PC-10 as a predictor of prognosis after antigen retrieval in posterior uveal melanoma

PURPOSE

The immunoexpression of the PC-10 monoclonal antibody for the proliferating cell nuclear antigen is claimed to have prognostic value in diverse tumors, but previous data on posterior uveal melanoma are conflicting. The aim of the current study was to investigate further the potential value of the PC-10 antibody in predicting tumor-related death after enucleation for posterior uveal melanoma.

METHODS

One observer calculated the number of cells after antigen retrieval that showed immunoreactivity for PC-10 in the high expression areas of 212 specimens containing posterior uveal melanomas. Survival data for all patients were entered into stepwise multivariate Cox regressions that included other potential prognostic covariates. The prognostic accuracy was assessed by receiver operating characteristic curve analysis.

RESULTS

The only covariates of statistically significant prognostic value were the number of cells featuring immunoreactivity for PC-10 and the largest tumor diameter. When using the median PC-10 count as the cutoff, the cumulative 10-year survival proportion was 84% for the low PC-10 count group and 40% for patients harboring tumors with high PC-10 counts. Those with tumors featuring high PC-10 counts had a 5.8 times greater risk to die of metastatic melanoma. However, the prognostic accuracy of the PC-10 count was not significantly better than that of the largest tumor diameter, presumably because of insufficient statistical power.

CONCLUSIONS

The number of cells showing immunoreactivity for the PC-10 antibody may be used to assess prognosis in posterior uveal melanoma, provided that antigen retrieval is performed. Additional work using a larger sample size is warranted for better comparison of the predictive accuracy with that of other prognostic markers.

Cell growth and p53 expression in primary acquired melanosis and conjunctival melanoma

AIMS

To evaluate cell growth and the pattern of p53 suppressor gene expression in atypical primary acquired melanosis (PAM) and in recurrent conjunctival melanoma.

METHODS

Eighteen specimens of PAM with atypia and 24 specimens, comprising early and late lesions, from 12 patients with conjunctival melanoma were stained for the proliferating cell nuclear antigen using the PC10 antibody, and for the p53 gene product using the BP53-12-1, 1801 and DO7 clones. The immunoreactive cells were counted manually and the data evaluated statistically.

RESULTS

Seven of nine PAM specimens progressing to melanoma expressed PC10. None of these lesions expressed the p53 gene product. The number of proliferating cells was higher in the late than in the early lesions of conjunctival melanoma. Four of the 12 recurrent melanomas displayed focal, but minimal, p53 expression. The proliferating cell count in the p53 positive tumours was very similar to that of the p53 negative conjunctival melanomas.

CONCLUSION

Examination of the expression of proliferating cells in atypical PAM may be used as an adjunct to predict which lesions will progress to melanoma. The increase in the number of proliferating cells over time in recurrent conjunctival melanomas probably reflects more aggressive behaviour and may be used to monitor recurrence. The absence of p53 expression in PAM and minimal staining of conjunctival melanomas did not correlate with cell growth, suggesting that alterations in the p53 tumour suppressor gene are uncommon and late events in conjunctival melanoma, and that p53 expression is unlikely to be a useful prognostic indicator.

[A study of children with retinoblastoma. Diagnosis is often delayed]

Retinoblastoma is an uncommon but highly malignant ocular tumour of the early childhood. The delay in diagnosis following presentation at a health care facility was studied for 22 consecutive cases derived from the National Retinoblastoma Center in Sweden. Four of the children were regularly examined owing to a family history of retinoblastoma, but among the remaining 18 children the delay in diagnosis exceeded one month in five cases (including all children presenting with squint). However, there was no appreciable delay once appropriate fundus examination had been performed, thus stressing the need of early ophthalmological assessment in all cases of children manifesting signs consistent with retinoblastoma.

Proliferating cell nuclear antigen colocalization with corneal epithelial stem cells and involvement in physiological cell turnover

Corneal integrity is dependent on a constant turnover of epithelial cells. According to the current hypothesis essential contributors to this process, the so-called stem-cells, are localized in the limbal area of the cornea. However, histological identification of stem cells of the cornea is thus far not possible. In the present study we have used specific antibodies against proliferating cell nuclear antigen (PCNA). The nuclear protein is expressed in cells during replication. Prior to establishment of staining indices the optimal fixation procedure was found to be of major importance for the results and standardized for fixation in 4% formaldehyde. This procedure also gave the best preservation of the morphology. In the corneas of ten New Zealand rabbits the staining index for PCNA was found to be on average 23% (SD +/- 13%) for the basal layer of the limbal epithelium. In the mid-peripheral and central corneal epithelium only occasional staining of PCNA was detected with a 2% staining index (SD +/- 2%). The agglomeration of PCNA-positive cells in the basal layer of the limbal epithelium together with their colocalization with the known location of stem cells strongly suggests that PCNA could serve as a reliable indicator for the proximity of proliferating corneal epithelial stem cells in histological sections, which would be of significant clinical importance.

