Eye precancerous lesions mimic benign pyogenic granuloma

Not all pyogenic granulomas are equally safe. Some of them may comprise an elements of ocular surface squamous neoplasia, OSSN (conjunctival intraepithelial neoplasia, CIN). The paper Herwig-Carl MC, Grossniklaus HE, Müller PL, et al. Br J Ophthalmol Epub. doi:10.1136/ bjophthalmol-2018-312960 highlighted 9 such cases.

OSSN is extremely common in the areas with widespread HIV-prevalence. Human papilloma virus is responsible for this, as a typical opportunistic infection. Knowledge of the potential of OSSN to mimic pterygia and pyogenic granulomas is crucial, especially for the mid level ophthalmic personnel, as they are the primary surgeons for these conditions in many areas.

Pyogenic Granuloma Associated With Conjunctival Epithelial Neoplasia: Report of Nine Cases

Aims: To systematically describe the clinical and histopathological features of a case series of conjunctival carcinomatous lesions underlying as-and also masquerading-pyogenic granuloma.

Methods: Nine cases of conjunctival carcinomatous lesions underlying a pyogenic granuloma (which were clinically predominant) were retrospectively identified. Patients’ records were analysed for demographic data, clinical appearance and the postoperative course. Formalin-fixed paraffin-embedded specimens were routinely processed and stained with H&E and periodic acid-Schiff. Immunohistochemical stains for cytokeratin were performed in selected cases.

Results: All nine tumours were located in the conjunctiva (bulbar, tarsal, limbal conjunctiva) of patients between 44 and 80 years. The lesions exhibited clinical features of pyogenic granuloma which dominated the clinical appearance. Additional features comprised a papillomatous appearance of the adjacent conjunctiva, a more whitish aspect of the lesion and a history of squamous cell carcinoma (SCC) respectively surgery for other entities. Histopathological analysis revealed a carcinomatous lesion (conjunctival intraepithelial neoplasia or SCC) at the base of a classic pyogenic granuloma in all nine cases. Surgical removal (R0 resection) was performed. Three cases received adjuvant mitomycin C or interferon α2b treatment. Two lesions locally recurred within 2 years after initial presentation.

Conclusion: Carcinomatous lesions may be accompanied by a pyogenic granuloma which may dominate the clinical pictures. As the tumour is usually located at the base of the lesion, a complete surgical excision followed by histopathological analysis is mandatory for each lesion appearing as conjunctival pyogenic granuloma.

Keywords: conjunctival intraepithelial neoplasia; histology; pyogenic granuloma; squamous cell carcinoma; tumour.

One more squamous cell carcinoma of conjunctiva

In EnglishEN: A case of September 2016. Squamous cell carcinoma of conjunctiva (SCC). A young male patient had recently found out his positive HIV status. This SCC is yet presumably non-invasive to the sclera. This tumor was unresponsive to three on-off cycles of 5-fluorouracyl (5-FU) eye drops. The risk of recurrence after simple excision with antimetabolites is relatively high.

Of interest: the eye removal (enucleation) was not indicated. The tumor was excised (no-touch technique) with application of 5-FU. Superficial sclerectomy is also a good additional measure to avoid recurrence in cases suggestive of sclera invasion. However in this case an additional cryotherapy was planned, but failed due to machine failure. The patient was referred for the cryo into the capital city.

Also of interest: it is not wise to cover the resultant defect with conjunctiva, there is a risk of recurrence, which we can thus miss. Nevertheless, the option of amniotic membrane coverage is described in the literature, and I witnessed this technique in the USA.

The chances for exenteration in future in African setup are relatively high! The patients with the eyes, which can see 1,0, rarely allow eye amputation, thus receiving often a super-huge tumors, amenable only to exenteration!

A similar case was already presented in the Atlas (see the link below).

in Russian / по-русскиRU: Случай от сентября 2016 г. Плоскоклеточный рак конъюнктивы. Молодой пациент, недавно узнавший о своём положительном статусе по ВИЧ. Плоскоклеточный рак, предположительно пока без склеральной инвазии. Этой опухоли не помогли три цикла химиоредукции с 5-фторурацилом. Крайне высокие риски на рецидив, даже с применением антиметаболитов.

Ложе после удаления опухоли конъюнктивой не покрывается: это чревато пропуском рецидивов. Тем не менее, в США я наблюдал покрытие ложа амнионом. Такое описано в литературе и часто практикуется.

