Altan A. Özcan, MD,* Emine Çiloglu, MD,
† Ebru Esen, MD,* and Göksu H. S¸imdivar, MD* Purpose: To report our experience in the treatment of intraepithelial neoplasia of the conjunctiva using topical bevacizumab. Methods: Ten eyes of 10 patients with conjunctival neoplasia received 25 mg/mL bevacizumab topically. Changes in the lesions were documented weekly using digital photography. After topical treatment, excisional biopsy was performed. Results: The mean age of the patients was 60.5 6 12 (33–77) years. The mean duration of topical treatment was 7.8 6 1.3 (5–14) weeks. The size and vascularity of the tumors reduced weekly. All patients underwent excisional biopsy, cryotherapy, and amnion membrane transplantation. The histopathologic diagnosis of the lesions was carcinoma in situ. No recurrence was observed during the follow-up of patients for 6 months. Conclusions: Topical bevacizumab is an effective treatment to reduce the tumor size before surgery and may be a good alternative for adjuvant therapy of conjunctival neoplasms. Key Words: topical, bevacizumab, conjunctival intraepithelial neoplasia (Cornea 2014;33:1205–1209) Conjunctival intraepithelial neoplasia (CIN) is a frequent conjunctival tumor, and squamous cell carcinoma (SCC) is the most frequent malignant tumor of the conjunctiva.1 Early manifestation is a small mass that mimics pterygium growing at or around the limbus, occurring in middle-aged patients.2 The established method of the treatment for conjunctival neoplasms has been wide local excision, with or without supplemental cryotherapy to the surgical margins. Topical therapies offer a nonsurgical method for treating the entire conjunctival surface with less dependence on defining tumor margins by delivering high drug concentrations to the ocular surface. Topical chemotherapy may be used before surgery to decrease the size of the excision. These topical agents such as mitomycin-C (MMC), interferon alfa 2b (IFN-a2b), and 5-fluorouracil (5-FU) have been used by investigators to treat various premalignant and malignant lesions of the conjunctiva, such as primary acquired melanosis with atypia, conjunctival melanoma, and squamous intraepithelial neoplasia. Despite success of these agents, chemotherapeutic drugs can be potentially toxic to the ocular surface. Bevacizumab (Avastin), an anti–vascular endothelial growth factor (VEGF) drug, has been successfully used in recent years to treat ocular pathologies, mostly by intravitreal administration. It has been used in the treatment of various cancers and neovascular age-related macular degeneration, choroidal neovascularization (NV), central retinal vein occlusion, proliferative diabetic retinopathy, and iris NV in ophthalmology. The aim of this study was to evaluate the efficacy of topical bevacizumab in the management of CIN. METHODS The research was conducted according to the Declaration of Helsinki and the project was approved by an institutional ethics committee within which the work was undertaken. This study was performed between November 2012 and June 2013 at Cukurova University, Adana. Ten eyes of 10 patients who presented with elevated vascularized lesions of conjunctiva adjacent to the limbal area with or without corneal extension were enrolled in the study. Patients with a history of medical or surgical treatments, dry eye, uveitis, or glaucoma were excluded from the study. A complete ophthalmologic examination was performed. Ocular surface squamous neoplasia (OSSN) was diagnosed principally by clinical examination, relying on the characteristic features of OSSN: gelatinous, papilliform lesion with characteristic tufted, superficial, and so-called corkscrew vessels. Digital photographs were taken. Corresponding patient records were reviewed for age, gender, involved eye, visible lesion location (limbal, with or without corneal involvement, nonlimbal conjunctiva, corneal) and affected quadrant(s) of bulbar conjunctiva (superior, inferior, nasal, temporal), and size. The location and dimensions of the lesion were recorded at the start of treatment, with