a r c h s o c e s p o f t a l m o l . 2 0 1 2;8 7(3):82–85

ARCHIVOS DE LA SOCIEDADESPAÑOLA DE OFTALMOLOGÍA

www. e l sev ier .es /o f ta lmologia

Short communication

Conjunctival keratoacanthoma. Diagnosis, treatmentand monitoring by conjunctival impression cytology�

D. Rodríguez Feijoo ∗, I. Romero Moreno, C. López Gutierrez, M. Usabiaga Usandizaga,M. Cisneros Carpio, A. Amias Gorostiza, J. Alberdi Alberdi

Servicio de Oftalmología, Hospital Galdakao-Usansolo, Vizcaya, Spain

a r t i c l e i n f o

Article history:

Received 20 September 2010

Accepted 9 August 2011

Available online 20 June 2012

Keywords:

Conjunctival keratoacanthoma

Conjunctival tumor

Conjunctival impression cytology

Histopathology of keratoacanthoma

a b s t r a c t

Case report: We present a case report of a 28-year-old patient with a lesion that is compat-

ible both clinically and histopathologically with conjunctival keratoacanthoma (KA). The

treatment given was complete excision and 0.04% mitomycin C (MMC) eye drops in the

postoperative period. The outcome was a complete clinical remission during the follow-up

period (6 months).

Discussion: It is important to make a correct differential diagnosis between keratoacan-

thoma and squamous cell carcinoma, as well as carrying out close monitoring after surgery

due to the possibility of relapse and conversion to squamous cell carcinoma. For this rea-

son, we propose the use of conjunctival impression cytology as a non-invasive method for

monitoring such patients.

© 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights

reserved.

Queratoacantoma conjuntival. Diagnóstico, tratamiento y controlmediante citología de impresión conjuntival

Palabras clave:

Queratoacantoma conjuntival

Tumor de conjuntiva

Citología de impresión conjuntival

Histopatología del queratoacantoma

r e s u m e n

Caso clínico: Se presenta el caso de un paciente de 28 anos con una lesión compatible clínica

e histopatológicamente con queratoacantoma conjuntival. Fue tratado mediante excisión

completa, y colirio de mitomicina C al 0,04% en el posoperatorio. El resultado ha sido la

remisión clínica completa durante el tiempo de seguimiento (6 meses).

Discusión: Es importante hacer un correcto diagnóstico diferencial entre queratoacantoma

y carcinoma de células escamosas, así como un estrecho seguimiento postoperatorio

por la posibilidad de rec

proponemos la citología

seguimiento de estos pac

© 2010 Sociedad Españ

� Please cite this article as: Rodríguez Feijoo D, et al. Queratoacantomade impresión conjuntival. Arch Soc Esp Oftalmol. 2012;87:82–5.

∗ Corresponding author.E-mail address: david412194@hotmail.com (D. Rodríguez Feijoo).

2173-5794/$ – see front matter © 2010 Sociedad Española de Oftalmolo

idiva o conversión a carcinoma de células escamosas. Para ello

de impresión conjuntival como un método no invasivo para el

ientes.

ola de Oftalmología. Publicado por Elsevier España, S.L. Todos los

derechos reservados.

conjuntival. Diagnóstico, tratamiento y control mediante citología

gía. Published by Elsevier España, S.L. All rights reserved.

m o l . 2 0 1 2;8 7(3):82–85 83

I

KllbcHiom

at

C

AnppTlapi

cl(jc

hdlaflsfc

Fig. 2 – Injury morphology. Central crater full of keratin(20×).

after the first tests and without patient treatment during theperiod gave the same findings as the first tests.

a r c h s o c e s p o f t a l

ntroduction

A is a benign epidemic tumor characterized by a nodularesion exhibiting rapid and painless growth. At the histologicalevel it is characterized by a central keratin deposit surroundedy acanthotic epithelium in the form of a crater. It is relativelyommon in elderly patients in skin areas exposed to the sun.1

owever, the appearance of this pathology in the mucosa isnfrequent2 and its clinical importance derives from the needf carrying out an exact differential diagnostic against squa-ous cells carcinoma (SCC).This paper presents a clinic case of a patient diagnosed

t the clinical and histopathological level with a potential KAreated with excision and topical MMCafter surgery.

linic case

construction worker, age 28, referred due to an inflamedasal pinguecula in treatment with topical fluorometholonerescribed at an emergency service. The patient did not referrevious conjunctival disorders or relevant personal history.he best corrected visual acuity was of 1.0 and intraocu-

ar pressure of 13 mmHg in both eyes. The ophthalmologicalssessment gave normal results. The patient referred a rapidrogression of the injury (2–3 weeks) which greatly increased

n size, causing ocular hyperemia and foreign body feeling.The exploration identified a protruding lesion in the nasal

onjunctiva measuring 5 mm × 5 mm × 4 mm with an avascu-ar whitish central area which invaded the left eye limbusFig. 1). The differential diagnosis was performed between con-unctival granuloma, inflamed pinguecula and conjunctivalarcinoma.

