Topical interferon alpha-2b for treatment of noninvasive ocular surface squamous neoplasia with 360° limbal involvement

Topical 5-fluorouracil 1% as first-line therapy for giant ocular surface squamous neoplasia

PURPOSE

To evaluate the clinical outcomes of topical 5-fluorouracil (5-FU) 1% as first-line therapy for giant ocular surface squamous neoplasia (OSSN).

MATERIALS AND METHODS

This was a non-comparative cohort study. We included patients with biopsy-proven giant OSSN in a tertiary-care setting. Giant OSSN was defined as a single lesion≥15mm in the largest basal dimension or an extent of≥6 clock hours of limbal involvement. Topical 5-FU 1% was administered QID for one week, followed by a three-week drug holiday. This treatment cycle was repeated until resolution. Resolution rate was the primary outcome measure, where complete resolution was defined clinically and by tomography. Secondary outcomes were time to resolution and frequency of recurrence and side effects.

RESULTS

Twenty-seven eyes (27 patients) were included; the majority (19, 70%) were men, with a mean age of 69.2±15.7 years. Corneal/conjunctival intraepithelial neoplasia was diagnosed in 88%, and squamous cell carcinoma (SCC) in the remaining 12% of cases. The rate of complete resolution was 77.8% (21/27) after a mean of 5.1±2.1 cycles. The median time to complete resolution was 5 months (CI95% 4-6 months). During a mean follow-up of 10.2±2.9 months, recurrence was observed in one patient (4.8%) and four (14.8%) reported side effects. Patients with partial resolution were older and had a higher frequency of SCC diagnosis than those with complete resolution.

CONCLUSION

Topical 5-FU 1% appears to be useful as first-line therapy for giant OSSN, with good tolerance and a low frequency of recurrence. More studies with larger sample sizes and longer follow-up are needed.

Efficacy of topical 5-Fluorouracil in the management of ocular surface squamous neoplasia: a study of 101 eyes

OBJECTIVE

To study the efficacy and side-effect profile of topical 5-Fluorouracil (5-FU) in the treatment of ocular surface squamous neoplasia (OSSN).

METHODS

Retrospective study of 101 eyes of 100 patients treated with 5-FU with one week on and 3 weeks off regimen.

RESULTS

Of the 100 patients (101 eyes), the mean age at diagnosis of OSSN was 49 (median, 52 years; range, 11-87 years). History of prior intervention was noted in 6 (6%) eyes. Tumor epicenter included bulbar conjunctiva (n = 54; 53%), limbus (n = 27; 27%), and cornea (n = 20;20%). Mean number of cycles of topical 5-FU administered was 3 (median, 3; range, 1-8). Complete tumor regression was achieved with topical 5-FU in 89 (88%) eyes with a mean number of 2 cycles (median, 2; range, 1-6) of 5-FU. The remaining 12 (12%) lesions underwent additional treatment including excisional biopsy (n = 7), extended enucleation (n = 3), and topical Interferon alpha 2b (n = 2) for complete tumor control. Over a mean follow-up period of 6 months (median, 5 months; range, 1-36 months) following treatment, tumor recurrence was noted in 2 (2%) patients, and side-effects were noted in 7 (7%) eyes including conjunctival hyperemia (n = 1), punctal stenosis (n = 1), sterile keratitis (n = 4), and limbal stem cell deficiency (n = 1).

CONCLUSION

Topical 5-FU is an effective non-invasive therapy for OSSN with a minimal side-effect profile.

A Case of Conjunctival Melanoma Presenting as a Squamous Cell Carcinoma

Introduction

Conjunctival melanoma (CM) is a rare but potentially lethal ocular malignancy that arises from melanocytes in the conjunctiva. Its clinical presentation can mimic other more common conjunctival lesions, such as squamous cell carcinoma (SCC), leading to diagnostic challenges.

Case Presentation

We present a case of CM initially misdiagnosed as conjunctival SCC due to overlapping clinical features.

Conclusion

CM presenting as nonpigmented, conjunctival tumor is a diagnostic challenge. Clinicians should maintain a high index of suspicion for conjunctival melanocytic or amelanotic lesions, particularly those with atypical features.

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 .

Ocular surface squamous neoplasia with 360° limbal involvement: a study of 130 patients

PURPOSE

To describe the risk factors, clinical features and management outcomes of ocular surface squamous neoplasia (OSSN) with 360° of limbal involvement (360-OSSN) and compare with segmental limbal involvement (SL-OSSN).

