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Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 761-762

Conjunctival squamous cell carcinoma as a second primary malignancy in a patient with colon adenocarcinoma

Ocular Oncology Service, Institute of Oncology, 54 Tecnologico de Monterrey; School of Medicine and Health Sciences, Tecnologico de Monterrey, Monterrey, México

Date of Submission15-Nov-2021
Date of Acceptance15-Mar-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. David Ancona-Lezama
Ocular Oncology Service, Institute of Oncology, Tecnológico de Monterrey; School of Medicine and Health Sciences. Av. Ignacio Morones Prieto 3000. Colonia Los Doctores. CP 64710. Monterrey, Nuevo León
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2898_21

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Second primary malignancies (SPM) are observed in up to 8.1% of cancer patients and are often overlooked. We present the case of a 58-year-old male with ongoing treatment for colon adenocarcinoma who was discovered to have a mass in the conjunctiva in his right eye. Other than his oncologic diagnosis, he had no other risk factors, such as a history of smoking, unusual exposure to ultraviolet radiation, fair skin, or other conditions, that could explain the lesion.

Keywords: Conjunctiva, eye, multiple primary, second primary, squamous cell carcinoma

How to cite this article:
Ancona-Lezama D, Bastán-Fabián D, Ortiz-Morales G. Conjunctival squamous cell carcinoma as a second primary malignancy in a patient with colon adenocarcinoma. Indian J Ophthalmol Case Rep 2022;2:761-2

How to cite this URL:
Ancona-Lezama D, Bastán-Fabián D, Ortiz-Morales G. Conjunctival squamous cell carcinoma as a second primary malignancy in a patient with colon adenocarcinoma. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 13];2:761-2. Available from: https://www.ijoreports.in/text.asp?2022/2/3/761/351158

Conjunctival squamous cell carcinoma (SCC) is part of a broad spectrum of ocular surface squamous neoplasia (OSSN), ranging from conjunctival intraepithelial neoplasia to invasive SCC. These malignancies are strongly correlated with ultraviolet (UV) radiation, human papillomavirus (HPV) infection, and immunosuppression such as organ transplant patients.[1],[2] Diagnosis is made clinically and confirmed through a biopsy, which shows cellular and nuclear atypia, hyperkeratosis, parakeratosis, and varying degrees of acantholysis. Treatment options include excisional biopsy and topical chemotherapy and are usually guided by the tumor size, location, and symptoms.[1],[2],[3] A study analyzing epidemiological data from the National Cancer Institute from 1973 to 2015 reported only 1203 cases of ocular second primary malignancies (SPM) out of 3.5 million cancer cases. Most of the ocular SPMs in this database were discovered in the context of a skin melanoma or non-Hodgkin's lymphoma. Still, a small percentage of these were found during or after a gastrointestinal cancer diagnosis. Moreover, most ocular SPMs after gastrointestinal cancer were choroidal, followed by the eyelid, orbit, and conjunctiva in frequency.[4]

  Case Report Top

A 58-year-old male came to the Ocular Oncology Service with a 4-week history of an elevated, brownish-yellow lesion in his right eye, which caused him mild discomfort [Figure 1]a His past medical history was positive for a stage T4NXM1 colon adenocarcinoma. He had multiple liver metastases; had undergone a partial colectomy; and was currently taking panitumumab, irinotecan, 5-fluorouracil, and folinic acid (FOLFIRI plus Pani protocol). Of note, the lesion developed while undergoing systemic chemotherapy for his colon adenocarcinoma. His family history was positive for multiple unspecified malignancies, but no other diseases of importance were reported.
Figure 1: Conjunctival squamous cell carcinoma (SCC) as a second primary malignancy in a patient with colon adenocarcinoma. (a) A 58-year-old male undergoing systemic chemotherapy for colon cancer had a brownish-yellow lesion in his right eye. (b) The patient underwent an excisional biopsy following clinical and ultrabiomicroscopic findings (c) that suggested partial intrascleral invasion (white arrow). Adjuvant therapy with interferon-alpha 2-b was initiated following histopathologic confirmation (d) of invasive SCC given the patient's general condition

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The lesion was localized on the temporal conjunctiva of his right eye and measured 5 mm × 5 mm × 2 mm in diameter, with a yellow center and brown periphery and superficial vascularization. Visual acuity and eye movements were normal. An ocular ultrasound biomicroscopy was performed, and it showed full conjunctival and scleral involvement but no choroidal invasion [Figure 1]c.

