Konjonktival tümörlerin klinik ve histopatolojik analizi

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Introduction
The conjunctival neoplasms are clinically and histopathologically similar to the tumors which arise from other mucous membranes in the body, and
these tumors may originate from both epithelial and
stromal structures. The broad spectrum of conjunctival tumors ranges from non-neoplastic benign tumors to agressive malignancies, such as melanoma or
Kaposi’s sarcoma which may threat visual function
and life of the patient (1-5). These tumors are mainly
classified into melanocytic and non-melanocytic tumors based on clinical evidence of intrinsic pigment
and histopathologic findings (3). The aim of this
study was to analyze the clinicopathologic features of
conjunctival tumors followed at a tertiary care hospital in Turkey.
Material and Methods
This retrospective study included 164 eyes of 164
patients with conjunctival tumors who were operated between March 1995 and March 2010. Medical
records of patients including age, gender, clinical (visual acuity, slit lamp biomicroscopy, fundus evaluation, applanation tonometry) and histopathologic findings were reviewed retrospectively. Ethical guidelines of the Declaration of Helsinki were followed throughout, and the study was approved by the Ethics
Committee of Gulhane Military Medicine Academy
Review Board. The clinical diagnosis of conjunctival
tumor was based on the patients’ history and biomicroscopic features of the lesion. The most common indication for tumor resection was suspected growth of
the tumor according to the patients’ history. The therapeutic options included periodic observation with
digital photographs (Nikon D-100, Japan), surgical
excision and administration of antitumor agent. For
the confirmation of diagnosis, sections from each biopsy specimen were stained with hematoxylin and
eosin stain (1,4).
* Department of Ophthalmology, Gulhane Military Medical Faculty
** General Practitioner, Private Doctor
*** Elazığ Military Hospital
This study was presented as a poster presentation in the 15th Balkan Military
Medicine Meeting (Athens, May 30-June 3, 2010)
Reprint request: Dr. Osman Melih Ceylan, Department of Ophthalmology,
Gulhane Military Medical Faculty, Etlik-06018, Ankara
E-mail: drmelihceylan@hotmail.com
Date submitted: July 02, 2010 • Date accepted: September 14, 2010
SUMMARY
The aim of our study was to analyze the clinicopathologic features of conjunctival tumors followed at a tertiary care hospital in Turkey. One hundred
and sixty four patients with surgically excised conjunctival tumors followed
between March 1995 and March 2010 were retrospectively reviewed. Clinical data were collected from medical records. Age and gender of patients,
and clinical and histopathologic findings of lesions were identified. Of all the
patients 139 (84.75%) were male and 25 (15.24%) were female. The mean
age of the patients was 26.4 years (range 4 to 65 years). Of the 164 conjunctival lesions, 115 (70.12%) were nevus, 12 (7.31%) were chronic inflammation, 9 (5.48%) were pyogenic granuloma, 6 (3.65%) were limbal dermoid, 5
(3.04%) were racial melanosis, 4 (2.43%) were benign lymphoid hyperplasia,
3 (1.82%) were hemangioma, 2 (1.21%) were primary acquired melanosis, 2
(1.21%) were inflammatory polyp, 2 (1.21%) were squamous cell carcinoma,
1 (0.6%) was malignant melanoma, 1 (0.6%) was squamous papilloma, 1
(0.6%) was keratoacanthoma and 1 (0.6%) was non-Hodgkin lymphoma. In
our study, we found that the most common conjunctival benign tumor was
nevus. Although squamous cell carcinoma is a rare conjunctival malignant
tumor, it may be encountered in young age population.
