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 Table of Contents    
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 153-156  

Ocular and periocular tumors in 855 Asian Indian geriatric patients


1 Ocular Oncology Service, The Operation Eyesight Universal Institute for Eye Cancer (SK), Hyderabad, Telangana, India
2 Department of Eyesmart EMR and AEye (AVD), LV Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission25-May-2021
Date of Decision10-Jun-2021
Date of Acceptance29-Jun-2021
Date of Web Publication20-Oct-2021

Correspondence Address:
Dr. Swathi Kaliki
The Operation Eyesight Universal Institute for Eye Cancer, LV Prasad Eye Institute, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.OJO_174_20

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   Abstract 


OBJECTIVE: The objective of this study was to describe the eye tumors in Asian Indian geriatric population (age >60 years) presenting to a multitier ophthalmology hospital network in India.
METHODS: This was a retrospective study of 855 Asian Indian geriatric patients.
RESULTS: During the 3-year study period, 855 geriatric patients were diagnosed with eye tumors. The mean age at presentation with an ocular or periocular tumor was 68 years (median, 67 years; range, 60–91 years). There were 458 (54%) benign tumors and 397 (46%) malignant tumors. The distribution of benign versus malignant tumors in different age groups was 324 (71%) versus 259 (65%) in 60–70 years, 116 (25%) versus 99 (25%) in 71–80 years, and 18 (4%) versus 39 (10%) in >80 years' age groups. The three most common benign tumors included eyelid cyst (n = 99, 22%), eyelid nevus (n = 50, 11%), and pseudotumor or nonspecific orbital inflammatory disease (n = 38, 8%). The three most common malignant tumors included ocular surface squamous neoplasia (OSSN) (n = 208, 52%), periocular sebaceous gland carcinoma (n = 68, 17%), and periocular basal cell carcinoma (n = 25, 6%). Overall, OSSN was the most common tumor in all age groups (22% of all tumors in 60–70 years, 27% in 71–80 years, and 39% in >80 years' age groups).
CONCLUSION: Overall, there is an increasing trend of malignant tumors with increasing age. OSSN is the most common tumor in the geriatric population encountered in a referral-based comprehensive ocular oncology practice in India.

Keywords: Cancer, eye, geriatric, India, oncology, ocular surface squamous neoplasia


How to cite this article:
Kaliki S, Das AV. Ocular and periocular tumors in 855 Asian Indian geriatric patients. Oman J Ophthalmol 2021;14:153-6

How to cite this URL:
Kaliki S, Das AV. Ocular and periocular tumors in 855 Asian Indian geriatric patients. Oman J Ophthalmol [serial online] 2021 [cited 2021 Dec 8];14:153-6. Available from: https://www.ojoonline.org/text.asp?2021/14/3/153/328601




   Introduction Top


With increasing life expectancy, geriatric population is increasing in number across the world, stressing the need for modifying policies across all sectors, including health care and thus be an inclusive society. In a data analysis on the estimated and projected number of geriatric population aged 60 years or older, it was noted that the global population aged 60 years or older was 382 million in 1980, which increased more than twice to 962 million in 2017, and is expected to double again to nearly 2.1 billion by 2050.[1] It was also noted that two-thirds of the world's geriatric population was in developing nations in 2017, and is estimated that 79% of the world's geriatric population would be living in developing nations by the year 2050.[1] These estimates signify the increased burden on the health-care system to ensure healthy aging, which remains a challenge in developing nations like India.

In India, geriatric population aged 60 years or older was 1.2 million in 2017 and is expected to increase to 3.2 million by the year 2050.[1] Geriatric population is a vulnerable population with multiple health-related issues including cancer. It is noted that 80% of all cancers are diagnosed beyond the age of 55 years and the median age of diagnosis of most tumors is beyond 60 years of age.[2],[3] In a study of 1100 malignant cancers in Asian Indian population, it was noted that 45% of cancers were noted in geriatric population aged 60 years or older.[4] The most common cancer in older males was prostate cancer (23%) and in older females was breast (24%) cancer.[4] Eye cancer constituted only 0.5% of all cancers in the geriatric population, including 0.2% of all cancers in older males and 0% in older females.[4] Literature search revealed no big data analysis focusing on ocular and periocular tumors in geriatric population. Herein, in this study, we review the incidence and distribution pattern of benign and malignant ocular and periocular tumors in Asian Indian geriatric patients.


