Mucoepidermoid carcinoma of the conjunctiva: a series of three cases

A Conjunctival Papillary Tumor in a 77-Year-Old Woman

A 77-year-old woman presents to the ophthalmology department with a 5-year history of a painless neoplasm in her left eye and no history of tumors. Slitlamp examination shows a papillary tumor on the limbal conjunctiva, with blood vessels extending to the tumor. What would you do next?

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.

Conjunctival 'mucoepidermoid carcinoma' revisited: a revision of terminology, based on morphologic, immunohistochemical and molecular findings of 14 cases, and the 2018 WHO Classification of Tumours of the Eye

In 2018, the consensus meeting for the WHO Classification of Tumours of the Eye decided that conjunctival mucoepidermoid carcinoma should be reclassified as adenosquamous carcinoma, as this represented a better morphological fit. To examine the applicability of this terminology, we studied the clinical, histopathological, immunohistochemical and molecular pathology of 14 cases that were originally diagnosed as conjunctival mucoepidermoid carcinoma. There were 7 (50%) females and 7 (50%) males. The median age was 64 years. The left eye was affected in 8 and the right eye in 6 patients. In-situ carcinoma was present in 11/14 (79%) cases and comprised in-situ squamous cell carcinoma (SCC) and conjunctival intraepithelial neoplasia with mucinous differentiation (CIN-Muc). Invasive carcinoma was present in 11/14 (79%) cases. Group 1 (1/11 cases, 9%) comprised invasive SCC only. Group 2 (6/11 cases, 55%) comprised SCC with mucinous differentiation, manifesting as scattered intracellular mucin, occasionally together with intercellular mucin, with no evidence of true glandular differentiation. Group 3 (3/11 cases. 27%) comprised true adenosquamous carcinoma. Group 4 (1/11 cases, 9%) comprised pure adenocarcinoma. Thirteen of 14 cases (93%) underwent FISH for MAML2 translocation and none were rearranged. Two cases harboured high-risk HPV (type 16 and 18). The combined findings confirm that all lesions in our study were not mucoepidermoid carcinoma, but represented predominantly SCC with mucinous differentiation and adenosquamous carcinoma. We, therefore, recommend future revision of the WHO classification to include SCC with mucinous differentiation alongside adenosquamous carcinoma.

Conjunctival Adenosquamous Carcinoma Lacks MAML2 Translocation: A Variant of Squamous Cell Carcinoma With Mucoepidermoid Differentiation and Aggressive Behavior?

Conjunctival adenosquamous carcinoma, also known as mucoepidermoid carcinoma (MEC), is a rare tumor that preferentially affects the perilimbal area of the conjunctiva with aggressive local invasion. Consisting of infiltrative proliferation of squamous cells and mucous cells, its morphologic features are reminiscent of the salivary gland-type MEC except for the absence of intermediate cells and frequent keratin production. We reported 2 cases of conjunctival adenosquamous carcinoma and, for the first time, studied the MAML2 translocation status of this rare entity. The 2 patients were women, aged 45 and 42 years, presenting with an erythematous lesion in the left lower palpebral conjunctiva and a pigmented nodule over the left nasal conjunctiva, respectively. One tumor recurred 6 months after the initial biopsy. Excision with lid reconstruction and postoperative radiotherapy was performed for margin involvement and perineural invasion. This patient was disease free at 3-year follow-up. The other patient was lost to follow-up after tumor excision. Fluorescence in situ hybridization and reverse transcription polymerase chain reaction failed to demonstrate MAML2 translocation and CRCT1-MAML2 transcripts in both tumors. The absence of this characteristic translocation and reappraisal of the cellular composition, morphologic features, and precursor lesion suggest that conjunctival MEC may represent a variant of conjunctival squamous cell carcinoma but not related to the salivary gland-type MEC.

