Conjunctival epitheliomas and related lesions

R Gogi; K Nath; AK Govil

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Year : 1976 | Volume : 24 | Issue : 4 | Page : 1-8

Conjunctival epitheliomas and related lesions

R Gogi, K Nath, AK Govil
M. U. Institute of Ophthalmology, Aligarh, India

Correspondence Address:
R Gogi
M. U. Institute of Ophthalmology, Aligarh
India

Source of Support: None, Conflict of Interest: None

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How to cite this article:
Gogi R, Nath K, Govil A K. Conjunctival epitheliomas and related lesions. Indian J Ophthalmol 1976;24:1-8

How to cite this URL:
Gogi R, Nath K, Govil A K. Conjunctival epitheliomas and related lesions. Indian J Ophthalmol [serial online] 1976 [cited 2021 Apr 18];24:1-8. Available from: https://www.ijo.in/text.asp?1976/24/4/1/31273

Table 1

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Epithelioma of the conjunctiva is a grade I carcinoma.[5] It commonly occurs at the limbus where two types of epithelia merge together and it generally affects the interpalpebral zone on temporal side.[13] However, there are reports of its occurance on the nasal side as well.[19],[28],[30],[38],[48] The other common site is the caruncle, where it may arise from the epithelium of sebaceous gland [4],[11],[20],[22],[36],[37] Rarely the tumour may be bilateral [1],[7],[30][32],[33] and is common in old age.[25]

Clinically the lesion may appear either as a small grey raised patch which rapidly increases in size and gets vascularized into a papillary type[13] or it may remain stationary for a variable period and then start growing.[13],[19] A sudden increase in the size of a small yellowish nodule that was present for 29 years has also been reported.[28] Epitheliomas extend over the cornea and bulbar conjunctiva, the corneal ones are frequently marked by keratitis and iridocyclitis,[13] but rarely penetrate the sclera.[18],[51]

Limbal epitheliomas rarely metastasize.[19] Beside the typical clinical manifestations, a neoplasm of the conjunctiva can masquerade for a long period as cases of conjunctivitis and keratltis.[43],[44]

Apart from the established cases of epitheliomas, there is another limbal lesion which is slightly elevated, vascularized, gelatinous looking and remains entirely confined to the epithelium for years. It is intraepithelial epithelioma or Bowen's disease[35] or carcinoma in-situ.[51] This lesion was first described by Bowen[8] in 1912 in the skin who considered it to be a precancerous condition. The subject was put on firm footing by Darier[9] and Jessner.[21] Thereafter, reports on limbal manifestations of Bowen's disease also started appearing in the literature.[3],[15][23],[26],[27],[31],[34],35],[40],[41],[42],[46],[49],[50]

There is another group of non neoplastic lesions of the conjunctiva which clinically may look like epithelioma or carcinoma-in-situ but histologically these are benign, such as pseudoepitheliomatous hyperplasia and leukoplakic lesions. In the present paper we want to share our experiences regarding conjunctival epitheliomas and other related lesions in eight such cases studied at M.U. Institute of Ophthalmology, Aligarh.

Case Reports

Eight cases from different age groups manifesting as conjunctival or limbal swellings were examined. Various clinical findings and presumptive clinical diagnosis are shown in [Table - 1].

Biospy material was taken in all the cases after cauterizing the feeding blood vessels. Histopathology of the material suggested malignancy in cases 1 to 6 and the lesion was obviously benign looking in cases 7 and 8. Accordingly enucleation was carried out in cases no. 2, 3, 4 and 6 [Figure - 7],[Figure - 8]. Since the lesion was localized to the upper palpehral conjunctiva in case 5, the eye was not sacrificed and a local excision was attempted. Case No.1 did not agree for enucleation therefore the diagno sis was based on biopsy material. In the remaining two patients (Case No. 7 & 8) local excision of the mass was carried out.

Histopathological Features

On histological examination of the tissues, four types of histology were seen, viz. carcinoma in situ (1) epithelioma (5), pseudoepitheliomatous hyperplasia (1) and leukoplakic lesion (1).

I. Carcinoma in situ. In case no. 3, there was abrupt transition from the normal corneal and conjunctival epithelium [Figure - 9]. There was loss of polarity in the epithelial cells which varied in size, shape and staining characteristics [Figure - 10]. Some of the cell nuclei were clumped and showed hyperchromatism.

Typical Bowen's cells were conspicuously absent. Bowman's membrane and basement membrane of the cogjunctiva were intact and there was intense lymphocytic infilteration and increased vascularity under these membranes [Figure - 11]. Sections at different levels of the eyeball did not show any variation.

II. Epitheliomas . In the patient it was localized to the palpebral conjunctiva (Case 5, [Figure - 4]), while amongst the rest it affected both the bulbar conjunctiva and cornea. Histologically, the cells of the surface epithelium were dipping down into the cornea and sclera in a branching pattern [Figure 12]. There was formation of epithelial purls or cell nests [Figure 13]. Epithelial cells showed hyperchromatism and abnormal mitosis. However, case No. 2, proved to be an invasive carcinoma as the malignant cells were seen to infilterate the ciliary body [Figure - 14] and iris [Figure - 15].