   Methods Top


This was a retrospective observational/interventional hospital-based study of geriatric population diagnosed with eye tumors presenting between November 2015 and October 2018 – 4 referral centers spread across 4 states in India. For this study, geriatric population was defined as 60 years or older. Consent for electronic data privacy was obtained from the patient at the time of registration. No identifiable information of the patient was used for analytical purposes. Each patient underwent a comprehensive ophthalmic examination, and the data were entered into a browser-based in-house developed electronic medical records system (eyeSmart EMR).[5] The study adhered to the Tenets of Declaration of Helsinki and was approved by the Institutional Ethics Committee of the institute.

The data of all geriatric patients diagnosed with eye tumors during the study period were retrieved from the EMR database. The patients with a confirmed clinical and/or histopathology diagnosis were included in this study. All patients who underwent surgical intervention had a confirmed histopathological diagnosis. Those with uncertain diagnosis or inadequate data were excluded. The data on patient demographics, ocular diagnosis, tumor status, and anatomical category were exported for analysis.

Statistical analysis

Descriptive statistics using mean (± standard deviation) and median (± range) were used to elucidate the demographic data. All tables for age, gender, diagnosis, and anatomical category were drawn by using Microsoft Excel 2013 (Microsoft Corporation, Redmond, USA).


   Results Top


Of the 728,077 new patients presenting to the 4 tertiary centers of the network between November 2015 and October 2018 in the multitier hospital network, 124,268 (17%) patients were 60 years or older. Of these 124,268 older individuals, 865 (1%) were diagnosed with eye tumors. Of these, 10 patients who did not have a confirmed diagnosis of eye tumor were excluded from the study, and 855 patients with a definitive diagnosis of benign or malignant tumor either by clinical examination or confirmed histopathology were included in the study.

The mean age at presentation with an ocular or periocular tumor was 68 years (median, 67 years; range, 60–91 years). Majority of patients (68%) were in the age group of 60–70 years. Of the 855 patients, 503 (59%) were male and 352 (41%) were female. The demographic details are listed in [Table 1].
Table 1: Demographics and clinical findings of geriatric patients

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Of the 855 tumors, 458 (54%) tumors were benign and 397 (46%) were malignant. Overall, the most common anatomical part involved by the tumors was eyelid with 335 (39%) cases. Conjunctiva was the most common tissue involved by malignant tumors (n = 218, 55%), while eyelid had the most benign tumors (n = 228, 50%). The anatomical distribution of the tumors is presented in [Table 2].
Table 2: Anatomical distribution of tumors and tumor status according to age group

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Including both benign and malignant eye tumors, the three most common tumors included ocular surface squamous neoplasia (OSSN) (n = 208, 24%), eyelid cyst (n = 99, 12%), and periocular sebaceous gland carcinoma (SGC) (n = 68, 8%). Among the benign tumors, the three most common benign tumors included eyelid cyst (n = 99, 22%), eyelid nevus (n = 50, 11%), and pseudotumor or nonspecific orbital inflammatory disease (NSOID) (n = 38, 8%). Among the malignant tumors, the three most common malignant tumors included OSSN (n = 208, 52%), periocular SGC (n = 68, 17%), and periocular basal cell carcinoma (n = 25, 6%). The most common tumor in the eyelid was eyelid cyst (n = 99, 30%), caruncle was caruncular nevus (n = 1, 100%), conjunctiva was OSSN (n = 208, 66%), iris was iris pigment epithelial cyst (n = 12, 86%), ciliary body was melanoma (n = 1, 50%), vitreous was intraocular lymphoma (n = 4, 80%), retina was combined hamartoma of retina and retinal pigment epithelium (n = 8, 57%), choroid was choroidal melanoma (n = 16, 31%), orbit was NSOID (n = 38, 33%), and lacrimal sac was papilloma (n = 2, 67%).

Overall, OSSN was the most common tumor in all age groups (22% of all tumors in 60–70 years, 27% in 71–80 years, and 39% in >80 years' age groups). Comparing the distribution of benign versus malignant tumors based on decade of presentation, there were 324 (71%) benign versus 259 (65%) malignant tumors in 60–70 years' age group (1.2:1), 116 (25%) versus 99 (25%) in 71–80 years (1.2:1), and 18 (4%) versus 39 (10%) in >80 years' age groups (1:2.2).

