Varying approaches to challenging area of ocular surface tumours

Leigh Spielberg

Posted: Saturday, October 7, 2017

Dr Sotiria Palioura addressing delegates at the  Focus Session on Ocular Surface Tumors

The Focus Session on Ocular Surface Tumors at the 8th EuCornea Congress in Lisbon was well attended, as delegates packed the auditorium to hear five experts discuss their approach to this challenging disease category.

Dr Sotiria Palioura, Athens Vision Eye Institute, Athens, Greece, presented delegates with an overview of the etiopathogenesis and diagnosis of ocular surface tumours (OSTs). These include ocular surface squamous neoplasia (OSSN) and conjunctival melanoma.

Dr Palioura explained her systematic approach, starting with clinical history, review of risk factors, examination, clinical features, tissue biopsy and imaging. Very useful were her tips on how to make crucial clinical decisions, such as when to biopsy primary acquired melanosis (PAM).

“This should be done when the lesion is thickened, vascular, large or multifocal, if there is pigment in the fornix or the tarsal conjunctiva, or if the patient has a history of skin cancer,” she said. Biopsy is necessary
to identify atypia.

Professor Harminder Dua, Queen’s Medical Centre, Nottingham, UK, elucidated his medical management of OSTs.

“Medical treatment can be given before, after or before and after surgery of OSSN,” said Prof Dua. His chemotherapy regimen is three cycles of mitomycin-C in the relatively high concentration of 0.04%. Topical interferon alpha 2b (1 million units/ml) and intralesional 5-fluorouracil (2.5mg in 0.1ml) are alternatives, and oral cimetidine 800mg can be associated.

“With modern treatment, local recurrence rates are 5% and regional lymph node metastasis <2%,” he said.

After Prof Dua’s talk on medical management, Ann Schalenbourg, Jules-Gonin Eye Hospital,
Lausanne, Switzerland, covered
the surgical approach.

“General principles include a no-touch technique, dry surgery, prevention of haemorrhage and changing of all instruments once the tumour has been removed,” said Dr Schalenbourg, highlighting the need to avoid spread of tumour cells. “I treat every naevus as though it’s a melanoma, because you really never know for sure.”

Perfect preparation of the specimen is also crucial, as this allows proper analysis of the excisional margins by the pathologist.

“Surgical treatment often requires a strategy combining excision with circumscribed radiation therapy, cryotherapy and topical chemotherapy. A proactive management approach at the first intervention is the best guarantee to avoid recurrence,” she advised. But what about the situation after treatment?

Raffaele Parrozzani, University of Padova, Italy, covered his strategy for monitoring and follow-up of patients with OSTs. This is a crucial period regarding prognosis. “Improvement in survival rates is due to the treatment of a higher proportion of pre-malignant proliferation rather than waiting for malignancy to occur and then treating them,” said Dr Parrozzani. The watch-and-wait approach is not treatment and does not improve patient survival.

So, what needs to be monitored? Conjunctival naevi? “No, these patients simply need to be reassured.” Primary acquired melanosis? “No, these need to be treated.” Strange or undefined lesions? “No, these need to be referred to an ocular oncologist for biopsy and correct diagnosis.”

Professor Carol Karp, Bascom Palmer Eye Institute, Miami, Florida, USA, then outlined how the use of OCT has revolutionised her ocular surface oncology practice.

“Every patient of mine gets an OCT,” said Dr Karp. Although it is not a substitute for histopathology, it provides a lot of clues as to the nature of the lesion as well as its location, assisting the surgeon to biopsy  correctly and efficiently.