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PubMed2006

[Analysis of ocular surface alterations following proton beam radiation in eyes with conjunctival malignant melanoma].

BACKGROUND: In cases of large, diffuse or multilocular growth pattern of conjunctival melanoma, proton beam irradiation can serve as an alternative therapy to exenteration. In extended tumours, ocular surface problems can result after therapy. In this study we examined ocular surface integrity of ten patients who underwent proton beam radiation between 1996 and 2002. METHODS: The patients were examined during their follow-up. Eight of the ten cases who underwent proton radiotherapy were recurrent tumours, which were previously treated with other adjuvant therapies. We performed a standard ophthalmological examination and detailed tear film diagnostics. RESULTS: The follow-up was 17-87 months (mean: 40.9+/-20.1). In six cases more than 50% of the upper and lower eyelids were included in the radiation field. All of these cases showed moderate to severe sicca symptoms. The impression cytology revealed squamous metaplasia of conjunctival cells in nine of ten cases. CONCLUSIONS: Squamous metaplasia of conjunctival epithelia indicates a radiogenic, persisting disturbance of differentiation of the conjunctival epithelial cells. The tear film instability correlates with the loss of mucin-secreting goblet cells and meibomian gland dysfunction.

Adult↗
PubMed2006

[Squamous cell carcinoma of the conjunctiva with orbital invasion: orbital exenteration or minimally invasive procedure?].

BACKGROUND: Here we present a case of a female patient with squamous cell carcinoma with orbital invasion who insisted on a globe-sparing excisional biopsy rather than a more invasive procedure. CASE: A 48-year-old patient presented with a conjunctival tumor at the medial canthus of the right eye. The visual acuity in this eye was 1.0. MRI showed a 25 mm x 12 mm tumor, with orbital invasion, no metastasis, but on CT scan damage of the lamina papyracea was suspected. Histology of a punch biopsy confirmed a moderately differentiated, squamous cell carcinoma. As requested by the patient, simple tumor excision with a 5-mm safety margin, reconstruction of the lower fornix with amniotic membrane, and adjuvant mitomycin C therapy were performed. Intraoperatively the medial orbital wall was found to be intact. No local or systemic recurrence has occurred 3.5 years postoperatively. The patient's VA is still 1.0; no visual field defects are detectable, and there are only minor upper lid levator restriction and diplopia in maximum upgaze. CONCLUSION: In view of this case the choice of surgical treatment for malignant tumors of the conjunctiva with orbital invasion - between exenteration or a minimally invasive procedure - should be carefully discussed with the patient. A follow-up of 5 years is strongly recommended.

Carcinoma, Squamous Cell↗
PubMed2003

Prognostic value of cell-cycle markers in ocular adnexal lymphoma: an assessment of 230 cases.

BACKGROUND: To determine the prognostic value of cell-cycle associated markers in ocular adnexal lymphoma (OAL). METHODS: Two hundred sixty-one consecutive cases of ocular adnexal lymphoproliferative lesions were subdivided into reactive lymphoid hyperplasia (RLH), atypical lymphoid hyperplasia (ALH) and OAL. The latter were sub-typed according to the new WHO Lymphoma Classification. All lesions were investigated applying standard immunohistochemical methods with antibodies specific for pRB, p53, p16, p21, BCL-6 and for multiple myeloma oncogene-1-protein (MUM1, also known as IRF4). The main endpoints included the development of a local recurrence, of systemic disease and of lymphoma-related death. The association of prognostic variables with endpoints was assessed by multiple logistic and Cox regression models, respectively. RESULTS: The ocular adnexal lymphoproliferative lesions were categorised as OAL ( n=230; 88%), RLH ( n=29; 11%), and ALH ( n=2; 1%). The major lymphoma subtypes included 136 extranodal marginal zone B-cell lymphoma (EMZL), 31 diffuse large cell B-cell lymphomas, 27 follicular lymphomas, 9 plasmacytomas, 9 lymphoplasmocytic lymphoma/immunocytomas and 8 mantle cell lymphomas. The median follow-up time was 44.5 months. Most OAL patients had Stage IE disease and were treated with radiotherapy. Thirty-seven (25%) Stage IE patients had tumour relapses: these were significantly associated with an increased BCL6 blast percentage. Sixty-two (42%) Stage IE patients developed systemic disease: they had "non-EMZL" with large growth fractions and increased blast percentages for BCL6. Fifty-seven (25%) OAL patients died because of their lymphoma; lymphoma-related death was significantly associated on multivariable analysis with advanced clinical stage, an age >60 years and large tumour growth fractions. CONCLUSION: Subtyping of OAL according to the new WHO Lymphoma Classification, the stage of disease and tumour cell growth fraction aided the prediction of (1) tumour relapse, (2) the development of systemic disease and (3) lymphoma-related death in OAL.

