[Malignant conjunctival melanoma. Clinical review with recommendations for diagnosis, therapy and follow-up]

BACKGROUND

Malignant conjunctival melanoma is a rare disease with an incidence of 0.03 - 0.08. This tumour is potentially lethal, even after prompt and proper treatment, especially after delayed onset of therapy. Conjunctival melanoma arises from primary acquired melanosis (PAM), from a preexisting nevus or "de novo" without any precursor at all. In contrast to uveal melanomas, conjunctival melanoma metastasizes via the ipsilateral lymph nodes and in rare cases through the lacrimal duct into the nasal cavities.

RESULTS

Removing the local tumour with preservation of visual functions and avoidance of metastases is the therapy of choice. Excision alone is followed by a high rate of recurrence. To minimize local recurrence rate surgical excision should be combined with an additional procedure such as cryotherapy, irradiation, or local chemotherapy with MMC. Surgical technique is characterized by a so-called "no-touch" method avoiding any direct manipulation of the tumour to prevent tumour cell seeding into a new area. The behaviour of conjunctival melanomas is individually unpredictable. Prognostic factors are tumour size and tumour location. Tumours growing extralimbal especially at the fornix, plica and caruncle have a significantly poorer prognosis than limbal tumours. In our own patients the 5-year, 10-year, and 15-year cumulative melanoma-specific survival rate was 84.4 %, 77.7 %, and 75.0 %, respectively. Up to now there is no effective treatment of the metastatic disease.

CONCLUSION

In all cases with pigmented lesions of the conjunctiva exclusion of a malignant melanoma has to be the first aim. A patient suffering from a conjunctival melanoma should be referred to an ophthalmo-oncological center for proper treatment. An indefinite follow-up including photodocumentation is necessary since the rate of recurrence is high. An international prospective study would be worthwhile to answer open questions and to develop new kinds of treatment of this potentially fatal tumour.

Sentinel node biopsy as a tool for accurate staging of eyelid and conjunctival malignancies

Sentinel lymph node (SLN) biopsy has emerged as a technique for accurate staging of solid tumors. This technique permits the detection of microscopic metastases in clinically negative regional lymph nodes and may be indicated for malignancies that have a propensity for regional nodal metastasis. With the exception of basal cell carcinoma, almost all malignancies of the eyelid and conjunctiva metastasize to regional lymph nodes as the site of first metastasis. The histologic status of the SLNs has been shown to be the most significant prognostic factor with respect to recurrence and survival in patients with cutaneous melanoma. The indications for and the feasibility of SLN biopsy for eyelid and conjunctival tumors and our experience with this technique are reviewed.

Ocular adnexal lymphomas: five case presentations and a review of the literature

The ocular adnexal lymphomas represent the malignant end of the spectrum of lymphoproliferative lesions that occur in these locations. The Revised European and American Lymphoma (REAL) Classification and the new World Health Organization Classification of Tumors of Hemopoietic and Lymphoid Tissues are the most suitable for subdividing the ocular adnexal lymphomas, whereby the extranodal marginal zone B-cell lymphoma represents the most common lymphoma subtype. This review is based on five cases subtyped according to the above classifications-three "typical" lymphomas (an extranodal marginal zone B-cell lymphoma, a diffuse large cell B-cell lymphoma arising from an extranodal marginal zone B-cell lymphoma, and a follicular lymphoma) and two "atypical" lymphomas (a non-endemic Burkitt lymphoma in an immune competent elderly patient, and a primary Hodgkin lymphoma of the eyelid) of the ocular adnexa. Management of patients with ocular adnexal lymphomas includes a thorough systemic medical examination to establish the clinical stage of the disease. The majority of patients with ocular adnexal lymphoma have stage IE disease. Current recommended therapy in stage IE tumors is radiotherapy, while disseminated disease is treated with chemotherapy. Despite usually demonstrating an indolent course, extranodal marginal zone B-cell lymphomas are renowned for recurrence in extranodal sites, including other ocular adnexal sites. Long-term follow-up with 6-month examinations are therefore recommended. Major prognostic criteria for the ocular adnexal lymphomas include anatomic location of the tumor; stage of disease at first presentation; lymphoma subtype as determined using the REAL classification; immunohistochemical markers determining factors such as tumor growth rate; and the serum lactate dehydrogenase level.

