Conjunctival melanoma in the black population

Demographics, clinical presentation and risk factors of ocular surface squamous neoplasia at a tertiary hospital, South Africa

AIMS

The aim of this study is to describe the demographic, presenting features and associated risk factors of ocular surface squamous neoplasia (OSSN) at a tertiary eye hospital in Johannesburg, South Africa.

METHODS

An interventional prospective study of patients presenting with conjunctival masses was conducted. An electronic questionnaire was completed to document demographic data, presenting history, and associated risk factors. A slit lamp examination and photos were used to document and describe the clinical features at presentation. Cases (OSSN) and controls (benign lesions) were determined by histology.

RESULTS

There were 130 cases and 45 controls. Median age was 44 years (IQR: 35-51) with an equal gender distribution in cases. The prevalence of HIV in cases was 74% and was strongly associated with OSSN (p < 0.001). Vascularisation, leukoplakia and pigmentation were clinical features that distinguished cases from controls. A fibrovascular morphology was strongly associated with a benign histology (p < 0.001), whereas leukoplakic and gelatinous morphologies were associated with OSSN. Conjunctival intra-epithelial neoplasia made up 82% of cases.

CONCLUSION

Our study describes a sample of OSSN that is young and has no gender predisposition. The majority of cases presented with CIN lesions, rather than SCC reported in other African countries. HIV was the most significant risk factor in this study population.

Conjunctival Melanoma in Asian Indians: A Study of 42 Patients

Purpose: To describe the clinical features, treatment, and outcomes of conjunctival melanoma in Asian Indians. Methods: Retrospective study of 42 patients. Results: The mean age at presentation of conjunctival melanoma was 43 years (median, 45 years; range, 9-78 years). There were 20 (48%) males and 22 (52%) females. Nineteen patients (45%) had a known history of a preexisting pigmented conjunctival lesion. Bulbar conjunctiva (n = 28; 67%) was the most common tumor epicenter, and medial ocular surface quadrant (n = 15; 36%) was more commonly involved. The mean tumor basal diameter was 12 mm (median, 10 mm; range, 4-30 mm), and the mean tumor thickness was 4 mm (median, 2 mm; range, 1-30 mm). Majority of the patients had a pigmented tumor (n = 33; 79%). The tumors arose de novo (n = 17, 41%) or were associated with conjunctival nevus (n = 9; 21%) or primary acquired melanosis (n = 16, 38%). Wide excisional biopsy, adjunctive cryotherapy, and amniotic membrane grafting were performed in 27 (71%) patients, 11 (29%) underwent orbital exenteration, and 4 were lost to follow-up prior to definitive treatment. Over a mean follow-up period of 24 months (median, 9 months; range, <1 to 136 months), four (11%) patients had tumor recurrence, seven (18%) had locoregional lymph node metastasis, and four (11%) developed systemic metastasis and died due to metastatic disease. Conclusion: Conjunctival melanoma predominantly occurs in middle-aged Asian Indians and is associated with a high rate of systemic metastasis and death.

Advances in the management of conjunctival melanoma

Malignant melanoma of the conjunctiva is a rare but serious condition. Over the last several years, there have been important advances in the classification, diagnosis, and treatment of this condition. Recent cytogenetic and immunohistochemical studies are increasing understanding of its tumorigenesis. Diagnosis, although still made via histopathology, has been aided with imaging techniques such as ultrasound biomicroscopy and anterior segment optical coherence tomography. Primary treatment consists of surgical excision. But adjuvant treatments with cryotherapy, topical chemotherapy, and radiation therapy have shown increased success. Sentinel lymph node biopsy has shown early promise of detecting micro-metastasis. Long term follow-up of patients with conjunctival melanoma with systemic surveillance is necessary to detect recurrences and metastases.

Current appraisal of conjunctival melanocytic tumors: classification and treatment

Conjunctival melanocytic tumors represent a spectrum of pigmented tumors that include benign, premalignant and malignant tumors. Conjunctival nevi are the most common pigmented tumors and are typically found in the interpalpebral bulbar conjunctiva. These lesions usually contain fine clear cysts on slit lamp biomicroscopy. Primary acquired melanosis includes lesions from increased melanin pigmentation without proliferation of melanocytes to melanoma in situ. In the new classification system, the idea is to use the term 'primary acquired melanosis' only as a clinical description, highlighting the fact that the biologic behavior of acquired melanotic lesions cannot be predicted solely based upon clinical grounds without histopathologic examination. Conjunctival melanoma represents only 5% of all melanomas arising in the ocular region and is associated with a high mortality rate. The management of primary acquired melanosis, nevi and conjunctival melanomas involves various modalities used either alone or concomitantly depending on the size and extent of the lesion.

Population-based incidence of conjunctival melanoma in various races and ethnic groups and comparison with other melanomas

PURPOSE

To investigate racial and ethnic differences in the incidence of conjunctival melanoma in a large population-based study.

DESIGN

Observational cross-sectional study.

