Melanoma of the eyelid and periocular skin: Histopathologic classification and molecular pathology

Head and neck melanoma: the eyelid region has a better prognosis and easier management. A retrospective survey and systematic review

Eyelid melanoma (EM) is a malignant neoplasm accounting for around 1% of eyelid malignancies. Because of its rarity, most of our knowledge of EM is currently based on studies of cutaneous melanomas located elsewhere. Accordingly, this study aimed to specifically evaluate EM characteristics, management strategies, and prognosis. A retrospective study was carried out on patients diagnosed with EM at Careggi University Hospital, Florence between May 2012 and May 2022. In addition, a systematic review of relevant literature was conducted, encompassing studies published from 2013 to 2023. Clinical, histopathological, therapeutical, and prognostic data were analyzed to assess the metastasis rate and the 5-year survival rate of patients with EM. Separate data were extracted for in situ and invasive disease. Our original study included 19 patients diagnosed with EM with a 5-year survival rate of 100% for in situ and 83.3% for invasive EM. The literature review identified five poorly detailed large database reviews and 14 original studies on EM with an overall 5-year survival rate of 79.7%. The present research indicates that EM is a challenging malignancy, but has a relatively better prognosis and easier management than other melanomas of the head and neck region. These are probably related to the anatomical location which leads to early diagnosis. Therefore, EM should be considered as a specific disease requiring dedicated treatment. Based on the personal authors' experience and comprehensive overview of the current knowledge, a dedicated protocol is proposed.

New therapies for unresectable or metastatic cutaneous eyelid and orbital melanoma

PURPOSE

Newer treatment options offer the promise of improved outcomes for metastatic and unresectable melanoma. This investigation was performed to review these modalities for cutaneous eyelid and orbital disease.

METHODS

A search for articles that were related to this subject was performed in the PubMed database, and the bibliographies of these manuscripts were reviewed to ensure capture of the appropriate literature. Data was abstracted and analyzed.

RESULTS

Historically, patients who suffer from melanoma of the ocular adnexa have fared poorly. Approaches that employ BRAF and mitogen-associated protein kinase inhibitors, immunotherapy, and novel cellular therapies improve outcomes and survival rates, although the side effect profiles of these agents are problematic. Most of the existing strategies have not explored ocular adnexal disease specifically, and treatment plans are generally adapted from the general cutaneous oncology literature.

CONCLUSIONS

Thanks to advances in our comprehension of the cellular biology of the disease, the management of unresectable and metastatic melanoma has evolved considerably over the past several years. Newer modalities will likely continue to improve survival and reduce adverse events.

Personalized treatment concepts in extraocular cancer

Background

The periocular skin is neoplasms-prone to various benign and malignant. Periocular malignancies are more aggressive and challenging to cure and repair than those in other skin areas. In recent decades, immunotherapy has significantly advanced oncology, allowing the autoimmune system to target and destroy malignant cells. Skin malignancies, especially periocular tumors, are particularly sensitive to immunotherapy. This technique has dramatically impacted the successful treatment of challenging tumors.

Main text

Extraocular cancers, including eyelid (basal cell carcinoma, squamous cell carcinoma, melanoma, merkel cell carcinoma), conjunctival tumors (conjunctival melanoma, ocular surface squamous neoplasia) and other rare tumors, are unique and challenging clinical situations. Several genetic alterations associated with the pathogenesis of these diseases have been identified, and molecular mechanism are essential for the development of the immunotherapy agents, such as Hedgehog pathway inhibitors (vismodegib and sonidegib) for basal cell carcinoma, BRAF/MEK inhibitors (vemurafenib, dabrafenib, and encorafenib) for melanoma, and immune checkpoint inhibitors (Avelumab, pembrolizumab) for Merkel cell carcinoma.

Conclusions

The optimal treatment for periocular skin cancer depends on the type and size of the tumor and whether it involves orbital and adnexal structures. Adjuvant and neoadjuvant therapy with chemotherapy-targeted therapies and immune checkpoint inhibitors should be considered based on tumor type, tumor molecular profile, expected response rate, and candidacy for systemic treatment.