Long-term follow-up of patients with conjunctival melanoma

Data from long-term follow-up examinations of patients with conjunctival melanoma are limited. A retrospective study of survival rates and local tumor relapse rates was performed on 85 patients initially treated between 1958 and 1993. Therapeutic procedures were local excision, local excision followed by brachytherapy, local excision combined with cryotherapy, and local excision followed by either irradiation or cryotherapy and adjuvant mitomycin C (MMC) application. The Kaplan-Meier method was used to estimate cumulative survival rates and event rate curves. Clinical parameters of the patients and the tumors were obtained and analyzed for their relation to tumor recurrence and death from metastatic melanoma using the multivariate Cox hazards modeling. The median follow-up duration among the surviving patients was 13.1 years (mean 13.8 years). The cumulative 10-year survival rate of the 85 patients based on all causes of death was 62.5%, and that based on tumor-related death was 77.7%. Patient age greater than 55 years, higher TNM category, and unfavorable tumor location (palpebral conjunctiva, fornix, caruncle, corneal stroma, eyelid) were identified as prognostic factors for death from metastatic melanoma. Tumors with unfavorable location, higher TNM grade, and excision alone as initial therapy showed a higher cumulative probability of local relapse than favorably located (bulbar and limbal conjunctiva) tumors, lower TNM grade, and excision plus adjuvant therapy. The behavior of conjunctival melanomas remains unpredictable in individual cases. To minimize local recurrence rate surgical excision should be combined with an adjunctive procedure such as irradiation, cryotherapy, or local chemotherapy with MMC. Randomized prospective multicentric studies are required.

Clinical aspects of conjunctival melanoma

Conjunctival melanoma is a rare but important condition encountered in ophthalmology. This paper reviews conjunctival melanoma as a clinical entity, with particular emphasis on differential diagnosis, management and prognostic factors. Relevant references were located through a comprehensive search of articles published between 1980 and early 2001 on Medline, using both the WinSpirs and PubMed platforms. The references of these articles were then checked for further articles of relevance. The condition is uncommon and its presentation variable; therefore, relevant studies were found to suffer from small numbers of subjects. This may be the cause of the confusion that still surrounds the condition and its management.

Combined surgery, cryotherapy, and mitomycin-C for recurrent ocular surface squamous neoplasia

PURPOSE

To report the outcome of combined excision, cryotherapy, and antimetabolite treatment of recurrent ocular surface squamous neoplasia.

METHODS

The patients with recurrent ocular surface squamous neoplasia were treated by excision of lesion, cryotherapy of limbus, and conjunctival margin followed by 0.02% Mitomycin C application at the time of surgery. Patients have been followed up for at least 1 year.

RESULTS

A total of five eyes of five patients with recurrent ocular surface squamous neoplasia were treated by combined excision, cryotherapy, and Mitomycin C. Histopathologic diagnosis included invasive squamous cell carcinoma in four cases and squamous dysplasia in one case. No recurrences have been noted for a follow-up period of more than 1 year now.

CONCLUSION

Combining excision with cryotherapy and Mitomycin C application at the time of surgery is a very effective therapy for recurrent ocular surface squamous neoplasia. It is relevant for cases in large, poor countries where patients present late and are less likely to come for follow-up care.

Prognostic value of clinical and histopathological parameters in conjunctival melanomas: a retrospective study

AIM

To determine prognostic factors for recurrence of disease and tumour related mortality in patients with conjunctival melanoma.

METHODS

A retrospective analysis of clinical and histopathological data of 69 patients with histologically verified conjunctival melanoma.

RESULTS

As univariate analysis showed, significant risk factors for the development of recurrence were: irregular pigmentation (RR = 2.0, p = 0.0007), incomplete surgical excision (RR = 3.5, p = 0.008), tumour invasion deeper than in substantia propria (RR = 3.9, p = 0.008), and presence of epithelioid tumour cells (RR = 2.9, p = 0.05). For tumour related mortality a significantly increased risk was found for tumour location in palpebral conjunctiva, caruncle, plica, or fornices (RR = 5.9, p = 0.001), for tumour infiltration deeper than the substantia propria (RR = 5.5, p = 0.001), for incomplete surgical excision (RR = 4.4, p = 0.05), and for nodular or mixed (nodular and superficial) growth pattern of the tumours (RR = 1.2, p = 0.002). The use of an adjuvant therapy for the surgical excision of the melanomas had no statistically significant influence upon the development of recurrent disease nor upon the tumour related mortality.

CONCLUSION

These data present similar clinical and histopathological risk factors for patients with conjunctival melanoma as reported previously. The present study also addresses the failure of retrospective studies on conjunctival melanoma to prove the efficacy of a supplementary therapy to surgical excision.