Adolescent↗
PubMed2005

Topical mitomycin chemotherapy for conjunctival malignant melanoma and primary acquired melanosis with atypia: 12 years' experience.

PURPOSE: To report 12-year follow-up experience with topical mitomycin chemotherapy for diffuse and multifocal primary acquired melanosis (PAM) with atypia and conjunctival melanoma. METHODS: Interventional case series of 16 patients. Mitomycin was a primary treatment for residual epithelial disease in ten patients (eight with PAM with atypia and two with conjunctival melanoma) and as an adjuvant to excision and cryotherapy in six with conjunctival malignant melanoma. Primary treatments consisted of mitomycin 0.04% qid for 28 days (two 14-day cycles) and for 7 consecutive days as adjuvant therapy. Patients were followed for both local recurrence and metastatic disease. RESULTS: Sixteen patients were followed for a mean 81 months (range 13-144 months) after treatment. All tumors responded to chemotherapy. Recurrence was noted in eight (three adjuvant and five primary treatment patients). Three underwent orbital exenteration. The remaining five were treated conservatively. The mean time to recurrence was 36.9 months. The short-term mitomycin-related complications included transient keratoconjunctivitis (n=14), severe keratoconjunctivitis (n=1) and one corneal abrasion with scar formation. The long-term complications included pannus (n=2) and corneal haze (n=1). Visual acuity was maintained within two lines in 14 patients (including measurements just prior to exenteration). Three patients died, one of metastatic conjunctival melanoma. CONCLUSIONS: Conjunctival melanoma and PAM responded to mitomycin 0.04% topical chemotherapy; subepithelial nests appeared resistant to treatment. Treatment-related complications were acceptable. In this series, as primary and adjuvant therapy, topical mitomycin yielded an overall recurrence rate of 50%.

Administration, Topical↗
PubMed2005

Expression of p63 in conjunctival intraepithelial neoplasia and squamous cell carcinoma.

BACKGROUND: p63 is a homologue of the tumour suppressor gene p53, which is expressed in human basal squamous epithelium. Some investigators maintain that p63 plays a role in the development of squamous epithelium and, despite its homology to p53, it is considered to act as an oncogene. This study investigated the expression of p63 in conjunctival intraepithelial neoplasia of different grades, and conjunctival squamous cell carcinoma and its correlation to the proliferation marker MIB-1. MATERIAL AND METHODS: Seventeen conjunctival specimens excised with the suspicion of either conjunctival intraepithelial neoplasia (CIN) or squamous cell carcinoma were diagnosed histologically as follows: 2 squamous cell carcinomas of the conjunctiva, 2 CIN grade I, 3 CIN grade II, 7 CIN grade III, 2 CIN with beginning invasion and 1 normal conjunctiva with no dysplasia. Sixteen microscopically-normal postmortem conjunctival specimens and normal conjunctiva, CIN and carcinoma specimens were stained immunohistochemically with antibodies against p63 and MIB-1. At least 500 cells per specimen were counted and the percentage of positively-stained cells of each antibody was calculated. RESULTS: A mean of 80% (57-89%) of the dysplastic cells from the CIN specimens stained positively with antibodies against p63, especially in the lower two-thirds of the epithelium, statistically significantly more compared with the normal specimens (9-55%, mean 36%, p<0.001). Nevertheless, we did not find a correlation between the percentage of p63-positive cells and the differentiation grade of the malignant specimens. MIB-1 positivity was shown by 0-1% of the cells in the normal postmortem controls, by 3-30% (mean 12%) of the cells in the basal and occasionally in the middle layer of the CIN specimens, and 16-61% (mean 23%) in the carcinoma specimens. CONCLUSION: In conjunctival intraepithelial neoplasia and squamous cell carcinoma of the conjunctiva, p63 is preferentially expressed in the immature dysplastic epithelial cells. Its staining does not correlate with MIB-1-expression, and therefore does not appear to be linked to cell proliferation.

