The familial occurrence of cutaneous melanoma, intraocular melanoma, and the dysplastic nevus syndrome

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.

Posterior uveal melanoma. The Swedish perspective

Posterior uveal melanoma is the most common primary intraocular malignant tumour and in Sweden some 70-80 new cases present each year. While uveal melanoma is more prevalent in the setting of ocular melanocytosis and neurofibromatosis, there is little conclusive data on the aetiology. Most patients experience a progressive visual field defect and present with a grey or greyish-brown mass of the posterior choroid. Diagnostic procedures include fluorescein angiography, ultrasound and magnetic resonance imaging. In some cases, intraocular biopsy may be required to make a correct diagnosis. Posterior uveal melanomas can usually be managed by any of a number of eye-preserving options like plaque radiotherapy and charged particle irradiation, but eyes containing large tumours are often enucleated. Nearly half of patients with posterior uveal melanoma, and in particular those with large tumours, ultimately succumb to metastatic disease. While most patients with tumour dissemination are treated with systemic chemotherapy possibly combined with interferon, metastatic spread confined to the liver may potentially be managed by intraarterial perfusion chemotherapy or liver resection. However, outcome of patients with systemic disease remains extremely poor with a median survival following detectable tumour dissemination of only two to five months. There are still insufficient data on the impact of various treatments on survival, but a large prospective trial addressing this issue is in progress. The present review summarizes the state-of-the-art knowledge and current management of posterior uveal melanoma from a Swedish perspective.

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.

Conjunctival and uveal melanoma in the dysplastic nevus syndrome

The dysplastic nevus syndrome was conceptualized in the late 1970s, and the subsequent proposal of a genetic relationship with ocular melanoma has stimulated debate in the literature which remains unresolved. We present the case of a 60-year-old man with histologically proven sporadic dysplasic nevus syndrome and a prior history of nine cutaneous melanomas, who developed a large, exophytic melanoma of the cornea and limbal conjunctiva. Cytogenetic analysis of this melanoma revealed a clonal 1;14 translocation. We believe this is the first reported case to use cytogenetic techniques in the analysis of conjunctival melanoma, either associated with dysplastic nevus syndrome or in isolation. We review the clinical literature as well as the cytogenetic and molecular genetic data related to the possible association of cutaneous melanoma, conjunctival and uveal melanoma and the dysplastic nevus syndrome.

Three cases of primary acquired melanosis of the conjunctiva as a manifestation of the atypical mole syndrome

We report three patients with the atypical mole syndrome (AMS) [also known as dysplastic naevus or FAMMM syndrome] who presented with primary acquired melanosis (PAM). PAM is a melanocytic lesion of the conjunctiva which may progress to conjunctival melanoma. The association of this rare condition with the AMS phenotype in three individuals suggests that PAM may be a conjunctival manifestation of the AMS.

Ocular melanoma in families with dysplastic nevus syndrome

Five families with the dysplastic nevus syndrome, in each of which one member had ocular melanoma, are reported. These five families were examined within a 3-year period in one medical center. To date only five other families with such a combination have been reported. We suggest a causal relation between ocular melanoma and the familial dysplastic nevus syndrome.

Malignant melanoma of the conjunctiva. Report of a case

Malignant melanomas of the conjunctiva are extremely rare in children. The authors report an 11-year-old boy who had a nodule at the limbus in a pigmented area since early childhood. The lesion was excised and the diagnosis of atypical compound nevus was made. Five months later, the patient returned with multiple nodules in the bulbar and palpebral conjunctiva. One of the lesions was excised, and the diagnosis was malignant melanoma. He was lost for follow-up for 6 months; then he presented a large pigmented, vascularized mass protruding through the palpebral aperture. Results of systemic workup for metastatic disease were negative, and an exenteration was performed. A few months later, cervical lymphadenopathy developed followed by extensive metastatic disease.

