Management Issues in Conjunctival Tumours: Conjunctival Melanoma and Primary Acquired Melanosis

Pediatric conjunctival melanoma: A comprehensive case report and literature review

Purpose

This case report aims to present a rare instance of conjunctival melanoma in a 5-year-old patient and contribute to the limited body of knowledge on pediatric conjunctival melanoma. The purpose is to understand the characteristics, diagnosis, and management of this uncommon malignancy in young individuals.

Observations

The case describes a 5-year-old female with a progressively growing pigmented conjunctival lesion. The lesion was observed to be located on the temporal conjunctiva of the right eye and displayed distinctive features, including feeder vessels. Imaging revealed specific dimensions of the lesion and ruled out deeper invasions. Histopathological examination revealed architectural and cytologic atypia, positive immunohistochemical staining for HMB-45, and a Ki67 proliferation index of 20 %, confirming the diagnosis of conjunctival melanoma.

Conclusions

Conjunctival melanoma, an uncommon malignancy even more so in pediatric patients, typically presents with pigmented growths and feeder vessels. This case underscores the need for thorough diagnosis and early intervention, as conjunctival melanoma can lead to devastating outcomes. The rarity of such cases limits our understanding of their etiology and progression. This case contributes to the literature on pediatric conjunctival melanoma and reinforces the importance of vigilance in detecting and managing ocular pigmented lesions in children.

Biological characteristics and clinical management of uveal and conjunctival melanoma

Uveal and conjunctival melanomas are relatively rare tumors; nonetheless, they pose a significant risk of mortality for a large number of affected individuals. The pathogenesis of melanoma at different sites is very similar, however, the prognosis for patients with ocular melanoma remains unfavourable, primarily due to its distinctive genetic profile and tumor microenvironment. Regardless of considerable advances in understanding the genetic characteristics and biological behaviour, the treatment of uveal and conjunctival melanoma remains a formidable challenge. To enhance the prospect of success, collaborative efforts involving medical professionals and researchers in the fields of ocular biology and oncology are essential. Current data show a lack of well-designed randomized clinical trials and limited benefits in current forms of treatment for these tumors. Despite advancements in the development of effective melanoma therapeutic strategies, all current treatments for uveal melanoma (UM) and conjunctival melanoma (CoM) remain unsatisfactory, resulting in a poor long-term prognosis. Ongoing trials offer hope for positive outcomes in advanced and metastatic tumors. A more comprehensive understanding of the genetic and molecular abnormalities involved in the development and progression of ocular melanomas opens the way for the development of personalized therapy, with various potential therapeutic targets currently under consideration. Increased comprehension of the molecular pathogenesis of UM and CoM and their specificities may aid in the development of new and more effective systemic therapeutic agents, with the hope of improving the prognosis for patients with metastatic disease.

Brachytherapy in the prevention of recurrence of conjunctival melanoma : Results of a case report in a University Hospital in Valladolid, Spain

AIM

Describe the results of brachytherapy in the prevention of recurrences in conjunctival melanoma (CM) and describe a dosimetric protocol.

METHODS

Retrospective and descriptive case report. Eleven consecutive patients with a confirmed histopathological diagnosis of CM treated with brachytherapy between 1992 and 2023 were reviewed. Demographic, clinical, and dosimetric characteristics as well as recurrences were recorded. Quantitative variables were represented by the mean, median, and standard deviation, and qualitative variables by frequency of distribution.

RESULTS

Of a total of 27 patients diagnosed with CM, 11 who were treated with brachytherapy were included in the study (7 female; mean age at time of treatment: 59.4 years). Mean follow-up was 58.82 months (range 11-141 months). Of a total of 11 patients, 8 were treated with ruthenium-106 and 3 with iodine-125. Brachytherapy was performed in 6 patients as adjuvant therapy after biopsy-proven CM on histopathology and in the other 5 patients after recurrence. The mean dose was 85 Gy in all cases. Recurrences outside of the previously irradiated area were observed in 3 patients, metastases were diagnosed in 2 patients, and one case of an ocular adverse event was reported.