Of the 855 tumors, surgical intervention was performed in 345 (40%) tumors and histopathological confirmation of diagnosis was available in these tumors, while the remaining 510 (60%) tumors were diagnosed clinically and treated accordingly. Of these 345 tumors, 138 (40%) were benign and 207 (60%) were malignant tumors. Of the 138 benign tumors, incisional biopsy was performed in 21 (15%) cases while 117 (85%) underwent excisional biopsy. Of the 207 malignant tumors, incisional biopsy was performed in 43 (21%) cases followed by medical treatment/radiotherapy, excisional biopsy in 118 (57%) cases, enucleation in 18 (9%), and orbital exenteration in 28 (14%) eyes. Of these 345 tumors with histopathological diagnosis, accurate clinicopathological correlation was noted in 277 (80%) tumors, while discordance between clinical and histopathological diagnosis was noted in 67 (19%) tumors. Of the cases with a discordant clinical and histopathological diagnosis, 2 (<1%) tumors had a clinical diagnosis of benign tumor, while histopathology revealed a malignant tumor; 30 (9%) tumors had a clinical diagnosis of malignant tumor, while histopathology revealed a benign tumor; and 21 (6%) tumors had a different diagnosis in the same category of benign tumors; and 14 (4%) tumors had a different diagnosis in the same category of malignant tumors.


   Discussion Top


There is a complex relationship between cancer and aging. Studies on epidemiology of cancers have shown that many cancers display a rapid increase in the incidence and mortality with increasing age.[6] Fewer cancers such as childhood cancers and hormone-related cancers do not show this direct relationship with age.[6] Age per se may not be a determinant of cancer but rather a complex interplay between prolonged carcinogen exposure, increased susceptibility of the aging tissues to the carcinogens, and systemic effects of aging with immune senescence and increased cytokine production could influence the incidence of cancer.[7] In our study, there was an increasing incidence of malignant eye cancers with increasing age with the ratio of benign: malignant tumors being 1.2:1 at the age of 60–70 years which increased to 1:2.2 in patients aged older than 80 years.

The most common benign tumor in our study was eyelid cyst (n = 99, 22%). Eyelid cysts commonly include epidermal inclusion cysts, apocrine hidrocystoma, eccrine hidrocystoma, trichilemmal cysts, and milia.[8] In a clinicopathological study of 35 patients with eyelid cystic lesions including patients of all ages, the mean age at diagnosis of eyelid cysts was 57 years, suggesting older age at presentation of these lesions.[9] In our study, including only the geriatric population, the mean age at presentation of eyelid cysts was 68 years, with epidermal inclusion cyst (n = 46; 46%) being the most common eyelid cystic lesion.

The most common malignant tumor in our study was OSSN (n = 208, 52%). OSSN is a common ocular surface malignancy with a mean age at presentation of 68–69 years,[10],[11] indicating that OSSN is a disease of elderly population. The mean age at presentation of OSSN in our geriatric population was 69 years. In a study of 1954 conjunctival tumors (including benign and malignant tumors) in elderly population aged over 60 years, OSSN (n = 494, 25%) was the most common tumor encountered.[12] In our study, overall, including benign and malignant tumors, OSSN (n = 208, 24%) was still the most commonly encountered tumor in the geriatric population. This higher incidence of OSSN in the elderly population could be related to cumulative duration of exposure to ultraviolet irradiation, increased susceptibility of aging tissues, and immune senescence.

In our study, intraocular tumors were less common in the elderly population, accounting for only 10% of all tumors. The most common intraocular tumor in our study was uveal melanoma (n = 17, 2%). Although uveal melanoma is a very common malignant uveal tumor in the Caucasian elderly population with a mean age at diagnosis of 59–62 years, it is relatively less common in Asian Indian geriatric population.[13] It is more commonly seen in middle-aged adults with a mean age at presentation of 46 years.[13] The exact cause of this difference in the age at diagnosis is not known and could be related to unknown cultural and environmental factors.

In our study, orbital tumors constituted 13% of all tumors in the geriatric population. In a study of 200 geriatric patients, it was noted that most orbital tumors are malignant (63%), with malignant lymphoma (24%) being the most common tumor.[14] In our study, only 34% of all orbital tumors were malignant, and NSOID or pseudotumor was the most common orbital tumor accounting for 34% of all orbital tumors. The most common malignant orbital tumor was malignant lymphoma, accounting for 18% of all orbital tumors. This difference in the lower incidence of malignant tumors could be related to referral bias.

