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Clinical Ophthalmic
Oncology

Basic Principles
Arun D. Singh
Bertil E. Damato
Editors
Third Edition

123
Clinical Ophthalmic Oncology
Arun D. Singh • Bertil E. Damato
Editors

Clinical Ophthalmic
Oncology
Basic Principles

Third Edition
Editors
Arun D. Singh Bertil E. Damato
Department of Ophthalmic Oncology Nuffield Department of Clinical
Cole Eye Institute, Cleveland Clinic Neurosciences, University of Oxford
Cleveland, OH John Radcliffe Hospital
USA Oxford, UK

ISBN 978-3-030-04488-6    ISBN 978-3-030-04489-3 (eBook)

https://doi.org/10.1007/978-3-030-04489-3

Library of Congress Control Number: 2019932849

© Springer Nature Switzerland AG 2019

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Preface

Ophthalmic tumors are rare and diverse so that their diagnosis can be quite
complex. Treatment usually requires special expertise and equipment and in
many instances is controversial. The field is advancing rapidly, because of
accelerating progress in tumor biology, pharmacology, and instrumentation.
Increasingly, the care of patients with an ocular or adnexal tumor is provided
by a multidisciplinary team, consisting of ocular oncologists, general oncolo-
gists, radiotherapists, pathologists, psychologists, and other specialists.
For all these reasons, we felt that there was a need for the new edition of
the textbook providing a balanced view of current clinical practice. Although
each section of Clinical Ophthalmic Oncology, 3rd Edition, now represents a
stand-alone volume, each chapter has a similar layout with boxes that high-
light the key features, tables that provide comparison, and flow diagrams that
outline therapeutic approaches.
The enormous task of editing a multiauthor, multivolume textbook could
not have been possible without the support and guidance by the staff at
Springer: Caitlin Prim, Melanie Zerah, ArulRonika Pathinathan, and Karthik
Rajasekar. Michael D. Sova kept the pressure on to meet the production
deadlines.
It is our sincere hope that our efforts will meet high expectation of the
readers.

Cleveland, OH, USA Arun D. Singh, MD

Oxford, UK Bertil E. Damato, MD, PhD, FRCOphth

v
Acknowledgments

To my parents who educated me beyond their means, my wife Annapurna,

and my children, Nakul and Rahul, who make all my efforts worthwhile.
(ADS)
To my family, Frankanne, Erika, Stephen, and Anna. (BED)

 Arun D Singh
 Bertil E Damato

vii
Contents

1 Principles of Cancer Epidemiology������������������������������������������������   1

Annette C. Moll, Michiel Robert de Boer, Lex M. Bouter, and
Nakul Singh
2 Etiology of Cancer���������������������������������������������������������������������������� 11
Brian T. Hill
3 Cancer Pathology ���������������������������������������������������������������������������� 19
Gustav Stålhammar, Katarina Bartuma, Charlotta All-Eriksson,
and Stefan Seregard
4 Pathology Specimen: Handling Techniques���������������������������������� 33
Hardeep Singh Mudhar
5 Cancer Angiogenesis������������������������������������������������������������������������ 49
Werner Wackernagel, Lisa Tarmann, Martin Weger,
and Arun D. Singh
6 Immunology of Ocular Tumors������������������������������������������������������ 71
Martine J. Jager and Inge H. G. Bronkhorst
7 Cancer Genetics ������������������������������������������������������������������������������ 79
Elaine M. Binkley and Luke A. Wiley
8 Cancer Staging �������������������������������������������������������������������������������� 87
Claudine Bellerive and Arun D. Singh
9 Principles of Cryotherapy �������������������������������������������������������������� 93
Dan S. Gombos and Kayla Walter
10 Principles of Laser Therapy������������������������������������������������������������ 99
Hatem Krema
11 Principles of Radiation Therapy���������������������������������������������������� 107
Abigail L. Stockham, Allan Wilkinson, and Arun D. Singh
12 Ocular Complications of Radiotherapy ���������������������������������������� 117
Mitchell Kamrava, James Lamb, Vidal Soberón, and
Tara A. McCannel
13 Principles and Complications of Chemotherapy�������������������������� 129
Stacey Zahler, Nicola G. Ghazi, and Arun D. Singh

ix
x Contents

14 Ocular Complications of Targeted Therapy���������������������������������� 143

Ashley Neiweem, Denis Jusufbegovic, and Arun D. Singh
15 Counseling Patients with Cancer���������������������������������������������������� 161
Bertil E. Damato
16 Tumor-Associated Cataract������������������������������������������������������������ 173
Carlos A. Medina Mendez, Mary E. Aronow,
Guillermo Amescua, and Arun D. Singh
17 Tumor-Associated Glaucoma���������������������������������������������������������� 185
Reena Garg, Annapurna Singh, and Arun D. Singh
18 Graft-Versus-Host Disease�������������������������������������������������������������� 195
Edgar M. Espana, Lauren Jeang, and Arun D. Singh
19 Diagnostic Techniques: Angiography �������������������������������������������� 209
Kaan Gündüz and Yağmur Seda Yeşiltaş
20 Diagnostic Techniques: OCT���������������������������������������������������������� 235
Rubens Belfort and Arun D. Singh
21 Diagnostic Techniques: Autofluorescence�������������������������������������� 257
Edoardo Midena, Luisa Frizziero, Elisabetta Pilotto, and
Raffaele Parrozzani
22 Diagnostic Techniques: Ultrasonography�������������������������������������� 271
Brandy H. Lorek, Mary E. Aronow, and Arun D. Singh
23 Diagnostic Techniques: FNAB�������������������������������������������������������� 295
Hassan A. Aziz, David Pelayes, Charles V. Biscotti, and
Arun D. Singh
24 Diagnostic Techniques: Other Biopsy Techniques������������������������ 309
Bertil E. Damato, Armin Afshar, Sarah E. Coupland,
Heinrich Heimann, and Carl Groenewald

Index���������������������������������������������������������������������������������������������������������� 317
Contributors

Armin Afshar, MD, MBA Ocular Oncology Service, Department of

Ophthalmology, University of California San Francisco, San Francisco, CA,
USA
Charlotta All-Eriksson, MD, PhD Department of Ophthalmic Pathology
and Oncology Service and Department of Clinical Neuroscience, St. Erik Eye
Hospital and Karolinska Institutet, Stockholm, Sweden
Guillermo Amescua, MD Department of Cornea and External Diseases,
Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
Mary E. Aronow, MD Department of Retina Service and Ocular Oncology,
Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, USA
Hassan A. Aziz, MD Clemenceau Medical Center, Beirut, Lebanon
Katarina Bartuma, MD, PhD Department of Ophthalmic Pathology and
Oncology Service and Department of Clinical Neuroscience, St. Erik Eye
Hospital and Karolinska Institutet, Stockholm, Sweden
Rubens Belfort, MD, PhD Department of Ophthalmology and Visual
Sciences, Escola Paulista de Medicina – Federal University of São Paulo, São
Paulo, Brazil
Claudine Bellerive, MD, MSc Centre universitaire d’ophtalmologie,
Hôpital Saint-Sacrement, Centre hospitalier universitaire de Québec, Québec,
QC, Canada
Elaine M. Binkley, MD Department of Ophthalmology & Visual Sciences,
University of Iowa Hospitals and Clinics, Iowa City, IA, USA
Charles V. Biscotti, MD Department of Anatomic Pathology and Cole Eye
Institute, Cleveland Clinic, Cleveland, OH, USA
Lex M. Bouter, PhD Department of Epidemiology and Biostatistics, VU
University Medical Centre, Amsterdam, The Netherlands
Inge H. G. Bronkhorst, MD Department of Ophthalmology, Jeroen Bosch
Hospital, ‘s-Hertogenbosch, The Netherlands
Sarah E. Coupland, MBBS, PhD Department of Molecular and Clinical
Cancer Medicine, Institute of Translational Medicine, University of Liverpool,
Liverpool, UK

xi
xii Contributors

Bertil E. Damato, MD, PhD, FRCOphth Nuffield Department of Clinical

Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3
9DU, UK
Michiel Robert de Boer, PhD Department of Health Sciences, VU
Amsterdam, Amsterdam, The Netherlands
Edgar M. Espana, MD Department of Ophthalmology, University of South
Florida, Tampa, USA
Luisa Frizziero, MD IRCCS – Fondazione Bietti, Rome, Italy
Reena Garg, MD Department of Ophthalmology, Emory University
Hospital, Atlanta, GA, USA
Nicola G. Ghazi, MD Division of Ophthalmology and Vitreoretinal Service,
King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
Department of Ophthalmology, The University of Virginia, Charlottesville,
VA, USA
Dan S. Gombos, MD, FACS Section of Ophthalmology-Department of
Head and Neck Surgery, MD Anderson Cancer Center, The Retinoblastoma
Center of Houston (MD Anderson/Texas Children’s/Baylor/Methodist
Hospital), Houston, TX, USA
Carl Groenewald, MD Liverpool Ocular Oncology Centre, St Paul’s Eye
Unit, Royal Liverpool University Hospital, Liverpool, UK
Kaan Gündüz, MD Department of Ophthalmology, Ankara University
Faculty of Medicine, Ankara, Turkey
Heinrich Heimann, MD Liverpool Ocular Oncology Centre, St Paul’s Eye
Unit, Royal Liverpool University Hospital, Liverpool, UK
Brian T. Hill, MD, PhD Department of Taussig Cancer Institute, Cleveland
Clinic, Cleveland, OH, USA
Martine J. Jager, MD, PhD Department of Ophthalmology, LUMC,
Leiden, The Netherlands
Lauren Jeang, MD Department of Ophthalmology, New England Eye
Center/Tufts Medical Center, Boston, MA, USA
Denis Jusufbegovic, MD Department of Ophthalmology, Indiana University
School of Medicine/Glick Eye Institute, Indianapolis, IN, USA
Mitchell Kamrava, MD Department of Radiation Oncology, University of
California, Los Angeles, CA, USA
Hatem Krema, MD, MSc, FRCS Ocular Oncology Service, Princess
Margaret Cancer Center/ University Health Network, Toronto, ON, Canada
James Lamb, PhD Department of Radiation Oncology, University of
California, Los Angeles, CA, USA
Brandy H. Lorek, BS Cole Eye Institute, Cleveland Clinic, Cleveland, OH,
USA
Contributors xiii

Tara A. McCannel, MD, PhD Ophthalmic Oncology Center, Jules Stein

Eye Institute, Department of Ophthalmology, University of California, Los
Angeles, CA, USA
Carlos A. Medina Mendez, MD Retinal Consultants, Sacramento, CA,
USA
Edoardo Midena, MD, PhD Department of Ophthalmology, University of
Padova, Padova, Italy
IRCCS – Fondazione Bietti, Rome, Italy
Annette C. Moll, MD, PhD Department of Ophthalmology, VU University
Medical Center, Amsterdam, The Netherlands
Hardeep Singh Mudhar, BSc, PhD, MBBChir, FRCPath National
Specialist Ophthalmic Pathology Service (NSOPS), Department of
Histopathology, E-Floor, Sheffield Teaching Hospitals NHS Foundation
Trust, Royal Hallamshire Hospital, Sheffield, UK
Ashley Neiweem, MD Department of Ophthalmology, Indiana University
School of Medicine/Glick Eye Institute, Indianapolis, IN, USA
Raffaele Parrozzani, MD, PhD Department of Ophthalmology, University
of Padova, Padova, Italy
David Pelayes, MD Department of Ophthalmology, Buenos Aires University
and Maimonides University, Buenos Aires, Argentina
Elisabetta Pilotto, MD Department of Ophthalmology, University of
Padova, Padova, Italy
Stefan Seregard, MD PhD Department of Ophthalmic Pathology and
Oncology Service and Department of Clinical Neuroscience, St. Erik Eye
Hospital and Karolinska Institutet, Stockholm, Sweden
Annapurna Singh, MD Department of Ophthalmic Oncology, Cole Eye
Institute, Cleveland Clinic, Cleveland, OH, USA
Arun D. Singh, MD Department of Ophthalmic Oncology, Cole Eye
Institute, Cleveland Clinic, Cleveland, OH, USA
Nakul Singh, MS School of Medicine, Case Western University, Cleveland,
OH, USA
Vidal Soberón, MD Department of Retina/Oncology, Jules Stein Eye
Institute, Los Angeles, CA, USA
Gustav Stålhammar, MD, PhD Department of Ophthalmic Pathology and
Oncology Service and Department of Clinical Neuroscience, St. Erik Eye
Hospital and Karolinska Institutet, Stockholm, Sweden
Abigail L. Stockham, MD Department of Radiation Oncology, Mayo
Clinic, Rochester, MN, USA
Lisa Tarmann, MD, PhD Department of Ophthalmology, Medical
University Graz, Graz, Styria, Austria
xiv Contributors