Adult↗
PubMed2005

Expression of sex hormone receptors and cell cycle proteins in melanocytic lesions of the ocular conjunctiva.

BACKGROUND: Both dermal and ocular melanocytic nevi have been reported to undergo changes during pregnancy. This has been proposed to be related to hormonal influences; however, few studies have provided any proof. We therefore set out to evaluate the expression of sex hormone receptors and cell cycle proteins in melanocytic lesions of the ocular conjunctiva. METHODS: Formalin-fixed, paraffin-embedded material from 76 tumors--69 conjunctival nevi, 5 specimens of primary acquired melanosis (PAM), and 2 conjunctival melanomas--were included in a tissue microarray (TMA) format. The TMA sections were analyzed by immunohistochemistry with antibodies for progesterone and estrogen receptors, and cell cycle-related proteins (p16, MIB1-Ki67). RESULTS: Progesterone receptors were highly (96%) and similarly expressed in all lesions. In addition, progesterone receptor expression showed a tendency to increase with age (p=0.06). In contrast, estrogen receptor expression was completely absent in all tumors. The cell cycle regulator p16 was expressed in 97% of the lesions. The proliferation marker MIB1-Ki67 was expressed at low levels (mean+/-SD: 13+/-14%) in 79% of the lesions. No differences of expression were found between the different lesions and nevi types. The mean age of the patients was highest in conjunctival melanoma (70+/-22 years), followed by PAM (60+/-19 years) and nevi (36+/-18 SD years). The different types of nevi also showed significant age dependency (junctional 25+/-17 years, compound 34+/-17 years, dermal 49+/-15 years). CONCLUSION: Our findings reveal the expression of progesterone, but not estrogen, in melanocytic lesions of the ocular conjunctiva. In benign conjunctival lesions, p16 and MIB1-Ki67 expression was comparable to that in benign nevi of the skin.

Adolescent↗
PubMed2005

A case of primary botryoid conjunctival rhabdomyosarcoma.

BACKGROUND: Rhabdomyosarcoma is the most common childhood primary orbital malignancy, but the occurrence of this tumour in the conjunctiva is rare. METHODS: A 14-year-old girl presented with a visible case of conjunctival mass in the left eye. The year before, the patient was referred to another hospital for a biopsy of a conjunctival mesenchymal tumour in the same site, which was periodically checked after the excision. We intervened by partially removing the conjunctival mass. RESULTS: The histopathology revealed a botryoid rhabdomyosarcoma. The patient underwent chemotherapy and fractionated radiotherapy. The follow-up after three years revealed that the patient remained clinically tumor-free, with no ocular complication from the radiotherapy. CONCLUSION: It is evident that by not excising the tumour in its entirety it is therefore possible to preserve the underlying rectus muscles and not interfere with ocular motility. Subsequent radiotherapy and chemotherapy helped to destroy any residual tumour. Alternatively, surgical excision of the mass alone could lead to recurrence of the tumour after some months or years.

Adolescent↗
PubMed2005

Proton radiotherapy as an alternative to exenteration in the management of extended conjunctival melanoma.

BACKGROUND: Diffuse and multifocal patterns of conjunctival melanoma may not be treatable with standard eye-sparing methods. The purpose of this study was to evaluate the usefulness of proton beam radiation therapy as an alternative to exenteration. METHODS: Twenty patients with extended conjunctival melanoma were treated by proton beam irradiation. Most cases were T3 tumours which were not accessible to brachytherapy due to their extension, localisation with fornical or caruncular involvement. Only 2 patients had a tumour limited to the bulbar conjunctiva. Both were recurrent tumours with multiple lesions. Sixteen cases were recurrences after various pre-treatments. The area of the conjunctiva which was suspected to have microscopic disease was treated by 31 Gy in 6 fractions. The "high risk" areas with a clinically detectable tumour (primary target volume) were treated by an additional boost using a smaller beam size and applying 2 fractions up to 45 Gy. An individually shaped compensator was brought into the beam to modify the range of the protons so that the eye was irradiated only at a depth of 2 mm. RESULTS: The mean follow-up time was 38.1+/-26.6 months (median 34 months). Recurrent disease occurred in 6 cases (30%); 2 of them outside the irradiated volume, 3 within the target volume treated by 31 Gy, and just one in the primary target volume treated by 45 Gy. An exenteration followed only in two patients (10%). 6 patients (30%) suffered from metastatic disease and 4 (20%) of them have died by now. During follow up we found no statistically significant association between the occurrence of local recurrence after proton radiotherapy and the development of metastases. Best corrected visual acuity remained stable in 12 cases (60%); in 14 patients the best corrected visual acuity was 0.25 or better. A sicca-syndrome developed in 19/20 patients. However, only 10/20 patients used artificial tears more than 5x/d. A focal cataract developed in 7 patients (35%). There was eyelash loss in the area of irradiated eyelids. In 4 cases a limbal stem cell deficiency occurred with the consequence of corneal vascularisation. CONCLUSIONS: Proton radiotherapy may serve as an alternative to exenteration in case of T3 and diffuse T1 or T2 conjunctival melanomas.