Giant cell angiofibroma. A distinctive orbital tumor in adults

A series of seven cases of a previously unrecognized potentially recurrent tumor occurring in the orbit of adult patients is reported. This lesion shows histologic appearances intermediate between, but distinct from, solitary fibrous tumor and giant cell fibroblastoma of soft tissue. Morphologically it is characterised by a richly vascularized, patternless spindle-cell proliferation containing pseudovascular spaces. Multinucleate giant cells (often of floret type) and cells with large, rounded nuclei are present both in the cellular areas and also lining the pseudovascular spaces. The stroma is variably collagenized or sometimes myxoid. Immunohistochemically, the tumor cells exhibit positivity for vimentin and CD34. Follow-up in five cases (median duration 24 months) revealed local recurrence in one patient and persistent tumor in another. The clinical and morphologic features enable distinction of this lesion from both solitary fibrous tumor and giant cell fibroblastoma, and we suggest the designation "giant cell angiofibroma of the orbit".

Orbital presentation of ethmoid sinus adenocarcinoma

Ethmoid sinus adenocarcinoma with orbital invasion is distinctly uncommon. This case presented with epiphora, whereas proptosis and decreased ocular motility were later signs. Treatment was delayed for 4 months, while misdiagnoses like dacryocystitis and thyroid eye disease were entertained. Even an incisional biopsy was not sufficient for a conclusive diagnosis and adenomatous differentiation was only present in a small proportion of tissue available after an excisional attempt. The aggressive behaviour including this patient's death of metastatic disease, underlines the importance of considering secondary invasion from a sino-nasal malignancy in uncharacteristic orbital disease.

Prevalence of primary acquired melanosis and nevi of the conjunctiva and uvea in the dysplastic nevus syndrome. A case-control study

PURPOSE

To investigate whether conjunctival and uveal nevi and primary acquired melanosis are more common in individuals with the dysplastic nevus syndrome than in control subjects derived from the general population.

METHODS

Power calculations were used to determine the sample size. After invitation, 162 individuals with the dysplastic nevus syndrome and 119 control subjects, matched for sex and age but otherwise randomized from the Stockholm county census file, were entered into the study. All individuals were examined in a masked fashion by the same ophthalmologist, and the presence of conjunctival and uveal melanocytic lesions and the iris color, skin type, and hair color of each individual were recorded. Contingency tables and odds ratios were used for statistical evaluation.

RESULTS

The proportions of individuals with the dysplastic nevus syndrome featuring primary acquired melanosis of the conjunctiva, or nevi of the iris and choroid were not significantly different from those of control subjects. However, individuals with the dysplastic nevus syndrome appeared to have a more sun-sensitive skin type and a reddish or blond hair color more often than control subjects.

CONCLUSION

In contrast to previous reports, this study suggests that ocular melanocytic lesions are no more common in individuals with the dysplastic nevus syndrome than in the general population. Therefore, this work does not provide support that periodic ophthalmic surveillance of individuals with the dysplastic nevus syndrome for the purpose of detecting conjunctival or uveal melanomas, or their precursors, is meaningful.

Squamous spindle cell carcinoma of the conjunctiva. Fatal outcome of a plerygium-like lesion

Squamous spindle cell carcinoma of the conjunctiva is an infrequent entity that behaves distinctly different from "ordinary' squamous cell carcinoma. This case report reviews the clinical and histopathological features of a lesion, that despite an insidious clinical appearance caused the patient's death 14 months following the initial excision. Data from previous reports are outlined.

