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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 724-726

Verrucous carcinoma of the conjunctiva – A rare variant of squamous cell carcinoma


Department of Cornea and Refractive Services, Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India

Date of Submission14-Sep-2020
Date of Acceptance23-Apr-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Varun A Gupta
Department of Cornea and Refractive Services, Sadguru Netra Chikitsalaya, Jankikund, Chitrakoot - 210 204, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2965_20

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  Abstract 


Verrucous carcinoma is a rare and indolent variant of squamous cell carcinoma. We report the first histopathologically confirmed case of verrucous carcinoma of the conjunctiva. An 85-year-old male presented with complaint of mass in interpalpebral region in the left eye. Examination revealed a single, sessile, pale-colored exophytic mass with a pebble surface approximately 15 mm × 10 mm in size. Patient did not respond to topical therapy and underwent complete excision of the lesion with biopsy. Histopathological examination of the excisional biopsy revealed a diagnosis of verrucous carcinoma. The patient was healthy with no signs of recurrence at 2 years follow-up.

Keywords: Conjunctival neoplasm, squamous cell carcinoma, verrucous carcinoma


How to cite this article:
Meena AK, Parmar G, Gupta VA, Gupta S. Verrucous carcinoma of the conjunctiva – A rare variant of squamous cell carcinoma. Indian J Ophthalmol Case Rep 2021;1:724-6

How to cite this URL:
Meena AK, Parmar G, Gupta VA, Gupta S. Verrucous carcinoma of the conjunctiva – A rare variant of squamous cell carcinoma. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 21];1:724-6. Available from: https://www.ijoreports.in/text.asp?2021/1/4/724/327658



Verrucous carcinoma (VC) is an uncommon and indolent variant of squamous cell carcinoma, first described by Ackerman in 1948. The characteristic features of VC are slow growth, which is described as erosive rather than invasive, and a well-differentiated cellular pattern.[1] Literature of VC with ophthalmic involvement is limited to case reports of verrucous carcinoma of the eyelid, of which only two cases have been reported in Asia, with no reported case of VC of the conjunctiva.[2],[3] In this report, we present a histologically confirmed case of VC in conjunctiva.


  Case Report Top


An 85-year-old male farmer presented with a complaint of mass in the interpalpebral region of the left eye, with continuous increase in size and extension toward cornea since 12 months. He had no history of ocular trauma, and he smoked around one packet of cigarettes per day, for the past 50 years. Best-corrected visual acuity was light perception with an inaccurate projection of rays in the left eye and 20/200 in the right eye. Slit-lamp examination of the left eye revealed a single, sessile, pale-colored exophytic mass with a pebble surface covering 270° of the paracentral cornea and adjacent conjunctiva, approximately 15 mm × 10 mm in size. The features were suspicious of squamous cell carcinoma, with gelatinous elevation in the conjunctiva and clear corneal extension, along with a brown cataract [Figure 1]a. The right eye examination showed Grade II pterygium with immature senile cataract.
Figure 1: (a) A single, sessile, pale-colored exophytic mass with a pebble surface covering 270° of paracentral cornea and adjacent conjunctiva, approximately 15 mm × 10 mm in size. (b) Increase in growth noted, with involvement of entire cornea and adjacent 360° conjunctiva. (c) Fifteen-day follow-up postsurgical excision showing healing epithelial defect. (d) Post cataract surgery

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Fundoscopy was not possible in the left eye and was normal in the other eye.

A complete hemogram and renal and liver function tests were performed and revealed no abnormality. Patient's HIV (human immunodeficiency virus), HbsAG (hepatitis B surface antigen) tests were negative, and he had no other comorbidities.

The patient was started on topical mitomycin 0.04% one drop four times daily in the left eye with 7 days on and 7 days off regime. Topical lotepredenol 0.5% and gatifloxacin 0.3% combination eye drops were administered every 6 hours during the first week. The patient completed four cycles of mitomycin during which an increase in the growth was seen, with involvement of the entire cornea and adjacent 360° conjunctiva [Figure 1]b. The patient then underwent complete excision of the lesion with a dimension of 16 × 12 × 4 mm, followed by amniotic membrane transplantation in the same sitting. Topical therapy was resumed postoperatively with added topical lubricants. The patient was followed up after 7 days of excision, and an epithelial defect with healing margins of size 7 mm × 5 mm was noted. At 15 days follow-up, a decrease in epithelial defect size was noted, hence the same treatment was continued [Figure 1]c.

The histopathological examination revealed characteristic exoendophytic growth pattern with acanthosis and papillomatosis [Figure 2]a. Bulbous expansion, with typical projections pushing into underlying structures with leucocytic stromal infiltration, was observed [Figure 2]b and [Figure 2]c. Hyperplasia of well-differentiated stratified squamous epithelium was noted with mild–moderate atypia [Figure 2]d. The above features coupled with typical pebbly mammilated gross appearance led to the diagnosis of VC. Serial sections of the specimen revealed all the margins to be clear of malignant cells.
Figure 2: (a) Exoendophytic growth pattern showing acanthosis and papillomatosis. (b) Higher magnification showing hyperplasia of stratified squamous epithelium showing acanthosis and papillomatosis. Note the bulbous and blunt expansion into underlying structures (black arrows). (c) 40× view of papillomatosis showing leucocytic infiltration in the stroma. (d) High-power view showing hyperplasia of well-differentiated stratified squamous epithelium with mild–moderate atypia at the margins

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The patient underwent cataract surgery after 10 months of the procedure [Figure 1]d. Vision at 1 month follow-up was 6/12. The patient was reviewed every 6 months thereafter, and vision was maintained with no signs of recurrence at 2 years follow-up.