Malignant melanoma of the choroid in an infant with the dysplastic naevus syndrome

A 7-month-old Algerian boy with numerous skin naevi from birth was found to have a malignant melanoma of the choroid, giving symptoms from the age of 3 months. The ocular and cutaneous tumours were shown to be melanocytic by a battery of histochemical tests and by electron microscopy. The rarity of the case is discussed on basis of the literature, and it is concluded that the case is unique because of the early age at which both the ocular tumour and the dysplastic naevus syndrome occurred.

Melanocytic precursors of cutaneous melanoma. Estimated risks and guidelines for management

There are several recognizable melanocytic precursors of cutaneous melanoma. These precursors include lentigo maligna, dysplastic melanocytic nevi, congenital nevi (of any size), and darkly pigmented lesions of acral surfaces and mucous membranes. Lentigo maligna is an uncommon melanocytic dysplasia, present in 3 per 1000 individuals over the age of 50 years and accounting for 4 percent of all cutaneous melanomas. Dysplastic melanocytic nevi are present in 2 per cent of white adults, and may account for at least a fifth of cases of cutaneous melanoma. Congenital nevomelanocytic nevi are present in 1 per cent of newborns; the vast majority of congenital nevi are smaller than 3 to 4 cm in diameter, while very large congenital nevi are present in 1 in 20,000 to 1 in 500,000 newborns. Very large congenital nevi account for less than 0.1 percent of cutaneous melanomas, whereas small varieties of congenital nevi may account for 15 percent of cutaneous melanomas. If individuals with lentigo maligna live long enough, possibly a third to a half are said to develop melanoma. This figure may be biased high. Persons with dysplastic melanocytic nevi in the familial melanoma setting have an estimated lifetime risk of developing melanoma approaching 100 per cent. Persons with dysplastic melanocytic nevi in other settings may have a lifetime melanoma risk of 18 per cent. Persons with congenital nevi of any size may have a lifetime melanoma risk of at least 5 per cent. Early recognition of these precursor melanocytic tumors, particularly in high-risk individuals (i.e., those with a personal or family history of melanoma), and careful photographic follow-up or prophylactic excision of these lesions may be the most effective means of reducing the morbidity and mortality of cutaneous melanoma. The impact of routine screening and excision of presumed melanoma precursors is unknown. Clinical judgment is required to balance the theoretical risk of melanoma associated with a given precursor and the known risks of surgery and anesthesia for a given individual. It must be kept in mind that the vast majority of acquired melanocytic nevi in adults are harmless. Probably even the majority of dysplastic nevi and small congenital nevi will remain unchanged throughout life. The simple recognition of the existence of melanoma precursors will heighten suspicion for these lesions and raise awareness of the earliest signs of malignant change.(ABSTRACT TRUNCATED AT 400 WORDS)

Lack of association between intraocular melanoma and cutaneous dysplastic nevi

The occurrence of uveal and cutaneous malignant melanoma and the dysplastic nevus syndrome in the same individual suggests an etiologic relationship among these diseases. Thus, the dysplastic nevus syndrome could be viewed as marking an increased risk of both cutaneous and ocular melanoma. We postulated that if such a relationship exists, patients with both forms of melanoma should have a high prevalence of dysplastic nevi. We examined 44 patients (31 women and 13 men ranging in age from 20 to 80 years) with uveal melanoma for evidence of cutaneous melanoma and dysplastic nevi. We also examined photographs of 46 patients (24 men and 22 women ranging in age from 19 to 67 years) with nonfamilial cutaneous melanoma to determine the prevalence of dysplastic nevi. We found a 4.5% prevalence of dysplastic nevi in patients with uveal melanoma, significantly lower than the 41% prevalence in patients with cutaneous melanoma (two of 44 patients vs 19 of 46 patients). This study indicates that uveal and cutaneous melanoma are not etiologically linked through dysplastic nevi and suggests that patients with uveal melanoma are no more likely to have cutaneous dysplastic nevi than the general population.