Werner Wackernagel, MD Department of Ophthalmology, Medical

University Graz, Graz, Styria, Austria
Kayla Walter UT McGovern School of Medicine, Houston, TX, USA
Martin Weger, MD Department of Ophthalmology, Medical University
Graz, Graz, Styria, Austria
Luke A. Wiley, PhD Department of Ophthalmology & Visual Sciences,
Institute for Vision Research, University of Iowa, Iowa City, IA, USA
Allan Wilkinson, PhD Department of Radiation Oncology, Cole Eye
Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
Yağmur Seda Yeşiltaş, MD Department of Ophthalmology, Ankara
University Faculty of Medicine, Ankara, Turkey
Stacey Zahler, DO, MS Department of Pediatric Hematology, Oncology
and Blood & Marrow Transplantation, Cleveland Clinic Children’s Hospital,
Cleveland, OH, USA
 Principles of Cancer Epidemiology
Annette C. Moll, Michiel Robert de Boer,
Lex M. Bouter, and Nakul Singh
Introduction
During the last decade, evidence-based medicine
(EBM) has become a dominant approach in many
medical fields, including ophthalmology [1, 2].
Clinical epidemiological studies provide evidence
that can aid decision-making processes. An over-
whelming amount of clinical epidemiological
papers are being published every year, and critical
appraisal of the findings can be challenging, espe-
cially for the busy clinician who is not formally
trained in the field of clinical epidemiology.
Therefore, the available evidence is increasingly
bundled in clinical guidelines. The aim of this
chapter is to provide readers with some basic
knowledge to allow them to judge the value of
clinical epidemiological papers and thus of the pil-
lars of evidence-based clinical guidelines.
A. C. Moll (*)
Department of Ophthalmology, VU University
Medical Center, Amsterdam, The Netherlands
e-mail: a.moll@vumc.nl
M. R. de Boer
Department of Health Sciences, VU Amsterdam,
Amsterdam, The Netherlands
L. M. Bouter
Department of Epidemiology and Biostatistics,
VU University Medical Centre,
Amsterdam, The Netherlands
N. Singh
School of Medicine, Case Western University,
Cleveland, OH, USA
© Springer Nature Switzerland AG 2019
A. D. Singh, B. E. Damato (eds.), Clinical Ophthalmic Oncology,
https://doi.org/10.1007/978-3-030-04489-3_1
1
Examples from ocular oncology will be used to
illustrate the methodological principles.
Research Question
A clinical epidemiological study should always
start with a well-defined research question.
Similarly, when reading a paper, one should
always first identify the question(s) the authors
wish to address (Fig. 1.1). Research questions
can be aimed at explanation or description.
Explanatory research examines causal relation-
ships, while descriptive research is merely
descriptive. In addition, research questions are
also often being categorized as etiological, diag-
nostic, or prognostic (Table 1.1). For example, an
explanatory research question related to etiology
in the field of ocular oncology is as follows: are
children born after in vitro fertilization at higher
risk of developing retinoblastoma as compared to
children born after natural conception? [3] A cor-
rect explanatory research question should contain
information on the patients, interventions, con-
trast, and outcomes (PICO) at issue.
Outcome Measures
Traditionally, prevalence, incidence, and mortality
(survival) have been the outcome measures in clin-
ical cancer epidemiology studies. More recently,
1
2 A. C. Moll et al.

Research question(s)

• Identify patients, interventions

(exposures), controls and outcome
(PICO)
• Descriptive or explanatory purpose
• Focus on aetiology (including
prevention), diagnosis or prognosis
(including therapy)

Design Sample Measurements

Case series Source population Outcome

Cross sectional Target population Potential confounders
Cohort study Control population Validity, reproducibility and
RCT Sampling strategy responsiveness
Case control Inclusion/Exclusion criteria Time to follow-up

Other considerations

• Ethical aspects
• Practical limitations
• Budget constraints

Fig. 1.1 Steps in designing a clinical epidemiological research

Table 1.1 Types of epidemiological research

Type of research Purpose
Etiology (including prevention) To examine possible
etiological factors for the
occurrence of a disease
Diagnosis To examine the usefulness of
diagnostic tests for the
disease
Prognosis (including To examine possible
interventions) prognostic factors for the
disease
Example
Association between ultraviolet radiation and
uveal melanoma
Accuracy of magnetic resonance imaging in
determining choroidal invasion of
retinoblastoma
Association between external beam therapy for
retinoblastoma and the incidence of second
malignant neoplasms
1 Principles of Cancer Epidemiology
quality of life measures have become increasingly
popular. In ophthalmic oncology, visual acuity is
also an important outcome measure.
Prevalence
Prevalence refers to the proportion of the study
population with the condition of interest. Usually
prevalence is given for a specific moment in time
(point prevalence), but sometimes it is estimated
for a period of time (e.g., 1 year or lifetime preva-
lences). For example, the lifetime prevalence of
uveal melanoma in a Caucasian population with
oculo(dermal) melanocytosis is estimated to be
0.26% [4].
Incidence
Whereas prevalence relates to existing cases,
incidence relates to the proportion of new cases
in the study population. It is important that the
population under investigation is at risk of devel-
oping the condition. For example, persons with
bilateral enucleation are no longer at risk of
developing uveal melanoma. There are two dif-
ferent measures of incidence: cumulative inci-
dence (CI) and incidence density (ID). CI is the
proportion of new cases in a population at risk
over a specified period of time. For example, the
CI of second malignant neoplasms in hereditary
retinoblastoma patients is 17% at the age of
35 years [5]. ID refers to the rate of developing
the condition during follow-up, usually expressed
as a proportion per person-year at risk.
Mortality
Cancer is among the leading causes of mortality.
In order to understand the processes that either
hasten or delay this outcome, it is necessary to rig-
orously define the burden of disease. Clinical epi-
demiologists have created several concepts of
mortality, all with their own definition, interpreta-
tion, and uses. Unfortunately, many of these con-
cepts use similar nomenclature, so it is important
to always clarify the definition of mortality at
3
hand. Broadly speaking, mortality rate refers to the
incidence of death, and survival rate is its comple-
ment, i.e., survival rate = 100 – mortality rate.
Population mortality is the chance that a per-
son in the general population will die from a spe-
cific disease over a specified time frame. It is a
useful concept for measuring the burden of dis-
ease in a population. For example, the population
mortality for heart disease was 197.2 per 100,000
population per year in 2015. Therefore, it is a
measure more important for public health policy-
makers as opposed to clinicians. This measure is
calculated from death certificates, where cause of
death is known [6].
Overall mortality is the chance that a person
with a disease will die within a time period after
diagnosis. It is important to specify a time period
for the mortality statistics – in the long run, mor-
tality is 100% for any condition. Of note, this
definition is indifferent to cause of death. Overall
mortality is the most common measure of mortal-
ity in the literature and is often used to guide
prognosis. This measure is helpful in identifying
risk factors for poor prognosis, as well as measur-
ing disparities between populations. The inter-
pretation of this measure is complicated by
biases, including lead time, length, and overdiag-
nosis biases.
Cause-specific mortality is the chance that a
person with a disease will die within a time
period after diagnosis due to the disease. This is
in contrast to overall survival, which does not dis-
tinguish between causes of death. Cause-specific
mortality most closely measures the “deadliness”
of a disease, but similar to overall mortality, it
can be affected by lead time, length, and overdi-
agnosis bias.
Relative mortality is a proportion that com-
pares the overall mortality of people with a dis-
ease to that of an unaffected, but otherwise
identical population. Relative mortality measures
the excess mortality associated with a diagnosis
compared to the general population. It is a conve-
nient measure to calculate because it does not
require cause of death to be recorded. It is also a
helpful measure for understanding the deadliness
of a disease that affects the elderly, where patients
are at risk from dying from other causes. To cal-
culate relative survival, overall survival of a
4 A. C. Moll et al.

cohort of patients is compared to life tables of the endpoints argue that they are preferable for rea-
general population, matched by age, sex, race, sons of feasibility, cost, and length of study, with
and other important demographic features. possible expediency of the drug approval pro-
Conditional mortality is another clinically cess. Critics of surrogate endpoints point out that
informative measure of mortality, which mea- the evidence base for surrogate endpoints corre-
sures the chance that a person with a disease will lating closely with clinical outcomes is often
die within a specified time period after having tenuous.
already lived with the disease for a certain amount
of time. It is a helpful measure to assess how
prognosis changes over time. Conditional sur- Quality of Life
vival requires a cohort of patients where long-­
term follow-up is close to complete. With increasing survival rates and with severe
side effects of some treatment modalities, quality
of life measures have become increasingly
Time to Event important in ophthalmic oncology. These mea-
sures encompass symptoms and physical, social,
Another class of outcomes that is of interest to and psychological functioning from a patient’s
clinical epidemiologists is time to event. Time to perspective. Usually, quality of life is assessed
event measures the length of time that elapses with a structured questionnaire, and scores are
from some start point to a defined endpoint, the summarized assuming an interval scale. Several
most common time-to-event measure being sur- questionnaires have recently been developed for
vival, which is defined as time from diagnosis to patients with ocular diseases, such as the measure
death (not to be confused with survival rate). of outcome in ocular disease [MOOD]) [9].
Other events can be used as the endpoint, such as
relapse or radiographic progression. Time-to-­
event data is typically graphically presented with M  easures of Association
a Kaplan-Meier plot, which displays a nonpara-
metric estimation of the rate of survival in a pop- In epidemiological research, we are usually inter-
ulation as a function of time [7]. ested in how certain interventions or exposures
are associated with outcomes; for example, is
there an association between paternal age and
Surrogate Endpoints retinoblastoma in the offspring? [10]. There are
several statistical approaches that can be used to
While overall mortality and cause-specific mor- quantify associations, either as a ratio or as a dif-
tality are the two gold standard measures of mor- ference, depending upon the study design and
tality when evaluating the efficacy of statistical method used (Table 1.2).
interventions, other measures of efficacy are
being proposed, such as surrogate endpoints,
which are biomarkers that are intended to substi- Relative Risk
tute for a clinical endpoint. Of note, these are not
clinical quantities of interest but are correlated The ratio of cumulative incidences of exposed
with them. Examples of surrogate endpoints and unexposed individuals (or between treated
include evidence of radiographic progression, and untreated patients) is the relative risk (RR).
biochemical markers, and physical signs [8]. For example, in the Netherlands, the RR of reti-
These are controversial measures and are not uni- noblastoma in children conceived by in vitro fer-
formly accepted within the scientific and regula- tilization is between 4.9 and 7.2. This implies that
tory community. Proponents of surrogate the risk of getting retinoblastoma is between 4.9
1 Principles of Cancer Epidemiology 5

Table 1.2 The relation between outcome, measures of association, study designs, and statistical methods
Measure of
Outcome association Computation Study designs Statistical methods
Prevalence Prevalence rate P1/P2 Cross-sectional Chi-square test
Logistic regression
analysis
Prevalence P1 − P2 Cross-sectional Chi-square test
difference
Odds of exposure Odds ratio Odds of exposure group 1/ Case-control study Chi-square test
odds of exposure group 2 (cohort study, RCT) Logistic regression
Cumulative Relative risk CI1/CI2 Cohort study/RCT Chi-square test
incidence (CI) Risk difference CI1 − CI2 RCT
Incidence density Hazard ratio ID1/ID2 Cohort study/RCT Kaplan-Meier
(ID) Cox regression
Risk difference ID1 − ID2 RCT Kaplan-Meier
O/E ratio Observed ID/expected ID in Cohort study/registry
general population study
Quality of life Difference in X1 − X2 Cohort study/RCT Independent t-test
mean score Linear regression
analyses
P1 prevalence group 1, P2 prevalence group 2, CI cumulative incidence, CI1 CI group 1, CI2 CI group 2, ID incidence
density, ID1 ID group 1, ID2 ID group 2, O/E ratio observed to expected ratio, RCT randomized controlled trial,
X1 = mean score group 1; X2 = mean score group 2

and 7.2 times higher for children conceived after expected. This data can be expressed as stan-
IVF than naturally conceived children. dardized mortality ratio of 5.41 [11].

Hazard Ratio Odds Ratio

The ratio of incidence densities of unexposed
and exposed patients (or between treated and
untreated patients) is the hazard ratio (HR),
which has a similar interpretation as the RR. This
measure is often used in relation to mortality,
because we are generally interested not only in
the proportion of patients that die but also in the
time from baseline (diagnosis or start of treat-
ment) until death. A special application of the
HR is the ratio of the observed to the expected
number of cases (O/E ratio). In this case the
observed incidence density is calculated for the
study population, and this is compared to the
expected incidence density derived from a popu-
lation registry (e.g., cancer registration). For
example, in a study of lifetime risks of common
cancers among 144 hereditary retinoblastoma
survivors, 41 cancer deaths were observed,
whereas only 7.58 deaths due to cancer were
The odds ratio (OR) is the most commonly
reported measure of association in the literature,
due to the fact that this is the statistic that can be
derived from the popular logistic regression anal-
ysis. The OR is the ratio of the odds of outcome
of interest between the exposed and the
­unexposed. Generally speaking, the OR is a good
approximation of the RR or HR.
Differences in Risk
Differences in risks (RD) are preferably reported as
outcome in randomized controlled trials. The RD is
easy to interpret and can be used to calculate the
number of patients needed to treat (NNT) to pre-
vent one extra event (e.g., death) compared to the
standard treatment or placebo. The NNT can be
calculated as inverse of RD (1/RD). A related
6 A. C. Moll et al.
c­oncept is that of the number needed to screen
(NNS). This refers to the number of patients needed
to screen to prevent one extra event compared to
the situation without a screening program. The
NNS thus depends on the predictive probability of
the screening test as well as on the efficacy of treat-
ment for people that are diagnosed with that screen-
ing test. The value of routine neuroimaging
screening of pineoblastoma in retinoblastoma
patients is uncertain and a point of discussion [12].
Differences in Mean Score
For scores on interval scales, such as quality of
life, differences in mean score between exposed
and unexposed participants are the most impor-
tant measure of interest. These can be derived
from independent samples t-test of general linear
models (e.g., linear regression analysis).
Precision of the Estimate
When interpreting an outcome, we do not only
want to know the numerical value of the point
estimate but also the precision with which it has
been assessed. In other words, can we be confi-
dent that the outcome is not just a chance find-
ing? The usual standard for accepting an outcome
as being beyond chance is p (probability) <0.05.
A more informative description is provided by
the 95% confidence interval (CI). The rough
interpretation of the 95% CI is that there is a 95%
probability that the real value lies within the con-
fidence interval.
Statistical significance and the width of confi-
dence intervals are strongly dependent on the
sample size of a study. This means that in very
large samples, weak (and potentially unimport-
ant) associations can be statistically significant.
In contrast, in small samples, strong (and poten-
tially important) associations are sometimes not
statistically significant. Such findings should of
course not be dismissed as being irrelevant.
Instead they should be replicated in larger study
populations. Associations, although statistically
significant, need not be clinically important.
Therefore, interpretation of findings should never
solely rely on statistical significance.
Bias
An estimate can be very precise but nevertheless
inaccurate, because of bias. Three main sources
of bias exist: confounding, selection, and infor-
mation bias.
Confounding
Confounding occurs when the association
between exposure and outcome is influenced by a
third variable that is related both to the exposure
and the outcome (Fig. 1.2). A recent study found
an association between cooking (as occupation)
and the incidence of ocular melanoma [13]. It
could be argued that as many cooks work at night,
it is possible that they could have relatively high
exposures to sunlight due to daytime leisure
activities compared to people working during the
daytime. It is implied that the association between
cooking and ocular melanoma could potentially
(in part) be explained by a higher exposure to
sunlight by cooks.
Selection Bias
Selection bias may occur when the chance of
being included in the study population is not ran-
dom for all members of the source population. For
example, patients with advanced tumor stage are
more likely to be referred to a special cancer cen-
Exposure
Disease
(intervention)
r≠0
r≠0
Confounder
r = correlation
Fig. 1.2 Schematic representation of confounding
1 Principles of Cancer Epidemiology 7