Clinical spectrum of primary ophthalmic rhabdomyosarcoma

PURPOSE

To review the clinical presentation, histopathologic analysis, management, and ocular and systemic outcome of rhabdomyosarcoma affecting the ocular region.

DESIGN

Retrospective, noncomparative, consecutive, interventional case series.

PARTICIPANTS

Thirty-three consecutive patients with primary ophthalmic involvement of rhabdomyosarcoma from a single tertiary care center specializing in ocular oncology.

MAIN OUTCOME MEASURES

Final visual acuity, treatment complications, local recurrence, and distant metastasis.

RESULTS

The mean age at presentation was 10 years (median, 7 years; range, 1 month-68 years). At presentation, 8 patients (24%) were older than age 10 years and 4 patients (12%) were older than 20 years. The rhabdomyosarcoma was primarily located in the orbit in 25 cases (76%), conjunctiva in 4 cases (12%), eyelid in 1 case (3%), and uveal tract in 3 cases (9%). Symptoms or signs related to the tumor were present for a mean of 5 weeks and included proptosis in 10 patients (30%), eyelid swelling in 7 patients (21%), and blepharoptosis in 6 patients (18%). The initial diagnosis before referral to us included rhabdomyosarcoma in 8 cases (24%), conjunctivitis in 5 cases (15%), orbital or preseptal cellulitis in 5 cases (15%), idiopathic orbital inflammatory pseudotumor in 4 cases (12%), and others. Using the Intergroup Rhabdomyosarcoma Study Group staging and treatment protocols, the tumor was classified as group I in 4 cases (12%), group II in 12 cases (36%), group III in 16 cases (48%), and group IV in 1 case (3%). Treatment included surgical debulking and various regimens of chemotherapy and radiotherapy for the periocular tumors and enucleation for the three intraocular tumors. Local tumor recurrence was detected in 6 patients (18%). Orbital exenteration was necessary for tumor recurrence in 2 cases (6%). Long-term visual outcome of the 28 patients who maintained their globe was 20/20 to 20/40 in 11 patients (39%), 20/50 to 20/100 in 5 patients (18%), and 20/200 to no light perception in 12 patients (43%). Regional lymph node metastasis was detected in 2 patients (6%), one at initial visit and one after therapy. Distant metastasis occurred in 2 patients (6%), one detected at initial visit and one after therapy. With mean follow-up of 8.3 years, tumor-related death occurred in 1 patient (3%).

CONCLUSIONS

Rhabdomyosarcoma can present in the orbit, eyelid, conjunctiva, and uveal tract. After treatment, local tumor recurrence occurs in 18%, metastasis in 6%, and death in 3%.

Management of conjunctival and corneal melanoma with surgical excision, amniotic membrane allograft, and topical chemotherapy

PURPOSE

To illustrate a novel method of management for extensive conjunctival and corneal melanoma.

METHODS

Interventional case report. A 40-year-old Caucasian woman presented with a large, diffuse conjunctival melanoma involving 6 clock hours of the limbus. The remaining bulbar conjunctiva and the entire corneal epithelium were affected by diffuse, flat melanosis.

RESULTS

The conjunctival melanoma was completely resected microsurgically in one piece without disrupting the tumor. The conjunctival melanosis was treated with double freeze-thaw cryotherapy. The extensive conjunctival defect, involving one-half of the bulbar conjunctiva, was reconstructed with an amniotic membrane allograft. The corneal melanosis was subsequently treated with topical mitomycin C eyedrops. At 8 months follow-up, the conjunctiva and the cornea were completely healed with resolution of all pigment and 20/20 visual acuity.

CONCLUSION

Preliminary evidence suggests that combined therapeutic approaches, consisting of extensive tumor removal, cryotherapy, amniotic membrane allograft, and topical mitomyin C, can be effective in the management of diffuse conjunctival and corneal melanoma arising from primary acquired melanosis.

Plasmacytoma of the eye and orbit

BACKGROUND

Plasmacytomas of the ocular and adnexal tissue are rare. The variation in their clinical manifestations and potential association with multiple myeloma are not well appreciated.

METHODS

We reviewed the clinical features and laboratory data of five cases of plasmacytoma involving the eye and orbit.

RESULTS

Plasmacytomas involved the conjunctiva in one case, the orbit in three cases, and the iris in one case. Plasmacytoma was the solitary plasma cell neoplasm in a patient with a conjunctival lesion and another patient with an orbital lesion. Two other patients who developed plasmacytomas of the orbit and iris, respectively, had a known history of multiple myeloma. An orbital plasmacytoma preceded the onset of systemic plasma cell neoplasia in the final patient.

