眼球摘出を併用した腫瘍切除術が適切であった結膜由来眼表面腫瘍の2症例

Two cases of conjunctival-derived ocular surface tumor requiring enucleation

要約　目的：眼表面腫瘍は比較的悪性度の低い腫瘍が多いが，進行例や色素性上皮腫瘍では外科治療方法の選択に迷うことが少なくない。今回，眼球摘出を併用した腫瘍全切除術が適切な治療選択であった眼表面腫瘍2症例を経験したので報告する。

症例1：89歳，男性。前医で右結膜腫瘍切除後，病理検査で結膜上皮内新生物と診断されたが，再発疑いで当院を紹介され受診した。初診時，右眼に結膜充血，角膜表層への高度血管侵入および角膜炎を認め，生検を実施した。扁平上皮癌と診断でき，強膜浸潤が危惧され，眼球摘出併用眼表面悪性腫瘍全切除術を施行した。術後の病理診断で強膜および毛様体組織への眼内腫瘍浸潤を認めた。PET/CTでは遠隔転移がなく，経過良好である。

症例2：54歳，男性。左角膜輪部全周に色素沈着を，角膜半周に有色素性の上皮分布を，また球結膜および眼瞼結膜に色素病変を，円蓋部に隆起性腫瘍を認めた。悪性黒色腫を疑い，予後を考慮してマッピング生検は施行せず眼窩内容除去術を施行した。病理診断は悪性黒色腫であり，結膜断端は陰性であり，脈管浸潤は認めなかった。PET/CTでも遠隔転移はなく，経過良好である。

結論：眼表面深部への進行性腫瘍は比較的稀であるが，臨床像や経過から適切に悪性度や進行度を推測することが重要であり，深部浸潤や眼内浸潤が疑われる症例では適切なタイミングで眼球摘出を選択する必要がある。

Abstract　Purpose：Most ocular surface tumors are relatively low-grade tumors, but in advanced cases and pigmented epithelial tumors, it is often difficult to select an optimal operative method. We report two cases of ocular surface tumors for which enucleation of the eye was deemed an appropriate treatment option.

Case 1：An 89-year-old man. After resection of the right conjunctival tumor at another clinic, a pathological examination revealed a conjunctival intraepithelial neoplasia. A biopsy was performed because right conjunctival hyperemia, severe vascular invasion into the corneal surface, and keratitis were observed. A case of squamous cell carcinoma was diagnosed, and scleral infiltration was suspected. Therefore, enucleation of the eye was performed. Postoperative pathological diagnosis revealed infiltration of intraocular tumor into the sclera and ciliary tissue. However, positron emission tomography/computed tomography（PET/CT）showed no metastasis.

Case 2：A 54-year-old man. Pigmentation was observed on the entire limbus of the left eye and pigmented epithelial distribution was observed in half of the cornea. Pigment lesions were distributed on the bulbar and palpebral conjunctiva and elevated tumors were observed on the conjunctival fornix. Malignant melanoma was suspected, and in consideration of the prognosis, upper and lower eyelids and enucleation of the eye were performed without mapping biopsy. The postoperative pathological diagnosis was malignant melanoma, but no vascular infiltration was observed. PET/CT showed no metastasis.

Conclusion：Progressive tumors occurring deep into the ocular surface are relatively rare, but it is important to properly infer the degree of malignancy and progression from the clinical feature and clinical course, and enucleation should be selected at the appropriate time, if deep infiltration or intraocular infiltration is suspected.