Table 1.3 Advantages and disadvantages of different study designs

Considerations Type of study
Methodological Cross-sectional Cohort RCT Case-control
Confounding − − + −
Selection bias − ± ± −
Information bias ± ± ± −
Prior exposure − + + −
Incident cases − + + +
Practical Length of study + − ± +
Organization + ± − ±
Expenses + − − +
RCT randomized controlled trial
Negative score (−) indicates disadvantage compared to other study designs
Positive score (+) indicates advantage compared to other study designs
Equivocal score (±) indicates neither advantage nor disadvantage as compared to other study designs

ter than patients with a less advanced tumor stage.
This form of selection bias is called referral bias.
Selection bias could also be introduced in a study
by choosing the wrong control group, especially
if controls are selected from hospital patients.
adopted in order to address a research question.
Each of the study designs has its advantages and
disadvantages (Table 1.3).
Case Series

Information Bias In case series, the authors present the clinical

Information bias occurs when outcome or expo-
sure variables are not accurately assessed. This is
especially problematic when this occurs differ-
ently for exposed versus nonexposed cases or for
cases versus controls. A well-known type of
information bias is recall bias. This refers to the
phenomenon that patients tend to remember
more details about exposures that are possibly
related to their disease than controls. For exam-
ple, the patients with uveal melanoma are proba-
bly more aware of the fact that their disease could
be related to sunlight exposure. In turn, they
reflect upon their own past exposure to sunlight
in much more detail than healthy controls. This
can lead to a relative underestimation of exposure
in controls and hence an overestimation of the
association with sunlight exposure.
Study Designs
There are several research designs, such as case
series, cross-sectional, cohort, randomized con-
trol trial, and case-control study, which can be
data regarding a group of patients (e.g., tumor
response to chemotherapy combined with diode
laser in retinoblastoma patients). The major dis-
advantage is that this kind of study does not have
a comparative design and does not permit an
answer to a question such as “there is a good
response, but compared to what, as there is no
control group?” [13].
Cross-Sectional Study
In a cross-sectional study, the outcome (and
exposure) is assessed at one point in time. In
prevalence studies, only the outcome is measured
(e.g., prevalence of retinoblastoma in Denmark).
In addition, the outcome between exposed and
unexposed study participants can be compared in
order to explore etiological questions. In a cross-­
sectional study on the association between iris
color and posterior uveal melanoma, melanoma
patients (N = 65) with light iris color were sig-
nificantly more likely to have darker choroidal
pigmentation than controls (N = 218) (p = 0.005).
In addition, darker choroidal pigmentation was
8 A. C. Moll et al.
associated histologically with increased density
of choroidal melanocytes (p = 0.005). The authors
concluded that increased choroidal pigmentation,
as a result of an increase in the density of pig-
mented choroidal melanocytes, is not protective
but may actually be a risk factor for the develop-
ment of posterior uveal melanoma in white
patients [14].
The cross-sectional study design has the
advantage that it is relatively easy to plan, that
only one measurement is needed, and that it is
inexpensive and quick to perform. From a meth-
odological point of view, however, the design has
some disadvantages. As both exposure and out-
come are measured at the same time, we cannot
be sure that the exposure preceded the outcome
(the most important criterion for causality).
Moreover, the outcome is always measured in
terms of prevalent cases, and prevalent cases may
have a relatively better prognosis (they are still
alive) than the incident cases. Therefore, the
associations found in a cross-sectional study can
only rarely be interpreted as being causal.
Cohort Study
Some of the problems listed above can be over-
come by conducting a (prospective) cohort study.
At baseline, one starts with a cohort of people
free from the outcome of interest. During or at
the end of follow-up, incident cases in both the
unexposed and the exposed groups are identified,
and RRs or HRs can be calculated. Despite theo-
retical advantages of a cohort design, there are
some practical disadvantages. The cohort studies
often need large sample sizes and/or long follow-
up to accumulate enough incident cases for
­ case-control studies is not to assess the exposure
meaningful analyses. These studies are often
expensive. From a methodological point of view,
the potential bias of (residual) confounding can
never be totally excluded.
Randomized Controlled Trial
Randomized controlled trials are a specific type
of cohort study. At the start of the study, partici-
pants are randomly assigned to the intervention
group (treatment under investigation) or a control
group (no treatment, placebo, or standard treat-
ment). After the start of a treatment, patients
often get better. This may be due to the treatment
or to other circumstances such as spontaneous
resolution, effective co-interventions, and pla-
cebo effects. Only a sufficiently large random-
ized, blinded trial is useful to estimate the efficacy
of drugs and other treatments. The best compari-
son is often between the new treatment and the
best available one, not the sham treatment [15].
The randomization, if successful, ensures that
confounding factors are evenly distributed
between the intervention and control groups. As
with the cohort studies, incident cases in both
groups are determined during or at the end of
follow-up, allowing for the risk estimates to be
calculated.
For clinicians interested in evidence pertain-
ing most directly to a particular class of patients,
subgroup analyses can be very informative. The
strength of evidence for subgroup effects depends
on the question whether hypotheses have been
defined prior to analysis, whether potential prob-
lems regarding multiple comparisons have been
considered, and whether there is biological plau-
sibility of the effects found. Using these guide-
lines, the reader of a trial report should be able to
decide if presented subgroup effects are of clini-
cal importance or if the overall result is a better
estimate of treatment effect [16].
Case-Control Study
In contrast to cohort studies, the starting point in
status, but the disease status. People with the dis-
ease of interest are selected, and a control group
of people without the disease is subsequently
recruited. The control group should include peo-
ple from the same source population as the cases,
implying that if any of the controls had developed
the disease, they would have been eligible for
inclusion in the study as a case.
The selection of a valid control group is
important in case-control studies and has there-
1 Principles of Cancer Epidemiology
fore generated a fair amount of discussion in the
epidemiological literature. It is possible to select
population controls, hospital controls, friends or
relatives of patients, or any combination of these
[17]. Case-control studies have the advantage of
being relatively quick and inexpensive to conduct
and are especially appealing in rare diseases. A
disadvantage is the large potential for selection
bias, especially in the recruitment of controls. In
addition there is also a real danger for informa-
tion (recall) bias. Similar to cohort studies, bias
by confounding can never be totally ruled out.
Pilot Study
A pilot study is often performed before the start
of a large study. Its aim is to improve the method-
ological quality and evaluate the feasibility. The
estimate of the effect of an intervention in a pilot
study is determined to a large extent by chance
and therefore cannot be considered as conclusive.
However, inclusion of such results in a later
cumulative meta-analysis may lead to sufficient
power so as to assess the efficacy of an experi-
mental intervention [18].
Systematic Review
In a systematic review, all available evidence (lit-
erature) on a certain topic is reviewed in a sys-
tematic, transparent, and reproducible manner.
These studies can be especially useful when
results from single studies are contradictory and/
or have large confidence intervals due to small
sample size. When the studies in a systematic
review are reasonably homogenous, their results
can be pooled in meta-analyses. This results in
one effect size for all the studies together, with a
much smaller confidence interval than the indi-
vidual studies. An example is a systematic review
on the survival of patients with uveal melanoma
treated with brachytherapy. The result of this
meta-analysis showed that the 5-year melanoma-­
related mortality rate was 6% for small and
medium tumors and 26% for large tumors [19].
9
Conclusions
In general, ophthalmic tumors are rare compared
to other ophthalmic diseases. Therefore, it is dif-
ficult to conduct large studies with enough power
to get statistically significant and clinically rele-
vant results. A large number of studies are pub-
lished each year, most of which are descriptive,
concerning retrospective patient series. To con-
duct randomized clinical trials, international col-
laboration is necessary to include enough patients
in the different treatment arms of the study.
Furthermore, uniform definitions and study
methodology are very important to compare the
different studies in the literature and to be able to
perform systematic reviews and meta-analyses.
References
1. Sackett DL. Clinical epidemiology. What, who, and
whither. J Clin Epidemiol. 2002;55:1161–6.
2. Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users’
guides to the medical literature: XXV. Evidence-­
based medicine: principles for applying the users’
guides to patient care. Evidence-based medicine
working group. JAMA. 2000;284:1290–6.
3. Moll AC, Imhof SM, Cruysberg JR, et al. Incidence of
retinoblastoma in children born after in-vitro fertilisa-
tion. Lancet. 2003;361:309–10.
4. Singh AD, De Potter P, Fijal BA, et al. Lifetime
prevalence of uveal melanoma in white patients
with oculo(dermal) melanocytosis. Ophthalmology.
1998;105:195–8.
5. Moll AC, Imhof SM, Bouter LM, et al. Second primary
tumors in patients with hereditary ­retinoblastoma: a reg-
ister-based follow-up study, 1945–1994. Int J Cancer.
1996;67:515–9.
6. U.S. Department of Health and Human Services.
Centers for Disease Control and Prevention (CDC).
Principles of epidemiology in public health practice:
an introduction to applied epidemiology and biosta-
tistics. Atlanta, GA: Office of Workforce and Career
Development; 2006.
7. Kaplan EL, Meier P. Nonparametric estimation
from incomplete observations. J Am Stat Assoc.
1958;53:457–81.
8. Cohn JN. Introduction to surrogate markers.
Circulation. 2004;109(25):IV–20-IV-21.
9. Foss AJ, Lamping DL, Schroter S, et al. Development
and validation of a patient based measure of outcome in
ocular melanoma. Br J Ophthalmol. 2000;84:347–51.
10. Moll AC, Imhof SM, Kuik DJ, et al. High parental age
is associated with sporadic hereditary retinoblastoma:
10 A. C. Moll et al.

the Dutch retinoblastoma register 1862–1994. Hum
Genet. 1996;98:109–12.
11. Fletcher O, Easton D, Anderson K, et al. Lifetime
risks of common cancers among retinoblastoma sur-
vivors. J Natl Cancer Inst. 2004;96:357–63.
12. Moll AC, Imhof SM, Schouten-van Meeteren AYN,
et al. Screening for pineoblastoma in patients with
retinoblastoma. Arch Ophthalmol. 2001;120:1774.
13. Harbour JW. What is the best treatment for retinoblas-
toma? Am J Ophthalmol. 2004;138:471–3.
14. Harbour JW, Brantley MA Jr, Hollingsworth H, et al.
Association between choroidal pigmentation and
posterior uveal melanoma in a white population. Br J
Ophthalmol. 2004;88:39–43.
15. Abel U, Koch A. The role of randomization in clini-
cal studies: myths and beliefs. J Clin Epidemiol.
1999;52:487–97.
16. Oxman AD, Guyatt GH. A consumer’s guide to sub-
group analyses. Ann Intern Med. 1992;116:78–84.
17. Lasky T, Stolley PD. Selection of cases and controls.
Epidemiol Rev. 1994;16:6–17.
18. Friedman LM, Furberg CD, De Mets
DL. Fundamentals of clinical trials. St. Louis: Mosby;
1996.
19. Seregard S. Long-term survival after ruthenium
plaque radiotherapy for uveal melanoma. A meta-­
analysis of studies including 1,066 patients. Acta
Ophthalmol Scand. 1999;77:414–7.
Further Readings
Bouter LM, Zielhuis GA, Zeegers MP. Textbook of epi-
demiology. Houten: Bohn Stafleu van Loghum; 2018.
Fletcher RH, Fletcher SW, Wagner EH. Clinical epidemi-
ology: the essentials. Baltimore: Williams & Wilkins;
1996.
Guyatt G, Rennie D, editors. Users’ guide to the medical
literature: a manual for evidence-based clinical prac-
tice. Chicago: AMA Press; 2002.
Rothman KJ. Epidemiology: an introduction. New York:
Oxford University Press; 2002.
Sackett DL, Strauss SE, Richardson WS, et al. Evidence-
based medicine. Edinburgh: Churchill Livingstone;
2000.
User’s guide to evidence-based practice. Educative series
of articles from the JAMA. www.cche.net/users-
guides/main.asp.
Website of the centre for evidence-based medicine,
Oxford, United Kingdom. www.cebm.net.
 Etiology of Cancer
Brian T. Hill
Introduction
Cancer is a pathologic accumulation of clonally
expanded cells derived from a common precur-
sor. The fundamental cause of all cancers is
genetic damage, which is usually acquired but is
sometimes congenital. In general, the genetic
dysregulation that gives rise to uncontrolled cell
proliferation results from activation of growth-­
promoting oncogenes and/or deletion/inactiva-
tion of growth-inhibiting tumor suppressor genes.
Additional contributions to carcinogenesis come
from genes that regulate programmed cell death
(apoptosis) and genes involved in DNA repair.
The most widely accepted theory of cancer devel-
opment is the Knudson “2-hit” hypothesis, which
posits that a mutation in one predisposing gene is
necessary but not sufficient for malignancy and
that only after development of a second mutation
will invasive cancer develop (Fig. 2.1) [1]. In
addition, it has become increasingly apparent that
cancer cells must evade host immune responses
and this can sometimes be exploited to treat can-
cer. In this chapter, we discuss the major catego-
ries of carcinogens and their role in the etiology
of cancers, with an emphasis on common oph-
thalmic cancers.
B. T. Hill (*)
Department of Taussig Cancer Institute, Cleveland
Clinic, Cleveland, OH, USA
e-mail: hillb2@ccf.org
© Springer Nature Switzerland AG 2019
A. D. Singh, B. E. Damato (eds.), Clinical Ophthalmic Oncology,
https://doi.org/10.1007/978-3-030-04489-3_2
2
Carcinogenic Agents
Although a clearly defined cause is not apparent
in the majority of de novo malignancies, it is well
documented that carcinogenic agents contribute
to many human cancers. These fall into several
broad groups, which can be categorized as infec-
tive (e.g., viruses), chemical (including occupa-
tional, environmental, and therapeutic),
electromagnetic radiation (i.e., ultraviolet [UV],
X-ray, gamma ray), and immunosuppressive
(HIV, immunosuppressive medications). These
are shown in Table 2.1.
Chemical Carcinogens
Several hundred chemicals have been shown to
be carcinogenic in humans. Harm from these
chemical carcinogens can be a result of occupa-
tional (asbestos, aniline dyes), environmental
(alcohol, tobacco), or iatrogenic (chemotherapy)
exposure. While many carcinogens are directly
mutagenic to DNA, most carcinogens undergo
activation after exposure to reactive metabolites
that are responsible for genetic damage.
Environmental Exposure
Of the known environmental carcinogens, per-
haps the most well-documented agent known to
11
12 B. T. Hill

