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Clinical, Pathological, and Molecular Aspects ofRecurrent

Versus Primary Pterygium

SMF ILMU !S!"A#A$ MA#A RSU% %&II 'A(APURA

FAUL#AS !%&#!RA$

U$IV!RSI#AS C!$%!RA)ASI"

'A(APURA*PAPUA

Journal Reading

/y0 Martnisa (1 /idang

$IM0 234-+


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&56ecti7es

• To evaluate the clinical aspects

• And correlate with :

- The histopathological,- Immunohistochemical,

- Molecular characteristics (P53, i!"#$


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/ac8ground

•%&rovascular,

• usuall' triangular mem&rane (growing :lim&al epithelium corneal surace,

• )haracteri*ed :

- degenerative and h'perplastic con+epithelium,

- prolierative and in-ammator',

-

rich vasculature• The pathogenesis : incompletel' understood

.ltraviolet irradiation (important actor inits development$


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Materials and Methods

• Included // pter'gium patients• 0ho underwent e1cision &' the &are sclera

procedure

•

The tissues to a histopathologicale1amination :

an immunohistochemical anal'sis :

phospho!P53

i!"#

P)R or the human papillomavirus(2P$


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Results

• 2istopathological :

- epithelial and stromal in-ammation,

- vascular prolieration,

- %&rosis, and

- solar elastosis

- 4pithelial d'splasia (in /3"$

- The phospho!P53!positive (6"7$- The i!"#!positive (6"3$

- 2P 89A was not detected


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Conclusion

• The high reuenc' o epithelial d'splasiasupports the neoplastic theor' o pter'giumpathogenesis

• Phospho!p53 e1pression is increased in pter'gialepithelium as well as i!"# the highprolierative activit'

• The a&sence o 2P suggests that it is not anetiological actor or pter'gium pathogenesis in4g'pt


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ey9ords

• 2istopatholog',

• 2uman Papillomavirus,

•

Immunohistochemistr',• i!"#,

• p53,

•

Pol'merase chain reaction,• Per'gium


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; Introduction

• 2istologicall', characteri*ed &':

- 2'aloid degeneration o con+unctivalstroma,

- Accumulation o eosinophilic deposits

- intense %&ro&lastic prolieration

-

A rich vascular suppl'- 8egenerated t'pe I and t'pe I

collagen


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)ontinue=

• The p53 gene encodes the p53 protein preventing uncontrolled prolieration and tumorormation

• >everal studies have detected increased levelso p53 protein in pter'gia

•

the increased e1posure to .R causemutation in the p53 gene lead to increasedsta&ilit' o the p53 protein allowing itsdetection &' immunohistochemical methods


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• >everal studies point toward the involvemento 2P in pter'gium, although large regionaland racial di?erences have &een reported

• Man' authors have reported increased

e1pression o a&normal p53 associated with2P In pter'gia

• viral oncoproteins ma' pla' a role insuppressing p53 activit' 2owever, othersdetected increased p53 in pter'gium withoutevidence o 2P inection


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+1 Materials and methods

Pter'gial samples were o&tained rom// primar' and recurrent pter'giumpatients su&+ected to e1cision o

pter'gia at the @phthalmolog'8epartment, Menou%a .niversit'2ospital &etween Januar' 7;; and

June 7;7 4ighteen men and 7"women were recruited ranging in agerom 75 to ## 'ears


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a1 Preoperati7e e:amination

This included assessment o histor' :

age,

se1,

occupation,

degree o sun e1posure,

histor' o other medical conditions:2'pertension

dia&etes,

histor' o other surgeries,

histor' o e1cessive scaring and pattern o wound healing,

previous ocular surger', time rom previous pter'gium e1cision in recurrent cases

general e1amination (weight, height, cutaneous eaturessuggestive o chronic sun e1posure, especiall' on the &ac othe nec and ace$, and

detailed slit lamp ocular e1amination


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51 Surgical procedure

All pter'gia were e1cised in totalusing the &are sclera techniue


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c1 "istological

•2istological assessment o specimens included :

- whether the cornea was included,

- degree o d'splastic changes in the con+unctival orcon+unctivalB corneal +unctional epithelium,

- degree o in-ammation in the epithelium and stroma,

- degree o stromal %&rosis,

- degree o stromal angiogenesis, and

- presence and degree o solar elastosis

• 2istological changes were classi%ed :