CONCLUSION

Plasmacytomas of the eye and orbit are rare. They may or may not be associated with multiple myeloma.

Primary ophthalmic rhabdomyosarcoma in 33 patients

PURPOSE

To review the findings, management, and outcome in 33 cases of primary ophthalmic rhabdomyosarcoma.

METHODS

The records of 33 consecutive patients from a single ocular oncology center were analyzed retrospectively for outcomes of final visual acuity, local recurrence, and distant metastasis.

RESULTS

Rhabdomyosarcoma was primarily located in the orbit m 25 cases (76%), conjunctiva in 4 (12%), eyelid in 1 (3%), and uveal tract in 3 (9%). Findings had been present for a mean of 5 weeks and included proptosis in 10 patients (30%), eyelid swelling in 7 (21%), and blepharoptosis in 6 (18%). The initial diagnoses before referral to us included primarily rhabdomyosarcoma in 8 cases (24%), conjunctivitis in 5 (15%), cellulitis in 5 (15%), and pseudotumor in 4 (12%). Tumors were classified according to the Intergroup Rhabdomyosarcoma Study Group staging and treatment protocols as group I in 4 cases (12%), group II in 12 (36%), group III in 16 (48%), and group IV in 1 case (3%). Treatment included surgical debulking, chemotherapy, and radiotherapy. Local tumor recurrence was detected in 6 patients (18%), lymph node spread in 2 (6%), and distant metastasis in 2 (6%). Long-term visual outcome of the 28 patients who maintained their globe was 20/20 to 20/40 in 11 patients (39%), 20/50 to 20/100 in 5 (18%), and 20/200 or worse in 12 (43%). Mean follow-up was 8.3 years; tumor-related death occurred in 1 patients (3%).

CONCLUSIONS

Rhabdomyosarcoma can present in the orbit, eyelid, conjunctiva, and uveal tract. Following treatment, local tumor recurrence occurs in 18% of cases, metastasis in 6%, and death in 3%.

Mucoepidermoid carcinoma of the conjunctiva: a series of three cases

OBJECTIVE

To detail the clinical presentation and outcomes of currently available treatments for mucoepidermoid carcinoma of the conjunctiva (MCC).

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Three patients ranging from 40 to 63 years of age with MCC participated.

INTERVENTION

Excisional biopsies and various therapies were performed.

MAIN OUTCOME MEASURES

Clinical and surgical outcomes were measured.

RESULTS

Patient 1 is a 55-year-old man with right temporal MCC. He underwent two local excisions with adjuvant cryotherapy and has had no recurrence at 31 months follow-up. Patient 2 is a 63-year-old man with right temporal MCC who underwent fractionated iodine 125 plaque radiotherapy. He had a recurrence approximately 8 months after plaque treatment and subsequently underwent enucleation of the right eye. Clinical follow-up examinations revealed no further recurrence at 17 months. Patient 3 is a 40-year-old woman treated for right MCC with carbon dioxide laser with recurrence at 3 weeks. She subsequently underwent radiation treatment with the development of regional lymph node metastases 16 months later.

CONCLUSIONS

MCC is a rare neoplasm that displays an extraordinary capacity for aggressive local invasion. This series of three case reports demonstrates the high recurrence rate of MCC and the response of this tumor to different current modalities of treatment. Extended follow-up is required with this tumor because distant metastases can occur very late.

Massive corneal and conjunctival squamous cell carcinoma

A patient with massive, protuberant squamous cell carcinoma of conjunctiva invading the whole cornea, so as to hang from the surface, was referred with a visual acuity of hand motion near to face. A microscopically-controlled, frozen section guided excision, followed by double-freeze-thaw cryoapplication to the sclera and the edges of the conjunctival bed and lamello-lamellar sclerokeratoplasty, was performed. Three years later the patient's visual acuity was 20/60 with no evidence of recurrence of the lesion. Frozen section guided excision with adjuvant cryotherapy and lamellar sclerokeratoplasty is a viable therapy for massive squamous cell carcinoma of cornea and conjunctiva.

A presentation of a conjunctival malignant melanoma

BACKGROUND

We present a case report on a rare presentation of a conjunctival malignant melanoma in a Native American woman. Malignant melanoma is a rare finding in the general population, and even more rare in Native Americans. Ultraviolet radiation (UVR) damage is postulated as a causal agent for its development and may explain why the vast majority of lesions are found in sun-exposed areas of the body. Human beings with lighter complexion are known to have a higher risk of malignant melanoma as well. Diagnosis and management issues are discussed.