Radiation treatment to a postresection primary mucoepidermoid carcinoma (MEC) of the conjunctiva with positive margins at the Tenon's fascia-A case study

The primary occurrence of mucoepidermoid carcinoma (MEC) of the conjunctiva is extremely rare, aggressive, and easily mistaken for squamous cell carcinoma. With fewer than 50 cases reported in the literature, there is no consensus on the most effective treatment. Radiation is an alternative to enucleation or orbital exenteration with the potential of eye preservation. We investigated several radiation approaches for a case with postresection positive margins at Tenon's fascia, and reported the patient's clinical course during the treatment and for a short time thereafter. An otherwise healthy 64-year-old male presented with MEC extending to the deep margin at the Tenon's fascia. Plans for 4 different radiation therapy treatment modalities (Intensity Modulated Radiation Therapy [IMRT], Volumetric Modulated Radiation Therapy [VMAT], double scattering (DS) proton, and reverse eye plaque low dose rate [LDR] ) were created and compared based on tumor coverage and normal tissue doses. The planning target volume (PTV) was too large and nonuniform for an eye plaque application. Using the largest plaque available (22 mm), the calculated minimum dose to the PTV was 57% while the dose to the skin was 1000% of the prescription. The proton plan completely spared the contralateral ocular structures and reduced the max doses to the ipsilateral macula and optic nerve, but was not clinically available at the time of treatment. The IMRT and VMAT plans produced similar dose distributions to each other, but VMAT further minimized dose to the ipsilateral eye. Due to the uniqueness of this case, a thorough study of the available radiation treatment options was deemed necessary. All of the external beam treatment techniques produced acceptable plans with VMAT producing the best available plan in this case. The patient was treated with the VMAT plan with a prescription of 6600 cGy in 30 fractions. At 5 months post-treatment, the patient is recovering from expected acute responses to radiation with follow ups scheduled.

Treatment and Pathology of an Unusual Large Carcinoma of the Conjunctiva

Carcinoma of the conjunctiva is a malignant tumor which is mostly detected and surgically treated at an early stage because of medical or cosmetic problems. Exceptions of this rule may occur in developing countries, where patients do not have access to standard medical care systems. We report the case of a conjunctival carcinoma in an African patient with an unusually late presentation. Because of local medical shortcomings, and considering the severe, transmural inflammation of anterior ocular structures, an exenteration was performed although the orbit was not deeply involved with the tumor. The strong nuclear expression of p53 indicates a major role of UV exposure in this case. A total of 16-month follow-up in this patient and larger published series suggest that the risk of metastasis is rather low under those circumstances, even with invasive tumors.

Mucoepidermoid carcinoma of the transverse colon: A rare tumor entity with literature review

Mucoepidermoid carcinoma of the gastrointestinal tract is a rare entity. Here, we report a case of mucoepidermoid carcinoma of the transverse colon in a 77-year-old woman who presented with a 2-month history of epigastrium pain, diarrhea and melena. A giant tumor with apparently invading gallbladder was found by enhanced CT scan, then the extended resection of transverse colon was performed for the patient 2 weeks later. Microscopically, the tumor was composed of solid nests of epidermoid and Periodic Acid-Schiff (PAS)-positive mucin-producing cells with desmoplastic stroma. The epidermoid component of the tumor contained intercellular bridges and individual cell keratinization. Thus, the case was diagnosed as mucoepidermoid carcinoma of the transverse colon. Unfortunately, despite chemotherapy, the patient developed systemic failure and died 7 months postoperatively.

Mucoepidermoid carcinoma of the conjunctiva with lung metastasis

A 36-year-old lady presented with redness and decreased vision in right eye since 6 months. She was earlier diagnosed of cavitary lung lesion, presumed secondary to tuberculosis and treated with anti-tubercular treatment for 4 months. Examination of affected right eye revealed nil light perception, conjunctival congestion with an exuberant mass in the inferotemporal bulbar conjunctiva, proptosis, iris neovascularization, 360° closed angles, intraocular pressure of 48 mm Hg, exudative retinal detachment, uveal mass and orbital extension. A diagnostic needle biopsy of uveal mass revealed malignant cells. Computed tomography-guided lung biopsy revealed squamous cell carcinoma (SCC), indicating metastatic spread from the orbit. She underwent lid-sparing exenteration of the right eye. Histopathological examination of the orbital tissue revealed mucoepidermoid carcinoma arising from the conjunctiva with extensive invasion into the orbital tissue, muscle fibers, sclera, choroid and optic nerve. Multiple tumor emboli were seen in the lumen of orbital blood vessels. In conclusion, mucoepidermoid carcinoma of the conjunctiva is a rare, aggressive variant of SCC. Early intervention is essential to prevent intraocular invasion and systemic metastasis.