III. Pseudoepitheliomatous Hyperplasia . In case No. 7, histology revealed hyperkeratosis and acanthosis while the cells were dipping at different levels, basement membrane was intact and there was infilteration of the deeper tissues by chroncinflammatory cells. [Figure - 16]. There was no evidence of dyskeratosis or atypism and the whole process was entire!y benign and reactive.

An analysis of histological findings is summarised in [Table - 1].

Comments

In the present study in most of the cases the epithelioma occurred between 57 to 60 years of age, the youngest patient was 35 years old and four males and one female were affected. Carcinoma in situ was recorded in a 66 years old male. Conjunctival epitheliomas have been known to affect males predominen

tly.[2],[38],[39] In an analysis of 93 cases, Ash and Wilder[2] described 50-80 years as the commonest range for the occurence of this tumour. His youngest patient was 2 years and the oldest 97 years. Sheta,[39] in a study of 33 cases recorded that most of his cases were above 40 years of age. However, this lesion has been reported at 23 and 16 years of age.[29],[30] In the latter case the lesion was bilateral.[30]

Limbal epithelium; is the favourite site for the conjunctival epitheliomata,[13] however, palpebral conjunctiva is not immune to the neoplastic changes.[5],[20],[47] In one of our cases the lesion was entirely localized to the upper palpebral region (Case-5). Apart from these limbal tumours there are other non-neoplastic lesions such as epithelial plaques, pseudo-epitheliomatous hyperplasia and keratoacanthoma, which simulate closely the true tumours and create a major pitfall in the clinical diangosis.[16],[39],[48],[51] We also encountered the same problem with cases 7 and 8 and it was only after the examination of biopsy tissue that benign nature of the lesion vas confirmed. Short of biopsy conjunctival exfoliative cytology has also been suggested to be a reliable method to fix up the nature of the lesion. [10],[12],[14],[24],[25],[45] This technique has an added advantage that a masquerading timbal epithelioma as conjunctivitis or keratitis for a long period can also be diagnosed.[43],[44]

Bierge[6] while studying epitheliomata of eyelids, conjunctiva and cornea, stressed that the lesions of the conjunctiva are more malignant and have a higher mortality as compared to the lesions of lower lids. However, it is now established that conjunctival epitheliomas are carcinomas of grade I.[31],[51] These lesions tend to be exophytic and in the majority of cases do not show intraocular extensions.[2],[3],[18],[35] Malignancy of epibulbar squamous cell epitheliomas decreases with the proximity to the cornea.[19] The relative immunity of intraocular structures is due to the considerable resistance offered by Bowman's and Descement's membranes.[13] However, one of our patients (Case-2) did show complete penetration of the eye coats in the limbal region and tumour cells could be recognised in ciliary body and iris [Figure - 14][Figure - 15]. On clinical grounds case no. 2 and 3 were quite similar, so the eye was enucleated in case-3 [Figure - 7] as well. On histopathological examination the microscopic picture was very much disturbing as the findings were consistent with carcinoma in situ. We think this case might have been handled better by some other procedure short of enucleation. On clinical grounds it is not possible to decide as to which case requires simple excision or a radical enucleation. Even exfoliative cytology or a biopsy can not solve this delimma. We feel convinced with the argument that the limbal epitheliomas should be treated by local excision and the procedure can be repeated if necessary.[19] Zimmerman[51] described similar experiences where eye was enucleated because of extensive lesions but on histology there was no intraocular extension. He also advocated a conservative surgery in these cases especially when the carcinoma is low grade in the order of malignancy.

Finally, the terms like Bowen's carcinoma or intraepithelial carcinoma or carcinoma in situ require some clarification. Bowen's disease is a rare cutaneous tumour in which malignant changes in the cells remain localized to intraepithelial zone and metastasis from the skin rarely develops but there is a high incidence of associated cancer of vicera.[17] As there is no similarity between the Bowen's disease of the skin and that of conjunctiva, it will be better to call it carcinoma in situ or intraepithelial carcinoma and the term Bowen's disease should not be used too loosely.[51] In our opinion, Bowen's disease should be limited as a clinical term and carcinoma in situ or intraepithelial carcinoma as a histopathological diagnosis.

Summary

1. In the present study, clinico-pathological findings in one case of carcinoma in situ five cases of conjunctival epithelioma and one case each of pseudoepitl-eliomatous hyperplasia and leukoplakic lesion have been described.

2. Epitheliomas were situated on temporal side of the limbus (two cases), nasal side of limbos (one case), upper palpebral conjunctiva (one case) and covered whole of cornea and bulbar conjunctiva (one case).

3. In one case intraocular extensions were detected.

4. Difficulties in differentiating a carcinoma in situ and an invasive carcinoma on clinical grounds have been underlined.

5. Conservative treatment short of enucleation is advocated.

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