CONCLUSION

Brachytherapy is an adjuvant treatment option in invasive conjunctival melanoma. In our case report, only one patient had an adverse effect. However, this topic requires further research. Furthermore, each case is unique and should be evaluated by experts in a multidisciplinary approach involving ophthalmologists, radiation oncologists, and physicists.

Recurrence of Primary Acquired Melanosis and Conjunctival Intraepithelial Neoplasia

Introduction

The aim of this study was to investigate the frequency of recurrences, time to recurrence, and which patients had a recurrence after treatment of conjunctival intraepithelial neoplasia (CIN), carcinoma in situ, and primary acquired melanosis (PAM) with atypia.

Methods

A retrospective chart review of all patients included in the follow-up program after completion of treatment for CIN or PAM with atypia on October 18, 2021, at the Department of Ophthalmology, Sahlgrenska University Hospital, was conducted.

Results

There were five recurrences (5/31, 17%) in the group with CIN or carcinoma in situ: two for patients with CIN grade II and three for individuals with carcinoma in situ. Time to diagnosis of recurrence ranged from 6 to 288 months. No recurrence was diagnosed for the 26 patients followed after treatment for PAM with atypia.

Conclusion

With the strategy of radical treatment for CIN and PAM with atypia, whenever possible, subsequent follow-up can probably be ceased after 10 years if the patient is not immunocompromised. For completely excised PAM with atypia grade I, there is most likely no need for further clinical controls.

Bone metastasis in a case of primary acquired melanosis with atypia resulting from conjunctiva melanoma

A 66-year-old woman presented to a tertiary referral centre with a diagnosis of limbal stem cell deficiency secondary to multiple treatments for primary acquired melanosis (PAM) by her referring ophthalmologists. She was known with primary acquired melanosis with severe atypia of the right eye which had been treated with several excisions, cryotherapy and topical chemotherapy. She had PAM over 360° of alternating intensity. Throughout the follow-up period, she developed a cataract and subsequent a retinal detachment for which she underwent a phacovitrectomy on the right eye. There was no nodule present nor did the routine lymph nodes inspection show any enlargement. No abnormalities were observed on intranasal examination. Seven years after the last excision, a metastasis to the spine (Th3) was diagnosed. A complete systemic work-up and a pathological examination did not show any alternative primary melanoma in the body. The original histological material was reviewed again by an ophthalmopathologist. After a new round of stains and immunohistochemistry, the presence of atypical melanocytes in both the epithelium and stroma were found in a scar region leading to a renewed conclusion that the PAM in question was actually the primary melanoma.

Real-life data of adjuvant IFN-α2b and MMC in conjunctival melanocytic lesions

PURPOSE

We herein compare topical interferon alpha 2b (IFN-α2b) to topical mitomycin C (MMC) in the adjuvant management after excision of primary acquired melanosis with atypia (PAM) and melanoma of the conjunctiva/cornea (CM).

METHODS

We included 25 tumors from 25 patients (six with PAM and 19 with CM). After surgical excision, four patients started with adjuvant IFN-α2b (two in combination with radiotherapy), 19 with MMC, and two with radiotherapy alone. Five patients were switched from initial MMC/radiotherapy to IFN-α2b during follow-up. Efficacy was assessed via time to tumor recurrence and initial therapy response.

RESULTS

With initial IFN-α2b, three patients (3/4, two with additional radiotherapy) showed complete remission (follow-up: 1478-1750 days) and one recurrence (1/4) was noted after 492 days. With initial MMC, no recurrence was recorded in 15 of the 19 patients (follow-up: 99-4732 days). Five patients were switched from MMC or radiotherapy to IFN-α2b: two patients showed complete remission (2/5), while another two (2/5) experienced recurrences and remained without recurrence after repeated courses of IFN-α2b (follow-up: 1798 and 1973 days). Only one patient showed incomplete response. Adverse effects were recorded in five patients, all received MMC.

CONCLUSION

Topical IFN-α2b (arguably together with radiotherapy) may be a viable alternative to MMC in PAM and CM. We observed fewer side effects at similar response rates. However, when response to MMC was poor, IFN-α2b may also be of limited utility.