Fig. 2.1 Schematic

representation of
Knudson 2-hit Sporadic cancer
hypothesis in which (2 sequential mutations acquired) Cancer
normal cell require two * * *
successive mutations to
delete both functional
copies of a given gene to
develop cancer. In
contrast, cells with
germline mutations only
* *
require a single genetic Hereditary cancer
event to develop (1 inherited mutation, 1 acquired mutation) Cancer
malignancy (*mutation)

Table 2.1 Various types of carcinogens

Chemicals Radiation Infectious Dietary Iatrogenic
Occupational UV light Virus Fat Radiation
 Arsenic X-ray  HPV Calorie Immunosuppression
 Asbestos Gamma ray  EBV Low fiber Chemotherapy
 Coal tars Nuclear radiation  KSHV
 Soot  HTLV-1
 Benzene  HEP B/C
 Vinyl chloride
Behavioral Bacteria
 H. pylori
 C. psittaci
 Tobacco Fungus
 A. flavus
 Alcohol Parasite
 Schistosoma
 Clonorchis

cause cancer is asbestos. This is a naturally
occurring mineral that has a broad range of
industrial and commercial applications, but aero-
solized fibers of asbestos are known to lodge in
small airways, causing tissue damage and signifi-
cantly predisposing exposed individuals to both
lung cancer as well as mesothelioma [2].
A number of other agents have been associ-
ated with elevated risks of various cancers
through epidemiologic studies. For example, sev-
eral agents have been implicated in lung cancer,
including heavy metals [arsenic, cadmium, chro-
mium, and nickel, as well as BCME (bischloro-
methl ether)] [3]. Aromatic amines such as
4-AMP, 4-aminobiphenyl, naphthylamine, and
benzidine are associated with an increased risk of
bladder cancer [3]. Aflatoxin and vinyl chloride
are associated with liver cancers. An exhaustive
list of known environmental carcinogens is
beyond the scope of this text but should be con-
sidered when obtaining the occupational and
social history of patients with newly diagnosed
cancer.
Behavioral Exposure
Tobacco
Tobacco is responsible for over 30% of the cancer
deaths and represents the single most common
cause of preventable cancer. Cigarettes as well as
smokeless tobacco are associated with cancers of
2 Etiology of Cancer
multiple organs, including the oral cavity, phar-
ynx, larynx, lung, esophagus, stomach, pancreas,
colon, rectum, kidney, bladder, ureter, and cervix.
Over 60 carcinogens have been identified in
tobacco, with the highest carcinogenic potency
attributed to polycyclic aromatic hydrocarbons,
nitrosamines, and aromatic amines [4]. The risk of
tobacco-associated cancer is proportional to total
lifetime cigarette smoke exposure. The risk of lung
cancer among long-term heavy smokers is approx-
imately 10–20 times greater than non-smokers.
Alcohol
Excessive and repeated alcohol intake is associ-
ated with liver, rectal, and breast cancers.
Interestingly, simultaneous exposure to alcohol
and cigarette smoke results in a synergistic
increase in the risk of oral cancer, with a relative
risk relative to non-smoking, those who abstain
from alcohol of over 35-fold for the heaviest con-
sumers. Similar tobacco-alcohol interactions are
also known for esophageal cancer.
Electromagnetic Radiation
Ultraviolet Light
Ultraviolet light B (UV-B) has a wavelength
between 280 nm and 320 nm and is the primary
oncogenic form of UV light, whereas ultraviolet
A (UV-A, wavelength 320–400 nm) has insuffi-
cient energy to induce DNA damage, and ultra-
violet light C (UV-C, 200–280 nm) is absorbed
by the atmospheric ozone and therefore not a sig-
nificant cause of environmental cancer.
UV light induces cancer by the formation of
pyrimidine dimers in affected DNA, which can
result in inactivation of tumor suppressor genes
such as p53. Patients with the autosomal recessive
disorder, xeroderma pigmentosum (XP), lack the
ability to repair DNA damage caused by UV light,
owing to a defect in the nucleotide excision repair
pathway (NER), thereby resulting in an increased
risk of skin cancer that is at least 2000-fold rela-
tive to unaffected individuals [5, 6].
UV light from sun exposure is associated with
increased incidence of several types of skin can-
13
cer, including squamous cell carcinoma, basal
cell carcinoma, and melanoma [7]. In the eye,
UV exposure increases the risk of ocular surface
squamous neoplasia (OSSN), which includes
dysplasia, carcinoma in situ, and squamous cell
carcinoma of the conjunctiva or cornea.
In the case of uveal melanoma, sunlight expo-
sure has not been implicated as a cause of this con-
dition, known risk factors including Caucasian
race, light skin color, blond hair, and blue eyes [8].
I onizing Radiation (X-Rays
and Gamma Rays)
In the early twentieth century, it was recognized
that radiation can cause tissue damage and vari-
ous cancers, such as acute leukemia and skin can-
cer. Ionizing radiation causes cell death by DNA
damage, leading to the induction of apoptosis and
cell cycle arrest. In general, a dose-response rela-
tionship is well described, with both duration and
intensity of radiation affecting the relative risk of
developing cancer.
Sources of ionizing radiation include occupa-
tional exposure (e.g., X-rays) and exposure to
nuclear power or atomic weapons. Iatrogenic
sources of radiation for cancer treatment also
cause secondary malignancies. The best-­described
data documenting radiation-induced cancers
comes from the study of the survivors of the
Chernobyl nuclear power plant disaster as well as
the Hiroshima and Nagasaki atomic bomb events
of World War II [9, 10]. In the latter case, the rela-
tive risk of all cancers was 1.53 and included mul-
tiple solid tumors arising in the breast, lung,
esophagus, stomach, and GU tract. All these solid
tumors had a relative risk of between 1.2 and 2.4.
In this population, a notable outlier was leukemia,
which had a relative risk of 5.6 [9].
Infections Agents
A number of infectious agents are carcinogenic.
The mechanisms by which each pathogen causes
cancer are diverse and include induction of
genomic instability as a result of chronic
14
i­ nflammation, impairment of host immunity, and,
in some cases, a modulation of the balance
between proliferation and antiproliferation
signals.
Viruses
Several DNA and RNA viruses are carcinogenic.
Human papillomavirus (HPV), Epstein-Barr
virus (EBV), hepatitis viruses B and C, and
Kaposi sarcoma herpesvirus (KSHV) exemplify
the best-described oncogenic viruses.
 uman Papillomavirus (HPV)
H dence KS has decreased significantly.
HPV was one of the first viruses to be identified as
causing human cancer. Almost all of the 200+ gen-
otypes of HPV infect epithelial cells, causing
benign papillomas (warts) or squamous cell carci-
noma of the oral, laryngeal, cervical, and anogeni-
tal regions. The strongest associations with
invasive cervical carcinoma are with HPV sub-
types 16 and 18, which can be identified in approx-
imately 85% of cases. HPV causes uncontrolled
cellular proliferation by inactivating the tumor
suppressor proteins p53 and pRB. DNA of HPV
with high oncogenic potential has been identified
in dysplastic and malignant lesions of the conjunc-
tiva and cornea suggesting that HPV may contrib-
ute to the development of OSSN [11, 12].
Epstein-Barr Virus
Epstein-Barr virus (EBV) has been implicated in
the pathogenesis of a number of cancers includ-
ing the African form of Burkitt lymphoma, B-cell
lymphomas in immunosuppressed individuals
(having a condition such as posttransplant lym-
phoproliferative disorder [PTLD]), and nasopha-
ryngeal carcinoma. The mechanism by which
EBV transforms B lymphocytes is not clearly
defined but most likely involves viral protein
expression that leads to a viral latency program
associated with proliferation. This is particularly
relevant to carcinogenesis in the absence of a host
antiviral response, as with HIV-associated lym-
phoma and/or PTLD. EBV infection is not clearly
linked to ophthalmic cancer. Although DNA from
B. T. Hill
viral EBV has been identified in primary intra-
ocular and ocular adnexal lymphomas, this find-
ing is of uncertain significance [13].
 aposi Sarcoma Herpes Virus
K
Kaposi sarcoma herpes virus (KSHV), also
known as human herpesvirus 8, is the causative
agent of Kaposi sarcoma (KS). KS can affect the
skin of any site but can also involve the eyelid
and the conjunctiva. This malignancy is rare in
immunocompetent individuals. Its incidence
increased significantly during the AIDS epidemic
of the 1980s. Since the introduction of highly
active antiretroviral therapy (HAART), the inci-
Human T-Cell Lymphotropic Virus-1
Human T-cell lymphotropic virus type 1 (HTLV-­
1) infection is endemic in Asia, Africa, and much
of Latin America. The most well-described can-
cer associated with HTLV-1 is T-cell leukemia/
lymphoma. Known ophthalmic manifestations of
HTLV-1 include ocular infiltrates in patients with
adult T-cell leukemia/lymphoma as well as non-
malignant ocular complications, such as retinal
degeneration, neuro-ophthalmic disorders, uve-
itis, necrotizing retinal vasculitis, and keratocon-
junctivitis sicca [14].
 epatitis B and C Virus
H
Chronic infections by hepatitis B or hepatitis C
viruses are well-defined risk factors for hepatocel-
lular carcinoma. In addition, extranodal marginal
zone lymphoma is increased in patients with hep-
atitis C. Importantly, from the standpoint of oph-
thalmic cancers, there have been conflicting
reports of an increased incidence of hepatitis C in
patients with ocular adnexal lymphoma [15, 16].
Bacteria
 elicobacter pylori
H
Helicobacter pylori (H. pylori) infection is asso-
ciated with peptic ulcer disease, gastric carci-
noma, and mucosa-associated lymphoid tissue
(MALT) lymphoma of the stomach [17, 18]. It is
2 Etiology of Cancer 15

hypothesized that chronic inflammation from the nodeficiency syndrome (AIDS), before the
infection leads to atrophic gastritis and conse- advent of highly active antiretroviral therapy
quent achlorhydria, gastrointestinal bacterial (HAART) [20]. AIDS causes several subtypes of
overgrowth, excess reduction of nitrates to lymphoma as well as Kaposi’s sarcoma.
nitrites, DNA damage, and, thus, carcinogenesis Furthermore, cancers arising in the context of
in gastrointestinal epithelium and mucosa-­ chronic inflammation as well as those with a high
associated lymphoid tissue. In the case of iso- mutational burden, such as UV-associated malig-
lated gastric MALT lymphoma, H. pylori nancies (e.g., melanoma) and smoking-related
eradication can result in complete and durable lung cancer, evade T-cell surveillance by MHC
remission, thereby obviating the need for chemo- downregulation or by upregulation of checkpoint
therapy or radiation. inhibitors [21].

 hlamydia psittaci
C
A number of human diseases, including cancers,
are strongly associated with infection by
Chlamydia. C. trachomatis and C. pneumoniae
have been shown to be associated with cervical
carcinoma and lung cancer. In addition, C. psit-
taci has been associated with ocular adnexal lym-
phomas, although there appears to be geographic
variation in the strength of this association [19].
Fungus
Aspergillus flavus is a fungus found in grains and
peanuts. It produces aflatoxins that cause liver
cancer, with the highest incidence occurring in
the developing world, China and South Africa.
Dietary Factors
A significant proportion of cancer deaths can be
attributed at least partially to dietary factors.
Diets with excessive calories from saturated fat
are known to increase the risk of hormone-­
dependent cancers such as breast, ovarian, and
endometrial cancers in females and prostate can-
cer in males. In contrast, a low-fiber diet is asso-
ciated with an increased risk of colorectal cancer,
whereas high dietary intake of red meat has been
strongly associated an increased risk [22].
Genetic Susceptibility

