conjunctival squamous cell carcinoma with massive intraocular invasion fiona roberts, glasgow baop,...
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Conjunctival Squamous Cell Carcinoma with Massive
Intraocular InvasionFiona Roberts, Glasgow
BAOP, Manchester 7-8th April, 2011
Clinical History
• 75 year old male• 15 month history of left limbal mass• Biopsied
Clinical History
• Invasive poorly differentiated squamous cell carcinoma
• Excision was considered best treatmentHowever• Not a good 75 year old and generally frail• Decision to treat with topical mitomycin C• Review in 3 months
3 Month Review• Condition significantly deteriorated. • Struggling to open the left eye. • Vision had decreased from 6/24 to hand movement. • Mass had increased in size with dystopia• Rubeosis, posterior synechiae and an anterior uveitis. • No fundal view. • Pressure in the left eye was slightly raised
Pathology
CK14
Pathology Summary
• Squamous cell carcinoma of the conjunctiva• Extensive intraocular spread
– anterior chamber with malignant epithelial downgrowth and invasion of trabecular meshwork
– Ciliary body– Choroid with mass forming posteriorly
• Secondary effects of raised intraocular pressure
Conjunctival Squamous Cell Carcinoma
• Relatively uncommon worldwide • Geographical variation in incidence of 0.02 to
3.5/100,000• Part of the spectrum of ocular surface squamous
neoplasia (OSSN)• Occurs in sun-damaged ocular surface usually at
the limbus in elderly males• Also associated with immunosuppression (AIDS,
Transplant etc.)
Intraocular Invasion of Conjunctival SCC
• Reported to be rare (2 to 13% of cases)• Char et al. BJO, 1992 identified approximately
60 reported cases of intraocular invasion• Since then around a further 18 cases (13 as
part of several series and 5 case reports)• Even been reported in a 12 year old Haflinger
gelding
Kaps et al. Veterinary Ophthalmology, 2005
Intraocular Invasion - Features• Most commonly in older patients with one or 2
recurrences Shields et al. 1999
• Tumour usually located near corneoscleral limbus• Heralded by onset of low-grade inflammation and
secondary glaucoma• A white mass generally was observed in the anterior
chamber angle• Most cases reported to date confined to anterior
chamber and ciliary body and extension posteriorly is unusual Schlote et al. , Klin Monbl Augenheilkd, 2001
Risk Factors 1• Neglected primary malignancy
– Did failure to excise primary tumour in this case equate with neglect ?
– Topical mitomycin C is recognised as an effective treatment of SCC of the conjunctiva
– Thin tumours less than 4mm can show complete regression even if extensive
– Larger/thicker tumours may show only a partial response
– Mitomycin C for chemoreduction prior to surgery
Shields et al., Arch Ophthamol, 2005
Risk Factors 2
• Recurrent tumours/Inadequate primary excision– 73 year old male who had conjunctival SCC with
intraocular invasion removed by corneoscleral resection with iridocyclectomy
– Initial excision showed clear margins– Recurrence one year later in iris and trabecular
meshwork well away from primary tumour
Glasson et al., Arch Ophthalmol, 1994
Risk Factors 3• Histological tumour type
– Mucoepidermoid carcinomas• Lacour et al. J Fr Ophthalmol, 1991• Seitz & Henke, Klin Monbl Augenheilkd, 1995• Gunduz et al. Ophthalmology, 2000
– Spindle cell squamous carcinoma• Shields et al., Cornea, 2007
– Both regarded as more locally aggressive and to have a higher recurrence rate
– However, each histological subtype accounts for few than 5% of squamous cell carcinomas of the conjunctiva
Summary• Intraocular invasion from conjunctival
squamous cell carcinoma is uncommon• Usually occurs in elderly males with mass at
the limbus• Involves anterior chamber with signs of
inflammation and raised intraocular pressure• Extension posteriorly is uncommon• Ocular prognosis is poor but survival is good