Ocular surface squamous neoplasia: evidence for topical chemotherapy

Safety and efficacy of topical interferon alpha 2B and mitomycin C for localized conjunctival intraepithelial neoplasia: long-term report of their pharmacological safety and efficacy

PURPOSE

Ocular surface squamous neoplasia (OSSN) comprises a wide spectrum of squamous tumors, from which corneal/conjunctival intraepithelial neoplasia (CIN) is the most common one. The classic treatment is complete excision, but recurrence rates are high. Antineoplastic drugs such as mitomycin C (MMC) and interferon alpha 2b (IFNα2b) have been used as adjuvants or as primary treatment. To evaluate the efficacy and safety of topical IFNα2b and MMC in patients with CIN, a phase IIb double-blind clinical trial was performed.

METHODS

Patients diagnosed with localized CIN were evaluated by slit lamp and impression cytology and were randomly given MMC 0.04% or INF2b (1 million IU/mL) 4 times daily until neoplasia resolution. Time of resolution and frequency of adverse effects were analyzed to determine the pharmacological efficacy and safety of both medications.

RESULTS

Seventeen patients were included. Nine patients were treated with MMC and 8 with IFNα2b. All patients responded to treatment. The resolution time in days was 59.11 ± 24.02 in patients treated with MMC and 143.50 ± 47.181 in those treated with IFNα2b (p < 0.001). In the MMC group, one recurrence was reported (11%). There were no recurrences at 2 years of follow-up in the IFNα2b group. Regarding adverse effects, one or more mild adverse reaction occurred in 77% of patients managed with MMC and in 50% of patients managed with IFNα2b (p > 0.05). No serious adverse effects were reported.

CONCLUSIONS

Topical chemotherapy with MMC and IFNα2b demonstrate pharmacological safety and efficacy. Therefore, these drugs could be considered as primary therapies for localized CIN .

Conjunctival squamous cell carcinoma with massive apoptosis and immune cell infiltration: A case report

This case reports a rare case of conjunctival squamous cell carcinoma in China. The elderly (86-year-old) female patient was diagnosed and treated effectively after three times of diagnosis. During this period, she was misdiagnosed and ineffective treatment for many times. Therefore, we propose to make an integrated diagnosis based on histopathological diagnosis, combined with a variety of diagnostic methods including MRI and CDFI, supplemented by updated multiple immunohistochemically techniques, so as to achieve the purpose of accurate diagnosis.

Pegylated Interferon Alpha 2a for the Treatment of Ocular Surface Squamous Neoplasia

PURPOSE

The purpose of this study was to introduce the initial experience in the use of topical pegylated interferon alpha 2a (PegIFN-α-2a) for ocular surface squamous neoplasia (OSSN).

METHODS

A retrospective medical record review of 8 eyes of 8 patients diagnosed with OSSN and treated with PegIFN-α-2a was performed. All cases were diagnosed of noninvasive OSSN both clinically and histologically. The pegIFN-α-2a was prescribed at a concentration of 20 μg/mL and applied 4 times a day for at least 3 months.

RESULTS

In all 8 cases, topical PegIFN-α-2a was well-tolerated and did not lead to discomfort or any adverse side effects. It resulted in reduction in lesion size and extent in all cases and complete resolution of the lesions.

CONCLUSIONS

Topical PegIFN-α-2a might be an effective and safe treatment option for noninvasive OSSN.

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.

Recombinant Interferon Alpha-2b as Primary Treatment for Ocular Surface Squamous Neoplasia

Purpose

To investigate the effects of topical and perilesional interferon alpha-2b as primary treatment for ocular surface squamous neoplasia (OSSN).

Methods

In this prospective interventional case series, topical interferon alpha-2b (3 MIU/mL) was used as the initial treatment of OSSN, with perilesional interferon alpha-2b (3 MIU/mL) added based on clinical response. The primary outcome was complete tumor resolution. Spearman's rank correlation test was used to investigate the association of complete tumor resolution and time to resolution with baseline tumor characteristics and the American Joint Committee on Cancer (AJCC) classification for OSSN.

Results

Ninety-two patients (92 OSSN tumors) were included in the study. The total follow-up duration was 13.57 ± 2.14 months (median: 12, range: 3-23). The median basal tumor diameter was 4 mm (mean: 4.13 ± 1.37). Complete tumor resolution was achieved in 89 cases (96.73%), with a median time to complete tumor resolution of 5 months (mean: 4.64 ± 1.92). Complete tumor resolution was 57 of 57 in T1 (100%), 8 of 9 in T2 (88.88%), and 21 of 23 in T3 (91.30%). There were statistically significant correlations between AJCC classification and complete tumor resolution (Spearman's r = -0.22, P = 0.03) and maximal basal tumor diameter and the time to complete resolution (Spearman's r = 0.35, P = 0.001). There were no recurrences during the study follow-up period.