There are a number of well-defined cancer syn-

Parasites
Schistosoma, Clonorchis, and Opisthorchis cause
chronic inflammation, thereby leading to the
development of cancer. The best-described asso-
ciation of a cancer with parasitic infection is that
of bladder cancer in individuals suffering from
schistosomiasis.
Immune Evasion
It has been well established for several decades
that patients with compromised immunity have
an increased susceptibility to cancer. This is par-
ticularly evident in patients with acquired immu-
dromes, including Li-Fraumeni, hereditary non-
polyposis colon cancer, and polyposis colon
cancer syndromes, mutations in the Brca-1 and
Brca-2 oncogenes, and others. In the case of
breast cancer, however, only approximately 10%
of patients have an identifiable germline muta-
tion. Many of the inherited cancer predisposition
syndromes such as Brca-1 and 2 involve defects
in DNA repair pathways.
In the case of ophthalmic cancers, inheritance
of the retinoblastoma gene is particularly relevant
because it shows an autosomal dominant
­inheritance pattern. In contrast, xeroderma pig-
mentosum is autosomal recessive. A more com-
prehensive discuss of cancer genetic factors is
discussed in Chap. 7.
16
Iatrogenic Cancers
Immunosuppression
Immunosuppression increases the risk of cancer,
particularly lymphoma. After solid organ trans-
plantation, lifelong immunosuppression with cal-
cineurin inhibitors is well known to increase the
risk of PTLD, which is commonly EBV-positive.
Inhibitors of tumor necrosis factor-alpha (TNF-­
α), such as infliximab, also increase the risk of
lymphoma. In addition, solid tumors are also
more common after organ transplant than in the
general population.
Chemotherapy
In patients who have received chemotherapy
alone, the rate of secondary malignancy may be
as high as 10%. Hodgkin lymphoma, testicular
cancer, small cell lung cancer, and other cancers
with higher cure rates are associated with higher
rates of secondary malignancy, because of longer
survival. The most carcinogenic agents are alkyl-
ating agents such as cyclophosphamide and
topoisomerase inhibitors such as etoposide.
Radiation Therapy
Therapeutic radiation causes DNA damage and
can result in a variety of cancers, including sar-
coma, breast cancer, and hematologic malignan-
cies such as myelodysplastic syndrome and acute
leukemia. In patients with retinoblastoma, the
increased risk of sarcomas after radiation is well
documented [23].
Summary
The development of cancer can only rarely be
attributed to a single cause. Genetic predisposi-
tion confers significant risks for developing can-
cer in a minority of patients. Risk can be increased
by carcinogen exposure, immunosuppression, and
environmental/iatrogenic causes. It can be diffi-
B. T. Hill
Infectious Chemical
causes carcinogens
Genetic Radiation
predisposition exposure
Genetic
instability
Malignancy
Fig. 2.2 Schematic representation of multiple factors
potentially involved in malignant transformation
cult to quantitate the individual contribution of
several risk factors, but this should change, thanks
to the impressive genetic advances that are taking
place (Fig. 2.2). Immune evasion by cancer cells
is an inherent requirement to their survival. It is
noteworthy that, with few exceptions, most cancer
treatment is independent of the etiology.
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6. Harris CC, Hollstein M. Clinical implications of
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ocular lymphoma. Trans Am Ophthalmol Soc.
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14. Buggage RR. Ocular manifestations of human T-cell
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17
15. Arnaud P, Escande MC, Lecuit M, et al. Hepatitis C virus
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 Cancer Pathology
Gustav Stålhammar, Katarina Bartuma,
Charlotta All-Eriksson, and Stefan Seregard
Introduction
The earliest known descriptions of tumors (Latin
for swelling. In Greek: Onkos) or tumorous
growths as a disease appear on papyri from
Ancient Egypt. Hippocrates described several
distinct types of such tumors, referring to them
by the Greek word for cray or crayfish (karkinos
or carcinos) by appearance of their cut surface.
Later, this was translated to its Latin equivalent
(cancer). The term Cancer now usually signifies
a malignant neoplasm.
Currently, the field of oncology spans the
research, prevention, diagnosis, and treatment of
several hundreds of different types of tumors,
including the ones originating from the eye and
its immediate surroundings.
This text is intended as an overview of cancer
pathology with particular reference to classifica-
tion, tumorigenesis, microscopic features, sam-
pling, and diagnostic techniques for ocular
cancer.
G. Stålhammar (*) · K. Bartuma · C. All-Eriksson ·
S. Seregard
Department of Ophthalmic Pathology and Oncology
Service and Department of Clinical Neuroscience,
St. Erik Eye Hospital and Karolinska Institutet,
Stockholm, Sweden
e-mail: gustav.stalhammar@ki.se
© Springer Nature Switzerland AG 2019
A. D. Singh, B. E. Damato (eds.), Clinical Ophthalmic Oncology,
https://doi.org/10.1007/978-3-030-04489-3_3
3
Classification of Neoplasia
As noted above, tumors may be classified as
benign or malignant depending on their potential
for metastatic spread. Both types of neoplasm
might however lead to morbidity and death,
depending on factors such as cell of origin,
immunological responses, nutritional conditions,
and extent and location of the growth.
Consequently, one should not confuse benign
tumors for being uniformly harmless.
On the histological-morphological level, fur-
ther characteristics separate malignant from
benign lesions. Besides metastasis, no single
characteristic can however reliably isolate on
from the other without exceptions. For example,
basal cell carcinoma – the most frequently occur-
ring human cancer – can display significant cel-
lular dedifferentiation and pleomorphism and
most certainly invades the stroma across the
basement membrane but exceedingly rarely
metastasizes. Typical differences between benign
and malignant tumors are summarized
(Table 3.1).
Benign Tumors
Benign tumors are usually labeled by the suffix
-oma. Some exceptions tend to cause confusion;
lymphoma and melanoma are by definition
malignant irrespective of the -oma suffix. To
19
20 G. Stålhammar et al.

Table 3.1 Typical histological differences between in other organs such as the lacrimal gland or in
benign and malignant tumors peripheral blood.
Feature Benign Malignant • Melanomas are malignant tumors that origi-
Cellular pleomorphism None or Mild to nate from melanocytes, i.e., cells containing
mild severe
intracytoplasmic pigment lodged in melano-
Cellular dedifferentiation None or Mild to
mild severe somes. These cells appear in the skin, uvea,
Necrosis Rare Occasionally conjunctiva, and a variety of other tissues.
Basement membrane Never Frequent
invasion
Proliferation and growth Low High
rate
Tumorigenesis
Metastatic spread Never Occasionally
Advances in techniques for studying cancer
genetics, gene expression, proteomics, metabo-
emphasize this, terms like malignant lymphoma lism, and tumor microenvironment have revolu-
and malignant melanoma are sometimes used. tionized our understanding of the tumorigenesis
process, in which normal cells and tissues pro-
• Adenomas are composed of cells originating gressively evolve to a neoplastic state [1]. The
from glandular epithelium. rapidly accumulating information on the genetic
• Hamartomas are composed of physiologic and epigenetic constitution of malignancies has
cells normally occurring at the affected site. made it possible to tailor novel therapeutic agents,
• Choristomas are composed of physiologic several of which are in clinical use. Hanahan and
cells not normally occurring at the affected Weinberg structured “hallmarks” of cancer, which
site. mark the steps of tumorigenesis [1]. These hall-
• Teratomas are composed of pluripotent cells marks include genomic instability and mutations,
forming different types of tissue originating evading immune destruction, proliferative signal-
from one or more of the three germ cell layers. ing and reprogramming energy metabolism,
A teratoma may be either benign or resisting growth suppressors, escaping cell death,
malignant. replicative immortality, angiogenesis, invasion
and metastasis, and the tumor microenvironment.
The hallmarks are briefly outlined below; the
Malignant Tumors genes involved in tumorigenesis are discussed in
greater detail elsewhere (Chap. 7).
• Carcinomas are malignant neoplasms of epi-
thelial origin. For example, an adenocarci-
noma of the lacrimal gland is a cancer derived Genomic Instability and Mutations
from the glandular epithelium of the lacrimal
gland. Believed to underlie many of the hallmark capa-
• Sarcomas are derived from mesenchymal bilities of neoplastic cells, genomic instability
tissue. generates random mutations including chromo-
• Blastomas are malignant tumors of embryonic somal rearrangements (Fig. 3.1). Conceptually
origin. For example, retinoblastomas are and in a very broad sense, tumors progress by
derived from retinoblasts in the developing stepwise accumulation of gain-of-function muta-
retina. tions of oncogenes that promotes cell survival
• Leukemias are malignancies of blood cells and proliferation or loss-of-function mutations of
that arise from bone marrow precursor cells tumor suppressor genes. Genetic aberrations
and are present in the peripheral blood. such as replication errors, deletions, DNA dam-
• Lymphomas are malignancies derived from age and methylation, and histone modifications
lymph nodes but may occasionally be present and amplifications can occur randomly, be inher-
3 Cancer Pathology
Chromosomal abnormalities
a Translocation d Copy number gain
Complete trisomy
b Insertion
Intrachromsomal
amplification
c Inversion
Fig. 3.1 Chromosomal abnormalities in human cancer. A
multitude of different chromosomal aberrations underlie
tumorigenesis. These may lead to the formation of fusion
gene or over- or underexpression of a structurally normal
gene. The most common abnormalities are included in
this figure. (a) Translocation: one chromosomal segment
is translocated from one chromosome to another and vice
ited, or be induced by external factors such as
radiation, oxidative stress, viral infection, or a
breakdown of the genomic maintenance machin-
ery. Mutations that give a subclone of cells a
selective advantage will accumulate throughout
cell divisions and drive tumor evolution.
Similarly, subclones of cells with increased
genomic instability will more frequently generate
events that either promote or impede expansion,
further increasing both the genomic instability
and number of candidates for selective advan-
tage. Non-tumorigenic regions may harbor “pas-
senger” mutations that are not pathogenic but
may serve as biomarkers [2]. Recurrent genetic
aberrations and mutations in across several dif-
ferent tumor types indicate that certain subsets of
genetic regions are important drivers of tumori-
genesis [3]. The advent of deep sequencing of
entire cancer cell genomes has increased our
knowledge of the tumorigenic potential and hier-
archical arrangement of tumor subclones and the
substantial plasticity in differentiation and dedif-
21
e Copy number loss
Partial trisomy LOH Monosomy
Extrachromsomal Submicroscopical Large-scale
amplification deletion deletion
versa. (b) Insertion: a chromosomal segment is inserted
into another chromosome. (c) Inversion: a 180° rotation of
a segment. (d) Copy number gain can occur through, e.g.,
complete or partial trisomy, intrachromosomal, and extra-
chromosomal amplifications. (e) Copy number loss
includes copy number neutral loss of heterozygosity
(LOH), submicroscopic, or large-scale deletions
ferentiation that follows genomic instability. The
latter is one of the mechanisms proposed as an
explanation to refractory treatment responses,
after an initial period of tumor regression [4].
Studies have shown that mutations of telomerase
and telomeres are required to achieve endless
replication and survival [5]. However, more
recent evidence suggests that cells that survive
the telomere erosion enter breakage-fusion-­
bridge cycles with resulting gross genetic aberra-
tions. Tumor cells with these complex genetic
alterations exemplify accelerated acquisition of
mutations and rapidly progress to more malig-
nant states [6].
Evading Immune Destruction
The immune system plays an important role in
eliminating both micrometastases and late-stage
tumors [1]. Studies on patients with acquired
immunodeficiency syndrome as well as mouse
22
models have revealed that deficiencies of NK and
T cells result in a higher risk of developing can-
cer, which suggests that both the adaptive and
innate immune systems serve as barriers to tumor
progression [7, 8]. Tumor cells must therefore be
able to evade immunological killing in order to
thrive. This can be achieved, e.g., by altering
immunological reactions by secreting immuno-
suppressive factors such as TGF-β or inhibitory
checkpoint molecules such as BTLA, CTLA-4,
PD-1, IDO and TIGIT [9–11].
Proliferative Signaling
and Reprogramming Energy
Metabolism
Proliferative signaling has been recognized as
one of the earliest and most important steps in
tumorigenesis [1]. It is mediated in large by
growth factor ligands that bind to cell-surface
receptors (frequently tyrosine kinase domains),
which mediate proliferative signals, such as
progression through the cell cycle, growth, sur-
vival, and energy metabolism [1]. By altering
the proliferative signaling network, neoplastic
cells become independent of their environment
and are placed in a continuous proliferative
state. Recently, new light has been shed on the
adjustments of energy metabolism to suit the
rapid growth of cancer cells [1]. The energy
metabolism of cancer cells has been demon-
strated to be different compared to normal
cells; by using aerobic glycolysis, tumor cells
can increase their uptake and utilization of glu-
cose, which has been documented in many
tumor types and is utilized to visualize tumor
dissemination in PET-scan examination [12].
Resisting Growth Suppressors
Apart from activating proliferation, tumor cells
must also be able to avoid signaling pathways that
negatively regulate cell proliferation. The genes
controlling progression in the cell cycle and inhib-
itory signaling are commonly referred to as tumor
suppressor genes. Three of the classic suppressor
genes are BRCA1, BRCA2, and RB1. The activity
G. Stålhammar et al.
of these is downregulated in a wide range of
tumors [13]. Approximately 70% of women who
inherit BRCA1 mutation will develop breast can-
cer by the age of 80, and individuals with germline
mutations of RB1 suffer a >90% risk of developing
retinoblastoma, as well as an increased risk for
several other tumor types. In normal cells, cell-to-
cell contact mediates suppression of growth [1]. If
normal cells lose the cell-to-cell contact, they
undergo programmed cell death. This inhibitory
signal is often lost in tumor cells. A set of cell-
surface adhesion molecules, most notably the cad-
herins (E-cadherin and N-cadherin), are commonly
altered in tumor cells enabling the tumor cell to let
go and then reattach, thus serving as an important
step in metastatic spread [14, 15].
Escaping Cell Death
Apoptosis, the orderly conducted programmed
cell death, can be triggered by environmental
stress, elevated levels of oncogene signaling,
telomere shortening, DNA damage, infection,
and loss of attachment to other cells. It functions
as a guardian against malignant genetic change
[16]. By escaping programmed cell death, tumor
cells manage to survive even though they harbor
multiple genetic changes.
Replicative Immortality
Normal cells are only able to replicate a limited
number of times before they enter either senes-
cence or cell death. Telomeres protect the ends of
chromosomes and are intimately involved in repli-
cative immortality [1]. While telomerase, a protein
that adds repeat sequences to the end of telomeres
and thereby elongates them, is barely expressed in
normal cells, its overexpression in malignancies
allows the cells to escape destruction [4, 17].
Angiogenesis
Tumors must acquire new vasculature by angio-
genesis to be able to grow beyond a size of
approximately 2 mm3 (Chap. 5).
3 Cancer Pathology 23