- Minimal,

- Moderate

- Mared


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d1 Immunohistochemistry for p.; and 8i*


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e1 Polymerase chain reaction forhuman papilloma7irus

DNA isolation

• 41tracted using the Ciagen silica!mem&rane!&asednucleic acid puri%cation s'stem

• The uantit' and ualit' was assessed using a

spectrophotometer at 7"B7D• >amples with at least 7 ng o 89A were used or the

assessment o 2P

Analysis for the human papillomavirus

• A ualitative multiple1 P)R was carried out to assess thepresence or a&sence o 2P 89A in the e1cised tissues odi?erent patients

• 89A samples e1tracted rom 2eEa cell cultures that are

positive or 2P were used as a positive control


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;1 Results

• The stud' included // patientsF one o them wasound to have a con+unctival c'st wasthereore e1cluded

• @ the remaining /3 patients, ;D (/;6$ weremen and 75 (5D;$ were women

•

Their ages ranged rom 7" to ## 'ears, mean/5/6 G ;77/ >8

• Thirt'!%ve cases were primar' pter'gium and

eight cases were recurrent pter'gium


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a1 "istopathological >ndings

• @ut o /3 cases, onl' 36 cases wereavaila&le or a histopathologicale1amination

•

!pithelial dysplasia /3" (;# o 36specimens$

• Primary pterygium /57 (;/B3;$

• Recurrent pterygium 3#5 (3BD$

9ith no signi>cant di?erence 5et9eenthe t9o groups1


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@ther histopathological %ndings :

•

!pithelial in@ammation minimal ocal (D/7$and moderate (;5D$

• Stromal in@ammation (3" cases$ minimal(#;D$, moderate (;53$, mared (5;$

•

Vascular proliferation minimal (/D#$,moderate (3D5$, and mared (;7D$

• Stromal >5rosis (3# specimens$ minimal(73;$, moderate (/D#$, and mared (73;$

•

Solar elastosis (3 specimens$ minimal (73;$,moderate (7D7$, and mared (75"$

#here 9as no signi>cant di?erence 5et9een

primary and recurrent pterygia in terms of allhistopathological >ndings1


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51 Immunohistochemistry for phospho*P.; and 8i*


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)ontinue=

• pecimens with immunostaining o more than ; ocells were considered positive or i!"# e1pression

• 75 pter'gium specimens (6"3$ were positive or i!"# e1pression, including 7 (657$ o primar' pter'gia

and all si1 recurrent pter'gia (;$, whereas onl' onecase (3#$ was negative or i!"# e1pression

#here 9as no signi>cant di?erence 5et9een primaryand recurrent pterygia in 8i*


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c1 Polymerase Chain Reaction for "umanPapilloma7irus

•

suHcient tissue with high!ualit' 89A wasavaila&le or P)R or 2P onl' or ;D cases(;5 primar' and three recurrent pter'gia$

• All the ;D specimens (;$ werenegative or 2P 89A,

#here 9as no signi>cant di?erence 5et9eenprimary and recurrent pterygia


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%iscussion


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a1 "istopathological features

• In this stud', several histopathological features wereidenti%ed in pter'gium specimens These included :

- epithelial d'splasia

- epithelial and stromal in-ammation,

- vascular prolieration,

- %&rosis, and

- solar elastosis

• 4pithelial d'splasia (/3"$ signi%cantl' higher than that

detected &' other authors (aton et al) #his highfreuency o d'splastic changes in pter'gium samples thema6or importance of histopathological e:amination 0

- >uch cases with mared d'splasia and )I> carr' the ris oprogression into invasive carcinoma

- To avoid a misdiagnosis


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)ontinue=

#here 9as no signi>cant di?erence5et9een primary and recurrentpterygium in all histopathological

>ndings1

• This is similar to 9uhoglu et al. ( 6 caseswith primar' pter'gium with ;; cases withrecurrent pter'gium$


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Right primar' nasalpter'gium

Eet recurrent nasalpter'gium


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2istological eatures o pter'gium The con+unctiva showed withinnormal epitheliumF the su&stantiapropria showed mared %&rosisandsolar elastosis (red arrow$ (2 and 4,K7$