The patient's general health was good with no signs of precancerous lesion of skin, mouth, or malignancy elsewhere.


  Discussion Top


VC is characterized by a slow-growing, well-circumscribed tumor. Owing to the tumor's tendency to erode rather than invade, the style of growth of the tumor has been described as “bulldozing, rather than stabbing.”[4]

Etiological factors responsible for VC remain debatable. Human papilloma virus has been implicated as a causative agent, but a causal association has not been established.[5] A strong association has been found between VC and tobacco use. More than a third of the patients in Ackerman's original report were tobacco users.[1]. History of exposure to sunlight, chronic trauma, and alcohol consumption has been implicated by some authors.[4] Our patient was a heavy smoker and an outdoor worker, which might have put him at increased risk.

VC of the conjunctiva differs from invasive squamous cell carcinoma by having an intact basement membrane. Histopathologically, the presence of a well-differentiated tumor with acanthotic projections, keratosis along with low degrees of atypia, and mitosis differentiates from conventional carcinoma in situ, or conjunctival intraepithelial neoplasia, which is characterized by the presence of anaplastic cells and poor cell differentiation.[4],[6],[7]

Inverted conjunctival papilloma is a rare entity that may present with mixed exophytic as well as endopyhtic growth pattern.[8] VC is characterized by epithelium downgrowths into connective tissue albeit without frank invasion, whereas papilloma shows finger-like projections extending above the mucosal surface. The absence of characteristic features such as vascular hairpin loops and koilocytes further rule out diagnosis of papilloma.[6],[7]

Complete surgical resection with biopsy is the recommended primary line of management in other parts of the body, and the same has been successful for eyelid VC.[2],[3],[9] Immunomodulators have been unable to preclude the need for surgery, whereas radiation therapy has been associated with regional as well as distant metastasis. Hence, neither is recommended as monotherapy.[9],[10] Chemotherapy was attempted but was unsuccessful in our case, whereas surgical excision showed excellent outcome and helped establish the diagnosis.

Prognosis is generally good due to a low degree of dysplasia, rare local metastasis, and absence of distant metastasis.

To the best of our knowledge, this is the first reported case of VC of the conjunctiva.


  Conclusion Top


In conclusion, VC of the conjunctiva can be considered a rare differential diagnosis for a locally invasive nonmetastasizing tumor of the conjunctiva. Complete surgical excision with biopsy appears to be the best line of management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We thank Dr. Vinita Kothari, MD, for assistance with histopathology specimens, and Dr. Shreya Hajari, DDVL [FRGUHS], for comments that greatly improved the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery 1948;23:670-8.  Back to cited text no. 1
    
2.
Mak ST, Io, IY-F, Tse RK-K. Verrucous carcinoma: A rare tumor of the eyelid. Ophthalmic Plast Reconstr Surg 2011;27:e32-4.  Back to cited text no. 2
    
3.
Monescillo J, Mencía-Gutiérrez E, Gutiérrez-Díaz E, Santos-Bríz A, Rodríguez-Peralto JL. Verrucous carcinoma of the eyelid. Eur J Ophthalmol 2002;12:432-4.  Back to cited text no. 3
    
4.
Mohs FE, Stahl WJ. Chemosurgery for verrucous carcinoma. J Dermatol Surg Oncol 1979;5:302-6.  Back to cited text no. 4
    
5.
Samman M, Wood H, Conway C, Berri S, Pentenero M, Gandolfo S, et al. Next-generation sequencing analysis for detecting human papillomavirus in oral verrucous carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:117-25.e1.  Back to cited text no. 5
    
6.
Schwartz RA. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol 1995;32:1-21; quiz 22-4.  Back to cited text no. 6
    
7.
Stagner AM, Jakobiec FA, Chi A, Bradshaw SH, Mendoza SD. Conjunctival inverted squamous papilloma: A case report with immunohistochemical analysis and review of the literature. Surv Ophthalmol 2015;60:263-8.  Back to cited text no. 7
    
8.
Shields JA, Shields CL. Conjunctival benign epithelial tumors. In: Shields JA, Shields CL, editors. Eyelid, Conjunctival, and Orbital Tumors: An Atlas and Textbook. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. p. 268-75.  Back to cited text no. 8
    
9.
Koch H, Kowatsch E, Hödl S, Smola MG, Radl R, Hofmann T, et al. Verrucous carcinoma of the skin: Long-term follow-up results following surgical therapy. Dermatol Surg 2004;30:1124-30.  Back to cited text no. 9
    
10.
Risse L, Négrier P, Dang PM, Bedane C, Bernard P, Labrousse F, et al. Treatment of verrucous carcinoma with recombinant alfa-interferon. Dermatology 1995;190:142-44.  Back to cited text no. 10
    


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