Conclusion

Topical interferon alpha-2b is effective and well tolerated as a primary treatment for OSSN, with a high rate of tumors responding completely to therapy.

Comparison of the Effectiveness of Onion Extract, Topical Steroid, and Petrolatum Emollient in Cosmetic Appearance of Upper Blepharoplasty Scar

Purpose

To compare the effectiveness of onion extract, topical steroid, and petrolatum emollient in the prevention of scars in cases who underwent bilateral upper eyelid blepharoplasty.

Methods

A prospective, interventional, comparative, double-blinded case series was designed on cases who underwent upper lid blepharoplasty. After suture removal (1 week following the surgery), the eyelids of participants were randomly allocated into the three groups: The first group used onion extract on the right eyelids (n = 18), and the second group used topical steroid on the right eyelids (n = 19). In the third group, the control group, petrolatum emollient was used on the left eyelids (n = 37) of the first and second group's cases. They used drugs for 2 months and were evaluated by the Manchester Scar Scale (MSS) objectively by two graders who were blinded to the type of medication. MSS evaluates five different characteristics of the scar in addition to the Visual Analog Scale (VAS). These characteristics include color, distortion, contour, texture, and transparency. VAS scores the overall scar appearance which ranged among 0-10. The sum of the scores for the five different parameters, and VAS was calculated, analyzed, and compared among the groups.

Results

A total of 37 cases (74 eyelids) who underwent bilateral upper blepharoplasty were included. The mean ± standard deviation (SD) of age was 51.94 ± 9.26 years, 49.40 ± 9.37 years, and 47.00 ± 9.06 years in the onion extract, topical steroid, and petrolatum emollient groups, respectively (P = 0.275). There were no statistically significant differences in the mean ± SD of the sum of the MSS scores among the three groups (P = 0.924) or between the onion extract and topical steroid groups (P = 0.951). Furthermore, the color, distortion, contour, texture, transparency, and VAS scores were not statistically significantly different among the three groups or between the onion extract and topical steroid groups (P > 0.05).

Conclusion

There were no significant differences among these three groups of drugs regarding the appearance of the upper blepharoplasty scar.

Observational study of ocular surface squamous neoplasia: Risk factors, diagnosis, management and outcomes at a tertiary eye hospital in South Africa

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is the most common ocular surface tumour. Diagnosis and management have traditionally been by excision biopsy. Recently there has been success with the use of topical chemo or immunotherapy, which has resulted in a move from invasive diagnosis by histology to an array of non-invasive diagnostic tests.

METHODS

This observational study aims to describe the characteristics of patients with OSSN at St John Eye Hospital in Johannesburg, South Africa. Non-invasive diagnostic tests (impression cytology, anterior segment-OCT, methylene blue staining) will be compared to the gold standard, histology. Treatment success, recurrence and adverse events will be documented between three treatment options that include: surgical excision, topical 5-Fluorouracil (5FU) chemotherapy, and topical 5FU with retinoic acid therapy.

DISCUSSION

There is a trend to the use of less invasive diagnosis and management for OSSN. Minimally invasive diagnostic tests include cytology, anterior-segment OCT and methylene blue staining. The study will compare these to the gold standard histology, thereby providing evidence for their use in clinical practice. Interferon alpha 2b is commonly used as immunotherapy for OSSN. The cost of this medication is prohibitive to its adoption in a developing country. We therefore decided to use 5FU as the chemotherapeutic agent of choice in this study. The success, adverse events and recurrence rates with this agent may provide additional evidence for its use in the management of OSSN. Overall, if diagnosis and management can be implemented with good success in the outpatient environment, care can be improved for this condition in a developing country.

Update on pharmacotherapy for ocular surface squamous neoplasia

The most frequently encountered non-pigmented tumor of the ocular surface is ocular surface squamous neoplasia (OSSN). Over the past two decades, the pharmacological management of OSSN has grown, with topical 5-fluorouracil, mitomycin, and interferon alpha 2b all being successfully used to treat this disease. Other agents, such as anti-vascular endothelial growth factor (VEGF), retinoic acid, cidofovir and Aloe vera, have less frequently been used in the treatment of OSSN. This review will discuss these pharmacologic agents, summarizing available data and presenting the approach to the treatment of these tumors.