METHODS

Retrospective comparative study of 360-OSSN vs SL-OSSN. All 360-OSSN and every 10th patient with SL-OSSN during the study period (2012-2020) were included. Lesions with uncertain diagnosis were excluded.

RESULTS

Of 1250 patients diagnosed with OSSN during the study period, 30 (2%) had 360-OSSN. A total of 100 patients of OSSN with SL-OSSN were included for comparison. 360-OSSN patients more often had longer duration of symptoms (mean, 17 vs 8 months; p, 0.003), prior misdiagnosis (17% vs 6%, p, 0.13) and prior intervention (47% vs 13%; p, 0.0002) than patients with SL-OSSN. 360-OSSN had higher incidence of scleral fixity (57% vs 16%; p < 0.0001), corneal/scleral melt (17% vs 0%; p, 0.0005), intraocular tumor extension (17% vs 0%; p, 0.003), orbital tumor extension (33% vs 1%; p < 0.0001), and advanced T stage at presentation (Tis: 37% vs 76%, T1: 0% vs 15%; T2: 7% vs 4%; T3: 27% vs 4%; T4: 30% vs 1%; p < 0.001). Over a mean follow-up of 14 months, lymph node metastasis (8% vs 0%; p, 0.05) and distant metastasis (4% vs 0%; p, 0.23) were more common in 360-OSSN group compared to SL-OSSN group.

CONCLUSION

Risk factors of 360-OSSN include prolonged symptoms, prior misdiagnosis and prior intervention. It represents an advanced form of disease with propensity for corneo-scleral melt and invasive disease which requires aggressive management.

The Management of Ocular Surface Squamous Neoplasia (OSSN)

The rise of primary topical monotherapy with chemotherapeutic drugs and immunomodulatory agents represents an increasing recognition of the medical management of ocular surface squamous neoplasia (OSSN), which may replace surgery as the standard of care in the future. Currently, there is no consensus regarding the best way to manage OSSN with no existing guidelines to date. This paper seeks to evaluate evidence surrounding available treatment modalities and proposes an approach to management. The approach will guide ophthalmologists in selecting the most appropriate treatment regime based on patient and disease factors to minimize treatment related morbidity and improve OSSN control. Further work can be done to validate this algorithm and to develop formal guidelines to direct the management of OSSN.

Topical Chemotherapy for Treating Ocular Surface Squamous Neoplasia with a Combination of Interferon α-2b and 5-Fluorouracil

Introduction

This study evaluated the efficacy of combined interferon α-2b (IFNα2b) and 5-fluorouracil (5-FU) as primary treatment for ocular surface squamous neoplasia (OSSN).

Methods

In this retrospective study, 27 eyes with OSSN followed by topical application of combined IFNα2b and 5-FU were examined. Reported outcome measures were tumor response, visual acuity, time to complete resolution, recurrence and treatment complications.

Results

Twenty-six patients (17 male, 9 female) had a mean age of 63.9 (median, 67; range 22–83) years. Complete tumor response was observed in 24 eyes (88.9%). Three eyes (11.1%) showed partial response to the chemotherapy agents and later underwent surgical tumor removal. The median time to complete resolution was 6 (mean, 6.1; range, 3–11) weeks. Of these, the patients received between one to three cycles of 5-FU therapy (median, 2; mean, 1.8). Complications noted were transient irritation at 5-FU cycle (11 eyes, 40.7%). There was no tumor recurrence at mean follow-up of 16.1 (median, 12; range 6–38) months.

Conclusions

Combination therapy of IFNα2b and 5-FU was a safe and effective treatment, inducing a short duration of administration and low recurrence rate for OSSN.

Trial Registration

Retrospectively registered, UHCT22048.

Topical interferon alpha-2b for a giant ocular surface squamous neoplasia: 7 years of follow-up after complete remission

A man with a history of blind eye due to trauma 22 years earlier consulted at 53 years of age with a large conjunctival neoplastic lesion, compromising almost the entire temporal limbus, and reaching a size of approximately 16 mm on its larger diameter, in the conjunctiva. Management was started with topical and subconjunctival chemotherapy (interferon alpha-2b) in order to perform immunoreduction, but a dramatic response with total disappearance of the lesion was observed. In the follow-up time period of more than 7 years, there were no signs of recurrence.