Supportive treatment to chemotherapy with MMC, in patients with ocular surface squamous neoplasia or conjunctival melanocytic tumor

PURPOSE

Since there is a lack of clear information regarding the benefit to combine supportive therapies (such as artificial tears) to mitomycin C (MMC) in the treatment of ocular surface neoplasia, the primary purpose of the study was to evaluate hyaluronic acid eye drops and hyaluronic acid-conjugated lactobionic acid (LACTOyal FREE) eye drops as supportive therapy.

METHODS

Retrospective evaluation of patients with ocular surface squamous neoplasia or conjunctival melanocytic tumor treated with MMC, who had used also artificial tears as supportive treatment. A 6-month follow-up with evaluation of subjective and objective tests for ocular surface integrity was conducted.

RESULTS

A total of 35 patients were analyzed, most of them with squamous disease (71.4%). The break-up time (BUT), Ocular Surface Disease Index (OSDI) and Schirmer test values showed a significant difference at any time point with overall population. No statistical difference was found among subgroups (Lactoyal vs No Lactoyal).

CONCLUSION

The use of an ancillary therapy based on hyaluronic acid allows to improve both subjective and objective ocular parameters, reducing MMC induced adverse effects. Meantime, hyaluronic acid-conjugated lactobionic acid eye drops highlighted the same advantages with a more positive trend in OSDI results.

Use of interferon alpha 2b to manage conjunctival primary acquired melanosis and conjunctival melanoma

Primary acquired melanosis (PAM) is acquired conjunctival pigmentation that can give rise to conjunctival melanoma (CM), a malignant tumor of the bulbar and palpebral conjunctiva or the caruncle. Surgical excision is the treatment of choice for this neoplasm. Topical chemotherapy is also used for patients with PAM with atypia or CM, hand in patients with recurrent or extensive disease, this may be an important option. Of the several chemotherapeutic drugs used, topical interferon alpha 2b (IFN-α2b) has become popular because of its low toxicity. Clinical evidence from case reports and case series supports the efficacy of IFN-α2b as the preferred adjuvant treatment for PAM and CM. In addition, topical IFN-α2b has been successfully applied to melanocytic tumors refractory to other treatments, such as cryotherapy and topical mitomycin C. In patients with locally advanced CM, the combination of IFN-α2b and systemic immunotherapy may serve as an alternative to exenteration. Given the low frequency of CM, long-term multicenter studies are needed to demonstrate the efficacy of IFN-α2b for preventing local recurrence and distant metastasis.

Current Management of Conjunctival Melanoma Part 2: Treatment and Future Directions

Conjunctival melanoma is a rare disease which requires tailored management in most cases. The mainstays of treatment can be classified as surgery, topical chemotherapy, radiotherapy, cryotherapy, and other emerging treatment modalities. Herein we review conventional approaches as well as more recently introduced treatment options, together with advances in molecular biology in this particular disease.

Case of Rapidly Expanding Conjunctival Malignant Melanoma Initially from Primary Acquired Melanosis Diagnosed 14 Years Earlier

Primary acquired melanosis (PAM) of the conjunctiva is a potentially serious melanocytic lesion that can lead to the development of a melanoma. A 60-year-old woman noticed pigmentation of the conjunctiva of her left eye for more than 10 years. She underwent excisional biopsy combined with cryotherapy and was diagnosed with PAM without atypia by intraoperative consultation. She was followed for 7 years, and no changes were observed. Fourteen years after the initial biopsy, she noted a growing conjunctival tumor, and a melanoma was suspected. She underwent orbital exenteration and skin grafting procedures. Histopathological examination of the specimen led to a diagnosis of conjunctival malignant melanoma. Re-examination of the initial biopsy specimen revealed that there was a proliferation of melanocytes that partially expanded over the basal layer of the conjunctiva which had been diagnosed as PAM with moderate atypia. We conclude that this case of conjunctival PAM had progressed to a conjunctival malignant melanoma after 14 years. Pathological evaluation of intraepithelial lesions has its limitations; thus, cases of PAM, even in the absence of obvious atypia, require careful follow-up.