Key words: Conjunctiva, eye, tumor
ÖZET
Konjonktival tümörlerin klinik ve histopatolojik analizi
Bu çalışmanın amacı Türkiye’de üçüncü basamak bir sağlık merkezinde takip
edilen konjonktival tümörlerin klinik ve histopatolojik özelliklerinin değerlendirilmesiydi. Mart 1995 ile Mart 2010 arasında konjonktiva tümörü cerrahi rezeksiyonu uygulanan 164 hasta retrospektif olarak değerlendirildi. Klinik veriler hasta dosyalarından toplanarak elde edildi. Hastaların yaş ve cinsiyetleri ile
lezyonun klinik ve histopatolojik özellikleri belirlendi. Çalışmadaki hastalardan
139’u (%84.75) erkek, 25’i (%15.24) kadın idi. Hastaların ortalama yaşı 26.4
(aralık, 4-65) yıl idi. Yüz altmış dört konjonktival lezyondan 115’i (%70.12)
nevüs, 12’si (%7.31) kronik inflamasyon, 9’u (%5.48) piyojenik granülom,
6’sı (%3.65) limbal dermoid, 5’i (%3.04) ırksal melanozis, 4’ü (%2.43) benign lenfoid hiperplazi, 3’ü (%1.82) hemanjiyom, 2’si (%1.21) primer kazanılmış melanozis, 2’si (%1.21) inflamatuvar polip, 2’si (%1.21) skuamoz hücreli
karsinom, 1’i (%0.6) malign melanom, 1’i (%0.6) hastada skuamoz papillom,
1’i (%0.6) keratoakantoma ve 1’i (%0.6) non-Hodgkin lenfoma olarak belirlendi. Çalışmamızda konjonktivanın en sık gözlenen iyi huylu tümörü nevüs olarak saptanmıştır. Yassı hücreli karsinoma nadir görülen kötü huylu konjonktiva
tümörü olmakla birlikte, genç yaş grubunda da karşılaşılabilir.
Anahtar kelimeler: Konjonktiva, göz, tümörVolume 52 • Issue 4 Conjunctival tumors • 249
Results
Of the 164 patients who had conjunctival tumor
resection, 139 (84.75%) patients were male and 25
(15.24%) patients were female. The mean age of the
164 patients was 26.4 years (range 4 to 65 years). In
our series, the most common histopathologic diagnosis of 164 excised lesions was nevus in 70.12%
(n=115), followed by chronic inflammation in 7.31%
(n=12), pyogenic granuloma in 5.48% (n=9), limbal
dermoid in 3.65% (n=6), racial melanosis in 3.04%
(n=5) (Figure 1), benign lymphoid hyperplasia in
2.43% (n=4), hemangioma in 1.82% (n=3), primary
acquired melanosis (PAM) in 1.21% (n=2), inflammatory polyp in 1.21% (n=2), squamous cell carcinoma
(SCC) in 1.21% (n=2), malignant melanoma in 0.6%
(n=1) (Figure 2), squamous papilloma in 0.6% (n=1),
keratoacanthoma in 0.6% (n=1) and non-Hodgkin
lymphoma (NHL) in 0.6% (n=1), respectively (Table
I). The most common indication for tumor resection
was suspected growth of the tumor. In all cases, the
tumor was excised surgically, 2 (1.21%) SCC and 1
(0.6%) malignant melanoma were treated with topical mitomycin C after tumor resection. None of the
malignant lesions had systemic metastasis and local
recurrence.
Discussion
Tumors of the conjunctiva have a large spectrum
which range from benign lesions to aggressive life
and vision threatening malignancies. Conjunctiva is
a readily visible mucous membrane and it is easy to
evaluate clinical features of lesions by slit lamp biomicroscopy (2). Management of conjunctival tumors
depend on the size and extent of the lesion, which
consist of observation, biopsy, cryotherapy, chemotherapy, radiotherapy, enucleation, orbital exenteration and author’s personal experience. Chi and Baek
reported that most common conjunctival tumors
were melanocytic nevi in 54.2%, and 29.2% of these
tumors was compound nevus (1). Amoli and Heidari
reported that the most common benign primary conjunctival tumor was nevus 38.7% (mean age of the
patients 22.27) and the most common malignant tumor (25.1%) was SCC (mean age of the patients 58.63)
in their series (2). In the present study, the most common tumor was conjunctival nevus in 115 (70.12%)
of the patients and the compound nevus was the
most common type (Figure 3). Conjunctival SCC is
generally seen in elderly male patients. It occurs with
increased frequency in patients with long time exposure to sunlight and xeroderma pigmentosum (2).