CASE REPORT

A 44-year-old Native American woman manifested symptoms of general eye irritation for a period of 3 to 4 months. Examination revealed healthy eyes, except for the presence of an irregularly pigmented lesion on the tarsal conjunctiva of her left eye. Incisional biopsy further revealed this lesion to be malignant melanoma. Surgical excision of the entire lesion was performed. Six months status--post excision, the surgical wound site has healed completely and the patient has shown no signs of recurrent melanoma.

CONCLUSIONS

Our case is unique in that melanoma was found in a non-sun-exposed area of the body in a patient with a very dark complexion. Because of the high mortality rates and the association of malignant melanoma with cancer in other parts of the body, it is important for all eye care providers to recognize this lesion when present.

Clinical study of [123I] N-(2-diethylaminoethyl)-4-iodobenzamide in the diagnosis of primary and metastatic ocular melanoma

PURPOSE

To assess the value of scintigraphy with [123I]N-(2-diethylaminoethyl)-4-iodobenzamide (BZA), a phase II clinical trial was performed on 48 patients with a suspicion of ocular melanoma.

METHODS

56 examinations were performed to image lesions with a clinical diagnosis of primary ocular melanoma before and/or after treatment, to observe the results in simulating lesions or to image metastases.

RESULTS

Ocular BZA-scintigraphy demonstrated a sensitivity of 86%, and a specificity of 83%. Whole-body scintigraphy was used in the follow-up of treated patients and could be repeated. We imaged orbital recurrence, known and occult metastases, specially in the liver. After 9 conservative treatments ocular BZA-scintigraphy was negative in 9 eyes.

CONCLUSION

The BZA-scintigraphy in combination with other diagnostic procedures appeared to be a suitable method in the diagnosis of ocular melanoma and a potentially useful imaging modality to screen for ocular malignant melanoma metastases.

Kaposi's sarcoma of the ocular adnexa

During the last 15 years, KS has been elevated from a position of only limited academic interest to the distinction of being the most common malignancy seen in HIV-infected patients. Ophthalmologists need to become versed in the proper diagnosis and management of this condition, as ocular involvement may be seen in up to 1 in 5 patients with KS. The possibility of occult HIV disease should be entertained in a young person with an atypical hordeolum or subconjunctival hemorrhage, as KS sometimes mimics these common lesions and represents the initial presenting sign of AIDS. The patient with ocular lesions must also be evaluated appropriately for life-threatening visceral disease. Current concepts regarding the pathogenesis of KS center on a model in which an initial event, possibly infection by human herpesvirus 8, transforms normal mesenchymal cells such that they become abnormally sensitive to the high levels of cytokines present during HIV infection. Subsequent proliferation and additional mutational events result in clinically apparent disease. Present treatments include systemic chemotherapy for widespread disease and local methods such as excision, cryotherapy, radiotherapy, and intralesional injection. However, the majority of ocular lesions may be followed up with observation only. The appropriate strategy to pursue depends on the overall clinical scenario, including the patient's general health, the extent of disease, the degree of morbidity secondary to local ocular tumors, and the size of the lesions to be treated. Future therapeutic options will be aimed at modulating specific pathogenetic factors responsible for tumor development, including host cytokines, viral replication factors, and angiogenic mediators.

Conjunctival 'MALToma' with systemic recurrence

We report the recurrence of a localized conjunctival lymphoma arising in mucosal-associated lymphoid tissue (MALToma) in the psoas muscle, 18 months after initial treatment with radiotherapy. Findings from systemic investigations demonstrated MALToma recurrences in the psoas muscle and the stomach. Ocular adnexal MALTomas typically manifest as localized tumors, which respond well to radiotherapy, but a proportion may recur in typical MALT sites. To our knowledge, this is the first report of a recurrence in the psoas muscle, and the clinical implication is that all patients with ocular adnexal lymphomas need to be followed up for an indefinite period.

Conjunctival melanoma

Conjunctival melanoma is an uncommon tumor that is likely to recur and carries an overall mortality rate of approximately 30%. The seemingly unpredictable and enigmatic character of this entity has initiated much debate over the past decades regarding the etiology, histogenesis, prognosis, and preferred management. This review outlines the historical perspective; incidence and demographics; etiologic factors; histogenesis; cytogenetic findings; clinical characteristics; histopathologic and ultrastructural features; differential diagnoses; classifications; management of primary, recurrent, and systemic disease; survival after conjunctival melanoma; and diverse factors of potential prognostic significance. Finally, a brief outlook on present and future research objectives is provided.