Тактика на момент лечения не включала в себя удаление глаза! Эта опухоль была иссечена. Недостаточно глубоко.. Планировал крио, но вышли проблемы с газом. При отсутствии крио шансы на повторный рост были очень высокие: такие опухоли требуют помимо аппликации антиметаболитов и некоторый объём склерэктомии (чего в данном случае не было сделано). Пациент был направлен на криолечение в столицу. Шансы на то, что закончиться это могло, тем не менее, не энуклеацией – экзентерацией, – относительно немалые, по простой причине: пациенты, особенно с рецидивами, и особенно со зрением единица – не готовы к удалению глаза, запуская рост опухоли до крайних размеров.

Аналогичный случай с похожей опухолью уже представлен в атласе: Conjunctival Squamous Cell Carcinoma.

Advanced OSSN

Advanced OSSN

Advanced OSSN

Advanced OSSN

Advanced OSSN ultrasound biomicroscopy

Invasive squamous cell carcinoma of conjunctiva looks like melanoma

In EnglishEN: Case of May 2016: patient presented with this brown elevated slowly-growing mass. Differential in our setup will always include OSSN. We know that conjunctival melanoma, uveal melanoma and skin melanoma are all quite rare in dark skinned people, though we consider it for differential as well (PMID 18191091). Histopathology confirmed invasive squamous cell carcinoma. It is hardly probable for OSSN to be black in white people. Nevertheless it is quite common in blacks.

Ideal treatment: wide excision with no-touch technique, followed by antimetabolites (5-FU/MMC) or cryotherapy. Lamellar sclerectomy is indicated when invasion is suspected. This case was managed without cryo. The technique for cryo is good described here:

Cryoprobe was placed on the lifted conjunctival margin for 3 seconds and then allowed to thaw. • A subsequent 3-second application would be applied adjacent to and slightly overlapping the prior application. Upon reaching the limbal margin, the cryoprobe was placed such that it would freeze the limbus and about 0.5mm of cornea.


in Russian / по-русскиRU: Инвазивный плоскоклеточный рак: чёрный маскарад. Случай от мая 2016 г.
Редкий случай чёрной поверхностной неоплазии глаза. В дифференциальный диагноз входила меланома, однако гистология подтвердила инвазивный плоскоклеточный рак. Довольно нетипичная пигментация, даже для чернокожих. Известно, что поверхностная неоплазия у белых людей практически не бывает пигментированной. В то же время, это не редкость среди людей с тёмной кожей. Полезный факт – всё глазные варианты меланомы – меланома кожи, сосудистой оболочки глаза и конъюнктивы глаза – встречаются значительно реже у чернокожих людей. Средняя по больнице заболеваемость конъюнктивальной меланомой – 0,012 на 100 тыс. населения (PMID 9763137). Но у чернокожих людей частота меланомы минимум в 3-4 раза меньше, чем у белых (PMID 18191091).

Invasive pigmented squamous cell carcinoma of conjunctiva. DDx: melanoma.

Invasive pigmented squamous cell carcinoma of conjunctiva. DDx: melanoma.

Pterygium-Werewolf: pterygium or OSSN?

In English

In EnglishCase of April, 2016.
This is pterygium, believe it or not. This was, however, sent for histopathology after excision. The results excluded neoplasia. We used to treat such cases like an OSSN (ocular surface squamous neoplasia), i.e., with no-touch ablastic technique and 5-FU application at the end of surgery. Ideally cryo is to be added to the margins of the conjunctiva +/- to the scleral bed, when invasion is suspected.
We had had several similar cases, where presumed OSSN hosted at the pterygium. Several of them were confirmed only as pterygium via pathology. To our deepest surprise. The only thing to be added here, is that that pathology was highly likely performed by the same one pathologist. Which naturally cares risk of bias.

Случай от апреля 2016 г.in Russian / по-русски

Птеригиум-оборотень. Случай, показывающий общность механизмов развития птеригиума и плоскоклеточных неоплазий поверхности глаза.
По результатам гистологии в этом образовании дисплазии замечено не было (!). Заключение: птеригиум. Подобные истории уже бывали. Правда, все они были интерпретированы одним гистологом из столицы. В этом месте мог зарыться глубокий bias.

Pterygium or OSSN? Looks like the mix, confirmed as pterygium.