14 cases of keratoconjunctival tumor

Satoru Tsuda, Shunji Yokokura, Akira Kubota, Megumi Uematsu, and Kohji Nishida

Department of Opthalmology and Visual Science, Tohoku University Graduate School of Medicine

The authers have no financial interest

Purpose

• To characterize squamous neoplasm in keratocinjuntival tumor

　 For example , squamous cell papilloma (SCP)

　 conjunctival intraepithelial neoplasia (CIN)

　 squamous cell csarcinoma (SCC)

• To analyze the prognosis after the operation

Method

Design• Operative case series• Retrospective study

Subjects• Squamous 　 neoplasms at the limbus.• All patients were performed operation and histopathologically

diagnosed at the Department of Ophthalmology, Tohoku University Hospital from May,2006 to October, 2009.

Analysis• Age, gender, tissue type, surgical procedure• Prognosis after the operation

Surgical procedure

•　 Excision 　　　　　　 •　 Cryotherapy 　　　　　　　•　 Intraoperative use of Mitomycin C (MMC)

Tumors were removed with local excision combined with cryotherapy and/or intraoperative use of MMC

Reconstraction of ocular surface was applied if tumors involved widely the corneal limbus and bulbar conjunctiva.

•　 Limbal transplantation 　 •　 Aminion membrane transplantation 　　　　

Demonstration of the extent of tumor

Figure : Keratoconjunctival tumor at the limbus. Figure : Fluorescein stains dysplastic epithelium

Fluorescein stains was used intraoperatively to demonstrate the extent of tumor 1).

Excision

Figure : Resection of the demonstrative lesion.

Exicision of tumor demonstrated by fluorescein stain.

Cryotherapy

Cryotherapy was applied to the involved limbal area and cut conjunctiva edges and bare scleral bed for 3 seconds.

Figure : Cryotherapy to cut conjunctival edge

Intraoperative use of MMCSponges absorbing MMC 0.04% was attached to bare corneal and scleral bed and conjunctival edge for 5 minutes.

Figure : Sponge absorbed MMC 0.04% was attached .

Results

• The fourteen eyes of 14 patients were analysed.

• Male : female = 12 : 2.

• Primary case : recurrent case = 13 : 1

• All patients were Japanese.

• Mean age were 75.4 years(median, 78.5 years; range, 40-94 years).

• All patients were followed up for a mean of 23.7 months (median, 23.5; range,4-44 months).

• Only one case had a local recurrence twice.

• All cases did not develop metastases.

Result

CaseGender Age Primary Pathology Operation Follow up interval Recurrence

1 M 81 Yes SCP Exc LT＋ 39M No2 M 75 Yes SCP Exc Cryo AMT＋ ＋ 42M No3 F 65 No SCP Exc Cryo→ Cryo AMT MMC→ LT AMT MMC+Cryo＋ ＋ ＋ ＋ ＋ 28M Yes4 F 90 Yes SCP Exc KEP＋ 44M No5 M 81 Yes CIN Exc LT＋ 26M No6 M 76 Yes CIN Exc Cryo MMC AMT＋ ＋ ＋ 17M No7 M 86 Yes CIN Exc LT＋ 11M No8 M 72 Yes CIN Exc Cryo AMT＋ ＋ 13M No9 M 60 Yes CIN Exc 24M No10 M 81 Yes CIN Exc LT＋ 4M No11 M 94 Yes SCC Exc MMC AMT＋ ＋ 23M No12 M 40 Yes SCC Exc Cryo AMT＋ ＋ 16M No13 M 82 Yes SCC Exc AMT＋ 39M No14 M 72 Yes SCC AMT MMC＋ 6M No

SCP : Squamous cell papillomaCIN : Conjunctival intraepithelial neoplasiaSCC: Squamous cell carcinoma

Ex : Excision M : monthsCryo : CryotherapyMMC : intraoperative use of mitomycin C 0.04%AMT : Amnion membrane transplantationLT : Limbal transplantation

Table 1 : Age and Gender, Progress, Pathology, Operative procedure, Follow up time

Result

SCP CIN SCCCases 4(28.6%) 6(43.0%) 4(28.6%)

Median Age 78 78.5 77Gender M/ F 2/ 2 6/ 0 4/ 0

Primary/ Recurrence cases 3/ 1 6/ 0 4/ 0Recurrence after the operation 1 0 0Table : Comparison of each tissue type

• CIN was the most common type.• Median age of every tissue type was similar.• CIN and SCC were usually male.• Only one recurrent case of SCP had a local recurrence twice.• The recurrent case was operated with excision and cryotherapy.

Discussion

Squamous cell papilloma

• SCP is benign tumor, with little tendency to undergo malignant transformation .

• Lesions may occur anywhere on conjunctiva,singly or multiply.

• Multiple lesions suggest the presence of infection with HPV. 1)

• Management is difficult and complecated because of multiple recurrences. 1)

• Local excision with cryotherapy and/or is the effective treatment. 4)

Discussion

• CIN and SCC occupy 2% in epibulbar tumor 2).

• CIN and SCC occur more commonly from 50s to 70s 2).

• Most occur at the limbus, especially within the sunexposed interpalpebral fissure 2).

• The pathogenic factors are sun exposure, light skin pigmentation, male population, smoking, HIV infection, HPV infection and so on.

• Local excision with cryotherapy reduces the recurrence rate. 3)

• Adjunctive topical MMC is also useful.

CIN, SCC of the Conjunctiva

Conclusion

• Patients were usually male and elderly.• Excision with cryotherapy and/or intraoperative use

of MMC may reduce the recurrent rate.• Primary cases had no recurrence in any tissue types.• Recurrent cases should be carefully management be

cause of frequent recurrences.

References1) Krachmer et al : Cornea 2nd Ed : 557-570, Elsevier Mosby Publishers 2005.

2) Ash, J.E. : Epibulbar Tumor. Am. J. Ophthalmol. 33: 1203-1219, 1950.

3) Fraunfelder, F.T. & Wingfield, D. : Management of intraepithelial conjunctival tumors and squamous cell carcinomas. Am. J. Ophthalmology 95 : 359-363, 1983.

4) Hawkins A.S et al : Treatment of recurrent conjunctival papilomatosis with mitomycin C. Am J Ophthalmology 128 : 638, 1999.