Successful Treatment of Intraocularly Invasive Conjunctival Squamous Cell Carcinoma With Proton Beam Therapy

Abstract

Due to an increase in UV light exposure, conjunctival squamous cell carcinoma has become increasingly more prevalent throughout the world. However, primary intraocular invasion from conjunctival squamous cell carcinoma still remains rare and is therefore often misdiagnosed. Larger, more aggressive lesions that invade the eye are frequently not amenable to standard excision and cryotherapy. For the treatment of such lesions, most authors advocate enucleation or exenteration if there is evidence of orbital invasion. 1-4 The present case suggests that proton beam therapy may be a reasonable alternative to enucleation for the treatment of squamous cell carcinoma with intraocular invasion. To our knowledge, this is the first report of the treatment of invasive conjunctival squamous cell carcinoma using proton beam therapy.

Treatment of invasive ocular surface squamous neoplasia with proton beam therapy

“…It has been used successfully to treat head and neck SCCs, 4 carcinomas elsewhere, 5 as well as other ocular tumours (mainly choroidal melanoma). 6 Only one case is reported in the literature for which PBT was successfully used as primary treatment for invasive OSSN 7 and we report the first two successful cases in United Kingdom. A case series in which PBT was used for recurrent OSSN or where the surgical margins were involved after excision was published with encouraging results.…”

Treatment of invasive ocular surface squamous neoplasia with proton beam therapy

“…It has been used successfully to treat head and neck SCCs, 4 carcinomas elsewhere, 5 as well as other ocular tumours (mainly choroidal melanoma). 6 Only one case is reported in the literature for which PBT was successfully used as primary treatment for invasive OSSN 7 and we report the first two successful cases in United Kingdom. A case series in which PBT was used for recurrent OSSN or where the surgical margins were involved after excision was published with encouraging results.…”

Intraocular Invasion by Conjunctival Squamous Cell Carcinoma: Clinical Presentation, Histopathological Findings, and Outcome

“…However, conservative treatments do not allow safe oncologic surgical margins, and recurrences occurred in ∼50% of cases managed by both techniques, that ultimately required enucleation. A treatment with proton-beam therapy only after excisional biopsy has also been reported, without recurrence over a short follow-up of 9 months [10]. In our series, the 4 cases were not eligible to primary irradiation (by brachytherapy, proton therapy, or external photon therapy) due to the impossibility to assess the exact microscopical limits of intraocular spread, and because we usually indicate irradiation to treat microscopic residual disease, and believe that the delivered dose would have not been sufficient to control macroscopic disease before surgical removal.…”

“…Cases reporting history of superficial surgery for recurrent atypical pterygium, or one or several excision biopsies for conjunctival SCC may be explained by multifactorial mechanisms, such as scleral or limbal microarchitecture perturbation, local inflammation, weakening and thinning of the sclera and/cornea leading to easier invasion by the SCC through the eye wall. History of intraocular surgery had been reported in a few cases [10,13,[17][18][19], usually performed in the case of misdiagnosed or subclinical conjunctival SCC. In those cases, intraocular invasion may have occurred by direct intraocular insemination of tumor cells by surgical instruments.…”

Gamma Knife Stereotactic Radiosurgery for Conjunctival Squamous Cell Carcinoma Invading the Anterior Orbit: A Case Series

“…SCC limited to the conjunctiva is well known to be responsive to treatment with ionizing radiation in the form of brachytherapy and proton beam radiotherapy [18][19][20][21][22]. The radiation dose needed to treat orbital SCC is on average 50 Gy [23,24], which exceeds the tolerance of the eye Color version available online and periocular structures and is likely to cause radiation related complications if delivered using EBRT.…”

Treatment of invasive ocular surface squamous neoplasia with proton beam therapy

“…It has been used successfully to treat head and neck SCCs, 4 carcinomas elsewhere, 5 as well as other ocular tumours (mainly choroidal melanoma). 6 Only one case is reported in the literature for which PBT was successfully used as primary treatment for invasive OSSN 7 and we report the first two successful cases in United Kingdom. A case series in which PBT was used for recurrent OSSN or where the surgical margins were involved after excision was published with encouraging results.…”

