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