METHODS

Using data from 1992 through 2003 provided by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program, we calculated age-adjusted incidence rates of conjunctival melanoma in various racial and ethnic groups (Black, American Indian, Asian and Pacific Islander, Hispanic, and non-Hispanic White). In addition, we calculated the standard incidence ratios (risk ratios) and 95% confidence intervals to describe the differences within these racial and ethnic groups.

RESULTS

From 1992 through 2003, there were a total of 168 conjunctival melanomas diagnosed in 13 SEER registries with known racial and ethnic groups. The annual age-adjusted incidence rates (per million population) of conjunctival melanoma was 0.18 (Blacks), 0.17 (American Indians), 0.15 (Asians), 0.33 (Hispanics), and 0.49 (non-Hispanic Whites). The difference in the incidence of conjunctival melanoma between Whites and Blacks or Asians was statistically significant, but was not significant between Blacks and Asians.

CONCLUSIONS

The overall White-to-Black incidence ratio in conjunctival melanoma was 2.6:1, which is much less than that of uveal melanoma (18:1) and cutaneous melanoma (13:1 to 26:1), but is similar to that of mucosal melanoma (2.2:1 to 2.3:1). The cause and significance of this difference of racial and ethnic incidence in various melanomas are discussed.

Malignant melanoma of the conjunctiva in children: a review of the international literature 1965-2006

PURPOSE

Conjunctival melanoma is rare in children. This article presents a comprehensive review and discusses the clinical significance of the published cases of malignant melanoma of the conjunctiva in children younger than 15 years.

MATERIALS AND METHODS

To obtain prior reports of conjunctival melanoma in children, a systematic search of the world literature was conducted. Additional studies were identified from the bibliographies of the retrieved articles, as well as from major ophthalmic textbooks.

RESULTS

A review of the literature resulted in 28 reported cases of conjunctival melanoma in children younger than 15 years, and only 8 had adequate case details.

CONCLUSION

Malignant melanoma of the conjunctiva is a rare condition in children. Limited knowledge for management and prognosis of this condition in children is largely due to its low occurrence.

Population-based incidence of uveal melanoma in various races and ethnic groups

PURPOSE

To investigate racial/ethnic differences in the development of uveal malignant melanoma in a large population-based study.

DESIGN

Observational cross-sectional study.

METHODS

With the 1992 to 2000 data that was provided by the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, we calculated age-adjusted incidence rates of uveal melanoma in various racial/ethnic groups (black, Asian and Pacific Islander, Hispanic, and non-Hispanic white). In addition, we calculated the standard incidence ratio (risk ratio) and 95% confidence interval to describe the differences within these racial/ethnic groups.

RESULTS

From 1992 to 2000, there were a total of 1352 uveal melanomas that were diagnosed in 11 Surveillance, Epidemiology, and End Results registries with known racial/ethnic groups. The annual age-adjusted incidence (per million population) of uveal melanoma was 0.31 (black), 0.38 (Asian), 1.67 (Hispanic), and 6.02 (non-Hispanic white). The difference in the incidence of uveal melanoma between each racial/ethnic group was highly statistically significant, with the exception of the black versus the Asian population in which there was no statistically significant difference.

CONCLUSION

The relative risk of uveal melanoma was 1.2 for Asian and Pacific Islander patients, 5.4 for Hispanic patients, and 19.2 for non-Hispanic white patients as compared with the black patients. If the non-Hispanic white population and the Hispanic population were combined, then the overall white:black ratio was 18:1.

[Nodular melanoma on primary acquired conjunctival melanosis]

A 74-year-old woman consulted for bloody tears. The etiology was a large conjunctival nodular melanoma hidden in the left superior fornix that had developed quietly on an unknown primary acquired melanosis. In this report the clinical and histological features as well as the treatment are presented. A decisional tree summarizes the treatment for conjunctival melanosis.

Conjunctival melanoma arising from diffuse primary acquired melanosis in a young black woman

PURPOSE

To report a case of conjunctival melanoma arising from diffuse primary acquired melanosis (PAM) with atypia in a young black woman in the context of previously published cases of this lesion in blacks.

METHODS

Retrospective case report with literature review. The number and percentage of conjunctival melanomas occurring in black patients were determined from case series in which race was specified, published from 1950 to the present.

RESULTS

Nodular multifocal conjunctival melanoma in a 30-year-old black woman was treated using surgical excision and adjuvant cryotherapy. Extensive PAM with severe atypia, including areas of microinvasive melanoma, was treated using topical mitomycin C. Literature review revealed 35 cases of conjunctival melanoma occurring in black patients. No previous reports of mitomycin C use in black patients with melanoma or PAM were identified.

CONCLUSIONS

Conjunctival melanoma is an exceedingly rare tumor in black patients. The current case brings the total of reported cases to 36. We successfully treated nodular melanoma and diffuse PAM in a young black woman using a combination of excision with cryotherapy and topical mitomycin C, suggesting that these lesions are amenable to the same types of therapy previously described for white patients.