Seitz B, Fischer M, Holbach L M, Naumann G O
Augenklinik mit Poliklinik, Universität Erlangen-Nürnberg.
Klin Monbl Augenheilkd. 1995 Oct;207(4):239-46. doi: 10.1055/s-2008-1035375.
Epithelial tumors of the epibulbar conjunctiva are rare in northern Europe. There are no reliable clinical criteria to predict the histological nature of the lesion. Even histologically proven malignant tumors typically do not show ocular invasion or metastasis.
From 1980 to 1993, 112 epithelial epibulbar tumors were classified in our ophthalmopathological laboratory. Surgical management of 50 papillomas (mean age 46 +/- 18 years, 58% males), 49 conjunctival/corneal intraepithelial neoplasias (CIN) (28 mild, 21 severe) and 12 squamous cell carcinomas (mean age 63 +/- 13 years, 69% males) included excisional biopsy (61%), with additional lamellar keratectomy (14%), epithelial abrasion (10%), cauterisation (3%), cryotherapy (2%), excimer laser ablation (2%). Other management regimes were lamellar keratoplasty (2%), penetrating keratoplasty (2%), epithelial abrasion (2%). One eye with intraocular invasion of a mucoepidermoid carcinoma was enucleated.
Fifty five per cent of the papillomas were located at the caruncle or semilunar fold. Seventy eight percent of the papillomas had a pedunculated appearance. Two lesions involved the epibulbar conjunctiva as well as the opposite tarsal conjunctiva ("kissing papilloma"). Eighty eight percent of CIN/carcinoma were located at the limbus. The clinical differential diagnoses of CIN/carcinoma were squamous cell carcinoma (26%), papilloma (18%), leukoplakia (10%), pinguecula/pterygium (10%), dysplasia (8%), malignant melanoma (5%), trachoma (3%), chronic keratoconjunctivitis with corneal pannus (2%), "granuloma" (2%), non-pigmented naevus (2%). After a mean follow-up of 6.3 +/- 3.5 years, 13% of the papillomas showed a local recurrence. After a mean follow-up of 4.8 +/- 3.7 years, there were 30% local recurrences of CIN/carcinoma (50% each in severe CIN and carcinoma, 9% in mild CIN). But there was no recurrence of CIN/carcinoma in patients who had received a complete tumor resection initially. If the surgical margins were involved, there was a 64% recurrence rate (80% each in severe CIN and carcinoma). Thirteen per cent of the patients with CIN/carcinoma showed an additional malignant tumor elsewhere in the body.
Local recurrences after excision of CIN/carcinoma did occur only if the surgical margins where involved, and most often within the first year following surgery. Dedifferentiation of epithelial tumors in recurrences was not observed. The diagnosis of CIN/carcinoma of the conjunctiva requires the exclusion of an additional extraocular neoplasia. Histopathological classification and assessment of resection margins of epibulbar tumors is indispensable, especially in view of the more aggressive treatment necessary in mucoepidermoid carcinomas.
在北欧，眼球结膜上皮性肿瘤较为罕见。目前尚无可靠的临床标准来预测病变的组织学性质。即使是经组织学证实的恶性肿瘤，通常也不会出现眼部侵犯或转移。
1980年至1993年期间，我们的眼科病理实验室对112例眼球结膜上皮性肿瘤进行了分类。50例乳头状瘤（平均年龄46±18岁，男性占58%）、49例结膜/角膜上皮内瘤变（CIN）（28例轻度，21例重度）和12例鳞状细胞癌（平均年龄63±13岁，男性占69%）的手术治疗方式包括切除活检（61%），另外还有板层角膜切除术（14%）、上皮擦除术（10%）、烧灼术（3%）、冷冻疗法（2%）、准分子激光消融术（2%）。其他治疗方案包括板层角膜移植术（2%）、穿透性角膜移植术（2%）、上皮擦除术（2%）。1例黏液表皮样癌侵犯眼内的患者接受了眼球摘除术。
55%的乳头状瘤位于泪阜或半月皱襞。78%的乳头状瘤呈有蒂外观。2例病变累及眼球结膜以及对侧睑结膜（“接吻性乳头状瘤”）。88%的CIN/癌位于角膜缘。CIN/癌的临床鉴别诊断包括鳞状细胞癌（26%）、乳头状瘤（18%）、白斑（10%）、睑裂斑/翼状胬肉（10%）、发育异常（8%）、恶性黑色素瘤（5%）、沙眼（3%）、伴有角膜血管翳的慢性角结膜炎（2%）、“肉芽肿”（2%）、无色素痣（2%）。平均随访6.3±3.5年后，13%的乳头状瘤出现局部复发。平均随访4.8±3.7年后，CIN/癌的局部复发率为30%（重度CIN和癌各为50%，轻度CIN为9%）。但最初接受肿瘤完整切除的患者中，CIN/癌未出现复发。如果手术切缘受累，复发率为64%（重度CIN和癌各为80%）。13%的CIN/癌患者身体其他部位出现了另外的恶性肿瘤。
CIN/癌切除术后，仅在手术切缘受累时才会发生局部复发，且大多发生在术后第一年。复发时未观察到上皮性肿瘤的去分化现象。结膜CIN/癌的诊断需要排除眼外其他肿瘤。眼球肿瘤的组织病理学分类及切缘评估必不可少，尤其是考虑到黏液表皮样癌需要更积极的治疗。