Utility of high-resolution anterior segment optical coherence tomography in the diagnosis and management of sub-clinical ocular surface squamous neoplasia

Background

To evaluate the frequency and characteristics of sub-clinical ocular surface squamous neoplasia (OSSN) detected by high-resolution anterior segment tomography (HR- OCT) in patients with clinically unapparent disease following topical treatment.

Methods

A retrospective chart review of patients with OSSN identified through a pharmacy database at the Bascom Palmer Eye Institute from January 2013 to December 2018 was conducted. Patients undergoing primary therapy with topical 5-fluorouracil 1% (5-FU) (4 times a day for 7 days with a 21-day break) or interferon-alpha-2b (IFN) (4 times a day) were reviewed. Patients were separated into two groups. Group 1 included individuals whose clinical resolution of OSSN aligned with complete resolution on HR-OCT. Group 2 (sub-clinical OSSN group) included individuals with clinical OSSN resolution but with features of persistent disease on HR- OCT. Patients excluded included those treated at an outside institution and those who used topical therapy as a surgical adjunct.

Results

A total of 95 patients (95 eyes) were reviewed. Sub-clinical OSSN was detected at a frequency of 17% in our study patients (n = 16 patients, 9 treated with 5-FU and 7 treated with IFN). In the 16 individuals, the mean time to clinical resolution was 3.6 ± 1.0 cycles for 5-FU and 4.0 ± 0.0 months for IFN. An additional 2.1 ± 0.8 cycles for 5-FU and 1.2 ± 0.4 months for IFN were needed to achieve HR-OCT resolution of OSSN. Recurrence in Group 1 was noted in 10 patients (12%) while no recurrences occurred in Group 2, the cohort with subclinical disease that received the extended medical therapy. The mean follow-up was 24.0 ± 17.9 months.

Conclusion

We found that at least 17% of individuals with apparent clinical resolution of OSSN have sub-clinical disease detected on HR-OCT. This information can be used to optimize treatment and extend therapy past the point of clinical resolution.

Resolution of giant ocular surface squamous neoplasia with topical 5-fuorouracil 1

An 82-year-old man presented with a left eye elevated single ocular surface squamous neoplasia. The tumor involved 360° of limbus, three quadrants of cornea and conjunctiva; this was compatible with the diagnosis of giant ocular surface squamous neoplasia. Topical 5-fluorouracil 1% was planned four times daily for 1 week followed by 3 weeks off-treatment. Patient inadvertently continued 5-fluorouracil, four times daily for 4 weeks, presenting with clinical resolution of the ocular surface squamous neoplasia and subtotal corneal epithelial defect associated with 5-fluorouracil toxicity. One month later, we observed a transparent cornea and no signs of toxicity. Total tumor resolution was observed for at least 6 months of follow-up.

Comparison of Topical 5-Fluorouracil and Interferon Alfa-2b as Primary Treatment Modalities for Ocular Surface Squamous Neoplasia

PURPOSE

To compare the efficacy of topical 5-fluorouracil 1% (5FU) and interferon alfa-2b 1 MIU/mL (IFN) eye drops as primary treatment modalities for ocular surface squamous neoplasia (OSSN).

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Fifty-four patients who received 5FU and 48 patients who received IFN as primary therapy for OSSN were included. Primary outcome measures were the frequency of clinical resolution and time to OSSN recurrence by treatment modality. Secondary outcome was the frequency of side effects with each therapy.

RESULTS

The mean age of patients was 68 years. More Hispanics were treated with 5FU. In a univariable analysis, frequency of OSSN resolution was higher with 5FU (96.3%, n = 52) than with IFN (81.3%, n = 39), P = .01. In a multivariable analysis, treatment modality did not remain a significant predictor of resolution. In patients whose OSSN resolved, time to resolution was similar with both agents, (5FU mean 6.6 months, standard deviation (SD) 4.5 vs IFN mean 5.5 months, SD 2.9, P = .17). Of the 52 eyes whose OSSN resolved with 5FU, 11.5% of lesions (n = 6) recurred, whereas of the 39 eyes whose OSSN resolved with IFN, 5.1% of lesions (n = 2) recurred, P = .46. Kaplan-Meier survival curves of OSSN recurrence were similar between groups (log-rank = 0.16). One-year recurrence rates were 11.4% with 5FU and 4.5% with IFN. Eyelid edema (P = .04) and tearing (P = .02) were more significant with 5FU.