Adolescent↗
PubMed2005

Treatment of large conjunctival nevus by resection and reconstruction using amniotic membrane.

BACKGROUND: Nevus of the bulbar conjunctiva is a benign pigmented lesion of the ocular surface. Unless a biopsy is required for ruling out malignant melanoma, a nevus is usually excised for cosmetic reasons only. However, with large lesions involving two or more quadrants of the bulbar conjunctiva, a total resection can be difficult. In this report, we present a case of a huge nevus treated by surgical excision and amniotic membrane transplantation for reconstruction of the bulbar conjunctiva. METHODS: A 54-year-old Japanese man was referred to our clinic with suspected malignant tumor of the bulbar conjunctiva in his right eye. A large and diffuse pigmented tumor with numerous small cysts was present mainly on the upper bulbar conjunctiva. Resection of the conjunctival tumor and amniotic membrane transplantation for reconstruction of the bulbar conjunctiva were performed. RESULTS: The histopathological diagnosis was conjunctival nevus. Epithelialization of the bulbar conjunctiva over the amniotic membrane sheet was completed 4 weeks after resection. At 44-month follow-up, there was no recurrence or any postoperative complication. CONCLUSION: Surgical resection combined with reconstruction by amniotic membrane transplantation is effective for the treatment of large conjunctival nevus.

Amnion↗
PubMed2005

Vesicular stomatitis virus induces apoptosis in the Wong-Kilbourne derivative of the Chang conjunctival cell line.

BACKGROUND: Virotherapy represents a novel therapeutic modality for the treatment of malignant diseases. Vesicular stomatitis virus (VSV) has been shown to exert antitumor effect in several tumor types. Since the potential oncolytic activity of VSV has not yet been evaluated in epithelial tumors of the conjunctiva, we set out to investigate the susceptibility of the immortalized Wong-Kilbourne derivative of the Chang conjunctival cell line (WK) to VSV and analyze the role of apoptosis in VSV-mediated induction of cell death. METHODS: WK cells were infected with VSV at various multiplicities and maintained for different periods of time. VSV-infected cells were analyzed by inverted microscopy for the development of cytopathic effects (CPE). Virus replication was measured by indirect immunofluorescence assay, Western blot analysis and plaque titration. The apoptotic response of the infected cells was quantitated by ELISA detecting the enrichment of nucleosomes in the cytoplasm. Western blot analysis was used to determine the levels of Bcl-2 and Bax proteins. RESULTS: The WK cell line was highly permissive to VSV replication and was highly susceptible for the CPE of this virus. VSV infection elicited the apoptotic death of WK cells. Mock-infected cells exhibited endogenous expression of Bcl-2 and p21 Bax proteins. VSV infection caused a significant decrease in the expression level of Bcl-2. Moreover, in parallel with a slight decrease in the level of p21 Bax, p18 Bax protein accumulated in VSV-infected WK cells. CONCLUSIONS: VSV is a powerful inducer of apoptosis in immortalized WK cells. The VSV-mediated alterations in the expressions of Bcl-2 and Bax proteins may play important roles in the apoptotic responses of infected cells and may also sensitize to other apoptotic stimuli. This virus may possess oncolytic activity in epithelial tumors of the conjunctiva.

Apoptosis↗
PubMed2005

Subconjunctival mucosa-associated lymphoid tissue (MALT) lymphoma arising in Tenon's capsule.