Differential diagnoses included conjunctival metastasis and OSSN due to his oncologic diagnosis, and an excisional biopsy was performed [Figure 1]d. The biopsy reported atypical squamous cells with pleomorphic nuclei and prominent nucleoli with loss of cellular polarity, which invaded the full thickness of the epithelium, thus confirming a locally invasive conjunctival SCC. Adjuvant treatment with topical interferon-alpha 2-b was initiated considering the patient's general condition. The treatment scheme consisted of one drop every 6 h to the affected eye, with a concentration of 1 million IU/1 mL, which proved helpful in improving the patient's clinical condition [Figure 1]b.

  Discussion Top

Given this patient's metastatic status, we initially considered the lesion to be conjunctival metastasis or OSSN, sporadic tumors in the context of colon adenocarcinoma.[5] Therefore, a correct approach of histopathologic analysis helped establish the correct diagnosis. In this case, the biopsy revealed the rare diagnosis of SPM SCC, which uncovered a deep state of unsuspected immunocompromise.[1],[2],[5]

Treatment may be medical, surgical, radiotherapy as monotherapy, or in combination. Medical treatment is useful in recurrent, extensive, or corneal tumors for patients who do not wish to undergo surgery. Topical medical treatment with interferon alpha-2-beta is the mainstay of treatment due to its excellent efficacy and good side effect profile; this is due to its benefit of boosting the immune system and ease of use. Topical mitomycin C and 5-fluorouracil are also good alternatives of treatment when interferon is not readily available, but side effects (tearing, hyperemia, punctate epithelial keratopathy, among others) are more common.[6],[7],[8],[9] Surgical management depends on the location and size of the tumor. Limbal lesions should be managed with “no-touch” alcohol epitheliectomy, while corneal lesions are best managed by lamellar keratectomy or penetrating keratoplasty.[2],[3],[6],[7],[8],[9]

This case report highlights the possibility of ocular SPMs. SCC is frequently found in patients who have a coexisting infection with the human immunodeficiency virus (HIV), HPV, or organ-transplant recipients, thus suggesting that immunocompromise is a major factor in developing this type of disease malignancy. The tumor arose despite the current chemotherapy regimen, which consisted of the FOLFIRI + PANI protocol; this is important because SCC is known to respond to 5-FU. Perhaps the panitumumab was also a factor due to its inhibitory effect on epidermal growth factor and angiogenesis.[10]

  Conclusion Top

Clinicians should consider SCC a potential diagnosis when encountering a new growth in a suspected immunocompromised patient. The current treatment options are excellent in curing and staving off recurrences. Although thinking of two primary malignancies in a patient can be rather astonishing, the pathophysiology of a squamous-cell carcinoma makes sense in the context of the patient.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Shields CL, Shields JA. Tumors of the conjunctiva and cornea. Indian J Ophthalmol 2019;67:1930-48.  Back to cited text no. 1
[PUBMED]  [Full text]  
Kiire CA, Srinivasan S, Karp CL. Ocular surface squamous neoplasia. Int Ophthalmol Clin 2010;50:35-46.  Back to cited text no. 2
Pe'er, J., Frenkel, S. (2019). Conjunctival and Corneal Tumors: Examination Techniques. In: Pe'er, J., Singh, A., Damato, B. (eds) Clinical Ophthalmic Oncology. Springer, Cham. https://doi.org/10.1007/978-3-030-06046-6_12  Back to cited text no. 3
Alfaar AS, Saad AM, KhalafAllah MT, Elsherif OE, Osman MH, Strauß O. Second primary malignancies of eye and ocular adnexa after a first primary elsewhere in the body. Graefes Arch Clin Exp Ophthalmol 2021;259:515-26.  Back to cited text no. 4
Ostriker PJ. Metastasis of adenocarcinoma of colon to conjunctival surface of lid. AMA Arch Ophthalmol 1957;57:279-81.  Back to cited text no. 5
Tunc M, Erbilen E. Topical cyclosporine-a combined with mitomycin C for conjunctival and corneal squamous cell carcinoma. Am J Ophthalmol 2006;142:673-5.  Back to cited text no. 6
Peter J. Ocular surface squamous neoplasia: Evidence for topical chemotherapy. Int Ophthalmol Clin 2015;55:9-21.  Back to cited text no. 7
Shields CL, Naseripour M, Shields JA. Topical mitomycin C for extensive, recurrent conjunctival-corneal squamous cell carcinoma. Am J Ophthalmol 2002;133:601-6.  Back to cited text no. 8
Nanji AA, Sayyad FE, Karp CL. Topical chemotherapy for ocular surface squamous neoplasia. Curr Opin Ophthalmol 2013;24:336-42.  Back to cited text no. 9
Hocking CM, Townsend AR, Price TJ. Panitumumab in metastatic colorectal cancer. Expert Rev Anticancer Ther 2013;13:781-93.  Back to cited text no. 10


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