Invasion and Metastasis obtained in uveal melanoma (and several other

tumors) as tumor vessel counts have been associ-
Tumor metastases account for approximately ated with a poor prognosis [23]. Following
90% of tumor-related deaths [18]. By pinpoint- intravasation, the tumor cells must survive the
ing the processes underlying metastasis, greater detachment from the supporting tumor matrix,
understanding and treatment options will emerge the hemodynamic forces in the circulation, as
[19]. The metastatic process is thought to start well as a hostile immune system. The process of
with individual tumor cells dislodging from the extravasation begins when the cell attaches to the
primary tumor and spreading by blood or lym- vessel wall in the target tissue. This is achieved
phatic vessels. The timing of tumor dissemina- either by a tumor forming in the vessel wall,
tion remains a subject of debate. There are two which eventually ruptures the vessel wall, or by
major models: the linear progression model penetrating the endothelial cells and pericyte lay-
where a cell acquires a set of characteristics ers and thereby establishing micrometastasis
through stepwise alteration before dissemination (Box 3.1) [24]. Tumors originating within the eye
and the parallel progression model where cells undergo hematogenous dissemination, because
that are not yet fully neoplastic are circulating, there is no lymphatic drainage. Tumors originat-
suggesting that they are disseminated from an ing in the orbit or eyelids may undergo either
early malignant lesion [20, 21]. The invasion-­ hematogenous or lymphatic spread, depending
metastasis cascade is a complex, multistep pro- on the tumor type and specific relation to the
cess where tumor cells must be able to invade respective vascular system.
locally through the extracellular matrix and stro-
mal cell layers. The precisely organized archi-
tecture of surrounding normal epithelium serves Box 3.1 Steps in Metastatic Process
as an effective barrier, which is overcome by
invading tumor cells when the metastatic process
starts [19]. The matrix metalloproteinases • Tumor cell epithelial-mesenchymal
secreted by macrophages at the tumor periphery transition and invasion of local vessels
contribute to the loss of the basement membrane • Tumor cell survival in the circulation
by proteolysis, which facilitates invasion of the • Cellular extravasation and mesenchymal-­
stromal compartment [19, 22]. Invading cells epithelial transition
must also become motile to escape the primary • Adaption to environment at distant site
tumor; this is achieved by alterations in cell-sur- and establishment of a micrometastasis
face proteins that promote migration. Alteration • Acquirement of supportive microenvi-
of the cytoskeleton allows for movement along ronment including nutrient, growth fac-
the extracellular matrix and surface of other tor, and vascular supply for growth to
cells. Further, the Ras family of GTPases alters macrometastasis
actin and myosin activity, which promotes move-
ment [1].
After leaving the primary tumor and invading Little is known about the predilection for par-
the stroma, the tumor cells must intravasate into ticular metastatic targets, but two major theories
blood or lymph vessels. Intravasation into blood have emerged: the mechanistic theory where
vessels is facilitated by the insufficient pericyte tumor cells arrest within capillary beds due to
coverage and weak endothelial interaction of size restrictions of the capillary vessels. The
malignant blood vessels [19]. Acquiring an other theory describes receptor-ligand binding
intrinsic vasculature, driven by secreted factors between tumor cells and capillaries, also known
such as vascular endothelial growth factor as the “seed and soil” theory: the provision of a
(VEGF), is important for primary tumors in order fertile environment in which compatible tumor
to metastasize and for metastases to grow beyond cells can grow. Most likely the combination of
a certain size. Indirect evidence for this has been both theories is true for the majority of metastatic
24
malignancies. Some microenvironments seem to
be more hospitable than others, exemplified by
preferential dissemination by a wide range of dif-
ferent tumor types to the liver, bone marrow, and
lung tissue [25]. Extravasation of tumor cells is
more challenging than intravasation since intrav-
asation occurs at the primary tumor site where
the vasculature is already quite leaky and there-
fore easy to traverse [19]. After intravasation, the
cancer cells must be able to adapt to a very differ-
ent environment from that of the primary tumor.
The process of metastasis is very inefficient.
Indeed, it has been suggested that only <0.01% of
tumor cells that enter the circulation go through
the metastatic process to establish clinical metas-
tasis [25]. This is supported by the fact that tumor
cells from primary breast, lung, colon cancer, as
well as skin and uveal melanoma have been
found in the peripheral circulation long before
any clinically detectable metastasis occurs [26].
Even if the tumor cells initially survive in the new
microenvironment, it is not certain that they will
grow rapidly. On the contrary, most micrometas-
tasis seems to go through a state of dormancy.
This may be because of incompatibilities with
the foreign environment or from failure to form
sufficient vascular supply; it may also be that the
cells proliferate, though a net increase does not
occur because of the counteracting effects of a
high apoptotic rate [19].
The Tumor Microenvironment
Tumors are rarely isolated masses of homoge-
nous proliferating cells but rather a makeup of
different tumor subpopulations as well as tumor-­
associated stroma, normal tissue, vasculature,
nerves, and infiltrating immune cells. A tumor
can thereby be regarded as an organ of itself, and
not merely a bag of sick cells. Recent studies
have shed light on the importance of recruitment
of normal cells, which play a distinct role in the
development of neoplasms and also have been
implicated in processes such as drug resistance
[27]. The stroma surrounding the tumor is fre-
quently reactive and shares similar upregulated
G. Stålhammar et al.
pathways, e.g., chronic inflammation or wound
healing tissue [28]. The tumor-associated stroma
is induced by the neoplasm. In turn, the stromal
cells may increase the aggressive behavior of the
tumor by releasing growth-stimulating factors
that enhances an epithelial-mesenchymal transi-
tion (EMT), in which malignant epithelium
acquires characteristics necessary for dissemina-
tion [19, 29]. Other incidents in the symbiosis of
the tumor and its microenvironment may increase
the reactivity of the tumor surrounding stroma
further. As an example, necrotic cell death
releases pro-inflammatory signals into the sur-
rounding microenvironment, which recruits
inflammatory cells [28]. These cells may pro-
mote angiogenesis, cancer cell proliferation, and
invasiveness [30]. Necrosis may therefore act
tumor promoting; indeed tumors with necrosis
are associated with worse clinical prognosis.
Solid tumors constitute a mixture of different
tumor clones at different stages of development,
which lead to genetic heterogeneity [31]. The
existence of cancer stem cells as an important
composition of the proliferating neoplasm has
been a source of ongoing discussion (Fig. 3.2).
Cancer stem cells are defined by their ability to
seed new tumors when inoculated in host mice
[32]. They have been suggested as the culprits of
acquired chemotherapy resistance as well as dis-
ease recurrence after successful debulking of pri-
mary disease where no residual disease can be
detected [33].
Microscopic Features of Neoplasia
Certain histopathologic features differentiate
benign and malignant tumors from surrounding
normal tissues. In general, the differences from
the normal tissue are more marked in malignant
tumors than in benign tumors.
Cellular Proliferation
Many malignant tumors feature a large number
of dividing cells with abnormal mitotic patterns
3 Cancer Pathology
Cancer-associated fibroblast
(CAF)
Endothelial Cell (EC)
Pericyte (PC)
Local and bone marrow-
derived stromal stem
and progenitor cells
Core of primary tumor Invasive tumor
microenvironment microenvironment
Fig. 3.2 The cells of the tumor microenvironment.
Upper: an assemblage of distinct cell types constitutes
most solid tumors. Both the parenchyma and stroma of
tumors contain distinct cell types and subtypes that col-
lectively enable tumor growth and progression. Notably,
the immune inflammatory cells present in tumors can
include both tumor-promoting as well as tumor-killing
subclasses. Lower: the distinctive microenvironments of
tumors. The multiple stromal cell types create a succes-
sion of tumor microenvironments that change as tumors
(Fig. 3.3a). Cell proliferation markers like pro-
liferating cell nucleolar antigen (PCNA), phos-
phohistone H3 (PHH3), Ki-67, and the cyclins
often reveal a larger proportion of proliferating
cancer cells than detected by mitotic counts
alone (Fig. 3.3b). A high mitotic index (mitotic
count per unit of microscopic area) is often
found in rapidly growing tumors although this
25
Cancer Stem Cell (CSC)
Cancer Cell (CC)
Immune
inflammtory cells
(ICs)
Invasive cancer cell
Metastatic tumor
microenvironment
invade normal tissue and thereafter seed and colonize dis-
tant tissues. The abundance, histologic organization, and
phenotypic characteristics of the stromal cell types, as
well as of the extracellular matrix (hatched background),
evolve during progression, thereby enabling primary,
invasive, and then metastatic growth. The surrounding
normal cells of the primary and metastatic sites, shown
only schematically, likely also affect the character of the
various neoplastic microenvironments. (Reprinted from
Hanahan and Weinberg [1] with permission from Elsevier)
is usually balanced by the presence of many
apoptotic cells. Not all cancers show high cell
proliferation rates; typically uveal melanoma
features comparatively low counts but nonethe-
less may metastasize. However, in many can-
cers, including uveal melanoma, a high cell
proliferation rate is associated with poor prog-
nosis [34, 35].
26
a Cellular Differentiation
b ated, whereas others are poorly differentiated or
Fig. 3.3 Many malignant tumors feature a large number
of dividing cells with abnormal mitotic figures (a). Cell
proliferation markers like proliferating cell nucleolar
antigen and Ki-67 often reveal a larger proportion of
proliferating cancer cells than detected by mitotic counts
alone (b)
Cellular Pleomorphism
When tissue and cellular architecture is distorted,
the tissue is classified as dysplastic. Epithelial
dysplasia may be divided into mild, moderate,
and severe dysplasia. Severe dysplasia is charac-
terized by full-thickness dysplasia with promi-
nent cellular atypia and is synonymous with
carcinoma in situ. It is debatable whether a slight
or even moderate degree of dysplasia is precan-
cerous, a condition inevitably leading to cancer.
When tissue architecture is considerably dis-
torted with individual cells showing a significant
degree of variation in shape and size including
abnormal nuclei sometimes featuring binucleate
or multinucleate forms, this is referred to as pleo-
morphism at the cellular level. Cellular pleomor-
phism, including the extreme state when the
tissue of origin is no longer recognizable (anapla-
sia), is a hallmark of cancer.
G. Stålhammar et al.
Typically, cancers recapitulate the architecture of
the tissue of their origin to some extent. For exam-
ple, squamous cell carcinomas grow in sheets of
keratin-producing cells attached to each other with
an abundance of intercellular bridges, and skin
melanomas can preserve a nest-building tendency
with physiological production of pigment. This
recapitulation may closely resemble the original
structure, and such cancers are highly differenti-
even anaplastic. Usually, poorly differentiated
cancers carry a worse prognosis than cancers more
closely mimicking the original tissue appearance.
In retinoblastoma, the rosettes appearing in mod-
erately and highly differentiated retinoblastoma
are believed to be an attempt to recapitulate the
original retinal structure (Fig. 3.4a). In uveal mela-
noma, the tumor spindle cell morphology resem-
bles the original melanocytes, and the presence of
less differentiated epithelioid cells is associated
with an adverse outcome (Fig. 3.4b, c) [36].
Nuclear Cytoplasmic Ratio
Most neoplastic cells have a relatively large
nucleus in relation to the amount of cytoplasm.
However, this varies significantly with the type of
neoplasia. Clear cell carcinoma of the kidney fea-
tures large cells with abundant cytoplasm,
whereas the retinoblastoma typically is com-
posed of cells with relatively large nuclei and
small amounts of cytoplasm.
Invasion of Surrounding Tissues
Tumor cells invade surrounding tissue by direct
infiltration or by dissemination along blood or
lymphatic vessels. In carcinoma, breakdown of the
basement membrane and stromal invasion signify
the progression of an in situ carcinoma to invasive
carcinoma. Note that this is not the case with
tumors of non-epithelial origin such as uveal mela-
nomas, retinoblastomas, and sarcomas whose
­relation to a basement membrane is more or less
3 Cancer Pathology
a Tumor Infiltration by Normal Cells
b
c tochemistry, which is conducted to characterize
Fig. 3.4 Highly differentiated retinoblastoma with tumor
cells arranged in a radiating, flowerlike pattern referred to
as Flexner-Wintersteiner rosettes (a). Uveal melanoma
specimens featuring spindle-type tumor cells (b) and cells
with epithelioid appearance (c)
irrelevant for malignant classification. Carcinomas
with minimally invasive features are sometimes
referred to as microinvasive.
Some malignant tumors show a particular
affinity for spread along peripheral nerves
extending a considerable distance away from the
primary site (e.g., perineural growth in squamous
cell carcinoma or adenocystic carcinoma of the
lacrimal gland). In some of these tumors, pain,
tingling, or hypoesthesia due to invasion or com-
pression of sensory nerve fibers may be the first
clinical presentation.
27
In some malignant tumors, infiltration by macro-
phages or lymphocytes is a characteristic feature
reflecting recruitment of the immune system as
well as physiologic cells by neoplastic tissue.
Macrophage infiltration in uveal melanoma is
associated with a poor prognosis [37].
Tissue Sampling and Processing
Cytological Sampling
Sampling typically includes a number of indi-
vidual cells disrupted from their original tissue.
Diagnosis is therefore usually made on the mor-
phological appearance of individual cells because
the relationship to surrounding cells is lost.
Cytological samples may be used for immunocy-
protein expression, and for auxiliary techniques
such as flow cytometry. Two basic techniques are
used for sampling:
Exfoliative Cytology
Exfoliative cytology involves sampling of cells
that are dispersed in fluids (e.g., cerebrospinal
fluid sampled by lumbar puncture) or forcibly
removed by a spatula, brush, or some other instru-
ment or filter paper. Cells may also be dislodged
from a surface by a touch preparation, for exam-
ple, imprint cytology for conjunctival tumors. The
exfoliative sample is then spread on a glass slide
and stained. Vitrectomy samples may be filtered
through a membrane (e.g., Millipore filter), cen-
trifugated in a pellet (cytospin preparation), or
paraffin-embedded as a cell block.
Aspiration Cytology
Aspiration cytology may be applied to palpable
lesions, guided by ultrasound or computerized
tomography imaging. Intraocular fine-needle
aspiration biopsy (FNAB) is performed with nee-
dles between 21 and 25 gauges [38]. A pars plana
approach guided by indirect ophthalmoscopy
may be used, but clear cornea and transscleral
routes have also been advocated [39–41]. The
28 G. Stålhammar et al.