PURPOSE: We report the first case of subconjunctival mucosa-associated lymphoid tissue (MALT) lymphoma arising in Tenon's capsule (fascia bulbi). METHODS: A 75-year-old woman presented with painless swelling of the superior bulbar conjunctiva in her left eye. During the biopsy of the bulbar lymphoid lesion, it was noticed that the conjunctiva was movable and that the lesion was located in the subconjunctiva. The tissues were studied by conventional light microscopy, immunohistochemistry, flow cytometry, and gene rearrangement analysis. RESULTS: Histopathological examination revealed that a diffuse lymphoid infiltrate consisting of small-sized lymphoid cells was present in Tenon's capsule but not in the substantia propria of the conjunctiva. Immunohistochemical and flow cytometric studies documented tumor cells of B-lymphocyte lineage. Molecular analysis demonstrated positive immunoglobulin heavy chain gene rearrangement. The final diagnosis was subconjunctival MALT lymphoma arising in Tenon's capsule. CONCLUSION: Ophthalmologists and pathologists need to distinguish the subconjunctival lymphoma that arises in Tenon's capsule from the conjunctival lymphoma in the substantia propria during diagnosis of epibulbar lymphoid tumors.

Aged↗
PubMed2006

In vivo confocal microscopy of pigmented conjunctival tumors.

PURPOSE: To analyze the appearance of conjunctival pigmented tumors as seen by in vivo confocal microscopy. METHODS: Twenty-eight pigmented conjunctival tumors including 6 nevi, 13 acquired melanoses, 7 conjunctival melanomas, and 2 extrascleral growths of uveal melanomas were examined by in vivo confocal microscopy using the Heidelberg Retina Tomograph (HRTII)/Rostock Cornea Modul (RCM). Confocal images were analyzed using predefined criteria by an observer masked to final histological diagnosis and a preliminary diagnosis was established. After excision, histology and immunohistochemistry using antibodies against S-100, Melan-A, HMB-45, Ki-67, CD3, and CD68 were performed in all specimens and compared with in vivo confocal images of the same lesions. RESULTS: Confocal microscopy images confirmed typical histopathological features of conjunctival pigmented tumors. Nest or diffuse collections of medium-sized uniform hyper- or hyperreflective cells in the stroma and stromal cysts lined with a multilayered epithelium were visible in 100% of conjunctival nevi. Small dendritic cells were typically observed in 100% of primary acquired melanoses (PAM) without atypia and in 2 out of 6 nevi. Large networks of hyperreflective dendritic cells were present in 100% of PAM with atypia. Whereas images of PAM without atypia and secondary complexion-associated melanosis showed hyperreflective granules confined to the basal epithelium in 67% of lesions, PAM with atypia presented with hyperreflective granules and patches throughout the epithelium in all cases. Malignant melanomas of the conjunctiva and extrascleral growths of uveal melanomas demonstrated large hyperreflective cells with prominent nuclei and nucleoli. In vivo confocal microscopy showed a sensitivity of 89% and a specificity of 100% to establish the correct diagnosis of conjunctival melanoma compared with histology. CONCLUSIONS: High correlations were found between in vivo confocal microscopy using near-infrared laser light and histology in the diagnosis of pigmented conjunctival lesions. In vivo confocal microscopy seems to be a valuable new tool in the differential diagnosis and follow-up of pigmented conjunctival tumors. It does not replace histology, but may assist in performing guided biopsy in tumors suspected clinically and/or with in vivo microscopy. In addition, in vivo confocal microscopy may support the clinical diagnosis of extrascleral involvement in uveal melanoma.

Adolescent↗
PubMed2006

Malignant melanoma of the conjunctiva with intraocular extension: a clinicopathological study of three cases.

BACKGROUND: Malignant melanoma of the conjunctiva is a rare tumour with an unpredictable behaviour, characterised by the high risk of local recurrence and metastatic spread. Intraocular extension of a conjunctival melanoma is rare. We present three cases of primary conjunctival melanoma with intraocular extension. METHODS: Three patients presented with primary conjunctival melanomas, which either arose at or later involved the limbus on a background of primary acquired melanosis. Despite adequate primary local excision and adjuvant chemotherapy, all three patients experienced several recurrences, requiring further surgery. Two of the patients had excision of the tumour that required superficial keratectomy. One of these patients then required two further procedures in which the anterior chamber was breached. RESULTS: All three patients ultimately required enucleation or exenteration to control local disease. All three specimens showed intraocular extension. CONCLUSIONS: The management of conjunctival melanoma can be difficult. In addition to local recurrence and metastases, limbal melanomas may rarely show intraocular extension, particularly if surgery to excise the tumour requires the removal of Bowman's membrane. Regular follow-up of these patients is mandatory.

Aged↗