Updates on eyelid cancers

In this review, we aim to provide an overview of the five most common malignant eyelid tumors with current treatment recommendations based on international guidelines. Particular attention is paid to the clinicopathological correlation and the update with regard to adequate treatment. Newer systemic therapies enrich the existing treatment options, of which complete tumor excision remains the most important therapeutic measure.

Diagnosis and treatment of malignant eyelid tumors

BACKGROUND

Malignant tumors of the eyelid are much less frequent than benign eyelid alterations. These are frequently incidental findings without symptoms which are often overlooked or misinterpreted by patients.

OBJECTIVE

This article gives an overview of clinical aspects, diagnostics and treatment of the five most common malignant eyelid tumors and exemplarily explains the essential principles of evidence-based treatment of malignant eyelid tumors.

METHODS

This narrative review was prepared based on a selective literature search. The depiction of the treatment of eyelid tumors is supported by illustrations of clinical cases.

RESULTS

The medical history and inspection provide initial indications of malignancy. Every eyelid change suspected of being malignant should be examined histologically to confirm a diagnosis. By far the most common malignant eyelid tumor in Europe is basal cell carcinoma, which metastasizes only in exceptional cases. Squamous cell carcinomas, sebaceous adenocarcinomas, melanomas and Merkel cell carcinomas occur much less frequently. In these cases, potential metastasis in particular must be considered when making the diagnosis and staging has to be initiated. Surgical excision into healthy tissue with tumor-free margins is the gold standard for malignant eyelid tumors. Non-surgical adjuvant or neoadjuvant forms of evidence-based treatment can be initiated based on the individual case to minimize the risk of recurrence and metastasis.

CONCLUSION

It is essential to recognize eyelid changes at an early stage, to classify them correctly and to initiate the appropriate treatment. The interaction between the general condition and the personal needs of a patient as well as state of the art medicine are the keys to a good personalized treatment.

Pediatric ocular melanoma: a collaborative multicenter study and meta-analysis

PURPOSE

To investigate clinical manifestations and prognoses in pediatric patients (≤12 years old) with ocular melanoma.

METHODS

This was a retrospective, multicenter cohort study with individual participant data (IPD) meta-analysis pooling available published cases, and unpublished cases from an international collaboration of seven ocular oncology centers.

RESULTS

There were 133 eyes of 133 pediatric patients with choroidal or ciliary body (n = 66 [50%]), iris (n = 33 [25%]), conjunctival (n = 26 [19%]), and eyelid (n = 8 [6%]) melanoma. Overall, the mean patient age at presentation was 7 years (median, 8; range, 1-12 years), with 63 males (49%). The mean age by tumor site was 6.50 ± 3.90, 7.44 ± 3.57, 9.12 ± 2.61, and 5.63 ± 2.38 years, for choroid/ciliary body, iris, conjunctiva, and eyelid melanoma, respectively (P = 0.001). Association with ocular melanocytosis was seen in 15%, 11%, 4%, and 0%, respectively (P = 0.01). Frequency of ocular melanoma family history did not vary by tumor site (7%, 17%, 9% and 12%, resp. [P = 0.26]). After mean follow-up of 74, 85, 50, and 105 months (P = 0.65), metastasis was seen in 12%, 9%, 19%, and 13% of choroid/ciliary body, iris, conjunctiva, and eyelid melanoma, respectively. Death was reported in 5%, 3%, 8%, and 0%, respectively, with survival analysis indicating higher mortality in choroidal/ciliary body and conjunctival melanoma patients.

CONCLUSIONS

Ocular melanoma in the pediatric population is rare, with unique clinical features and outcomes. Iris melanoma accounts for about one-third of pediatric uveal melanoma cases.

[Diagnosis and treatment of malignant eyelid tumors]

BACKGROUND

Malignant tumors of the eyelid are much less frequent than benign eyelid alterations. These are frequently incidental findings without symptoms which are often overlooked or misinterpreted by patients.