appropriate measurements obtained using the slit-lamp. The patients were treated with topical bevacizumab (25 mg/mL, 1.25 mg/mL per drop) 4 times daily for 5 to 14 weeks. The drug was kept at +4°C in the refrigerator by the Received for publication March 26, 2014; revision received May 20, 2014; accepted May 21, 2014. Published online ahead of print July 9, 2014. From the *Faculty of Medicine, Department of Ophthalmology, Çukurova University, Adana, Turkey; and †Department of Ophthalmology, Adana Numune Training and Research Hospital, Adana, Turkey. The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.corneajrnl.com). Reprints: Emine Çilo
glu, MD, Adana Numune E
gitim ve Aras¸tirma Hastanesi, Göz Hastaliklari Klini
gi 01030 Adana, Turkey (e-mail: drciloglu@ gmail.com). Copyright © 2014 by Lippincott Williams & Wilkins Cornea
Volume 33, Number 11, November 2014 patients. The duration of the treatment was determined based on lesion size and treatment response. Our protocol involved 4 times daily topical bevacizumab treatment until no further regression was evident, which means no change in the dimensions of the lesion in consecutive visits. Patients were followed weekly, and ophthalmologic examination was performed at every visit. Digital photographs were taken. Tumor size and vascularity were evaluated by slit-lamp examination and comparative photography at each interval. Patients were monitored for any ocular and systemic adverse effects. Surgery was performed at least 2 weeks after the discontinuation of bevacizumab to allow for recovery of the conjunctiva. Excision involved complete superficial dissection from the cornea and limbus with a 2-mm margin on the conjunctival aspect. Excised specimens were sent to the pathology department for histopathologic diagnosis. Approximately 3 months after beginning topical treatment, the remaining conjunctival lesion underwent excisional biopsy. Patients were examined monthly for 6 months after surgery. Data are expressed as mean 6 SD. SPSS software (version 20; SPSS Inc, Chicago, IL) was used to analyze mean values. RESULTS Ten eyes of 10 patients, 6 males and 4 females, were included in this study. The mean age of the patients was 60.5 6 12 (33–77) years. The right and left eyes were involved in 8 and 2 patients, respectively (see Table, Supplemental Digital Content 1, http://links.lww.com/ICO/A235, which demonstrates demographic and clinical information of patients with OSSN). All the lesions were primary. Two patients had conjunctival neoplasia at the temporal limbal region (Fig. 1). Seven patients had conjunctival neoplasia at the nasal limbal region (Figs. 2, 3). One patient had neoplasia at the superonasal limbal region extended to the cornea (Fig. 4). The mean duration of topical treatment was 7.8 6 1.3 (5–14) weeks. All patients were documented to have regression of tumor NV after the first week of topical bevacizumab. No further regression was evident in the size of the tumor approximately 3 months after beginning topical treatment. All patients underwent excisional biopsy, cryotherapy, and amnion membrane transplantation. Histopathologic findings of the excisional biopsies were carcinoma in situ and CIN. No recurrence, systemic or ocular side effects, or epitheliopathy was observed during treatment and follow-up of patients for 6 months after surgery. DISCUSSION OSSN is a dysplasia of the conjunctival, limbal, or corneal epithelium. OSSN includes conjunctival and corneal intraepithelial neoplasia, intraepithelial carcinoma of the conjunctiva, and conjunctival SCC.3 Management modalities in OSSN range from complete excision to chemotherapy. Traditional treatment for OSSN involves excision with or without cryotherapy. Because most of these tumors arise at or near the limbus, extensive surgical excision or cryotherapy may cause limbal stem cell deficiency. Complete surgical removal of these tumors would have been difficult and resulted in obvious ocular surface FIGURE 1. OSSN of the conjunctiva with corneal extension. A, Baseline. B, After using topical bevacizumab for 10 weeks. C, The first month after excisional biopsy and amnion membrane transplantation. FIGURE 2. OSSN of the conjunctiva with prominent feeder. A, Baseline. B, After using topical bevacizumab for 7 weeks. C, The first month after surgery. Özcan et al Cornea
