SURGICAL EXCISION OF LIMBAL SQUAMOUS CELL CARCINOMA

WITH CRYOTHERAPY AND MITOMYCIN-C

Dr. Neelam yadavDr.somen misra

Dr. Shubhangi Nigwekar

INTRODUCTION

• Squamous cell carcinomas are commonly seen in eye at transitional zone of epithelium-the limbus and eye lid margin1.

• Limbal lesion spreads over the ocular surface and enters the fornices but rarely penetrates the globe.

• Cryotherapy is the application of extreme cold to destroy abnormal or diseases tissue.

• Its goal is to decrease cell growth and reproduction, increase cellular survival, decrease pain and spasm, promote the constriction of blood vessel.

• To prevent the high post surgical recurrence, intraoperative 0.02% Mitomycin-C eye drops have been used and for suspected post operative recurrence , topical 0.02% Mitomycin-C has been tried.

• For deep invasive carcinomas even destructive exenteration may be needed.

Case Report• A 40 year old male patient presented with

painless, progressive,reddish,thick irregular mass in the right eye with mild visual blurring since two months.

• Patient is HIV positive since 5year and on zidovudine-lamivudine-nevirapine

• No history of similar complaints or trauma in past.

• General and Systemic Examination of patient was normal.

• Best corrected visual acuity of patient was 6/9 in right eye and 6/6 in left eye.

Slit lamp examination : • Right eye showed 4mm x

6mm,irregular,reddish, vascularized mass at 3 o’ clock limbus which was encroaching 4mm on the cornea.

• Rest of the anterior and posterior segment examination was found to be normal in both eyes.

• Limbal carcinoma was the clinical diagnosis.

Management• Right eye nasal limbal mass was excised

under local anesthesia.• Deep keratectomy was performed and a

deep conjunctival excision was done leaving a bare sclera.

• Cryotheraphy to the bulbar conjunctiva adjacent to the incision around the lesion and to the sclera underlying the site excised limbal lesion was performed to reduce the likelihood of recurrence.

• Topical chemotherapy using mitomycin C (0.02%) drops were administered four times daily for 1 to 2 weeks after the corneal epithelium had healed.

• Histopathology confirmed the diagnosis of squamous cell carcinoma and showed stratified squamous epithelium with disordered proliferation of the cells having large pleomorphic, hyperchromatic nucleus, prominent nucleoli irregular membrane and scant cytoplasm with high N:C ratio.

• Postoperatively there was no recurrence.

Discussion

• The average annual incidence of squamous cell carcinoma of the conjunctiva across all age groups has been estimated to be 17-20 cases per million persons per year.

• Chronic irritation to the conjunctiva has been considered to be a predisposing factor. It tends to occur most frequently at transitional zones of two kinds of epithelia, namely the limbus and the lid margins2.

Discussion

• Histological picture of carcinoma in situ shows dysplastic changes throughout the epithelium and squamous cell carcinoma shows downward proliferation of irregular, dysplastic squamous epithelium with infiltration of subepithelial tissue.

• Invasive squamous cell carcinoma is characterised by a mass composing of malignant appearing cells invading through the basement membrane and invade the substantia propria of the conjunctiva or cornea.3

Discussion

• However post excision recurrence rate is high for which intraoperative application of 0.02% Mitomycin-C on bare sclera has been tried and if still recurrence is suspected, topical 0.02% Mitomycin-C can be used as QID for 2 weeks7.

• In our case, we performed wide total excision of the mass with cryotherapy and post operatively topical Mitomycin-C was used in tapering dose, which rewarded good postoperative cosmetic result without recurrence.

Discussion

• Treatment of squamous cell carcinoma ranges from simple topical 0.02% Mitomycin C eye drops or total surgical wide excision to exenteration based on the size of the lesion, deeper invasion and general health of the patient.4,5

• To prevent recurrence after excision, cryotheraphy is a good option.

CONCLUSION

• Squamous cell carcinoma in patients with concurrent AIDS are particularly likely to exhibit rapidly progressive malignant conjunctival and corneal neoplasm of the SSE and metastasis of those neoplasms.

• Patients whose conjunctival and corneal SSE tumors are excised completely by histopathological criteria are usually cured.

• Supplementation of excision with cryotherapy and administration of mitomycin C prevents the likelihood of recurrence.

References1.Maria et al. Squamous cell carcinoma of limbus. Indian J Ophthalmol 1965;13:68-70

2. Lee GA, Hirst LW. Ocular surface squamous neoplasia. Surv Ophthalmol 1995; 39: 429–50.

3. Waring III, GO Roth AM, Ekins MB. Clinical and pathological description of 17 cases of corneal intraepithelial neoplasia. Am J Ophthalmol 1984; 97: 547–59.

4. Shields JA et al. Surgical management of conjunctival tumors. Arch Ophthalmol 1997; 115: 808–15.

5. J. Freedman, Rohm. Surgical management and histopathology of invasive tumours of the cornea .British Journal of Ophthalmology 1979; 63: 632-635

6. Shields CL, Naseripour M, Shields JA. Topical mitomycin C for extensive, recurrent conjunctival-corneal squamous cell carcinoma. Am J Ophthalmol. 2002 May;133(5):601-6.