various techniques of intraocular biopsy are dis- Diagnostic Techniques

cussed in detail under uveal tumors. Local tumor
spread using FNAB in loosely cohesive tumors is
a concern. For this reason, FNAB should only be
used with extreme caution and almost never in
suspected cases of retinoblastoma. The require-
ments for tissue handling vary between laborato-
ries; therefore, it is advisable to contact the local
cytopathologist before sampling.
Traditionally, cancer diagnosis was made using
light microscopic examination, but recent advances
in molecular diagnostics have created a completely
new set of tools with which tumors may be more
accurately diagnosed and better characterized.
Some of these techniques are outlined below.

Histopathologic Sampling Light Microscopy

and Processing
Tissue is obtained by incisional or excisional When processed for routine light microscopy,
biopsy of the lesion. Caution not to coagulate or samples are usually fixed in formaldehyde and
otherwise maltreat the tissue sample is recom- then embedded in paraffin. This allows for the
mended. Incisional biopsies or core needle biop- cutting of 3–4-μm-thick sections. Paraffin sec-
sies with disruption of a tumor-surrounding tions are usually routinely stained with hematox-
capsule should be avoided in tumors prone to ylin and eosin, although this may differ depending
local recurrence, e.g., the pleomorphic adenoma on the local routine (Fig. 3.5a). Other stains like
of the lacrimal gland. In such tumors, primary the periodic acid-Schiff dye preferentially stain
complete excision or possibly diagnostic FNAB mucopolysaccharides and glycogen and are
followed by complete excision is recommended. appropriate for the study of basement membrane
The optimal fixative for the surgical biopsy varies material like the lens capsule.
depending on the local setting and the technique
used for histopathologic examination, but for a
most cases formaldehyde is sufficient.
When biopsying tissues like the conjunctiva
or iris, care should be taken to orientate the speci-
men and to make sure the tissue is maintained flat
and does not curl. This can be achieved by attach-
ing the tissue to a piece of filter paper and anno-
tating the specimen mount before immersion in
the fixative. Assessment of the surgical margins
is pivotal in any excisional tumor biopsy. To
facilitate this, the surgical margins may be
marked by the pathologist before gross section- b
ing and paraffin embedding. Also, special tech-
niques like Mohs technique using cryosectioning
or modifications using vertical paraffin-­embedded
sections have been advocated for eyelid and skin
tumors [42, 43]. Cryosectioning allows for a
rapid assessment (within 30 min) of margins or
malignancy and can be used as a preoperative
procedure; however, paraffin sections allow a
more reliable microscopic assessment. Specific
guidelines for histopathology reports on cancer
Fig. 3.5 Langerhans’ cell histiocytosis. Light micros-
specimens from the eye and adnexa have been copy (a) and immunohistochemical stain recognizing
discussed elsewhere [44]. S-100 protein (b)
3 Cancer Pathology 29

Immunohistochemistry tides. Distinct cancer biomarkers and gene

expression profiles have been identified through
The technique of staining specific cell surface, microarray studies. After vigorous evaluation,
cytoplasmic, and nuclear antigens with color-­ several assays have been developed and are now
labeled antibodies has revolutionized diagnostic in clinical use. Three of the earliest assays devel-
pathology in the last couple of decades. Several oped include the MammaPrint®, Oncotype
commercially available antibodies may be used DX®, and PAM50 assays for breast cancer [46].
in combination with routine fixatives like form- These assays predict prognosis and assess the
aldehyde, and staining may be enhanced by anti- likely benefit from treatment by analyzing signa-
gen retrieval techniques (Fig. 3.5b). Prolonged tures of multiple genes. This is crucial, since in
cold ischemia and fixation times may cause most cancers, the probability of curative treat-
reduced staining, and the wary pathologist uses ment and survival drops drastically once metasta-
negative and positive controls. It should be noted ses appear. In uveal melanoma, genome-wide
that the interpretation of immunohistochemical expression profiling has identified three distinct
stains is still somewhat subjective and that the molecular subclasses of tumors: low-grade (class
markers cannot be relied on to detect disease 1A) tumors with a 2% 5-year risk for metastasis,
with full sensitivity and specificity. For example, intermediate-grade (class 1B) tumors with a 21%
Ki67 will highlight proliferating tumor cells but 5-year risk for metastasis, and high-grade (class
also proliferating fully benign cells including the 2) tumors with a 72% 5-year risk for metastasis
lymphocytes that frequently infiltrate tumors. [47]. From these results, a 15-gene assay under
The reproducibility of immunohistochemical the trade name DecisionDx®-UM has been
evaluations can be increased with digital image developed [14, 48]. Through fine-needle biopsies
analysis and other automated procedures [45] of uveal melanomas in vivo or a sample of
(Fig. 3.6). archived formalin-fixed paraffin-embedded tis-
sue, the assay can be used to determine each
patient’s metastatic potential. In turn, this enables
 dditional Techniques
A accurate information to patients and relatives.
Potentially, the identification of a high-risk group
Recent advances in molecular pathology have also enables selection of patients to offer adju-
generated numerous techniques for the genetic vant therapy [49, 50]. This constitutes an impor-
and epigenetic study of tumors. One of the main- tant opportunity for randomized controlled trials
stay laboratory techniques is the polymerase of the effect of existing drugs and for the devel-
chain reaction (PCR). Several different types of opment of novel strategies. To this date, the
PCR have been developed, including competitive absence of effective adjuvant treatment even for
or real-time PCR, which allows for sensitive patients with a near certain likelihood for future
assays of gene expression at the RNA level. metastasis is however still a major obstacle for
Further, several experimental laboratory tech- the improvement of survival in uveal melanoma.
niques have been translated into clinical use, e.g., Several antibodies have been investigated and
flow cytometry in lymphoma and tissue imprints used, including aflibercept (VEGF-Trap) and ipi-
for gene rearrangements in rhabdomyosarcoma. limumab (anti-CTLA4) [51, 52]. Other drugs
In several cases, tissue needs to be submitted including anaplastic lymphoma kinase (ALK),
fresh, which requires close collaboration with the c-ros oncogene 1 (ROS1), VEGFR2, platelet-
examining laboratory for optimal results. derived growth factor receptor b (PDGFRb), and
Microarrays, DNA, and RNA sequencing have c-kit inhibitors are being investigated for their
revolutionized our understanding of the tumor potential to prevent the development of clinically
genome and transcriptome by making it possible detectable metastases (www.clinicaltrials.gov).
to study all genes or a subset thereof in one In line with the findings in microarray studies,
experiment to the resolution of single nucleo- proteomics hold a similar promise and generatew
30
Fig. 3.6 Illustration of digital image analysis. Two
adjacent tumor sections stained with a marker for the
type of cell to be analyzed (e.g., an epithelial pancyto-
keratin marker such as CkMNF116 in breast cancer, a
biomarker of choice (such as estrogen receptors (ER))
are aligned on top of each other. Thereby, the software
can distinguish the fraction of Ki67/ER-positive cells
within the cell population of interest. Middle: green dot-
ted line marks part of a region of interest, automatically
scored for Ki67 index. Blue polygons mark nuclei posi-
tive for both Ki67 and CkMNF116. Green polygons
G. Stålhammar et al.
mark nuclei positive for CkMNF116 but negative for
Ki67. The proportion of blue polygons to the sum of
blue and green polygons constitutes the Ki67 prolifera-
tion index. Bottom: illustration of heat map function
where the digital image analysis system has analyzed
the digitally scanned glass slide (left) for tumor area
with highest concentration of cells stained by both the
pancytokeratin marker and Ki67, marked in red (right).
Scale bar, middle = 50 μm. Scale bar, lower = 500 μm.
(Reprinted from Stålhammar et al. [45] with permission
from Springer Nature)
3 Cancer Pathology
vast amount of data on protein expression. Next-­
generation sequencing of the whole genome has
become a groundbreaking tool in the study of
cancer cells. It is used for the characterization
and identification of, e.g., DNA, RNA, exome,
and transcriptome sequences of tumor cells. It
enables identification of, e.g., copy number vari-
ants, sequence variants, mutations, and structural
changes such as chromosomal translocations,
and fusion genes. Various open-source projects
aim at collecting sequence variants and muta-
tions critical in the development of human can-
cers. Public sharing of data has enabled inclusion
in larger data sets for reanalysis and construction
of databases of cancer profiles.
Described here are only a handful of the tech-
niques developed for research and clinical study
of tumors. In the near future, many of the tech-
niques used for experimental purposes will delin-
eate central pathways in cancer cells with
prognostic, diagnostic, and treatment implica-
tions in human cancer.
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 Pathology Specimen: Handling
Techniques
Hardeep Singh Mudhar
Introduction
Clear communication between the ocular oncolo-
gist and ocular pathologist is crucial to ensure
that the patient’s final histopathology report is
intelligible and accurate and contains as much
relevant information to ensure safe patient
management.
The patient’s histopathology report is a culmi-
nation of several key events in a pathological
specimen’s journey. This commences with the
preparation and fixation of the specimen in the-
atre, the filling of the pathology request form, the
delivery of the specimen to the histopathology
laboratory, the handling of the specimen at the
time of ‘grossing/cut-up’ followed by the microt-
omy and staining of the slides and finally the
pathologist’s interpretation of the slide followed
by the creation of the pathology report. Errors
can occur at any step of this process so all accred-
ited histopathology laboratories follow standard
operating protocols that ensure a smooth running
of the specimen’s journey.
What follows is a simple guide to assist in the
optimal handling of different types of pathologi-
H. S. Mudhar (*)
National Specialist Ophthalmic Pathology Service
(NSOPS), Department of Histopathology, E-Floor,
Sheffield Teaching Hospitals NHS Foundation Trust,
Royal Hallamshire Hospital, Sheffield, UK
e-mail: hardeep.mudhar@sth.nhs.uk
© Springer Nature Switzerland AG 2019
A. D. Singh, B. E. Damato (eds.), Clinical Ophthalmic Oncology,
https://doi.org/10.1007/978-3-030-04489-3_4
4
cal specimens generated by ocular oncologists, in
the histopathology laboratory.
 athological Specimen Handling
P
in Theatre Before Fixation
 ultiple Biopsies from a Surgical
M
Procedure
Biopsies from different ocular locations should
be placed in separate formalin pots. If multiple
biopsies from different sites are placed in the
same formalin pot and one of the biopsies turns
out to be malignant, it is impossible to say from
where the biopsy originated, creating consider-
able anxiety for the clinician and patient.
Orientation of Specimens
This is an essential requirement to ensure the
pathologist can report the clearance of tumour
margins and the surgeon can return to the con-
taminated margin and remove further tissue to
achieve clearance if required. There are a variety
of ways to do this, but the simplest and most
effective way is to place marker sutures near par-
ticular margins and specifying which margin has
been marked on the pathology request form
(Fig. 4.1a).
33
34 H. S. Mudhar

Conjunctival Mapping Biopsies to allow the availability of appropriately skilled

Conjunctival biopsies are prone to curling if placed
straight into formalin. They should be attached to
a firm material, such as sponge (Fig. 4.1b), filter
paper or card, before placing into formalin. This
will keep them flat, greatly facilitating orientation
during embedding and allowing clear and safe
assessment for the presence or absence of invasion
by tumour. If multiple mapping biopsies are per-
formed, the pathology request form must state the
location of the biopsies (Fig. 4.1c).
Tissue Handling for Frozen Sections
Cases requiring frozen sections need to be
booked with the pathology laboratory in advance
pathology personnel. Frozen sections are
required usually for the assessment of tumour
clearance. Tissue destined for frozen sections
should be orientated with marker sutures and a
clear diagram drawn on the pathology request
form. The tissue must not be fixed. It’s useful to
place the tissue on some cotton gauze or card to
keep it as flat as possible and then put it into a
dry screw-top container. The surgeon’s tele-
phone number should be clearly written on the
pathology request form so that the pathologist
can contact the surgeon directly with the result
of the frozen section assessment. It is always
preferable for the pathologist to speak directly
to the surgeon rather than to another member of
the theatre to avoid error in the transfer of infor-
mation (Fig. 4.1d–h).