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2014 Lippincott Williams & Wilkins scarring such as tissue granulation, pseudopterygium, and symblepharon. These problems have stimulated clinicians to investigate alternative treatments. Topical therapy may be useful in reducing the tumor size and eliminating intraepithelial disease, thereby limiting the subsequent excision to the smaller invasive component. Topical chemotherapy has several advantages when compared with the traditional surgical excision and cryotherapy.4,5 The potential advantages include: treatment of the entire ocular surface, thereby eliminating the need to ensure clear tissue margins that is necessary with surgical excision. Also with topical treatment, the risk of limbal stem cell deficiency is lower than destructive therapies that involve the limbus. In addition, it is a more simple procedure than invasive treatments. Topical applications of 5-FU, MMC, and IFN-a2b have been extensively reported in the literature.6 MMC is administered as a topical medication for OSSN, but it is believed to be relatively unstable in solution, therefore requiring refrigeration and weekly replacement of the medication. Since its first use, several published studies have demonstrated the efficacy of MMC for OSSN with resolution rates between 82% and 100%.7–10 Severity of side effects has limited its use for the treatment of OSSN. In the review of studies of MMC for OSSN, short-term complications included conjunctival hyperemia in 60% of patients and ocular allergy in 23%; other side effects included superficial punctate keratitis, ocular pain, and epiphora.9,11 Long-term complications included recurrent corneal erosion and limbal stem cell deficiency in 17% of patients.7 5-FU is administered as a topical drop for the treatment of OSSN. It is easily handled and is stable in aqueous solution even without refrigeration. In the largest study of topical 5-FU to date, repetitive cycles of 5-FU treatment, daily for 1 month followed by 3 medication-free months, were used until complete regression of the tumor. Overall, lesions required treatment with 1 to 5 cycles. An average of 1.9 cycles was required for resolution.12 Complete resolution of the lesion occurred in 100% of patients, and recurrence of OSSN using this dosing regimen ranged between 7% and 20%.12,13 Treatment with 5-FU is generally well tolerated. Even with continuous monthly dosing, side effects are generally limited to transient conjunctivitis and superficial keratitis, which can be painful, but not as severe as MMC.13 IFN has been used in a recombinant form, IFN-a2b, both topically and as a subconjunctival/perilesional injection. The topical form of the medication is stable for 30 days but does require compounding and refrigeration. Tumor resolution has been found to occur in 87% to 100% of patients using IFN-a2b injections, over a mean period of 5 weeks and 5.5 injections.14,15 Recurrence rates with perilesional injections range from 0% to 7.7%. Rates of resolution have ranged from 80% to 100% with topical IFN-a2b, with lower rates in studies that included larger and more invasive tumors. The time for resolution using topical therapy in all tumor types ranges from 1 week to over 1 year, although the mean time to resolution is 5 months. The recurrence rate was 6% in follow-up ranging between 7 and 55 months.16–20 IFN-a2b in the topical form is extremely well tolerated, with mild irritation and follicular conjunctivitis as the main side effects. Both MMC and 5-FU have also been used as adjuvant therapy for recurrent lesions. Time for resolution is shortest FIGURE 3. OSSN of the conjunctiva. A, Baseline. B, After using topical bevacizumab for 5 weeks. C, The first month after surgery. FIGURE 4. OSSN of the conjunctiva and cornea. A, Baseline. B, After using topical bevacizumab for 14 weeks. C, The first month after surgery. Cornea