CONCLUSIONS

This is the first direct comparison study between 5FU and IFN eye drops as primary treatment modalities for OSSN. Both modalities resulted in a high frequency of tumor resolution and low recurrence rates and are effective treatment options for OSSN.

Conjunctival Squamous Neoplasia: Staging and Initial Treatment

PURPOSE

To evaluate the clinical relevance of the American Joint Committee on Cancer (AJCC) classification in the initial management of squamous neoplasia of the conjunctiva.

METHODS

This retrospective study enrolled 95 histopathologically proven cases of treatment-naive conjunctival squamous neoplasia. Tumors were classified into 4 histological groups: conjunctival intraepithelial neoplasia (CIN) with mild dysplasia (grade 1/3), moderate dysplasia (grade 2/3), severe dysplasia (grade 3/3 or carcinoma in situ), and invasive squamous cell carcinoma (SCC). Clinical findings such as tumor location, largest basal diameter, growth pattern, and adjacent structures involved were recorded.

RESULTS

CIN was observed in 74 cases (78%), and SCC was noted in 21 cases (22%). Based on the AJCC classification, all the 74 cases of CIN were classified as Tis (tumor in situ). Among the invasive SCC, there were 3 T1 tumors, 2 T2 tumors, and 16 T3 tumors. Complete excision with or without adjuvant therapy was selected as initial treatment in 80% of cases (76/95). Two cases of SCC with scleral invasion were treated using brachytherapy.

CONCLUSIONS

The AJCC stage does not correlate with the initial treatment of CIN. The AJCC T3 category should be reviewed to differentiate diffuse SCCs with broad surface extension from tumors with deep scleral invasion.

Widespread Ocular Surface Squamous Neoplasia Treated with Topical Interferon Alpha-2b

Purpose

To emphasize the importance of staging ocular surface squamous neoplasia when contemplating use of topical interferon alpha-2b alone.

Cases

Two patients with 360 degrees of limbal involvement.

Results

Two patients with in situ squamous cell carcinoma of the conjunctiva and clinical involvement of the entire limbus were treated with topical interferon alpha-2b. Thorough examination and multiple biopsies excluded invasive disease. The patients had complete response to therapy.

Conclusion

Widespread intraepithelial squamous neoplasia involving the entire limbus can be successfully treated with topical therapies. Biopsy plays a role in excluding invasive disease. Interferon alpha-2b is a preferable agent to start with because it is well tolerated. Since long-term risks of recurrence are unknown, appropriate monitoring is essential.

Clinical Management of Ocular Surface Squamous Neoplasia: A Review of the Current Evidence

Ocular surface squamous neoplasia (OSSN) is the most common non-pigmented malignancy of the ocular surface and is represented in a wide range of histologic diagnoses, ranging from mild epithelial dysplasia to invasive squamous carcinoma. Although surgical excision is still the gold standard for OSSN treatment, interest in conservative medical approaches is steadily growing. We have reviewed all of the literature on OSSN published in English in the MEDLINE database up to May 2018, using the keywords “ocular surface squamous neoplasia,” “squamous conjunctival carcinoma,” and “conjunctival carcinoma in situ,” with the aim to provide a comprehensive review of the most recent evidence on this distinct clinical entity.

Topical interferon alpha-2B topic as the first therapeutic option in a clinical case of conjunctival intraepithelial neoplasia

INTRODUCTION

Conjunctival intraepithelial neoplasia is a pre-malignant lesion of the ocular surface. It can be treated with topical interferon alpha-2b (INF α-2b) as first choice.

CLINICAL CASE

A 71-year-old man referred for corneal-conjunctival, gelatinous lesion in the left eye (LE) with an area of almost 270°. The clinical diagnosis was compatible with a corneal-conjunctival intraepithelial neoplasia. Topical treatment was started with INF α-2b at a dose of one million international units (IU)/ml, 4 times/day for 4 months, with remission being achieved.

CONCLUSION

The isolated use of topical INF α-2b is an effective treatment as a first option in the case of corneal-conjunctival intraepithelial neoplasia, positioning itself as a form of effective and safe treatment compared to other therapeutic options. Surgical excision and use of other chemotherapy agents could lead to severe limbic deficits and other side effects.