The limitations of our study include retrospective nature of the study and possible referral bias since it is a referral hospital-based study. However, the strength of the study includes larger number of patients and higher probability of an accurate diagnosis by a trained ocular/ophthalmic oncologist. Of the 345 cases with histopathology confirmation of the diagnosis, there was mismatch between diagnosis of benign versus malignant tumor in only 32 (10%) cases. In these cases, there was higher suspicion of malignancy, while histopathology revealed a benign tumor in 30 cases.


   Conclusion Top


OSSN is the most common tumor in Asian Indian geriatric population. OSSN should be ruled out in any geriatric patient presenting with an ocular surface lesion. These patients should promptly be referred to an ocular oncologist for an accurate diagnosis and definitive treatment. Although benign tumors were more common in our study, a thorough examination by an ocular oncologist is mandatory to rule out a masquerade. Even in benign tumors, immediate intervention is warranted when the tumor is vision threatening. General practitioners, who are the first point of contact in most of these cases, play an important role in the diagnosis and appropriate referral of geriatric patients with ocular and periocular tumors. The ultimate goal is accurate diagnosis and timely treatment so as to save a patient's vision, eye, and life.

Acknowledgment

The authors wish to acknowledge the support of our Department of eyeSmart EMR and AEye team, especially Mr. Ranganath Vadapalli and Mr. Mohammad Pasha.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2017-Highlights (ST/ESA/SER.A/397); 2017.  Back to cited text no. 1
    
2.
Pallis AG, Fortpied C, Wedding U, Van Nes MC, Penninckx B, Ring A, et al. EORTC elderly task force position paper: Approach to the older cancer patient. Eur J Cancer 2010;46:1502-13.  Back to cited text no. 2
    
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Marosi C, Köller M. Challenge of cancer in the elderly. ESMO Open 2016;1:e000020.  Back to cited text no. 3
    
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Kansal S, Rao S. Demographic transition-Cancer trends in geriatric population of North India. J Geriatr Oncol 2019;10:362-4.  Back to cited text no. 4
    
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Das AV, Kammari P, Vadapalli R, Basu S. Big data and the eyeSmart electronic medical record system – An 8-year experience from a three-tier eye care network in India. Indian J Ophthalmol 2020;68:427-32.  Back to cited text no. 5
[PUBMED]  [Full text]  
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Franceschi S, La Vecchia C. Cancer epidemiology in the elderly. Crit Rev Oncol Hematol 2001;39:219-26.  Back to cited text no. 6
    
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Balducci L, Beghe' C. Cancer and age in the USA. Crit Rev Oncol Hematol 2001;37:137-45.  Back to cited text no. 7
    
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Pe'er J. Pathology of eyelid tumors. Indian J Ophthalmol 2016;64:177-90.  Back to cited text no. 8
    
9.
Suimon Y, Kase S, Ishijima K, Kanno-Okada H, Ishida S. Clinicopathological features of cystic lesions in the eyelid. Biomed Rep 2019;10:92-6.  Back to cited text no. 9
    
10.
Kiire CA, Stewart RM, Srinivasan S, Heimann H, Kaye SB, Dhillon B. A prospective study of the incidence, associations and outcomes of ocular surface squamous neoplasia in the United Kingdom. Eye (Lond) 2019;33:283-94.  Back to cited text no. 10
    
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Darwich R, Ghazawi FM, Le M, Rahme E, Alghazawi N, Zubarev A, et al. Epidemiology of invasive ocular surface squamous neoplasia in Canada during 1992-2010. Br J Ophthalmol 2020;104:1368-72.  Back to cited text no. 11
    
12.
Shields CL, Alset AE, Boal NS, Casey MG, Knapp AN, Sugarman JA, et al. Conjunctival tumors in 5002 cases. Comparative analysis of benign versus malignant counterparts. The 2016 James D. Allen Lecture. Am J Ophthalmol 2017;173:106-33.  Back to cited text no. 12
    
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Kaliki S, Shields CL. Uveal melanoma: Relatively rare but deadly cancer. Eye (Lond) 2017;31:241-57.  Back to cited text no. 13
    
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Demirci H, Shields CL, Shields JA, Honavar SG, Mercado GJ, Tovilla JC. Orbital tumors in the older adult population. Ophthalmology 2002;109:243-8.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2]



 

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