Volume 33, Number 11, November 2014 Use of Topical Bevacizumab
2014 Lippincott Williams & Wilkins www.corneajrnl.com | 1207 with MMC and with perilesional 5-FU injections, but these 2 treatments are also associated with the highest rate of side effects, with MMC having long-term complications as well. Topical IFN-a2b has a longer time for tumor resolution but is better tolerated by patients. One disadvantage of IFN-a2b is the higher price of the medication compared with MMC and 5-FU. Comparing injection and topical use, injection can be less desirable and less comfortable for patients. VEGFs regulate the development and maintenance of blood and lymphatic vessels. VEGF is believed to be a key mediator in the process of NV.21 The prominent role of VEGF in the pathophysiology of corneal NV has been demonstrated in experimental models of corneal NV.22,23 It has been shown that VEGF is upregulated in inflamed and vascularized corneas in humans and in animal models.24 Generally, the reduction in corneal NV obtained after subconjunctival injection of bevacizumab ranges between 20% and 30%.25,26 Better results have been observed with bevacizumab eye drops, which provided a reduction ranging from 47% to 61%27,28 after a longer follow-up period of 6 to 12 months. Recently, these drugs have also been used in the treatment of recalcitrant OSSN. There are a few studies that evaluated the effect of anti-VEGF agents on OSSN.29–32 In all studies, it was revealed that anti-VEGF agents can decrease the size and vascularity of tumors. In 2009, Zaki et al29 reported encouraging findings with subconjunctival bevacizumab treatment for 10 eyes with CIN. In that study, patients were treated with a single 2.5-mg subconjunctival injection in the superotemporal bulbar conjunctiva. After 12 months, the researchers noted a total cure in 5 eyes, decrease in tumor in 3 eyes, and recurrence in 2 eyes. The eyes that demonstrated the highest response had the highest level of immunoreactivity in the expression pattern of VEGF, whereas the 2 eyes with recurrences were among those showing low immunoreactivity in VEGF expression. They hypothesized that anti-VEGF therapy could play a role in the management of patients with recalcitrant disease. Similar results were also shown by Faramarzi and Feizi.30 Five patients, each with extensive biopsy-proven SCC, were treated with a median of 22 injections of 0.5 mg ranibizumab every 2 to 4 weeks for a mean duration of 19 months.31 Three patients had complete regression with no clinically apparent disease and no recurrence, whereas 2 had initial regression, but then worsening of their tumors and required more invasive treatments. Our study showed that topical anti-VEGF bevacizumab may have a role in treating CIN. Reduction of NV and tumor were believed to be the response to topical bevacizumab treatment suggesting that VEGF may play a role in the pathogenesis of CIN. All patients were documented to have regression of tumor size and vascularity after the first week of topical bevacizumab. No significant local (ocular toxicity or corneal epithelial defect) or systemic side effects were observed during treatment. Topical bevacizumab may be a relatively safe and well-tolerated option for the treatment of CIN. However, this treatment did not replace first-line standard therapies including excision and cryotherapy. Topical bevacizumab is an adjunctive therapy and cannot be considered as a sole treatment of OSSN in the majority of cases. To the best of our knowledge, this is the first study of topical bevacizumab treatment in the management of conjunctival neoplasms. Future investigations are required to determine the appropriate dose and frequency. A limitation of this prospective study is the small sample size. Cost may also be a factor related to anti-VEGF therapy, especially when compared with MMC and 5-FU. Nevertheless, controlled prospective randomized trials are necessary to assess the longterm safety, tolerance, and efficacy of topical bevacizumab. REFERENCES 1. Shields JA, Shields CL, De Potter P. Surgical management of conjunctival tumors. The 1994 Lynn B. McMahan Lecture. Arch Ophthalmol. 