SQUAMOUS CELL CARCINOMA

Typical Practice in Rural African Setup

Dr. Anton VurdaftApril 2015

Squamous Cell Carcinoma of Conjunctiva: Definition

Squamous cell carcinoma is a cancer That means it is a malignant tumor It is non-melanocytic It is epithelial It can be on the surface only (non-invasive) It can be invasive to the eyeball and

adnexa

(1)

Risk Factors for SCC

• Living closer to equator (exposure to sunlight)

• More advanced stages and more common in men

• Human papillomavirus type 16 (HPV 16)• HIV (AIDS)

(9)

Squamous Cell Carcinoma: Localization

Eyelids Conjunctiva Cornea Orbit

(1)

Squamous Cell Carcinoma of the Eyelid

5-10% of all eyelid malignancies (second after basal cell carcinoma in western countries)

(1)

Squamous Cell Carcinoma of the Eyelid

(1)

Squamous Cell Carcinoma of the Eyelid

Actinic keratosis is often a precursor of SCC

Squamous Cell Carcinoma of the Eyelid: Pathology

(1) Surface ulceration

(2) Keratin pearls in large nests of squamous epithelium

(3) Isolated nests of malignant cells invading dermis

Squamous Cell Carcinoma of the Eyelid

(1)

Biopsy and histopathology are required most of the times prior to surgical treatment

Invasion of the dermis is the hallmark for the histopathologic diagnosis of invasive SCC

Orbital invasion may be diagnosed with imaging investigations

Squamous Cell Carcinoma of the Eyelid: Prognosis

Risk of metastatic dissemination is 1-21% Eyelid SCC is potentially fatal and

responsible for considerable morbidity Orbital invasion is a rare complication

that has been reported to occur in 2.5 %

(2)

Non-Invasive SCC of the conjunctiva

(3)

Invasive SCC of the Conjunctiva

Invasive conjunctival SCC (Pathology)

(1) – Carcinoma in situ and displasia(2) – Invasive nests of cancer cells

Squamous Cell Carcinoma of the Conjunctiva

Risk of metastatic dissemination is very low (0,5-3%)

Grading of Epithelial Precancerous and Cancerous Lesions of the

Conjunctiva and Cornea

Squamous cell carcinoma is not the only possible diagnosis for the lesion like this

(4)

Grading of Epithelial Precancerous and Cancerous Lesions of the

Conjunctiva and Cornea

Currently the proper diagnosis for any precancerous or cancerous epithelial lesion of the conjunctiva and cornea

before getting the results of histopathology

is OSSN(Ocular Surface

Squamous Neoplasia) (5)

OSSN Definition

Ocular Surface Squamous Neoplasia is any epithelial precancerous or cancerous lesion of the conjunctiva and cornea. This is the only diagnosis we can make without

histopathology.

(6)

(7)

OSSN

OSSN Grading

OSSN can be graded into: • Dysplasia

• Carcinoma in situ (CIS)• Squamous cell carcinoma (SCC)

(8)

Frequency of OSSN

• 0,3 per million in USA• 19 per million in Australia

• Much more common in countries with bigger HIV prevalence

(10)

Clinical SignsIt is difficult to differentiate

between conjunctival epithelial dysplasia, carcinoma in situ and

squamous cell carcinoma clinically

(11)

AIDS and OSSNHIV (AIDS) epidemics caused increased incidence of OSSN

Check CD4 in each patient with presumed OSSN

(12)

Differential Diagnosis of OSSN

Pingueculas, Pterygia, Squamous Papillomas

(13)

Pterygium and OSSN

(14)

Workup

(15)

Different types of cytology or incisional / excisional biopsy are needed to make proper

diagnosis

Workup

(16)

Check for most frequent metastases: preauricular, submandibular, cervical

lymph nodes, parotid gland, lungs, bones

Treatment of OSSN

(17)

1st: initiation of HAART if appropriate (even invasive SCC may resolve)

2nd: excision with safety margins (4 mm)

3rd: antimetabolites4th: frequent reviews for recurrences

OSSN and Recurrences

(18)

Treatment of SCC

(19)

1st: wide excision if possible2nd: eye amputation

3rd: radiotherapy4th: frequent reviews for

recurrences

Eye Amputations

(20)

• Evisceration• Enucleation•Exenteration

Enucleation

Enucleation

Exenteration

(21)

Exenteration: self-granulating wound

Exenteration: orbital invasive SCC

Exenteration: orbital invasive SCC

Exenteration: conjunctival SCC

Prognosis in Invasive Tumors

Invasion: conjunctival, scleral, corneal. Longstanding cases: invasion into the eye and orbit.Metastases: regional lymph nodes (relatively uncommon.Death from metastatic disease is rare (1-2%)

Take Home Messages

(22)

• Do not forget to check regional lymph nodes in patients with tumors

• Motivate patients with OSSN for early treatment

• Avoid excision without antimetabolites• Review patients post excision frequently• Check for HIV/CD4 in all OSSN patients• Do send for histopathology

Thank you