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.

Clinicopathological Correlates of Ocular Surface Squamous Neoplasia

Introduction

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

Methods

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

Results

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

Conclusions

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

Personalized treatment concepts in extraocular cancer

Background

The periocular skin is neoplasms-prone to various benign and malignant. Periocular malignancies are more aggressive and challenging to cure and repair than those in other skin areas. In recent decades, immunotherapy has significantly advanced oncology, allowing the autoimmune system to target and destroy malignant cells. Skin malignancies, especially periocular tumors, are particularly sensitive to immunotherapy. This technique has dramatically impacted the successful treatment of challenging tumors.

Main text

Extraocular cancers, including eyelid (basal cell carcinoma, squamous cell carcinoma, melanoma, merkel cell carcinoma), conjunctival tumors (conjunctival melanoma, ocular surface squamous neoplasia) and other rare tumors, are unique and challenging clinical situations. Several genetic alterations associated with the pathogenesis of these diseases have been identified, and molecular mechanism are essential for the development of the immunotherapy agents, such as Hedgehog pathway inhibitors (vismodegib and sonidegib) for basal cell carcinoma, BRAF/MEK inhibitors (vemurafenib, dabrafenib, and encorafenib) for melanoma, and immune checkpoint inhibitors (Avelumab, pembrolizumab) for Merkel cell carcinoma.

Conclusions

The optimal treatment for periocular skin cancer depends on the type and size of the tumor and whether it involves orbital and adnexal structures. Adjuvant and neoadjuvant therapy with chemotherapy-targeted therapies and immune checkpoint inhibitors should be considered based on tumor type, tumor molecular profile, expected response rate, and candidacy for systemic treatment.

Complete Response to Immunotherapy Using Pembrolizumab in a Patient With Conjunctival Squamous Cell Carcinoma With Nodal Metastasis

A 92-year-old woman presented with a large bulbar conjunctival mass in the OD. She also had a palpable parotid mass which on fine needle aspiration biopsy confirmed to be metastatic squamous cell carcinoma. The conjunctival mass was biopsied to confirm the diagnosis of squamous cell carcinoma with positive programmed cell death ligand 1 expression and a high tumor mutation burden. She was treated with pembrolizumab and had complete resolution of the conjunctival mass and the associated parotid metastasis after just 2 cycles of treatment. This case underscores the promising role of immune checkpoint inhibitors in the treatment of conjunctival squamous cell carcinoma, especially when surgery is associated with significant ocular morbidity, in patients who may not be good surgical candidates, or in patients with metastasis.

Comparison of non-invasive diagnostic modalities for ocular surface squamous neoplasia at a tertiary hospital, South Africa

AIMS

The aim of the study is to assess non-invasive diagnostic modalities for ocular surface squamous neoplasia (OSSN) when compared to histology.

METHODS

A prospective case-control study was conducted of patients presenting with conjunctival masses at a tertiary eye hospital in Johannesburg, South Africa. Patients completed an interview and had three non-invasive diagnostic tests: optical coherence tomography, impression cytology and methylene blue stain. A biopsy with histology was performed as the gold standard to confirm the diagnosis.

RESULTS

One hundred and eighty-two conjunctival masses of 175 patients were evaluated. There were 135 lesions identified as OSSN on biopsy and 47 lesions were benign on histology. Optical coherence tomography had a sensitivity and specificity of 87.2% (95% CI: 80.0-92.5) and 75.6% (95% CI: 60.5-87.1), respectively, when an epithelial thickness cutoff of 140 um was used. Shadowing was found in 46% of cases due to leukoplakia or increased thickness of the mass. Cytology had a sensitivity of 72.4% (95% CI: 62.5-81.0) and a specificity of 74.3% (95% CI: 56.7-87.5). Twenty-seven per cent of cytology specimens were excluded from analysis due to inadequate cellularity. Methylene blue had a high sensitivity of 91.9% (95% CI: 85.9-95.9), but low specificity of 55.3% (95% CI: 40.1-69.8).

CONCLUSION

Optical coherence tomography had a high sensitivity and specificity as a non-invasive test and liquid-based cytology performed well but had a lower sensitivity and specificity than with optical coherence tomography. Methylene blue performed well as a screening test, with a high sensitivity but low specificity.

Topical 5-fluorouracil 1% for moderate to extensive ocular surface squamous neoplasia in 73 consecutive patients: Primary versus secondary treatment

IMPORTANCE

Ocular surface squamous neoplasia (OSSN) is a spectrum of malignancies that generally includes conjunctival intraepithelial neoplasia (CIN) and squamous cell carcinoma (SCC). OSSN can be treated with topical therapies including interferon α-2b (IFN), mitomycin C (MMC), or 5-fluorouracil 1% (5FU). Recently, due to unavailability of IFN and toxicity associated with MMC, therapy has shifted towards 5FU.

OBJECTIVE

Herein, we compare the use of 5FU 1% as a primary versus (vs) secondary treatment regimen in eyes with moderate to extensive OSSN.

