The report of Mauriello et al. "Adenoid squamous carcinoma of the conjunctiva -- a clinicopathologic study of 14 cases" [1] has profoundly impressed us as plastic and reconstructive surgeons who encounter the problem of exenteration or enucleation. Facial plastic surgeons are most frequently asked to reconstruct the exenterated orbit, but also often meet the patient before surgery when the decision for exenteration or enucleation is undertaken with the ophthalmologist. We would like to share our opinion about the surgical treatment in cases of this highly invasive carcinoma of the conjunctiva inspired by the interesting material of Mauriello et al.

Though the paper principally reveals the histopathologic features of this type of carcinoma, the authors also report the results of their surgery. They point out that the optimum treatment includes wide excision with documented histologic clear margins of resection on permanent sections and frequent follow-up; in 1997, Tessier et al [2] considered epitheliomas involving the conjunctival fornices of the eyelids indicated for orbital exenteration. Moshfeghi et al [3] point out that enucleation is indicated in cases of intraocular tumors, otherwise exenteration should be performed. In our opinion when cancer involves the conjunctiva of the corneoscleral limbus and particularly bulbar conjunctiva, like in the cases of Mauriello et al, it is very likely that the process might have involved structures outside the eye bulb, not accessible for immediate verification, since the conjunctiva is practically outside the ocular bulb. This is confirmed by Johnson et al [4] who consider the conjunctival squamous cell carcinoma (SCC, which is less invasive according to Mauriello et al) the primary reason for secondary orbital SCC.

In cases of conjunctival involvement it would probably be wise to proceed directly to orbital exenteration. It is well known that the decision to perform exenteration, enucleation or evisceration is hard to take. However, surgeries in cases like those of Mauriello et al would probably lead to partial or total loss of sight. When the surgeons are certain that sight would be totally lost, probably the wisest decision would be to perform an exenteration which will provide clear margins. Moreover, some authors proceed directly to orbital exenteration even in cases of benign but aggressive tumors [5]. In our practice we had a case of SCC of the skin of the nasolabial fold involving the lower eyelid and conjunctiva. Tumor excision and hemirhinectomy was completed with orbital exenteration. Eight months later there was a recurrence of the part of the nose left after the primary operation but not in the orbit, which is free of recurrence after 12 months.

Perhaps, to ensure the life of the patient with conjunctival carcinoma, one should proceed to the larger surgical intervention, moreover the up-to-date achievements of plastic surgery provide options for successful reconstruction of the exenterated orbit.

C Shipkov and Y Anastassov
Plastic and Craniofacial Ward
Department of Pediatric Surgery
Higher Medical Institute
Plovdiv
Bulgaria

References

(1) Mauriello JA, Abdelsalan A, McLean, IW. Adenoid squamous carcinoma of the conjunctiva - a clinicopathologic study of 14 cases. Br J Ophthalmol 1997;81;1001-1005.
(2) Rougier J, Tessier P, Hervouet F, et al. L'extenteration de l'orbite. In: Chirurgie plastique orbito-palpebrale. 3d ed. Masson: Paris, 1997:33-43.
(3) Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Survey of Ophthalmol 2000;44;277-301.
(4) Johnson TE, Tabarra KF, Weatherhead RG, et al. Secondary squamous cell carcinoma of the orbit. Arch Ophthalmol 1997;115:75-78.
(5) Morand B, Bettega G, Bland G, et al. Oncocytoma of the eyelid: an aggressive benign tumor. Ophthalmology 1998;105:2220-24.