Fig. 4.1 (a) A skin ellipse excision of a basal cell carcinoma form the lower lid, containing orientation sutures placed
by the surgeon, to mark the superior and lateral margins. (b) A conjunctival mapping biopsy (tissue with brown hue)
placed on a sponge to keep it as flat as possible by the surgeon in theatre. (c) Pathology request form that shows a clear
diagram of the origin of the conjunctival mapping biopsies. (d) Fresh tissue sampled from the eyelid destined for frozen
sectioning. (e) The surgeon placing marker sutures into the tissue in (d). (f) The surgeon marking the new margin with
a marker pen. (g) The surgeon carefully sandwiching the fresh tissue between two pieces of sponge to keep it flat during
transit to the pathology laboratory. (h) The tissue being placed in a vessel for transport to the pathology laboratory. (i)
An enucleation specimen in a standard plastic pot containing 10% buffered formalin for fixation. (j) A short 25-gauge
needle attached to short tubing is inserted through the scleral bed into the tumour and aspiration is performed (left). The
contents of the needle, tubing and syringe are then rinsed into a tube of CytoLyt or other suitable transport medium
(right). (k) Vitreous washings sent up to the pathology laboratory in the vitreous bag. The surgeon has fixed the speci-
men in theatre with an equal volume of CytoLyt alcohol-based fixative. (l) A plastic impression cytology ring in a
standard plastic pot containing 10% buffered formalin for fixation. (m) The surgeon has drawn a very helpful diagram
on the pathology request form to aid orientation of the specimen. (n) A setup of the cut-up bench in a pathology labora-
tory for grossing ophthalmic pathology specimens. (o) A lower lid resection of a basal cell carcinoma, painted with
yellow and blue tissue dyes in the pathology laboratory to facilitate margin assessment during microscopy (p) The
specimen in figure o sliced into three pieces. (q) Crystal violet dye used to stain a conjunctival mapping biopsy in the
pathology laboratory. (r) The dyed conjunctival mapping biopsy from (q) being placed in the centre of some tracing
paper, to be wrapped up and then placed in a tissue net for processing. (s) Fresh tissue destined for frozen section being
unwrapped in the pathology laboratory. (t) The fresh tissue from s being measured. (u) The fresh tissue being placed in
cryo-matrix prior to freezing. (v) The frozen tissue being sectioned on the cryostat. (w) The frozen sections stained with
H&E ready for microscopic examination. (x) An iridectomy specimen containing a central brown melanoma. (y) An
irido-cyclectomy sample for a brown, dome-shaped ciliary body melanoma. (z) The gross sampling of the specimen in y.
(j: Reprinted from Singh et al. [13]. Copyright © 2011, Karger Publishers. y, z: Reprinted from Ford et al. [3]. With
permission from Elsevier.)
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The Project Gutenberg eBook of Cairo to Kisumu
 This ebook is for the use of anyone anywhere in the United
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Title: Cairo to Kisumu

Egypt—The Sudan—Kenya Colony

Author: Frank G. Carpenter

Release date: September 14, 2023 [eBook #71651]

Language: English

Original publication: Garden City: Doubleday, Page & Company,

1923

Credits: Peter Becker and the Online Distributed Proofreading

Team at https://www.pgdp.net (This file was produced
from images generously made available by The
Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK CAIRO TO

KISUMU ***
 CARPENTER’S
WORLD TRAVELS

Familiar Talks About Countries

and Peoples

WITH THE AUTHOR ON THE SPOT AND

THE READER IN HIS HOME, BASED
ON THREE HUNDRED THOUSAND
MILES OF TRAVEL
OVER THE GLOBE

CAIRO TO KISUMU
EGYPT—THE SUDAN—KENYA COLONY
 ON THE GREAT ASWAN DAM

“The dam serves also as a bridge over the Nile. I crossed on a car, my motive
power being two Arab boys who trotted behind.”

CARPENTER’S WORLD TRAVELS

CAIRO TO KISUMU
Egypt—The Sudan—Kenya
Colony

BY
FRANK G. CARPENTER
LITT.D., F.R.G.S.

WITH 115 ILLUSTRATIONS

FROM ORIGINAL PHOTOGRAPHS
AND TWO MAPS IN COLOUR

GARDEN CITY NEW YORK

DOUBLEDAY, PAGE & COMPANY
1923
 COPYRIGHT, 1923, BY
FRANK G. CARPENTER
ALL RIGHTS RESERVED, INCLUDING THAT OF TRANSLATION
INTO FOREIGN LANGUAGES, INCLUDING THE SCANDINAVIAN
PRINTED IN THE UNITED STATES
AT
THE COUNTRY LIFE PRESS, GARDEN CITY, N. Y.
First Edition
 ACKNOWLEDGMENTS
In the publication of this book on Egypt, the Sudan, and Kenya
Colony, I wish to thank the Secretary of State for letters which have
given me the assistance of the official representatives of our
government in the countries visited. I thank also our Secretary of
Agriculture and our Secretary of Labour for appointing me an
Honorary Commissioner of their Departments in foreign lands. Their
credentials have been of the greatest value, making available
sources of information seldom open to the ordinary traveller. To the
British authorities in the regions covered by these travels I desire to
express my thanks for exceptional courtesies which have greatly
aided my investigations.
I would also thank Mr. Dudley Harmon, my editor, and Miss Ellen
McBryde Brown and Miss Josephine Lehmann for their assistance
and coöperation in the revision of the notes dictated or penned by
me on the ground.
While most of the illustrations are from my own negatives, these
have been supplemented by photographs from the Publishers’ Photo
Service and the American Geographic Society.
F. G. C.
 CONTENTS
CHAPTER PAGE
I. Just a Word Before We Start 1
II. The Gateway to Egypt 3
III. King Cotton on the Nile 13
IV. Through Old Egypt to Cairo 22
V. Fellaheen on Their Farms 29
VI. The Prophet’s Birthday 41
VII. In the Bazaars of Cairo 49
VIII. Intimate Talks with Two Khedives 58
IX. El-Azhar and Its Ten Thousand Moslem
Students 70
X. Climbing the Great Pyramid 79
XI. The Pyramids Revisited 87
XII. Face to Face with the Pharaohs 96
XIII. The American College at Asyut 106
XIV. The Christian Copts 112
XV. Old Thebes and the Valley of the Kings 117
XVI. The Nile in Harness 128
XVII. Steaming through the Land of Cush 140
XVIII. From the Mediterranean to the Sudan 149
XIX. Across Africa by Air and Rail 160
XX. Khartum 167
XXI. Empire Building in the Sudan 175
XXII. Why General Gordon Had No Fear 181
XXIII. Omdurman, Stronghold of the Mahdi 187
XXIV. Gordon College and the Wellcome
Laboratories 200
XXV. Through the Suez Canal 208
XXVI. Down the Red Sea 218
 XXVII. Along the African Coast 224
XXVIII. Aden 229
XXIX. In Mombasa 236
XXX. The Uganda Railway 243
XXXI. The Capital of Kenya Colony 252
XXXII. John Bull in East Africa 261
XXXIII. With the Big-Game Hunters 269
XXXIV. Among the Kikuyus and the Nandi 277
XXXV. The Great Rift Valley and the Masai 285
XXXVI. Where Men Go Naked and Women Wear Tails 293
See the World with Carpenter 303
Bibliography 305
Index 309
 LIST OF ILLUSTRATIONS
On the great Aswan Dam Frontispiece
FACING PAGE
The bead sellers of Cairo 2
The veiled women 3
On the cotton docks of Alexandria 6
Nubian girls selling fruit 7
Woman making woollen yarn 14
Fresh-cut sugar cane 15
One of the mill bridges 18
The ancient sakieh 19
The native ox 19
Water peddlers at the river 22
Women burden bearers 23
Threshing wheat with norag 30
A corn field in the delta 30
The pigeon towers 31
In the sugar market 38
Flat roofs and mosque towers of Cairo 39
Tent of the sacred carpet 46
The Alabaster Mosque 47
“Buy my lemonade!” 54
A street in old Cairo 55
Gates of the Abdin Palace 62
The essential kavass 63
In the palace conservatory 66
The famous Shepheard’s Hotel 67
Learning the Koran 67
Approaching El-Azhar 70
In the porticos of El-Azhar 71
The Pyramids 78
Mr. Carpenter climbing the Pyramids 79
Standing on the Sphinx’s neck 82
Taking it easy at Helouan 83
View of the Pyramids 86
Uncovering tombs of ancient kings 87
The alabaster Sphinx 94
The great museum at Cairo 95
Students at Asyut College 102
American College at Asyut 103
Between classes at the college 103
In the bazaars 110
A native school in an illiterate land 111
The greatest egoist of Egypt 118
The temple tomb of Hatshepsut 119
Sacred lake before the temple 119
The avenue of sphinxes 126
The dam is over a mile long 127
Lifting water from level to level 134
Where the fellaheen live 135
A Nubian pilot guides our ship 142
Pharaoh’s Bed half submerged 143
An aged warrior of the Bisharin 150
A mud village on the Nile 151
Where the Bisharin live 151
A safe place for babies 158
Mother and child 159
A bad landing place for aviators 162
Over the native villages 162
The first king of free Egypt 163
Soldiers guard the mails 166
An American locomotive in the Sudan 167
Light railways still are used 167
Along the river in Khartum 174
Where the Blue and the White Nile meet 175
The modern city of Khartum 175
A white negro of the Sudan 178
Where worshippers stand barefooted for hours 179
Grain awaiting shipment down river 182
“Backsheesh!” is the cry of the children 182
Cotton culture in the Sudan 183
The Sirdar’s palace 183
The bride and her husband 190
Omdurman, city of mud 191
Huts of the natives 191
A Shilouk warrior 198
In Gordon College 199
Teaching the boys manual arts 206
View of Gordon College 207
On the docks at Port Said 207
Fresh water in the desert 210
The entrance to the Suez Canal 211
A street in dreary Suez 226
Ships passing in the canal 227
Pilgrims at Mecca 230
Camel market in Aden 231
Harbour of Mombasa 238
Where the Hindus sell cotton prints 239
The merchants are mostly East Indians 239
A Swahili beauty 242
Passengers on the Uganda Railroad 243
An American bridge in East Africa 246
Native workers on the railway 246
Why the natives steal telephone wire 247
In Nairobi 254
The hotel 255
Jinrikisha boys 255
A native servant 258
Naivasha 259
The court for white and black 259
Motor trucks are coming in 262
How the natives live 263
Native taste in dress goods 266
The Kikuyus 266
Wealth is measured in cattle 267
Zebras are frequently seen 270
Even the lions are protected 271
Giraffes are plentiful 271
Elephant tusks for the ivory market 278
How the mothers carry babies 279
Mr. Carpenter in the elephant grass 286
Nandi warriors 287
Woman wearing a tail 290
How they stretch their ears 291
The witch doctor 298
Home of an official 299
The mud huts of the Masai 299
MAPS
Africa 34
From Cairo to Kisumu 50
 CAIRO TO KISUMU
EGYPT—THE SUDAN—KENYA
COLONY
 CHAPTER I
JUST A WORD BEFORE WE START

This volume on Egypt, Nubia, the Sudan, and Kenya Colony is

based upon notes made during my several trips to this part of the
world. At times the notes are published just as they came hot from
my pen, taking you back, as it were, to the occasion on which they
were written. Again they are modified somewhat to accord with
present conditions.
For instance, I made my first visit to Egypt as a boy, when Arabi
Pasha was fomenting the rebellion that resulted in that country’s
being taken over by the British. I narrowly escaped being in the
bombardment of Alexandria and having a part in the wars of the
Mahdi, which came a short time thereafter. Again, I was in Egypt
when the British had brought order out of chaos, and put Tewfik
Pasha on the throne as Khedive. I had then the talk with Tewfik,
which I give from the notes I made when I returned from the palace,
and I follow it with a description of my audience with his son and
successor, Abbas Hilmi, sixteen years later. Now the British have
given Egypt a nominal independence, and the Khedive has the title
of King.
In the Sudan I learned much of the Mahdi through my interview
with Sir Francis Reginald Wingate, then the Governor General of the
Sudan and Sirdar of the British army at Khartum, and later gained an
insight into the relations of the British and the natives from Earl
Cromer, whom I met at Cairo. These talks enable one to understand
the Nationalist problems of the present and to appreciate some of
the changes now going on.
In Kenya Colony, which was known as British East Africa until after
the World War, I was given especial favours by the English officials,
and many of the plans that have since come to pass were spread out
before me. I then tramped over the ground where Theodore
Roosevelt made his hunting trips through the wilds, and went on into
Uganda and to the source of the Nile.
These travels have been made under all sorts of conditions, but
with pen and camera hourly in hand. The talks about the Pyramids
were written on the top and at the foot of old Cheops, those about
the Nile in harness on the great Aswan Dam, and those on the Suez
Canal either on that great waterway or on the Red Sea immediately
thereafter. The matter thus partakes of the old and the new, and of
the new based upon what I have seen of the old. If it be too personal
in character and at times seems egotistic, I can only beg pardon by
saying—the story is mine, and as such the speaker must hold his
place in the front of the stage.
 Beggars and street sellers alike believe that every foreigner visiting Egypt is not
only as rich as Crœsus but also a little touched in the head where spending is
concerned, and therefore fair game for their extravagant demands.
 Among the upper classes an ever-lighter face covering is being adopted. This is
indicative of the advance of the Egyptian woman toward greater freedom.