Interferon Alfa 2b for Ocular Surface Squamous Neoplasia: Factors Influencing the Treatment Response

PURPOSE

To study the factors influencing the response to treatment with interferon alfa 2b (IFN) in ocular surface squamous neoplasia (OSSN)Methods: Retrospective study of 91 patientsResults: The mean age at presentation of patients with OSSN was 58 years (median, 60 years; range, 21 to 83 years). The mean number of clock hours of conjunctiva/cornea/limbus involvement by the tumor was 6 (median, 6; range, 1 to 12). The mean duration of topical IFN was 3 months (median, 3 months; range, 1 to 6 months) and the mean number of subconjunctival injections of IFN was 2 (median, 2; range, 0 to 6), till complete tumor regression or initiation of alternate treatment. Of 91 OSSN cases treated with IFN, 72 (79%) patients showed complete response to treatment, while 19 (21%) showed partial response displaying mean % tumor reduction of 34% (median, 20%; range, 5% to 90%). Patient demographics, immune status, disease chronicity, tumor location, or morphological pattern were not predictive of tumor response to IFN. The only factor predictive of incomplete response of OSSN to IFN was more than 6 clock hour involvement of ocular surface by OSSN (p = .04). Of 31 (34%) cases with OSSN >6 clock hours, 23 (74%) patients showed complete tumor regression with IFN alone, while 8 (26%) patients displayed incomplete response; and of 60 (66%) cases with OSSN ≤6 clock hours, 49 (82%) patients showed complete tumor regression with IFN alone, while 11 (18%) patients displayed incomplete response. Tumor recurrence was noted in 3% cases and one case had corneal perforation secondary to infective keratitis over a mean follow-up period of 14 months (median, 8 months; range, 3 to 58 months).

CONCLUSION

Clock hour involvement of ocular surface by OSSN determines the response to IFN. Interferon alfa 2b is an effective immunotherapy agent for tumors ≤6 clock hours of ocular surface in 82% cases and serves as an immunoreducing agent for larger tumors involving >6 clock hours of ocular surface in 26% cases.

Short wavelengths filtering properties of sunglasses on the Canadian market: are we protected?

BACKGROUND

Exposure to solar radiation is a risk factor for multiple ocular pathologies. Ultraviolet (UV) radiation is involved in ocular diseases, including pterygium, ocular surface squamous neoplasia, and cataracts. High-energy visible light (HEV) is associated with age-related macular degeneration. Ocular protection against solar radiation seems essential to protect our eyes against the adverse effects of those harmful rays. Australia, New Zealand, Europe, and the United States are the only regions with mandatory standards for UV transmission for sunglasses. Adherence to Canadian standards by sunglasses manufacturers is not mandatory. In this study, we evaluated the UV and visible transmission of sunglasses in the Canadian market to test their compliance with Canadian standards.

METHODS

The transmittance of 207 pairs of sunglasses, divided in 3 categories according to their price range, was measured.

RESULTS

We show that close to 100% of the sunglasses tested respect the Canadian standards. The average HEV transmittance is around 10%, regardless the price range.

CONCLUSIONS

Our study demonstrated that even if following Canadian standards is optional, most sunglasses sold on the Canadian market follow national and international standards. We also found that sunglasses filter around 90% of HEV. With the recent findings on the potential effects of HEV in retinal pathologies, we can ask whether this filtering capacity is sufficient to protect eyes from harmful HEV light. More work needs to be done to determine acceptable HEV light transmission limits to the existing Canadian standards.

Conjunctival squamous papilloma refractory to interferon α-2b in a patient on systemic immunosuppression (tacrolimus)

Purpose

To describe a case of diffuse conjunctival papilloma in an immunocompromised individual on tacrolimus that was refractory to treatment with interferon α-2b, but responded to topical mitomycin-c.

Observations

A 79-year-old Caucasian female with a history of a liver transplant twenty years ago, who was immunosuppressed with tacrolimus (2 mg daily) presented with a diffuse conjunctival and corneal squamous papilloma. Following treatment with four weekly subconjunctival interferon-α2b injections (3 million units/0.5 mL) and 3 months of topical interferon-α2b therapy (1 million units/mL), four times daily, slow progression was documented. The patient was switched to topical mitomycin-c drops (0.04%) administered four times daily (one week on and one week off) with dramatic regression of the tumor.

Conclusions and importance

In cases of conjunctival squamous papilloma that do not respond readily to topical interferon, topical mitomycin-c is an alternate therapeutic option. We hypothesize that use of tacrolimus may have contributed to the lack of response to topical interferon-α2b.