Conjunctival melanoma: New insights in tumour genetics and immunology, leading to new therapeutic options

Recent developments in oncology have led to a better molecular and cellular understanding of cancer, and the introduction of novel therapies. Conjunctival melanoma (CoM) is a rare but potentially devastating disease. A better understanding of CoM, leading to the development of novel therapies, is urgently needed. CoM is characterized by mutations that have also been identified in cutaneous melanoma, e.g. in BRAF, NRAS and TERT. These mutations are distinct from the mutations found in uveal melanoma (UM), affecting genes such as GNAQ, GNA11, and BAP1. Targeted therapies that are successful in cutaneous melanoma may therefore be useful in CoM. A recent breakthrough in the treatment of patients with metastatic cutaneous melanoma was the development of immunotherapy. While immunotherapy is currently sparsely effective in intraocular tumours such as UM, the similarities between CoM and cutaneous melanoma (including in their immunological tumour micro environment) provide hope for the application of immunotherapy in CoM, and preliminary clinical data are indeed emerging to support this use. This review aims to provide a comprehensive overview of the current knowledge regarding CoM, with a focus on the genetic and immunologic understanding. We elaborate on the distinct position of CoM in contrast to other types of melanoma, and explain how new insights in the pathophysiology of this disease guide the development of new, personalized, treatments.

Orbital exenteration for conjunctival melanoma: comparison of long-term outcome between individualised and conventional techniques

BACKGROUND

Growing evidence supports an individualised approach rather than radical surgery for conjunctival melanoma (CM). This study aimed to compare the long-term outcome between individualised and conventional exenteration techniques.

METHODS

Our study retrospectively recruited advanced CM (clinical T3 stage) patients treated with individualised (13 cases) or conventional (18 cases) exenteration from June 2014 to April 2019. The individualised approach preserved at least three quadrants of the orbit, and the conventional procedures removed at least one third of the orbital tissues. The medical records were collected and analyzed during April 2020, including demographics, tumour characteristics, surgical details, postoperative rehabilitation and tumour-related prognosis.

RESULTS

The tumour basal diameter was statistically (P = 0.011) larger in the conventional group (23.3 ± 7.6 mm) than in the individualised group (15.4 ± 6.3 mm). More tissues were preserved in the individualised group, resulting in a shorter duration of wound healing (2.1 ± 0.6 vs. 3.6 ± 2.0 weeks, P = 0.018) and less incidence of hollow appearance (15% vs. 72%, P = 0.003) than the conventional group. After follow-up for 39.3 ± 17.3 months, a comparison of survival curves showed no significant differences (P = 0.638) between the two groups. The 1- and 2-year overall survival rates were estimated as 100% and 80.0% in the individualised group, and 93.8% and 72.5% in the conventional group, respectively. Low or mixed pigmentation was identified as the risk factor for tumour-related mortality based on multivariate regression analysis.

CONCLUSIONS

The individualised approach to exenteration offers improved aesthetic results while still maximises the curable chance for advanced CM.

Conjunctival and uveal melanoma: Survival and risk factors following orbital exenteration

PURPOSE

This study aims to analyse disease-free survival, overall survival and risk factors after orbital exenteration in patients with conjunctival and uveal melanoma.

METHODS

Patients who underwent orbital exenteration due to conjunctival and uveal melanoma were included in this retrospective study (March 2000 to March 2018).

RESULTS

A total of 76 patients were enrolled in this study: 60 patients had a conjunctival melanoma and 16 had a uveal melanoma. In conjunctival melanoma, the mean age was 68.4 years. The overall survival rate was 82% after 1 year and 52% after 5 years. Univariate analysis of overall survival found that the following parameters were predictive of a worse prognosis: gender, extent of the primary tumour, lymph node metastases, distant metastases, adjuvant chemotherapy or radiotherapy and relapse. In multivariate analysis, relapse and adjuvant radiotherapy appeared to contribute to a significantly worse prognosis. In uveal melanoma, the mean age was 63.6 years. Eleven patients died during follow-up (mean follow up 30.7 months). The overall survival and disease-free survival rates after 1 year were 62% and 57%, respectively. An analysis of risk factors was not possible due to the small number of cases.

CONCLUSION

Orbital exenterations in conjunctival and uveal melanoma are rarely necessary, but can be performed as an ultima ratio treatment with curative intent. Disease-free survival and overall survival are significantly lower for both groups due to the advanced stage of the disease compared to patients treated without exenteration in the literature. If a recurrence occurs after exenteration, the prognosis is poor in both groups.