DESIGN SETTING AND PARTICIPANTS

Retrospective cohort study of 73 consecutive patients with unilateral moderate to extensive OSSN treated at a single tertiary ocular oncology center from 2016 to 2023. Mean follow up time was 478.2 days overall, with 283.0 days for primary 5FU group and 860.3 days for secondary 5FU group.

INTERVENTION

Topical 5FU 1% 4 times daily for 2 weeks with option for 2-weekly extension until tumor control, either as primary treatment or as secondary treatment to surgical resection, topical IFN or topical MMC, or cryotherapy.

MAIN OUTCOMES

Outcome measures included tumor response, need for additional surgery, complications, and visual outcomes.

RESULTS

A comparison (primary vs secondary treatment) revealed no difference in mean tumor basal dimension (19.6 vs 17.2 mm, P = 0.46), thickness (3.7 vs 3.4 mm, P = 0.64), or tumor extent (4.4 vs 4.5 clock hours, P = 0.92). The primary treatment group showed greater complete tumor control (77% vs 38%, P = 0.04). Multivariable analysis comparison (primary vs secondary treatment) showed primary treatment more likely to achieve complete tumor control (P = 0.01). There was no difference in the complication rate from 5FU treatment between the groups. There was no difference in visual outcome, and no tumor-related metastasis (0%) or death (0%).

CONCLUSION AND RELEVANCE

Topical 5FU 1% is efficacious and safe as a primary or secondary treatment for moderate to extensive OSSN. Tumors treated with primary 5FU 1% demonstrated more complete resolution. In patients with moderate to extensive OSSN, primary treatment with topical 5FU 1% may be warranted.

Demographics, clinical presentation and risk factors of ocular surface squamous neoplasia at a tertiary hospital, South Africa

AIMS

The aim of this study is to describe the demographic, presenting features and associated risk factors of ocular surface squamous neoplasia (OSSN) at a tertiary eye hospital in Johannesburg, South Africa.

METHODS

An interventional prospective study of patients presenting with conjunctival masses was conducted. An electronic questionnaire was completed to document demographic data, presenting history, and associated risk factors. A slit lamp examination and photos were used to document and describe the clinical features at presentation. Cases (OSSN) and controls (benign lesions) were determined by histology.

RESULTS

There were 130 cases and 45 controls. Median age was 44 years (IQR: 35-51) with an equal gender distribution in cases. The prevalence of HIV in cases was 74% and was strongly associated with OSSN (p < 0.001). Vascularisation, leukoplakia and pigmentation were clinical features that distinguished cases from controls. A fibrovascular morphology was strongly associated with a benign histology (p < 0.001), whereas leukoplakic and gelatinous morphologies were associated with OSSN. Conjunctival intra-epithelial neoplasia made up 82% of cases.

CONCLUSION

Our study describes a sample of OSSN that is young and has no gender predisposition. The majority of cases presented with CIN lesions, rather than SCC reported in other African countries. HIV was the most significant risk factor in this study population.

Ocular surface squamous neoplasia in a patient following oral steroids for contralateral necrotising scleritis

A male patient in his 70s presented with left eye necrotising scleritis. His ocular history was significant for pterygium excision with mitomycin C 3 months prior in the affected eye, open-angle glaucoma, nuclear sclerosis cataract and previous sixth cranial nerve palsy. Scleral culture was negative and blood work was positive for rheumatoid factor and HLA-B27. The patient was treated for necrotising scleritis with oral doxycycline, vitamin C, ranitidine and prednisone with gradual taper over 45 days. Two months after initiating treatment, his necrotising scleritis achieved complete resolution; however, a new-onset ocular surface squamous neoplasia (OSSN) was identified at the temporal limbus of the contralateral eye. He was treated with topical interferon alpha-2b 1 million IU qid and achieved complete resolution after 4 months. The case highlights both the acute precipitation of OSSN following oral steroids and a sight-threatening complication following pterygium excision.

Ocular surface squamous neoplasia: management and outcomes

Ocular surface squamous neoplasia (OSSN) is the most common ocular tumour with an incidence ranging from 0.03 to 1.9 per 100,000 persons/year. The diagnosis is made on clinical suspicion and confirmed with anterior-segment optical coherence tomography (AS-OCT), cytology, or histology. The purpose of this review is to provide an overview of the management options available for OSSN and review their success and recurrence rates. Surgery is the gold standard for the management of small OSSN lesions. With the increased use of less invasive diagnostic modalities such as AS-OCT and cytology, there has been a move to use topical therapies for the management of OSSN. The most commonly used agents are interferon-α2b (IFN), mitomycin-C (MMC) and 5-fluorouracil (5FU). They have been shown to have similar resolution and recurrence rates but differ in cost and side effect profile. IFN has the lowest side effect profile, but is also the most expensive, whereas MMC has the greatest surface toxicity and is priced midway between the three. 5FU is the cheapest of the three topical agents with less surface toxicity than MMC. Radiotherapy is mostly employed as adjuvant therapy. Newer novel therapies are available but have not been widely adopted as mainstream therapy due to cost and lack of clinical evidence. OSSN has the benefit of many management options. No single modality has been shown to superior and some patients will need the use of combination therapy to achieve an optimal clinical outcome.