Mitomycin C or interferon as adjuvant therapy to surgery for ocular surface squamous neoplasia: comparative study

Background:

Traditionally, surgical excision has been the treatment of choice for ocular surface squamous neoplasia (OSSN). Recurrences after surgery are high. To reduce the risk of recurrence, adjuvant therapies have been increasingly used.

Purpose:

We compared recurrences and complications of 3 forms of treatment for OSSN: surgical excision (group A), surgical excision plus adjuvant topical mitomycin C (MMC) (group B), and surgical excision plus subconjunctival interferon-α-2b (IFN-α-2b) (group C).

Methods:

A retrospective comparative study was conducted between January 2006 and March 2016 at the Ocular Oncology Service of the Catholic University of Rome. Seventy-nine patients with a confirmed histological diagnosis of OSSN were included: 43 were treated with surgical excision (group A), 16 underwent surgical excision plus topical MMC (group B), and 20 underwent surgical excision plus adjuvant subconjunctival IFN-α-2b (group C).

Results:

The recurrences were different in the 3 groups. Thirty-one recurrences (72%) were seen in group A, 5 (31%) were found in group B, and 3 (15%) were seen in group C. Eight (50%) patients who received MMC 0.02% complained of ocular discomfort, 10 (62.5%) presented conjunctival hyperemia, while conjunctival chemosis and corneal epitheliopathy were noticed in 2 (13%) and 2 (13%) patients, respectively. All patients treated with subconjunctival IFN-α-2b reported flu-like symptoms. Two patients (10%) complained of ocular discomfort.

Conclusions:

Our study revealed that OSSN is not always manageable with simple excision. Adjuvant chemotherapy is strongly advisable after surgery to reduce recurrences. Interferon injections and MMC drops are effective in preventing recurrences and should be administered after surgery.

Multifocal Ocular Surface Squamous Neoplasia

A 64-year-old healthy female presented with a papillomatous limbal lesion involving 6 clock hours of superior limbus and diffuse involvement of upper tarsal conjunctiva of left eye of 6 months duration. Excision of superior limbal lesion on histopathology showed carcinoma in situ with focal breach in basement membrane and moderate degree of differentiation. The surgical base and margins were uninvolved. The tarsal lesion was initially treated with subconjunctival interferon alpha 2b (IFN alpha 2b) (3 cycles of IFN alpha 2b) with poor response. Subsequently treatment with topical mitomycin C 0.04% showed a dramatic response in the upper eyelid tarsal lesion. A small residual lesion needed excision. One year after treatment, she was completely tumor-free. In multifocal ocular surface squamous neoplasia, multimodal treatment with excision and topical mitomycin C may be effective in cases refractory to immunotherapy.

Pharmacotherapy and Immunotherapy of Conjunctival Tumors

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

Topical 1% 5-fluoruracil as a sole treatment of corneoconjunctival ocular surface squamous neoplasia: long-term study

Aims

To report long-term clinical outcome of topical 1% 5-fluoruracil (5-FU) as a sole treatment of ocular surface squamous neoplasia (OSSN).

Methods

41 patients affected by OSSN were included. Each patient underwent full ophthalmological examination at baseline, with cytological or histological confirmation. Patients were treated by topical chemotherapy with 1% 5-FU four times a day for 4 weeks. One course was defined as 4 weeks of topical chemotherapy. Adjunctive courses were administered after 1 month of chemotherapy-free interval.

Results

Mean follow-up was 105±32 months (range 60–171 months). Complete tumour regression was achieved in 34 cases (83%) after a mean of 1.5 courses (range, 1–3 courses). Univariate analysis revealed that complete response was significantly related to tumour thickness <1.5 mm (p=0.005), lack of fornix or tarsal involvement (p=0.015 and p=0.009, respectively) and the absence of multifocality (p=0.002). Histopathological diagnosis (intraepithelial neoplasia vs squamous cell carcinoma, p=0.019) and American Joint Committee on Cancer (AJCC) classification (T1 vs T2 or T3) (p=0.028) were also related to incomplete tumour response. In a multivariate analysis, just tumour thickness >1.5 mm (p=0.045) and multifocality (p=0.023) were correlated with incomplete tumour response. Transient and reversible low-to-mild local side effects were documented in 19 (48%) eyes.

Conclusion

Topical 5-FU, as a sole therapy, is a long-term safe and effective treatment for patients affected by preinvasive OSSN and for a limited proportion (50%) of invasive OSSN.