OBJECTIVE

This article gives an overview of clinical aspects, diagnostics and treatment of the five most common malignant eyelid tumors and exemplarily explains the essential principles of evidence-based treatment of malignant eyelid tumors.

METHODS

This narrative review was prepared based on a selective literature search. The depiction of the treatment of eyelid tumors is supported by illustrations of clinical cases.

RESULTS

The medical history and inspection provide initial indications of malignancy. Every eyelid change suspected of being malignant should be examined histologically to confirm a diagnosis. By far the most common malignant eyelid tumor in Europe is basal cell carcinoma, which metastasizes only in exceptional cases. Squamous cell carcinomas, sebaceous adenocarcinomas, melanomas and Merkel cell carcinomas occur much less frequently. In these cases, potential metastasis in particular must be considered when making the diagnosis and staging has to be initiated. Surgical excision into healthy tissue with tumor-free margins is the gold standard for malignant eyelid tumors. Non-surgical adjuvant or neoadjuvant forms of evidence-based treatment can be initiated based on the individual case to minimize the risk of recurrence and metastasis.

CONCLUSION

It is essential to recognize eyelid changes at an early stage, to classify them correctly and to initiate the appropriate treatment. The interaction between the general condition and the personal needs of a patient as well as state of the art medicine are the keys to a good personalized treatment.

Self-supervised learning mechanism for identification of eyelid malignant melanoma in pathologic slides with limited annotation

Purpose

The lack of finely annotated pathologic data has limited the application of deep learning systems (DLS) to the automated interpretation of pathologic slides. Therefore, this study develops a robust self-supervised learning (SSL) pathology diagnostic system to automatically detect malignant melanoma (MM) in the eyelid with limited annotation.

Design

Development of a self-supervised diagnosis pipeline based on a public dataset, then refined and tested on a private, real-world clinical dataset.

Subjects

A. Patchcamelyon (PCam)-a publicly accessible dataset for the classification task of patch-level histopathologic images. B. The Second Affiliated Hospital, Zhejiang University School of Medicine (ZJU-2) dataset – 524,307 patches (small sections cut from pathologic slide images) from 192 H&E-stained whole-slide-images (WSIs); only 72 WSIs were labeled by pathologists.

Methods

Patchcamelyon was used to select a convolutional neural network (CNN) as the backbone for our SSL-based model. This model was further developed in the ZJU-2 dataset for patch-level classification with both labeled and unlabeled images to test its diagnosis ability. Then the algorithm retrieved information based on patch-level prediction to generate WSI-level classification results using random forest. A heatmap was computed for visualizing the decision-making process.

Main outcome measure(s)

The area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity were used to evaluate the performance of the algorithm in identifying MM.

Results

ResNet50 was selected as the backbone of the SSL-based model using the PCam dataset. This algorithm then achieved an AUC of 0.981 with an accuracy, sensitivity, and specificity of 90.9, 85.2, and 96.3% for the patch-level classification of the ZJU-2 dataset. For WSI-level diagnosis, the AUC, accuracy, sensitivity, and specificity were 0.974, 93.8%, 75.0%, and 100%, separately. For every WSI, a heatmap was generated based on the malignancy probability.

Conclusion

Our diagnostic system, which is based on SSL and trained with a dataset of limited annotation, can automatically identify MM in pathologic slides and highlight MM areas in WSIs by a probabilistic heatmap. In addition, this labor-saving and cost-efficient model has the potential to be refined to help diagnose other ophthalmic and non-ophthalmic malignancies.

Clinicopathologic Characteristics and Prognostic Factors Impacting Survival in Melanoma of the Eyelid

PURPOSE

To examine prognostic factors for survival in patients with melanoma of the eyelid.

DESIGN

Retrospective cohort study.

METHODS

This population-based study reviewed patients with primary melanoma of the eyelid diagnosed in the Surveillance, Epidemiology and End Results database between 1975 and 2016. The primary outcomes included survival rates estimated by Kaplan-Meier analysis and mortality hazard ratios (HRs) for overall survival and disease-specific survival (DSS).

