Iatrogenic coronary dissection during coronary stenting
the LA D coronary artery w a s good before the intervention, but after the dissection despite good anastom osis with patch angioplasty, quality of the LAD coronary artery w as not satisfactory. If this c a se had been operated before dissection, postoperative LA D quality would have been better. So, after this complication we began to think that the results of surgery would be better in se ve re IS R treatment.
In co n clu sio n , IS R rem ain s a challenging problem and optimal m anagem ent is yet to be determined. Despite better percutenous coronary interventional re su lts, re ste n o sis and complication risk are still high in most c a se s . In patients having IS R with low potential su c c e ss and high com plication rate, C A B G surgery se e m s to yield the best outcome.
REFERENCES
1. Versaci F, G aspardone A, Tom ai F, Crea F, C liiariello L, G ioffre FA. /I com parison o f coronary artery stenting with angioplasty fo r isolated stenosis o f the p ro x im a l left an terior descending coronary artery. H Engl J N ed
1 9 9 7 ;3 3 6 :8 1 7 -8 2 2 .
2. Bairn D, Levine MJ, Leon NB, Levine S, Ellis SJ, Schatz RA. M an ag em en t o f restenosis within the Faim az-Schatz coronary stent ( the U.S. m u ltic e n te r experience: the U.S. Faimaz- Schatz Stent investigators). Am J C ardiol
1 9 9 3 ;7 1 :3 6 4 -3 6 6 .
3. Flues FIG, Radke PW, H offm an R, von D ahl J. Pathophysiology an d th erapeutic concepts in coronary restenosis. H erz 1 9 9 7 ;2 2 :3 2 2 -3 3 4 . 4. G hazzal ZMB, H earn JA, Litvack F, et at.
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c o m p lic a tio n s a fte r p e rc u ta n e o u s e x im e r la s e r co ro nary angioplasty: results o f co m p re h e n s iv e an g io g rap h ic analysis: im p o rta n c e o f th e e c c e n tric ity index. Circulation 1 9 9 2 ;8 6 :8 2 0 -8 2 7 .
5. Eltchaninoff H, Boning R, Tron C, Gupta V, C rib ie r A. B alloon a n g io p la s ty fo r the treatm en t o f coronary in-stent restenosis: im m ediate results and six-m onth angiographic recurrent restenosis rate. J Am Coll Cardiol
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7. M ah d i HA, Fathan AZ, B a rre l L, et al. D ire c tio n a l co ro nary a th e re c to m y fo r the tre a tm e n t o f F a im a z-S c h a tz in -stent restenosis. Am J Cardiol 19 9 8 :8 2 :1 3 4 5 -1 3 5 2 . 8. M ehran R, M in tz GS, S a tle r LF, e t al.
Treatm ent o f in-stent restenosis with e x im e r laser coronary angioplasty: m echanism and results com pared with FTCA alone. Circulation
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Treatm ent o f in-stent coronary restenosis by e x im e r la s e r angioplasty. Am J C a rd io l
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Case Report
C O N J U N C T I V A L S Q U A M O U S C E L L C A N C E R
Ö zlem Yenice, M .D . / H aluk K azo ko ğ lu , M .D .
D e p a r tm e n t o f O p h th a lm o lo g y , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is ta n b u l, T u rk e y .
ABSTRACT
With ad vancing age im m obile am elanotic conjunctival lesions of the interpalpebral area may often be se en . Considering these lesions, we should think of papillom a, leukoplaki and also conjunctiva c a n c e r. In this c a s e report we present an 80-year-old patient who w as admitted to our clinic with the complaint of a m ass in her right eye.
Key W ords:
Conjunctival can cer, Differential diagnosisINTRODUCTION
Conjunctival sq u am o u s cell c a n c e r (C S C C ) ch a ra cte ristica lly o c cu rs a s an am elanotic, fle sh y, often papillam otous m a ss n ear the corneascleral limbus or, occasio n ally, in the forniceal or palpebral co nju n ctiva (1 ). It frequently d isplays white ceratin on its surface (1 ) . In the conjunctiva, S C C occurs about ten times more frequently than the basal- cell type (2 ) . They usually arise at the limbus and spread to the cornea and adjacent bulbar conjunctiva. A limbal carcinom a som etim es invades the sclera and, very infrequently the cornea but usually Bow m an’s membrane acts a s a barrier to the corneal invasion (3 ,4 ). In extrem ely rare c a se s the tumor extends through the sclera into the intra ocular structures. Ophthalm ic, especially
conjunctiva tumors are not often seen in clinics and their differential diagnosis is usually made by inspection. It is som etim es difficult to differentiate benignant lesions from malignant ones.