1997;115:808–815. 2. McLean IW, Burnier MN, Zimmerman LE, et al. Tumors of the Eye and Ocular Adnexa 3rd Series. Washington, DC: Armed Forces Institute of Pathology; 1994:49–95. 3. Lee GA, Hirst LW. Ocular surface squamous neoplasia. Surv Ophthalmol. 1995;39:429–450. 4. de Keizer RJ, de Wolff-Rouendaal D, van Delft JL. Topical application of 5-fluorouracil in premalignant lesions of cornea, conjunctiva and eyelid. Doc Ophthalmol. 1986;64:31–42. 5. Yamamoto N, Ohmura T, Suzuki H, et al. Successful treatment with 5-Fluorouracil of conjunctival intraepithelial neoplasia refractive to mitomycin-C. Ophthalmology. 2002;109:249–252. 6. Zaki AA, Farid SF. Management of intraepithelial and invasive neoplasia of the cornea and conjunctiva: a long term follow up. Cornea. 2009;28: 986–988. 7. Ballalai PL, Erwenne CM, Martins MC, et al. Long-term results of topical mitomycin C 0.02% for primary and recurrent conjunctivalcorneal intraepithelial neoplasia. 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Treatment of conjunctival squamous cell carcinoma with topical 5-fluorouracil. Br J Ophthalmol. 2000; 84:268–272. 14. Karp CL, Galor A, Chhabra S, et al. Subconjunctival/perilesional recombinant interferon a2b for ocular surface squamous neoplasia: a 10-year review. Ophthalmology. 2010;117:2241–2246. 15. Vann RR, Karp CL. Perilesional and topical interferon alfa-2b for conjunctival and corneal neoplasia. Ophthalmology. 1999;106:91–97. 16. Galor A, Karp CL, Chhabra S, et al. Topical interferon alpha 2b eyedrops for treatment of ocular surface squamous neoplasia: a dose comparison study. Br J Ophthalmol. 2010;94:551–554. 17. Boehm MD, Huang AJ. Treatment of recurrent corneal and conjunctival intraepithelial neoplasia with topical interferon alfa 2b. Ophthalmology. 2004;111:1755–1761. 18. Karp CL, Moore JK, Rosa RH Jr. Treatment of conjunctival and corneal intraepithelial neoplasia with topical interferon alpha-2b. Ophthalmology. 2001;108:1093–1098. 19. 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2014 Lippincott Williams & Wilkins 21. Folkman J. Angiogenesis in cancer, vascular, rheumatoid and other disease. Nat Med. 1995;1:27–31. 22. Amano S, Rohan R, Kuroki M, et al. Requirement for vascular endothelial growth factor in wound and inflammation-related corneal neovascularization. Invest Ophthalmol Vis Sci. 1998;39:18–22. 23. Manzao RP, Peyman GA. Inhibition of experimental corneal neovascularization by bevacizumab (Avastin). Br J Ophthalmol. 2007;91: 804–807. 24. Philipp W, Speicher L, Humpel C. Expression of vascular endothelial growth factor and its receptors in inflamed and vascularized human corneas. Invest Ophthalmol Vis Sci. 2000;41:2514–2522. 25. Erdurmus M, Totan Y. Subconjunctival bevacizumab for corneal neovascularization. Graefes Arch Clin Exp Ophthalmol. 2007;245: 1577–1579. 26. Bahar I, Kaiserman I, McAllum P, et al. Subconjunctival bevacizumab injection for corneal neovascularization. Cornea. 2008;27:142–147. 27. DeStafeno JJ, Kim T. Topical bevacizumab therapy for corneal neovascularization. Arch Ophthalmol. 2007;125:834–836. 28. Dastjerdi MH, Al-Arfaj KM, Nallasamy N, et al. Topical bevacizumab in the treatment of corneal neovascularization: results of a prospective, openlabel, noncomparative study. Arch Ophthalmol. 2009;127:381–389. 29. Zaki AA, Fouad H, Emera S, et al. Subconjunctival anti VEGF for conjunctival intraepithelial and invasive neoplasia. Aust J Basic Appl Sci. 2009;3:3186–3189. 30. Faramarzi A, Feizi S. Subconjunctival bevacizumab injection for ocular surface squamous neoplasia. Cornea. 2013;32:998–1001. 31. Finger PT, Chin KJ. Refractory squamous cell carcinoma of the conjunctiva treated with subconjunctival ranibizumab (Lucentis): a two-year study. Ophthal Plast Reconstr Surg. 2012;28:85–89. 32. Teng CC, Chin KJ, Finger PT. Subconjunctival ranibizumab for squamous cell carcinoma of the conjunctiva with corneal extension. Br J Ophthalmol. 2009;93:837–838