Studies of large populations in Congo, Uganda, and
United States have shown that AIDS is an increased
risk factor for the development of conjunctival SCC
(6-8). In our study, SCCs were 1.21% (mean age of
patients 21) of all conjunctival tumors, and none of
Table I. Histopathological classification of conjunctival tumors
Conjuntival tumors (n=164) n %
Nevus 115 70.12
Chronic inflammation 12 7.31
Pyogenic granuloma 9 5.48
Limbal dermoid 6 3.65
Racial melanosis 5 3.04
Lymphoid hyperplasia 4 2.43
Hemangioma 3 1.82
Primary acquired melanosis 2 1.21
Inflammatory polyp 2 1.21
Squamous cell carcinoma 2 1.21
Malignant melanoma 1 0.6
Squamous papilloma 1 0.6
Keratoacanthoma 1 0.6
Non-Hodgkin lymphoma 1 0.6
Figure 1. Racial melanosis
Figure 2. Malignant melanoma250 • December 2010 • Gulhane Med J Ceylan et al.
the patients were affected by HIV or had a history of
long time sunlight exposure and xeroderma pigmentosum. Conjunctival defects more than 4 clock hours
due to excision of large SCCs have been used to repair with tissue replacement techniques (9,10). The disadvantages of conjunctival tissue replacement techniques such as symblepharon, pseudopterygium, tissue foreshortening and recurrence of tumor have encouraged clinicians to investigate alternative or adjuvant treatment options such as topical mitomycin C,
5-fluorouracil and interferon alpha-2B (11-15). In our
study, SCC was treated with topical mitomycin C in
2 (1.21%) cases and mean age of the patients was younger than that of the previously reported cases in
the literature. It is important to recognize the precursor lesions of malignant melanoma including PAM
with atypia and an enlarging or atypical nevus (16).
In our study, malignant melanoma was arised in the
area of PAM with atypia. Racial melanosis, which is
especially bilateral in more heavily pigmented races
is a benign proliferation of melanocytes, but rarely is
unilateral, acquired and can be a precursor of melanoma (16,17).
Ocular adnexal lymphoid tumors may commonly
be seen in the sixth to seventh decade with slightly
female preponderance (18). Non-Hodgkin lymphoma
may involve the eyelids, conjunctiva, orbital connective tissue or lacrimal gland (18). The present study showed 1 (0.6%) male patient presented with conjunctival metastasis of previous NHL which is a rare route of systemic spread. Conjunctival lymphomas often
appear to masquerade as conjunctivitis and a number
of misdiagnoses have been reported (19). Other conjunctival tumors that have malignant potential in our
study group were 2 (1.21 %) PAM, 1 (0.6%) squamous cell papilloma, 1 (0.6%) keratoacanthoma. One
form of conjunctival papilloma is squamous cell papilloma which is caused by infection with HPV (type
6, 11, 16, 33), and papilloma represents 7-10% of conjunctival tumors in childhood and young ages (20,21).
Squamous cell papilloma has a low risk of malignant
transformation and can be treated either by surgical
excision or cryotherapy, but the recurrence rate is unfortunately high (20,22). Conjunctival keratoacanthoma preferentially occurs in the limbic region and
can be mistaken as SCC which has very similar clinical and histopathological findings (23). PAM presents
as a unilateral patchy area of conjunctival pigmentation, mostly found in middle-aged or elderly white patients. The presence or absence of atypia is helpful in determining the potential for malignancy, because PAM without atypia is usually benign (24). In our
series, 2 (1.21%) PAM, 1 (0.6%) squamous papilloma
and 1 (0.6%) keratoacanthoma that have suspected to
be malignant potential were surgically excised and no
presence of atypia was seen except for 1 case with PAM
in histopathologic evaluation.
In conclusion, the present study demonstrated that
nevus was the most common benign conjunctival tumor and malignant tumors of conjunctiva may show
variable features. Conjunctival SCC is a rare malignant tumor and also can be seen in young patients.
Malignant lymphoid tumors of the conjunctiva should be considered in the differential diagnosis of conjunctivitis especially in elderly adults and must be
kept in mind as a rare presentation of systemic metastasis of NHL. Conjunctival melanoma is a potentially lethal neoplasm, and early recognition of precursor lesions have markedly reduced the late diagnosis.