Conjunctival Intraepithelial Neoplasia with Mucoepidermoid Differentiation: A Case Report of a Subtle Lesion

OBJECTIVE

To describe the clinical presentation, diagnostic imaging, and treatment options of conjunctival intraepithelial neoplasia (CIN) with mucoepidermoid differentiation, an in situ stage of mucoepidermoid carcinoma of the conjunctiva (MCC).

RESULTS

We report the case of an 86-year-old man presenting with a subtle limbal lesion that had only mild erythema and elevation. Based on a few atypical clinical features and an abnormal ultrahigh-resolution optical coherence tomography (UHR OCT), an incisional biopsy was performed revealing CIN with mucoepidermoid differentiation. Treatment involved aggressive surgical excision. No evidence of recurrence was noted in the 5 years of follow-up.

CONCLUSION

MCC is an aggressive tumor that has a tendency to be invasive and recur after treatment. Therefore, early diagnosis and treatment is critical. CIN with mucoepidermoid differentiation may represent the earliest stage of MCC. It can present subtly, with a clinical resemblance to benign and less aggressive ocular surface lesions. Imaging with UHR OCT may be helpful to detect early neoplasia. A high level of suspicion must be maintained when evaluating potential ocular surface tumors.

Ocular surface squamous neoplasia - Review of etio-pathogenesis and an update on clinico-pathological diagnosis

Ocular surface squamous neoplasia (OSSN) has a varied clinical presentation, the diagnosis of which rests on the histopathological examination of the excised lesion. The term OSSN includes mild dysplasia on one end of the spectrum and invasive squamous cell carcinoma on the other end. This lesion has a multi factorial aetiology with interplay of several factors like exposure to ultraviolet radiation, various chemical carcinogens and viral infections, however role of individual agents is not well understood. With the upsurge of infection with human immunodeficiency virus, a changing trend is seen in the clinical presentation and prognosis of patients of OSSN even in developed countries. Anterior segment optical coherence tomography (OCT) and confocal microscopy, hold promise in in-vivo differentiation of intraepithelial neoplasia from invasive squamous cell carcinoma. Variants of squamous cell carcinoma like Mucoepidermoid carcinoma, spindle cell carcinoma and OSSN associated with HIV infection should be suspected in a case of aggressive clinical presentation of OSSN or with massive and recurrent tumours. Surgery, chemotherapy and immunotherapy are the various treatment modalities which in combination show promising results in aggressive, recurrent and larger tumours.

An improved approach to diagnosing and treating conjunctival mucoepidermoid carcinoma

The current case of conjunctival mucoepidermoid carcinoma offers features that expand the biologic spectrum afforded by this tumor. More focused strategies should be developed for its earlier histopathologic diagnosis and improved management (historical recurrence rate of 85%). A 63-year-old woman with a history of rheumatoid arthritis and idiopathic sclerosing cholangitis developed scleral thinning, anterior chamber cells and flare, and uveal prolapse. Biopsies of the epibulbar lesion were initially misinterpreted as a squamous cell carcinoma but on review harbored CK7-positive cells and contained rare goblet cells brought out with Alcian blue and mucicarmine staining. Intraocular extension exhibited micro-and macrocysts with minimal goblet cells. Focal CK7 immunopositivity in any epibulbar squamous dysplasia or in invasive carcinoma should lead to suspicion of a mucoepidermoid carcinoma. Behaviorally aggressive or rapidly recurrent epithelial squamous tumors with "inflammatory" features or unusual clinical characteristics should be initially stained at multiple levels for the detection of parsimonious mucus secretion. Surgical options include wide excision and partial sclerectomy with cryotherapy for superficial invasion and/or interferon therapy. Results with radiotherapy and cryotherapy for deep scleral invasion have been unpredictable or unacceptable compared with surgery.

Histochemical analysis and immunohistochemical profile of mucoepidermoid carcinoma of the conjunctiva

PURPOSE

To elucidate the distinct histochemical and immunohistochemical profile of mucoepidermoid carcinoma of the conjunctiva (MECC) and to determine which combination of stains is most useful in diagnosing MECC and differentiating it from squamous cell carcinoma of the conjunctiva (SCC) in cases where the clinical or cytological findings are not definitive.

