously reported (two of six lesions treated with excision alone recurred and three of nine treated with extensive freezing recurred), but excision combined with superficial freezing produced a recurrence rate of only 8% (two of 23 lesions recurred), almost three times better than any previously reported. Both lesions recurred in patients who had undergone previous therapy.

The management of lid and conjunctival malignancies

Adnexal tumors are relatively rare in a general eye practice, and the most important component in their management is early recognition. The clear differentiation between stimulating lesions and lid or conjunctival tumors can be difficult. Any recurrent lid inflammation, chronic lid ulcer, chronic unilateral keratoconjunctivitis, or a suspicious pigmented conjunctival lesion should be biopsied. The choice of treatment in lid and conjunctival tumors is partially dependent on the available surgical expertise. Lid tumors can be treated with either surgery (using frozen section control), radiation, or cryotherapy. Conjunctival tumors should first be biopsied, then treated with surgery or radiation. Exenteration is rarely indicated in the management of conjunctival tumors. A metastatic evaluation should precede possible exenteration, especially if this procedure is planned because of a recurrent or large conjunctival melanoma.

The use of strontium-90 in the treatment of carcinoma in situ of the conjunctiva

Four patients with carcinoma in situ were treated with strontium-90 beta ray application. The dose used was 4,500 rads after surgical removal or with small recurrent tumor and 7,000 rads for primary treatment. All patients were disease-free at follow-up periods of 48 to 320 months after treatment. One patient required superficial x-ray treatment for recurrent disease. No serious complications developed with the treatment and no progressive cataracts have occurred.

beta-Ray treatment of malignant epibulbar melanoma

Sixty-eight patients suffering from conjunctival melanoma were treated by beta-irradiation. The dose given ranged between 15,000 and 20,000 rd at the tumor surface. In 75% the therapy was successful. In 67,4% the melanoma could be cured by beta-irradiation alone with a follow-up period between three and ten years. The lethality rate from proven metastases was only 6.2%. The regression time after beta-therapy, as a rule, exceeded several months. Beta-rays can be used either primarily or after tumor excision. Care should be taken that the applicator covers all the tissue containing tumor cells.