RESULTS

The cohort consisted of 2257 patients with cutaneous melanoma of the eyelid, representing 1380 cases of melanoma in situ and 877 cases of invasive melanoma. For melanoma in situ and invasive melanoma respectively, at 5 years, the overall survival rates were 88.6% and 77.1%, while DSS rates were 99.4% and 91.0%. Cox regression analysis for eyelid melanoma indicated that for invasive melanoma, age at diagnosis ≥75 years (HR 2.17 [95% confidence interval {CI} 1.02-4.60]; P = .04), T4 staging (HR 8.45 [95% CI 2.96-25.31]; P < .001), lymph node involvement (HR 3.61 [95% CI 1.12-11.60]; P = .03), and nodular melanoma (HR 3.31 [95% CI 1.50-7.32]; P = .003) histologic subtype were associated with decreased rates of survival. Sex and tumor ulceration did not impact survival.

CONCLUSIONS

This study is the largest analysis to date that focuses on DSS for cutaneous melanoma of the eyelid. The most significant predictors for invasive melanoma survival are age ≥75 years at diagnosis, T4 staging, lymph node involvement, and the nodular melanoma histologic subtype. Patients with these attributes are at higher risk and should be counseled regarding prognosis.

The Clinical Feature and Treatment Outcome of Ocular Melanoma: A 34-Year Experience in a Tertiary Referral Center

Malignant melanoma can arise from melanocytes in various structures of the eye, orbit, and ocular adnexa. We reviewed the clinical features and long-term results of all subjects with histologically proved melanoma originating from any of the ocular and periocular structures in a tertiary referral center. Overall, 88 patients including 47 men were recruited. The tumor was primarily located in the uvea, followed by the conjunctiva, orbit, eyelid, and lacrimal sac. Patients with uveal melanoma were diagnosed at a relatively younger age (47.0 years), while those with orbital and eyelid melanomas were older at presentation (79.5 years and 78.5 years, respectively). The overall local recurrence rate was 9% at a median follow-up of 41.0 months, among which orbital and eyelid melanomas recurred most commonly. The overall mortality rate was 41% in a median duration of 27.2 months (IQR, 13-58 months) from diagnosis, with the highest for lacrimal sac melanoma, followed by melanoma of the orbit, uveal, conjunctiva, and eyelid. Despite prompt local control, the risk for metastasis and mortality was high. Therefore, efficient modalities for early diagnosis and treatment of ocular melanoma are necessary.

Diseases of the Eyelids and Orbit

The eyelids and orbit encompass intricate bony and soft tissue structures that work harmoniously in concert to protect, support, and nourish the eye in order to facilitate and maintain its function. Insult to periorbital and orbital anatomy can compromise orbital and ocular homeostasis. This article provides a foundational overview of eyelid and orbital anatomy, as well as common and key disorders that may confront internists and medical subspecialists.

Epidemiological Profile and Clinical Stage at Presentation of Eyelid Malignancies in a Multi-Ethnic Country

ABSTRACT

Eyelid malignancies are frequently seen in clinical practice. There is a lack of studies that have assessed the features of these lesions in mixed population countries. The epidemiologic profile, clinical stage at presentation, management, and outcomes of patients with eyelid malignancies were assessed, in order to better understand the features of these lesions in a multi-ethnic country. The medical records of patients who underwent eyelid tumor excision in a tertiary service in Brazil, from 2014 to 2019 were retrospectively reviewed. It was recorded for each patient: age, gender, time of onset, location, diagnosis, management, and follow-up. The medical records of 298 patients who presented with eyelid tumors were evaluated and 67 (22.4%) were malignant. The mean age of patients with malignancies was 52.93 years and 50% were male. Basal cell carcinoma was the most prevalent (61.2%), followed by squamous cell carcinoma (SCC) (29.9%) and sebaceous gland carcinoma (3%). The average time it took from appearance to surgical treatment was 3 years; the lower eyelid was the most affected for both basal cell carcinoma and SCC; 70% of SCCs were locally invasive at presentation and metastasis occurred in 15%. Basal cell carcinoma was the most common eyelid malignancy observed, however, its frequency was lower when compared to other western countries. The advanced stage at presentation may reflect the lack of education of the population to seek early care, and the lack of specialized tertiary centers in remote areas, resulting in delayed diagnosis.