METHODS

Eight specimen of MECC from 4 patients and 4 specimens of SCC from 4 patients were examined using a variety of special stains and immunohistochemical markers. The results were then analyzed for usefulness in diagnosing MECC.

RESULTS

The most useful markers in diagnosing MECC and differentiating it from SCC are mucicarmine, colloidal iron, and alcian blue all with sensitivities of 88%, and a specificity of 100%; CEA with a sensitivity of 83% and a specificity of 75%; and, mucin-1 with a sensitivity of 100% and a specificity of 25%, but which showed a distinct pattern of staining of MECC when compared to SCC. In our series, the sensitivity of the CK7+/CK20- combination for MECC was only 38%.

CONCLUSIONS

The most useful stains in ruling out SCC in a suspected case of MECC were shown to be mucicarmine and the glycosaminoglycan (GAG) stains. However, in cases where mucicarmine and the GAG stains are negative or difficult to interpret and there is suspicion of a diagnosis of MECC, CEA and mucin-1 may be helpful for this diagnosis. The findings of CK7+/CK20- also may be of assistance, but are not as sensitive when compared to analogous salivary gland lesions, when differentiating MECC from SCC.

Mucoepidermoid carcinoma of the bulbar conjunctiva - an interventional case report

PURPOSE

Mucoepidermoid carcinoma is a rare variant of squamous cell carcinoma of the conjunctiva. It appears more frequently in the elderly, it is more aggressive than squamous cell carcinoma, and it has a higher recurrence rate and higher incidence of intraocular and orbital invasion.

METHODS

We report a case of a 74-year-old man who presented to the Emergency Department with a one month history of painful red left eye.

RESULTS

The patient presented with visual acuity was 10/10 in both eyes and a conjunctiva tumor on the bulbar conjunctiva of left eye. The UBM revealed a thickening of the conjunctiva-sclera complex with no signs of intraocular invasion. A biopsy was performed and the diagnosis was of mucoepidermoid carcinoma. Two local excisions with adjuvant cryotherapy and mitomycin C aplication were carried out in a period of 6 months. After 9 months of follow-up there has not been any sign of recurrence.

CONCLUSIONS

The early diagnosis and treatment of carcinoma is essential not only to prevent the intraocular spread and preserve visual function but also to prevent local or systemic recurrence and dissemination.

Conjunctival Mucoepidermoid Carcinoma in a Patient with Ocular Cicatricial Pemphigoid and a Review of the Literature

Invasive mucoepidermoid carcinoma of the conjunctiva of the left lower eyelid was diagnosed in an orbital exenteration specimen of a 57-year-old woman, after a biopsy of the same lesion was originally diagnosed as invasive squamous cell carcinoma. The woman was undergoing mitomycin C injections for ocular cicatricial pemphigoid, diagnosed in the same eye 2 years prior to identification of the neoplasm. The tumor invaded the cornea, sclera, lacrimal gland, regional small nerves, and lymphatics, but did not show intraocular involvement. The original biopsy specimen was reassessed with stains for mucin and found to be mucoepidermoid carcinoma of the conjunctiva. We reviewed 21 cases of mucoepidermoid carcinoma of the conjunctiva described to date in the English literature. We believe this number underestimates the true incidence of this condition, as it is frequently misdiagnosed both clinically and histopathologically. Evaluating suspected aggressive squamous cell carcinoma with special stains for mucin generally helps to identify mucoepidermoid carcinoma of the conjunctiva. More extensive surgical excision than that used for squamous cell carcinoma should be implemented in the management of mucoepidermoid carcinoma of the conjunctiva to prevent recurrence.

20 MHz high frequency ultrasound assessment of scleral and intraocular conjunctival squamous cell carcinoma

AIM

To assess in a prospective manner, high frequency ultrasound diagnosis of deep invasion by conjunctival squamous cell carcinoma.

METHODS

Prospective, non-randomised case series comparing 20 MHz high frequency ultrasonographic and clinicopathological data.

RESULTS

20 MHz high frequency ultrasound delineated the degree of deep involvement of this tumour into the sclera, globe, and orbit. The results of ultrasonography correlated with the clinicopathological results.

CONCLUSIONS

High frequency ultrasound is a useful diagnostic adjunctive test in patients with possible deep involvement by a conjunctival squamous cell carcinoma.