Prognostic indicators following enucleation for posterior uveal melanoma. A multivariate analysis of long-term survival with minimized loss to follow-up

Most previous reports on survival following enucleation for uveal malignant melanoma do not contain cumulative survival rates, do not use a multivariate approach and are liable to a considerable loss to follow-up. In this study, the long-term survival and tumour-related mortality were studied in 340 patients. Archival specimens containing posterior uveal melanomas were initially examined and sectioned by one pathologist. There was no loss to follow-up 6 to 22 years after enucleation. At the end of study, 233 (68.5%) individuals were dead; 137 (40.3%) of melanoma-related causes and 96 (28.2%) of other causes. Melanoma-related deaths appeared from 24 to 6848 days (18 years 8 months) after enucleation. The cumulative 5-year survival proportion based on melanoma-related deaths was 70% and the corresponding 10-year proportion was 56%. Multivariate Cox regression indicated that the largest tumour dimension, cell type, and tumour location all had independent prognostic value, the associated hazard ratios ranged from 1.2 to 1.4, suggesting a moderate increase of the relative risk. Pair-wise comparisons of the parameters indicated that large tumours were more common in the anterior choroid or ciliary body than in the posterior choroid. Similarly, large tumours were more often necrotic, composed of epitheloid cells, or featured extrascleral extension. Tumours with significant scleral invasion or extrascleral extension were more common in elderly patients.

Immunohistochemical characterization of surgically removed subfoveal fibrovascular membranes

Eighteen patients with age-related macular degeneration developed subfoveal membranes that were surgically removed and submitted for histopathological examination. Immunohistochemical techniques were performed, using a panel of monoclonal antibodies recognizing retinal pigment epithelial (RPE) cells, myofibroblasts, pericytes, endothelial cells, glial cells, smooth muscle cells and various types of macrophages. The PC10 antibody to proliferating cell nuclear antigen (PCNA) was applied as a marker of proliferating cells. The specimens displayed a core of neovascular stroma surrounded by a rim of more fibrous tissue. All specimens contained abundant RPE cells that in some cases appeared to envelop part of the membrane. Most cases had basal laminar deposits and thickened basement membrane material adjacent to the RPE cells suggestive of parts of Bruch's membrane. Often this Bruchlike membrane appeared at the surgical margin, forming a surgical cleavage plane. Chronic inflammatory cells were abundant, but polymorphonuclear leukocytes were notably absent. Nearly all specimens contained myofibroblasts and various types of macrophages. The presence of myofibroblasts suggests subretinal membrane contraction, which may induce new breaks and other pathology in RPE layer and Bruch's membrane.

Retinochoroiditis in the acquired immune deficiency syndrome. Findings in consecutive post-mortem examinations

A number of opportunistic agents may cause retinitis or retinochoroiditis in patients with the acquired immunodeficiency syndrome. Minimal consecutive data is available on the histopathologically confirmed prevalence of these ocular infections. A total of 48 consecutive patients with acquired immunodeficiency syndrome-related death underwent autopsy and had their eyes submitted for histopathological examination. Conventional light microscopy combined with immunohistochemistry revealed cytomegalovirus retinitis in 15 patients, toxoplasma gonddi retinochoroiditis in 3 patients and mycobacterial choroiditis in one individual with some infections being coexistent. Clinical examination prior to death was highly accurate in detecting cytomegalovirus retinitis, but failed to determine all non-cytomegalovirus causes of retinochoroiditis. Ten of 15 patients with cytomegalovirus retinitis had associated non-cular cytomegalovirus infections, most often in the brain and adrenals. After clinical detection of cytomegalovirus retinitis the median survival time was 5.5 months, not adversely affected by additional non-ocular cytomegalovirus infection.

Massive intracorneal invasion of a ciliary body melanoma

Massive intracorneal spread from ocular malignant melanoma is an infrequent event. This case illustrates the histopathological features of a large ciliary body melanoma with massive wedge-like intracorneal invasion, but without extraocular extension.

Apocrine adenocarcinoma arising in Moll gland cystadenoma

CASE REPORT

An 85-year-old woman had a bluish tumor medially on the margin of the left upper eyelid. Malignant melanoma of the conjunctiva was presumed; the lesion was excised and submitted for routine histopathologic examination. There are no signs of recurrence or metastatic disease after follow-up for 1 year.

METHODS

Light microscopy with routine and histochemical stains were used for diagnosis. Immunohistochemical analysis included the use of a broad-spectrum "cocktail" of cytokeratin antibodies (AE1/AE3).

RESULTS

The features were those of a cystic cavity lined with apocrine epithelium in one part infiltrating the wall and consistent with an apocrine adenocarcinoma derived from a Moll gland cystadenoma.

