INTRAORBITAL EXTENTION OF MODERATELY

DIFFERENTIATED SQUAMOUS CELL CARCINOMA OF CONJUNCTIVA

PRESENTATION BY DR. VAISHYA. MAULIK. P.

PROF. DR. SHUBHANGI. NIGWEKAR.

PROF. DR. S.V. BANGAL. PROF.DR.SANJAY. SHELKE.

INTRODUCTION•Squamous cell carcinoma of the conjunctiva is a rare malignancy; however, it is reported to be the most common malignant tumour of ocular surface.(1)

•In SCC the abnormal cells extend through the basement membrane into the conjunctival stroma & has the potential to penetrate the corneoscleral lamella into the anterior chamber of the eye or can breach the orbital septum to invade the soft tissues of the orbit, sinuses, and the brain. (2,3) •These tumours may metastasize via lymphatics or blood during the course of disease & owing to their possible aggressive behaviour, conjunctival SCCs are therefore known to be sight and life threatening.(3,4)

•Cytogenetic studies of conjunctival SCC have not revealed any consistent chromosomal abnormalities or gene mutations in tumor cells.(5)

•Generally, the tumors occur in older adults & affect all racial groups and both sexes.(5)

CASE REPORT

•In nov-2015, a seventy year old female came to ophthalmology opd.•Patient gives h/o left eye cataract sx 11 yrs back at nagar and got good vison.•But since last 6-7 yrs pt c/o pain, redness, watering, itching and sticky discharge with gradual,painful diminution of vision.•Patient was prescribed various eye drops but there was no relief.•No h/o any ocular trauma and similar swelling in past.

EXAMINATION•On examination hard,tender, irregular mass was present involving all intraocular contents which was adherent to eyelids.•There was mucopurulent discharge present in left eye with matting of eyelashes & lid edema.•Dilated and tortuous feeder vessels was present on temporal side of mass.•Visual acuity was 6/18 in right eye (pseudophakic) while there was no perception of light in left eye.•There was severe ciliary tenderness present.•Ocular movements were restricted and painfull in all directions of gazes.•On posterior segment examination no red glow was seen.•Clinically we suspected squamous cell carcinoma.

MANAGEMENT•Biopsy under local anesthesia confirmed the diagnosis of moderately differentiated squamous cell carcinoma.•Patient underwent exentration surgery with wide excision of both eyelids. •Skin grafting was done over the orbital cavity.•Post operatively pt was started on systemic antibiotics, analgesic and antiinflammatory.•Daily betadine dressing was done.

Ct scan showing intraorbital extention of squamous cell carcinoma of conjunctiva

HISTOPATHOLOGY

•Report showed lining of Stratified Squamous Epithelium(SSE), tumor arising from it and infiltrating the stroma.

•Tumor cells are arranged in cords and nest and scatterd singly.

•Individual tumor cells are large,pleomorphic with hyperchromatic nucleiwith prominent nucleoli,clumped chromatin irregular nuclear membrane and scanty cytoplasm giving rise to high N:C ratio.

•The stroma is fibrocollagenous and showinfiltration by chronic inflammatory cells with dilated blood vessels.

DISCUSSION•Squamous cell carcinoma of the conjunctiva is usually a slowly progressive neoplasm that rarely invades the eye or orbit.(6,7)

•Immunosuppressed patients are at increased risk to develop conjunctival squamous cell carcinoma.(5)

• Tumors in immunosuppressed patients can behave aggressively.(5)

•Metastasis of conjunctival squamous cell carcinoma occurs in less than 1% of patients, usually to the regional lymph nodes.(8)

• Rarely, intraocular invasion(6) or distant metastases to the lung and bone have occurred.(8)

•Recurrence of conjunctival squamous cell carcinoma is generally greater in patients with higher grade undifferentiated tumors and in those with incomplete initial excision.(9)

CONCLUSION•Advanced-stage SCC can be treated surgically. •An extensive surgical approach is sometimes inevitable. •Patients with surgical excision of advanced-stage disease should be reviewed closely as recurrences may occur and even after more than 5 years. •However, on early detection, most of these recurrences can be handled by local excision.

REFERENCES

(1) Sun EC, Fears TR, Goedert JJ. Epidemiology of squamous cell conjunctival cancer. Cancer Epidemiol Biomarkers Prev 1997; 6(2): 73–77. | PubMeds | CAS |

(2) Iliff WJ, Marback R, Green WR. Invasive squamous cell carcinoma of the conjunctiva. Arch Ophthalmol 1975; 93(2): 119–122. | Article | PubMed |

(3) Shields CL, Shields JA. Tumors of the conjunctiva and cornea. Surv Ophthalmol 2004; 49(1): 3–24. | Article | PubMed|

(4) Walsh-Conway N, Conway RM. Plaque brachytherapy for the management of ocular surface malignancies with corneoscleral invasion. Clin Exp Ophthalmol 2009; 37(6): 577–583. | Article |

(5) Yanoff and Duker, Ophthalmology, 4th Edition, Page 196.(6) Shields  JAShields  CL Premalignant and malignant tumors of the

conjunctiva epithelium. In:Shields  JAShields  CLeds.Atlas of Eyelid and Conjunctiva Tumors Philadelphia, Pa Lippincott Williams &Wilkins1999;226- 241

(7) Shields  JAShields  CLGunduz  KEagle  RC Intraocular invasion of conjunctiva squamous cell carcinoma in five patients: the 1998 Pan American Lecture. Ophthalmic Plast Reconstr Surg 1999;15153- 160

(8) Tabbara  KFKersten  RDaouk  NBlodi  FC Metastatic squamous cell carcinoma of the conjunctiva. Ophthalmology. 1988;95318- 321

(9) Rao  NADunn  SARomero  JLStout  W Bilateral carcinoma of the eyelid. Am J Ophthalmol. 1986;101480- 482