Total saponins from Rubus parvifolius L. inhibits cell proliferation, migration and invasion of malignant melanoma in vitro and in vivo

Background: Total saponins from Rubus parvifolius L. (TSRP) are the main bioactive fractions responsible for the anti-tumor activities. The work was aimed to evaluate the anti-tumor effect of TSRP in malignant melanoma (MM) in vitro and in vivo.

Methods and results: Anti-melanoma cell proliferation, invasion and migration effect of TSRP were detected in human MM A375 cells under the indicated time and dosages. In vivo anti-tumor effect of TSRP was measured in A375 xenograft immunodeficient nude mice. Sixty A375 xenografts were randomly divided into five groups: Vehicle, cyclophosphamide (CTX, 20 mg/kg), TSRP (25 mg/kg), TSRP (50 mg/kg) and TSRP (100 mg/kg) groups for 14 days’ treatment. In addition, the melanoma metastasis in lung in vivo of TSRP was detected in A375 tail vein injection mice, and the histopathalogical analysis of the lung metastasis was detected by Hematoxylin–Eosin (H&E) staining. TSRP significantly inhibited the cell proliferation, invasion and migration of A375 in vitro at the indicated time and dosages. TSRP treatment effectively blocked the tumor growth in immunodeficient nude mice. In addition, TSRP also significantly inhibited the lung metastasis of melanoma.

Conclusion: The present study indicated that the TSRP has a remarkable anti-MM effect, which mainly through the inhibition of the cell invasion, migration and tumor metastasis.

Epidemiology and Survival Outcomes for Eyelid Primary Malignant Melanoma: An Analysis of 1397 Cases in the SEER Database

Purpose

There has not been a recent population-based study regarding the epidemiological trend and survival of eyelid primary malignant melanoma (PMM). Our study aims to evaluate the updated incidence trends and discuss the factors affecting the survival outcomes of eyelid PMM.

Methods

A total of 1397 eyelid PMM cases diagnosed between 1975 and 2016 were retrospectively identified from the Surveillance, Epidemiology, and End Results (SEER) database. Age-adjusted incidence rates and annual percent changes (APC) were calculated. Kaplan-Meier and Cox proportional hazards regression models were used to calculate survival outcomes and identify potential prognostic factors.

Results

The overall age-adjusted incidence of eyelid PMM rose from 0.039 (95% confidence interval [CI], 0.012–0.088) in 1975 to 0.103 (95% CI, 0.070–0.143) per 100 000 population in 2016, with significant APC of 1.313% (p < 0.001). Male subjects showed a higher average age-adjusted incidence rate than female subjects (p < 0.001). Survival analyses showed that 5-year accumulative overall survival (OS) and disease-specific survival (DSS) for patients with eyelid PMM were 70.5% and 90.6%. Additionally, 10-year OS and DSS were 51.8% and 86.1%, respectively. Analyses of Kaplan-Meier survival curves with the log-rank test revealed that older age, White race, nodular melanoma, higher American Joint Committee on Cancer (AJCC) stage (II to IV), advanced stage, distant metastasis, and no-surgery treatment were associated with lower OS and DSS rates. Age, histology, AJCC stage, and stage at diagnosis were found to be independent predictors of OS and DSS in multivariate models.

Conclusion

The incidence of eyelid PMM increased with significant APC and male predominance. Age, histology, AJCC stage, and stage at diagnosis might be independent predictors of prognosis, emphasizing the importance of improved diagnosis of eyelid PMM.