CASE REPORT
An 80-year -old wom an w a s admitted to the hospital with a progressively enlarging, painless fleshy lesion in her right eye. Her history w as otherwise noncontributory. In the right eye, there w as a lesion superotem porally arising from the limbal co nju n ctiva and invading the co rn ea (Fig. 1). Dilated conjunctiva blood v e s se ls around the lesion were also observed.
F ig . 1: Conjunctival fleshy lesion invading the cornea.
Correspondence to: Özlem Yenice, M. D, - Department of Ophthalmology, Marmara University Hospital, Altunizade. 81190 Istanbul, Turkey
e.mail address: yeniceozlem(g)yahoo.com
(Accepted 3 April, 2002)
Marmara Medical Journal 2002;15(3):186-188
Conjunctival squamous cell cancer
T h e lesion w a s rem oved by partial keratoconjunctivectom y, marking the conjunctiva border elevated from the limbal cornea with su b co n ju n ctival serum physiologic injection. Postoperatively, there w a s no limbal insufficiency due to surgery.
M icroscopically, the tumor w a s confined to the epithelium, and the basem ent membrane w as intact. N on ceratin ized sq u a m o u s epithelia showed loss of its chromaticity and polarity, features of actinic keratozis, and underneath it had a layer of lymphocytic infiltration (Fig. 2, grey arrow). In the strom a, there w as an island of (F ig .2, black arrow) intensive atypical molecular cell infiltration which belongs to C S C C . (Fig. 3)
F i g .2 : The lesion after excision.
F i g .3 : Nonkeratinised squamous cell epithelia, underneath this an island of CSCC.
DISCUSSION
The decision on how to m anage conjunctiva lesions is based on a sse ssm e n t of relevant
history and the clinical features of the lesion. Information is limited on how well ophthalmologists p ro cess this information in order to make a correct diagnosis (5). The lesions which come to mind when faced with a conjunctiva lesion should include; papilloma, neoplastic papillom a, Bow en d ise a se and leukoplaki (6).
A papilloma may at times be confused with a S C C : in the transitional stage it may be difficult to determine, even on histological exam ination, whether it is a papilloma or early C S C C . But later on, the elevated appearance and the location (caruncular or forniceal not limbal) help in the differential diagnosis. Neoplastic papilloma which is often seen in older people, is usually one-sided and like bulbar conjunctiva and limbus. It may change to C S C C . Neoplastic papillom as may be m isdiagnosed a s C S C C due to the limbal localization of both lesions, but pathologically abundant core vascu lar structures surrounded by atypical cells of neoplastic papillom as help in differential d iag n o sis. Bow en d ise a se most commonly appears in the interpalpebral fissure, especially at the limbus. Clinically, these lesions may be covered by a white sc ale (keratin). The term leukoplaki literally m eans white plaque and conveys no information about the underlying problem which produced the e x c e ss keratin. In the differential d iag n o sis, reached by pathological exam ination, atypical cells present only in epithelia in carcinom a in situ and cells spread to the strom a p assin g b asem ent membrane in C S C C .
Although a C S C C may not show progression or m étastasés over some years, surgery is often necessary. Cryotherapy, excision, intra lesional alpha-interferon injection or combined surgery with Mitomycin-C has been reported to be successful in treating these lesions (6). During surgery the malignant neoplasm of the conjunctiva should be removed by meticulous microsurgery, taking great care not to disrupt the tumor.
In conclusion, conjunctiva cancers are rarely seen in clinics. It is possible to excise these lesions like in our c a se . Adjunctive therapy such as cryotherapy or Mitomycin C should not be used as a first line of treatment (6). In the follow-up of our patient for the first 3 years, we did not see any recurrence.
Özlem Yenice, Haluk Kazokoğlu
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3. Spalton D. The conjunctiva: Diseases and Tumours. In: Atlas o f Clinical OpIiLhalmology. London: Wolfe Publishing, 19 9 5 : 12 -1 8 .
4. Conlon MR, Alfonso EC, Stark T, A lb ert D. Tum ors o f the cornea an d conjunctiva. In: A lbert D, Jak o b ie c PA, eds. Principles an d Practice o f Ophthalm ology: C linical Practice. Philadelphia: WB S aunders Co, 1 9 9 4 :2 7 6 -2 9 5 .
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