The injury was treated with complete excision and sent foristological and cytological analysis. The histological reportescribed an acanthotic proliferation of the squamous epithe-

ium with inflammatory infiltrations at the base of the injurynd in the keratin-filled central crater (Figs. 2 and 3). Topicaluorometholone was prescribed for the immediate post-

urgery period, which did not present complications. Weeklyollow-ups were scheduled. After the second week, biomi-roscopy revealed a protruding lesion with a central keratin

Fig. 1 – Macroscopic appearance of the injury.

deposit on the site of the previous tumor (Fig. 4). Additionaltreatment was prescribed with 0.04% MMC for 5 weeks com-bined with occlusion of the upper and lower lachrymal tipswith silicone stoppers during said period.

After the topical MMC treatment the keratin nodules disap-peared and the conjunctival surface reorganized itself at thesurgery site, with only hyperemia persisting (Fig. 5). Due to theapparent good progress of the patient, conjunctival impres-sion cytology was utilized to assess the degree of underlyingchanges in the conjunctiva. The report indicated the exis-tence of large altered epithelial cells with intracellular unionchanges and a nucleus/cytoplasm ratio of 1:20 (Fig. 6). Thediagnosis was grade 4 squamous metaplasia.

At present the patient does not exhibit signs of relapse andthe residual hyperemia has disappeared. A second series ofconjunctival impression cytology tests carried out 3 months

Fig. 3 – (A) Acanthotic homogeneous squamousepithelium, with large cells and transparent cytoplasm;(B) part of the keratin crater; (C) external edge of the injury,conjunctival mucosa with squamous metaplasia.

84 a r c h s o c e s p o f t a l m o l . 2 0 1 2;8 7(3):82–85

Fig. 4 – Week 2 after surgery. The lesion has keratin

Fig. 6 – Microphotograph of the conjunctival epitheliumshowing dual-nucleus cells.

deposits.

Discussion

Since Rook and Whimster in 1950 and Freeman in 1961, veryfew cases of KA3 have been reported. The danger of theselesions is that they can become invasive SCCs at the locallevel. Some authors define KA as a variant of SCC. The behav-ior of KA has been discussed in the literature. It can be easilyconfused with SCC and in addition 3 different explanationshave been proposed about the transformation of SCC.4 In fact,the literature reported one case of KA transforming into SCCwith rapid recurrence after excision and with intraocular infil-tration that required enucleation.5 The pathogenesis of KA isunknown although various activation factors have been pro-posed, including excessive exposure to the sun, carcinogenicagents, previous traumatism and viral infections such as thehuman papilloma.6

Our patient exhibited a rapidly growing mass similar to

KA. Even so in these cases the possibility of SCC must alsobe histologically discarded because it is much more frequentthan KA in the conjunctiva and much more aggressive. In our

Fig. 5 – The keratin nodules disappeared after 5 weeksof treatment with topical mitomycin C.

case, after excision and the administration of topical MMC,conjunctival impression cytology indicated the existence ofsquamous metaplasia and the conjunctiva exhibited normalbiomicroscopic characteristics. The patient was followed upin our hospital without treatment or signs of relapse.

We recommend complete excision and topical treatmentwith MMC, carrying out follow-up in the subsequent monthswith biomicroscopy and conjunctival impression cytology dueto the possibility of recurrence as well as conversion intoSCC. Particularly, we believe that the utilization of conjunc-tival impression cytology is an adequate method to followthe progress of the ocular surface7 even in cases such as thepresent one in which it is possible to observe the completeclinical remission of the lesion.

Conflict of interests

No conflict of interests has been declared by the authors.

Acknowledgments

The authors would like to thank Dr. I. Zabalza Estévez for his

extraordinary technical support.

m o l

r

1

2

3

4

5

6

7

a r c h s o c e s p o f t a l

e f e r e n c e s

. Roth AM. Solitary keratoacanthoma of the conjunctiva. Am JOphthalmol. 1978;85:647–50.

. Artioli Schellini S, Alencar Marques ME, Grillo Milanezi MF,Bacchi CE. Conjunctival keratoacanthoma. Acta OphthalmolScand. 1997;75:335–7.

. Tulvatana W, Pisarnkorskul P, Wannakrairot P. Solitary

keratoacanthoma of the conjunctiva: report of a case. J MedAssoc Thai. 2001;84:1059–64.

. Sánchez Yus E, Simón P, Requena L, Ambrojo P, de Eusebio E.Solitary keratoacanthoma: a self-healing proliferation that

. 2 0 1 2;8 7(3):82–85 85

frequently becomes malignant. Am J Dermatopathol.2000;22:305–10.

. Grossniklaus HE, Martin DF, Solomon AR. Invasive conjunctivaltumor with keratoacanthoma features. Am J Ophthalmol.1990;109:736–8.

. Coupland SE, Heimann H, Kellner U, Bornfeld N, Foerster MH,Lee WR. Keratoacanthoma of the bulbar conjunctiva. Br JOphthalmol. 1998;82:586.

. Barros JN, Lowen MS, Ballalai PL, Mascaro VL, Gomes JA,

Martins MC. Predictive index to differentiate invasivesquamous cell carcinoma from preinvasive ocular surfacelesions by impression cytology. Br J Ophthalmol.2009;93:209–14.