1. 14 cases of keratoconjunctival tumor Satoru Tsuda, Shunji Yokokura, Akira Kubota, Megumi Uematsu, and Kohji Nishida Department of Opthalmology and Visual Science, Tohoku University Graduate School of Medicine The authers have no financial interest

2. Purpose To characterize squamous neoplasm in keratocinjuntival tumor For example, squamous cell papilloma (SCP) conjunctival intraepithelial neoplasia (CIN) squamous cell csarcinoma (SCC) To analyze the prognosis after the operation

3. Method Design Operative case series Retrospective study Subjects Squamous neoplasms at the limbus. All patients were performed operation and histopathologically diagnosed at the Department of Ophthalmology, Tohoku University Hospital from May,2006 to October, 2009. Analysis Age, gender, tissue type, surgical procedure Prognosis after the operation

4. Surgical procedure Excision Cryotherapy Intraoperative use of Mitomycin C (MMC) Tumors were removed with local excision combined with cryotherapy and/or intraoperative use of MMC Reconstraction of ocular surface was applied if tumors involved widely the corneal limbus and bulbar conjunctiva. Limbal transplantation Aminion membrane transplantation

5. Demonstration of the extent of tumor Figure : Keratoconjunctival tumor at the limbus.Figure : Fluorescein stains dysplastic epithelium Fluorescein stains was used intraoperatively to demonstrate the extent of tumor 1). Excision Figure : Resection of the demonstrative lesion. Exicision of tumor demonstrated by fluorescein stain.

6. Cryotherapy Cryotherapy was applied to the involved limbal area and cut conjunctiva edges and bare scleral bed for 3 seconds. Figure : Cryotherapy to cut conjunctival edge Intraoperative use of MMC Sponges absorbing MMC 0.04% was attached to bare corneal and scleral bed and conjunctival edge for 5 minutes. Figure : Sponge absorbed MMC 0.04% was attached.

7. Results The fourteen eyes of 14 patients were analysed. Male : female = 12 : 2. Primary case : recurrent case = 13 : 1 All patients were Japanese. Mean age were 75.4 years(median, 78.5 years; range, 40-94 years). All patients were followed up for a mean of 23.7 months (median, 23.5; range,4-44 months). Only one case had a local recurrence twice. All cases did not develop metastases.

8. Result SCP : Squamous cell papilloma CIN : Conjunctival intraepithelial neoplasia SCC: Squamous cell carcinoma Ex : Excision M : months Cryo : Cryotherapy MMC : intraoperative use of mitomycin C 0.04% AMT : Amnion membrane transplantation LT : Limbal transplantation Table 1 : Age and Gender, Progress, Pathology, Operative procedure, Follow up time

9. Result Table : Comparison of each tissue type CIN was the most common type. Median age of every tissue type was similar. CIN and SCC were usually male. Only one recurrent case of SCP had a local recurrence twice. The recurrent case was operated with excision and cryotherapy.

10. Discussion Squamous cell papilloma SCP is benign tumor, with little tendency to undergo malignant transformation. Lesions may occur anywhere on conjunctiva,singly or multiply. Multiple lesions suggest the presence of infection with HPV. 1) Management is difficult and complecated because of multiple recurrences. 1) Local excision with cryotherapy and/or is the effective treatment. 4)

11. Discussion CIN and SCC occupy 2% in epibulbar tumor 2). CIN and SCC occur more commonly from 50s to 70s 2). Most occur at the limbus, especially within the sunexposed interpalpebral fissure 2). The pathogenic factors are sun exposure, light skin pigmentation, male population, smoking, HIV infection, HPV infection and so on. Local excision with cryotherapy reduces the recurrence rate. 3) Adjunctive topical MMC is also useful. CIN, SCC of the Conjunctiva

12. Conclusion Patients were usually male and elderly. Excision with cryotherapy and/or intraoperative use of MMC may reduce the recurrent rate. Primary cases had no recurrence in any tissue types. Recurrent cases should be carefully management because of frequent recurrences. References 1) Krachmer et al : Cornea 2 nd Ed : 557-570, Elsevier Mosby Publishers 2005. 2) Ash, J.E. : Epibulbar Tumor. Am. J. Ophthalmol. 33: 1203-1219, 1950. 3) Fraunfelder, F.T. & Wingfield, D. : Management of intraepithelial conjunctival tumors and squamous cell carcinomas. Am. J. Ophthalmology 95 : 359-363, 1983. 4) Hawkins A.S et al : Treatment of recurrent conjunctival papilomatosis with mitomycin C. Am J Ophthalmology 128 : 638, 1999.