Incidence of Cutaneous Melanoma of Eyelid Analysis of the Surveillance, Epidemiology, and End Results Database

Purpose

The aim of this work was to report the annual incidence, incidence trend, histological types, and cause-specific survival of cutaneous melanoma of the eyelid from 1975 through to 2017.

Methods

Cases were identified in the Surveillance, Epidemiology, and End Results (SEER) database using the ICD-0-3 standard codes for diagnosis and anatomic location. Cutaneous melanomas of the face and scalp/neck were studied as comparison groups. Incidence rates were calculated using the SEER*Stat statistical analysis software with 95% confidence intervals. Melanoma-specific survival was estimated using the Kaplan-Meier product-limited method.

Results

There was an increase in annual incidence of eyelid melanoma over the 43-year study period, ranging from a low of 0.2 × 10⁶ population in 1978 (95% CI 0.04-0.6) to a high of 1.0 × 10⁶ population in 2016 (95% CI 2.3-3.5). The average annual percent change was 1.2% (95% CI 0.5-1.8). Cause-specific survival of melanoma of the eyelid and facial skin were almost identical (approx. 91.7%) at 60 months but significantly worse for melanoma of the scalp/neck (p < 0.05%).

Conclusions

Cutaneous melanoma of the eyelid is uncommon compared to melanoma of facial skin and the scalp/neck. This can be explained in part by the comparatively small surface area at risk. Like melanomas elsewhere, the annual incidence of eyelid melanoma has risen over the last 4 decades, but less than of facial skin and the scalp/neck. Over the span of this study, cause-specific survival from eyelid melanoma was comparable to that of facial skin and better than that of the scalp/neck.

Conjunctival Melanoma with Ipsilateral, Non-Contiguous Eyelid Involvement: A Case Report and Comprehensive Review of the Literature

While the majority of cases of conjunctival melanoma (CM) involve the bulbar conjunctiva, concurrent pigmentation of the ipsilateral eyelid can be seen in up to 15% of cases. Although extension of conjunctival melanoma into the eyelid (AJCC cT3b) occurs in 1% of cases, non-contiguous lesions are very rare with only 5 clearly documented reports in the English literature. Several pathophysiological mechanisms have been proposed, including separate primary melanomas, patchy involvement from primary acquired melanosis (which may be sine pigmento) and exfoliation of malignant tumour cells into the tear film. Herein we present a case of eyelid melanoma arising in a patient previously treated for CM at a non-contiguous site and provide a comprehensive review of the relevant literature.

Eyelid Melanoma in the United States: A National Cancer Database Analysis

BACKGROUND

Eyelid melanoma (EM) is a rare condition that accounts for <1% of all cutaneous melanomas. In this analysis, patients diagnosed with EM in the United States were compared to those with other melanomas in the head and neck.

METHODS

The National Cancer Database was used to select patients with head and neck melanoma from 2004 to 2015.

RESULTS

A total of 137,233 patients met the criteria of the study. Among them, 2694 were diagnosed with EM (2%) and 134,539 in other head and neck locations (98%). Regarding the patients with EM, the mean age was 68.56 years (standard deviation 14.04). A greater number of them were treated in Academic/Research Programs (53.6%), insured by Medicare (55.7%), tumor in situ (52.2%), stage 0 (49%), and without ulceration (75.9%). The mean time to treatment commencement was 18.96 days for EM compared to 14.4 days for other melanoma in the head and neck regions (P < 0.001). There was a greater proportion of EM in female patients (odds ratio [OR] 2.371 [2.191-2.566], P < 0.001), compared to male; age greater than 80 years (OR 1.622 [1.360-1.934], P < 0.001) compared to 0 to 49 years. Moreover, EM was an independent predictor for treatment in Academic/Research Programs (OR 1.258 [1.160-1.365], P < 0.001) and diagnosis at autopsy (OR 1.414 [1.083-1.847], P = 0.011) compared to other melanoma in the head and neck region.

CONCLUSION

These novel findings have the potential to guide clinical decision making in head and neck melanoma management.