Intraocular Invasion by Conjunctival Squamous Cell Carcinoma: Clinical Presentation, Histopathological Findings, and Outcome

“…However, conservative treatments do not allow safe oncologic surgical margins, and recurrences occurred in ∼50% of cases managed by both techniques, that ultimately required enucleation. A treatment with proton-beam therapy only after excisional biopsy has also been reported, without recurrence over a short follow-up of 9 months [10]. In our series, the 4 cases were not eligible to primary irradiation (by brachytherapy, proton therapy, or external photon therapy) due to the impossibility to assess the exact microscopical limits of intraocular spread, and because we usually indicate irradiation to treat microscopic residual disease, and believe that the delivered dose would have not been sufficient to control macroscopic disease before surgical removal.…”

“…Cases reporting history of superficial surgery for recurrent atypical pterygium, or one or several excision biopsies for conjunctival SCC may be explained by multifactorial mechanisms, such as scleral or limbal microarchitecture perturbation, local inflammation, weakening and thinning of the sclera and/cornea leading to easier invasion by the SCC through the eye wall. History of intraocular surgery had been reported in a few cases [10,13,[17][18][19], usually performed in the case of misdiagnosed or subclinical conjunctival SCC. In those cases, intraocular invasion may have occurred by direct intraocular insemination of tumor cells by surgical instruments.…”

Gamma Knife Stereotactic Radiosurgery for Conjunctival Squamous Cell Carcinoma Invading the Anterior Orbit: A Case Series

“…SCC limited to the conjunctiva is well known to be responsive to treatment with ionizing radiation in the form of brachytherapy and proton beam radiotherapy [18][19][20][21][22]. The radiation dose needed to treat orbital SCC is on average 50 Gy [23,24], which exceeds the tolerance of the eye Color version available online and periocular structures and is likely to cause radiation related complications if delivered using EBRT.…”

Treatment of invasive ocular surface squamous neoplasia with proton beam therapy

“…It has been used successfully to treat head and neck SCCs, 4 carcinomas elsewhere, 5 as well as other ocular tumours (mainly choroidal melanoma). 6 Only one case is reported in the literature for which PBT was successfully used as primary treatment for invasive OSSN 7 and we report the first two successful cases in United Kingdom. A case series in which PBT was used for recurrent OSSN or where the surgical margins were involved after excision was published with encouraging results.…”

Intraocular Invasion by Conjunctival Squamous Cell Carcinoma: Clinical Presentation, Histopathological Findings, and Outcome

“…However, conservative treatments do not allow safe oncologic surgical margins, and recurrences occurred in ∼50% of cases managed by both techniques, that ultimately required enucleation. A treatment with proton-beam therapy only after excisional biopsy has also been reported, without recurrence over a short follow-up of 9 months [10]. In our series, the 4 cases were not eligible to primary irradiation (by brachytherapy, proton therapy, or external photon therapy) due to the impossibility to assess the exact microscopical limits of intraocular spread, and because we usually indicate irradiation to treat microscopic residual disease, and believe that the delivered dose would have not been sufficient to control macroscopic disease before surgical removal.…”

“…Cases reporting history of superficial surgery for recurrent atypical pterygium, or one or several excision biopsies for conjunctival SCC may be explained by multifactorial mechanisms, such as scleral or limbal microarchitecture perturbation, local inflammation, weakening and thinning of the sclera and/cornea leading to easier invasion by the SCC through the eye wall. History of intraocular surgery had been reported in a few cases [10,13,[17][18][19], usually performed in the case of misdiagnosed or subclinical conjunctival SCC. In those cases, intraocular invasion may have occurred by direct intraocular insemination of tumor cells by surgical instruments.…”

Gamma Knife Stereotactic Radiosurgery for Conjunctival Squamous Cell Carcinoma Invading the Anterior Orbit: A Case Series

“…SCC limited to the conjunctiva is well known to be responsive to treatment with ionizing radiation in the form of brachytherapy and proton beam radiotherapy [18][19][20][21][22]. The radiation dose needed to treat orbital SCC is on average 50 Gy [23,24], which exceeds the tolerance of the eye Color version available online and periocular structures and is likely to cause radiation related complications if delivered using EBRT.…”