CONCLUSION

Malignant Moll gland tumors are extremely uncommon but may be confused with conjunctival malignant melanoma or metastatic disease. The differential diagnosis to other sweat gland tumors such as eccrine adenocarcinoma and benign apocrine tumor or to sebaceous carcinoma can be difficult.

Multiple melanocytic tumours in a case of ocular melanocytosis

A case of ocular melanocytosis with the simultaneous occurrence of a choroidal malignant melanoma, a ciliary body melanocytoma and a surface plaque iris naevus in an 80-year-old male Caucasian is reported. Patients with ocular or oculodermal melanocytosis are considered to be at risk for tumour formation and malignant transformation; the multiple melanocytic tumours of the present case support this hypothesis.

Cell proliferation as a prognostic indicator in conjunctival malignant melanoma

Expression of proliferating cell nuclear antigen, a DNA polymerase delta auxiliary protein, was studied in 20 specimens from 20 patients with conjunctival malignant melanoma by means of the total number of cells that showed immunoreactivity per square millimeter. The countings were shown to be reproducible with minimal intraobserver variability. In a multifactor analysis of variance (ANOVA) that adjusted for possible confounders, patients who subsequently died of metastatic disease had significantly higher counts of cells that were positive for proliferating cell nuclear antigen per square millimeter (P = .0011) than patients with a minimum survival of five years without clinical signs of metastatic disease. A multivariate Cox regression model confirmed the independent prognostic value (P = .048) of the cell counts. Individual hazard ratios were estimated in a final Cox model and two groups of patients with low and high hazard ratios were formed. Five-year cumulated survival proportions of the two groups were 90% and 60%, respectively. The total count of cells displaying immunoreactivity for proliferating cell nuclear antigen per square millimeter may be used as a prognostic indicator in patients with conjunctival melanoma.

AgNOR counts in conjunctival malignant melanoma lack prognostic value

Using a silver staining technique, argyrophilic nucleolar organiser region-associated proteins (AgNORs) have been studied in routinely processed paraffin sections of 46 invasive malignant melanomas (MM) of the conjunctiva. The aim of this retrospective study was to assess the value of the AgNOR method as a prognostic indicator for this neoplasm. The 46 cases were divided into two groups: (A) 14 cases of MM that metastasised and caused death of the patient within 5 years of (histological) diagnosis, and (B) 32 cases of MM that did not metastasise and in which patients survived beyond 5 years. The mean of the AgNOR counts per nucleus was 7.03 (95% CI: 5.81-8.24) in group A, and 7.15 (95% CI: 6.53-7.77) in group B. A comparison using a multifactor analysis of variance (ANOVA) model, which corrected for possible confounding effect of tumour thickness, site, and cell type showed no significant difference in AgNOR counts between groups A and B (p = 0.8). Analysis by the Cox proportional hazards regression model showed that survival was not influenced significantly by the mean AgNOR number (hazard ratio: 0.92). Whereas the AgNOR technique may be used to distinguish benign from malignant melanocytic lesions of the conjunctiva, we conclude it has no value in predicting the outcome for patients with conjunctival MM.

Conjunctival malignant melanoma in Sweden 1969-91

Clinical information, follow-up and histopathological parameters of the primary lesions were assessed for all (45) individuals with conjunctival malignant melanomas in Sweden presenting during a 22.5 year period (1969 to mid 1991). The annual incidence of conjunctival malignant melanoma in Sweden was 0.0240 per 100,000. On average, two new cases were diagnosed each year (population 8.6 million in 1991). Sixty-two per cent of the lesions recurred, but re-growth in itself was not correlated to reduced survival. The actuarial 10-year survival proportion using life-table analysis was 70%. A significantly reduced survival due to tumour-related death was noted in patients with tumours with high mitotic indices, many epithelioid cells and in lesions exceeding 10 mm in diameter. Other factors that may influence survival are presented in the context of previous reports. The present policy in Sweden for treating patients with malignant melanoma of the conjunctiva is outlined and discussed.

Two cases of primary bilateral malignant melanoma of the choroid

The first two Swedish cases of primary bilateral malignant melanoma of the choroid are presented. In one case bilateral histological confirmation was obtained as both eyes were enucleated. In the other case one eye was enucleated and the other irradiated with an episcleral ruthenium plaque. Sweden has a population of 8.38 millions, so that bilateral choroidal melanomas may be less rare than previously thought.