Diagnosis and Medical Management of Ocular Surface Squamous Neoplasia

INTRODUCTION

Topical chemotherapy has gained popularity among clinicians for the treatment of ocular surface squamous neoplasia (OSSN). The principal topical chemotherapy agents used in the management of OSSN are interferon-α2b, 5-fluorouracil, and mitomycin C. High-resolution optical coherence tomography (HR-OCT) is a non-invasive technique that can differentiate OSSN from other ocular surface lesions.

AREAS COVERED

This review highlights the current regimens and diagnostic modalities used in managing OSSN. A review of the literature was performed using the keywords "conjunctival intraepithelial neoplasia", "ocular surface squamous neoplasia", "optical coherence tomography", "interferon-α2b", "5-fluorouracil" and "mitomycin C".

EXPERT COMMENTARY

Topical chemotherapy for OSSN can be used as primary therapy, for chemoreduction prior to surgical excision, and postoperatively to prevent tumor recurrence. It has the advantage of treating microscopic disease as well as large tumors. HR-OCT provides an "optical biopsy" that can assist in diagnosis and guide management of OSSN lesions.

Topical 5-Fluorouracil 1% as Primary Treatment for Ocular Surface Squamous Neoplasia

PURPOSE

To determine the efficacy of topical 5-fluorouracil 1% (5-FU) as a primary treatment of ocular surface squamous neoplasia (OSSN).

DESIGN

Retrospective study.

PARTICIPANTS

Topical 5-FU was used as primary therapy in 44 patients with OSSN.

METHODS

5-Fluorouracil 1% administered topically 4 times daily for 1 week followed by a drug holiday of 3 weeks. Patients were identified through a pharmacy database. Patients were excluded if 5-FU was used as adjuvant therapy, if they did not complete therapy, or if they were still actively receiving treatment for OSSN at the time of last follow-up.

MAIN OUTCOME MEASURES

The primary outcome measures were the frequency of complete resolution with topical 5-FU treatment and the rate of OSSN recurrence.

RESULTS

Of the 44 patients identified, 32 were men and 12 were women. The mean age was 68 years. Complete resolution of OSSN was noted in 82% of patients (36/44); 18% (8/44) were considered treatment nonresponders. Patients were treated with a median of 4 cycles (range, 2-9 cycles). Nasal location was the only risk factor identified for nonresponse to therapy (P = 0.04). The median follow-up after resolution was 10 months (range, 2-77 months). In the 36 patients who showed complete resolution, 4 experienced tumor recurrence. Recurrence rates at 1 and 2 years were 6% and 15%, respectively, using Kaplan-Meier survival analysis. At least 1 side effect from the medication was reported by 61% of patients (21/44), but only 1 patient discontinued the medication because of intolerance. The most common side effect was pain (n = 17; 39%), followed by tearing (n = 10; 23%), photophobia (n = 6; 14%), itching (n = 4; 9%), swelling (n = 2; 5%), and infection (n = 1; 2%). No long-term complications were reported.

CONCLUSIONS

5-Fluorouracil is effective and well tolerated as a primary treatment for OSSN, with 82% of tumors responding completely to therapy.

Prevalence and Severity of Ocular Surface Neoplasia in African Nations and Need for Early Interventions

Ocular surface squamous neoplasia (OSSN) is a common ocular surface tumor with an increased incidence in African countries (3.4 and 3.0 cases/year/100,000). Despite its potential for vision loss and death, OSSN remains largely neglected by both eye and HIV care programs in Africa. The purpose of this review is to identify the barriers to timely diagnosis and early interventions for OSSN in Africa. PubMed searches were conducted targeting previous use of topical chemotherapy (interferon alpha 2b, Mitomycin-C, 5-Fluorouracil) and Human papillomavirus (HPV) vaccination in Africa. We found that OSSN is a significant vision and life-threatening health problem in Africa leading to significant loss of vision, as well as facial disfigurement and social stigma. We did not find any reports on the use of topical interferon, Mitomycin-C or HPV vaccination for OSSN in Africa. One report on the use of topical 5-FU for OSSN in Africa was found. Common barriers to early detection and management of OSSN in Africa include lack of sufficient laboratory infrastructure, lack of trained healthcare personnel, lack of compliance with follow-up visits, cost of topical chemotherapies, and cultural preferences for traditional medicines. In conclusion, OSSN is a significant vision and life-threatening health problem in Africa. There is not much literature on prevention or treatment options for early stages of OSSN in Africa. The use of topical chemotherapy as early interventions and judicious use of smart phone Apps to help with remote diagnosis of early OSSN should be further explored.