Pter'gium with mared d'splastic changes andprominent vascular prolieration The con+unctivashowed mared d'splastic changes and increasedepithelium cell thicness, with loss o polarit' andnuclear pol'morphism ('ellow arrow$F the su&stantiapropria showed e1u&erant granulation tissue, withprominent in-ammation and vascular prolieration(red arrow$ A normal part o the epithelium is alsoshown or comparison (white arrow$ (2 and 4, K;$


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)on+unctival carcinoma in situ. The conjunctivashowed increased epithelium cell thicness, withloss o polarit' and nuclear pol'morphismF

mared at'pia (red arrow$, irregularit', andpotential disruption o the &asement mem&raneare evident The su&stantia propria showedmared vascular prolieration with dilatedcongested &lood vessels, e1u&erant granulationtissue, with prominent in-ammation andvascular prolieration (white arrow$ A near&'con+unctival epithelium showed mild d'splastic

changes ('ellow arrow$ (2 and 4, K7$

Immunostaining or phospho!P53

anti&od' showing staining o nucleio the epithelium (3$


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Immunohistochemistry staining of a case using the

Ki-67 antibody. The epithelium showed prominent

positive staining of the nuclei (60! ("#00!.

Representative o the molecular studies or

the detection o human papillomavirus (2P$2P 89A was not detected in an' sample &'

P)R Ampli%cation o the glo&in gene wasdetected, indicating the high ualit' o the89A 2P 89A was detected onl' in the

positive control sample (2eEa cell line, whichhas 2P inection, 2P!;D$ The primers used

in the assa' could detect inection with an'2P su&t'pe (not +ust 2P!;D$


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51 P.; e:pression

• In this stud', the' utili*ed anti&odies or the activated(phosphor'lated$ P53

• >pecimens with immunostaining o more than ;

considered positive or pP53 e1pression 75pter'gium specimens (6"7$ consistent with otherstudies (increased e1pression o p53 in up to ; othe studied specimens in some instances$

#here 9as no statistically signi>cant di?erence5et9een primary and recurrent pterygium in p.;

o7ere:pression1 this result is consistent 9ith otherstudies including Cho9ers et al. and Zhang et al


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• @ther studies showed a considera&le varia&ilit' in therate o p53 e1pression in pter'gium, ma' &e &ecause:

- &ne is the di?erent types of p.; anti5odies used

- #he di?erent cuto? le7el for the percentage ofcells stained positi7ely for p.;

- #he di?erent races and 9ith di?erenten7ironmental factors such as UVR e:posure

• .eda et al. Japanese and Tunisian patients that thedi?erence in p53 positivit' ma' &e attri&uted to thedi?erent race and environmental actors statisticall'insigni%cant

• Pelit et al. expression in patients rom two Turish citieswith di?erent climatic conditions, a sunnier andwarmer (levels o .R e1posure$ insigni%cant


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c1 Immunohistochemistry for 8i*


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d1 Polymerase chain reaction for humanpapilloma7irus

• In this stud', all the specimens were negative or 2P89A, with no signi%cant di?erence &etween primar'and recurrent pter'gia

• These %ndings are consistent with other studies inother parts o the world that reported the a&sence o2P rom pter'gium

•2owever, other studies reported the presence o 2P inpter'gium, suggesting its possi&le s'nergistic role indisease pathogenesis, and the variation in theprevalence o the virus in geographicall' distant

populations


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• 2P was a&sent or detected in a smallinsigni%cant percentage o pter'gium specimensin studies carried out in Asia (Taiwan and Japan$,

.>A, some studies in ra*il, and some 4uropeancountries including erman', 8enmar, and

Ture'

• 0here as the virus was detected in a moderate tohigh percentage o pter'gia in studies carried outin some 4uropean countries (reece, .N, Ital',and Poland$ and >outh America (4cuador andra*il$

• This stud' suggests that 2P is not an etiological

actor or pter'gium pathogenesis in 4g'pt


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Conclusion

• The histopathological characteristics o pter'gium include

epithelial and stromal in-ammation, stromal vascularprolieration, %&rosis, and solar elastosis, in addition to the

high reuenc' o epithelial d'splasia, which supports theneoplastic theor' o pter'gium pathogenesis

• There was no signi%cant di?erence &etween primar' and

recurrent pter'gia in histopathological eatures

• It was ound that p53 e1pression is increased in pter'gial

epithelium as well as i!"#, which indicates the highprolierative activit'

• The a&sence o 2P suggests that it is not an etiological

actor or pter'gium pathogenesis in 4g'pt


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ThanOs or 'ou attention

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