Ocular findings in patients with dysplastic nevus syndrome

Population-based incidence of intraocular tumours in Olmsted County, Minnesota

BACKGROUND/AIMS

To determine population-based incidence of intraocular tumours in Olmsted County, Minnesota.

METHODS

Record review of the Rochester Epidemiology Project medical record linkage system from 1 January 2006 to 31 December 2015 for patient demographics, tumour type by clinical diagnosis and presence or absence of confirmation by histopathology. The incidence rate of any intraocular tumour and of each tumour type was calculated per million person-years. Poisson regression analysis was used to analyse changes in incidence over time.

RESULTS

There were 948 patients diagnosed with intraocular tumours resulting in an age-adjusted and sex-adjusted incidence rate of 727.5 per million (95% CI: 680.8 to 774.2, p<0.05). Most tumours were benign (953, 98%). Of the benign lesions, melanocytic lesions were the majority (942, 97%), with adjusted incidence rates of 646.9 (95% CI: 602.8 to 691.1) for choroidal nevus and 55.8 (95% CI: 43.2 to 64.8) for iris nevus. Malignant lesions were rare (16, 2%) with 13 cases of choroidal melanoma and 1 case each of iris melanoma, retinal leukaemic infiltration and metastasis. The adjusted incidence rate for choroidal melanoma was 7.1 (95% CI: 2.5 to 11.8).

CONCLUSION

In a population-based setting, most intraocular tumours are benign and melanocytic. Although malignant lesions are less common, it is important to remain vigilant with appropriate monitoring given the potential for vision loss and life-threatening malignancy.

Is it necessary to perform eye examination for patients with cutaneous atypical nevi?

Regular dermatological examination for patients with dysplastic nevi is indicated. However, the literature on whether those patients should also be examined by ophthalmologists or not regarding a relation between suspicious lesions for ocular melanoma and cutaneous dysplastic nevi is limited. In this study, we aimed to compare the findings of a single ophthalmologic examination between the group of patients with multiple atypical nevi with at least one histopathologically proven dysplastic nevus and another group without atypical nevi. We examined the eyes of 110 patients with multiple atypical nevi with at least one histopathologically proven dysplastic nevus (47 had the diagnosis of dysplastic nevus syndrome type A, B, C, D1 or D2) for any lesion and compared the results with a control group consisted of 110 gender, age and skin-type matched patients without atypical nevi no ocular melanoma was detected in any of the groups. The frequency of the conjunctival nevi, iris nevi, choroidal nevi and conjunctival acquired melanosis were similar in both groups. Iris freckles were detected more frequently in the study group. Conjunctival racial hyperpigmentation was detected more frequently in the control group (P < .05). In this study, any significant difference in the distribution of the ocular lesions with any risk of malignancy in the study and control groups was not observed. However, considering the limitations of the study, there may still be a need of regular ophthalmic examination for the patients with atypical nevi in case of having high risk factors for developing melanoma.

Characterization, treatment, and outcome of uveal melanoma in the first two years of life

BACKGROUND AND OBJECTIVES

Features and characteristics of uveal melanoma are well described in adults, but little is known about the presentation of uveal melanoma in infancy.

DESIGN

Systematic literature review.

METHODS

A review of published, peer-reviewed literature reporting on uveal melanoma presenting during the first two years of life. Outcome measures included demographics, clinical features, histopathological findings, extent of the disease, therapeutic interventions, management outcomes, association with skin lesions or systemic diseases, and survival data.

RESULTS

This review revealed 13 reported cases (seven boys and six girls) of uveal melanoma diagnosed within the first two years of life. The median age at diagnosis was seven months. Orbital mass and proptosis were the most common presentations (38%); only one tumor (8%) was melanotic, and pathologically 10 tumors (77%) had epithelioid component. Associated pigmented skin lesions (cutaneous disease) were seen in six cases (46%). All affected eyes were surgically removed; three patients received chemotherapy, and one received radiotherapy. At a median follow-up of 25months, two patients (15%) had metastasis, and one of them (8%) was dead at six months' follow-up with liver and multi-organ metastasis.

CONCLUSIONS

Uveal melanoma can present within the first two years of life. In very rare cases, it can present as an intraocular tumor that simulates retinoblastoma, but it can also present as an orbital tumor. It has a tendency to affect patients with cutaneous diseases like familial atypical mole, melanoma syndrome, and dysplastic nevus syndrome. Despite this, uveal melanoma in this group has a more favorable prognosis than adult melanoma.

Dysplastic nevi

Dysplastic nevi have been a subject of much debate since their original description in 1978. Although some question the biological potential of dysplastic nevi themselves, several studies have shown that their presence confers substantial risk for melanoma. In addition to predisposing patients to melanoma, dysplastic nevi have been shown to harbor genetic mutations, indicating their position on a continuum between banal nevi and melanomas. Dysplastic nevi are also clinically relevant as mimickers of melanoma, and can be challenging diagnostically. This article reviews the history, epidemiology, biology and genetics, clinical features, histopathologic features, and management guidelines for patients with these lesions.

Prevalence and characteristics of choroidal nevi: the multi-ethnic study of atherosclerosis

OBJECTIVE

To describe the prevalence of choroidal nevi in 4 racial or ethnic groups (white, black, Hispanic, and Chinese) in the United States.

DESIGN

Cross-sectional study.

PARTICIPANTS

Participants of the second examination of the Multi-Ethnic Study of Atherosclerosis (MESA), involving 6176 persons 44 to 84 years of age without clinical cardiovascular disease at baseline selected from 6 United States communities.

METHODS

Fundus images were taken using a 45° digital camera through dark-adapted pupils and were graded for choroidal nevi using the modified Wisconsin Age-Related Maculopathy Grading System and the Blue Mountains Eye Study protocol.

MAIN OUTCOME MEASURES

Choroidal nevi.

RESULTS

The overall prevalence of choroidal nevi in the whole cohort was 2.1%, with prevalences higher in whites (4.1%) than blacks (0.7%), Hispanics (1.2%), and Chinese (0.4%; P<0.001 for any differences among groups). The lowest prevalence of choroidal nevi occurred in those 75 to 84 years of age. The nevi were subfoveal in 4% of eyes with nevi and were not associated with a decrease in visual acuity. Characteristics of the nevi (size, shape, location, color, drusen on surface) did not differ among racial or ethnic groups. With the exception of associations with higher C-reactive protein levels (odds ratio [OR] per mg/dl on the logarithmic scale, 1.23; 95% confidence interval [CI], 1.06-1.43; P = 0.01) and lower systolic blood pressure (OR per 10 mmHg, 0.90; 95% CI, 0.82-0.99; P = 0.04), choroidal nevi were not associated with other potential risk factors (e.g., gender, smoking status, alcohol consumption, lipid levels, coagulation factors, or kidney disease).

CONCLUSIONS

Low prevalences of choroidal nevi were found in the 4 groups participating in the MESA cohort, with whites having higher prevalence than the other racial or ethnic groups. The higher prevalence in whites than in other groups was not explained by any of the factors studied. When choroidal nevi were present, their characteristics did not differ among racial or ethnic groups.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Atypical mole syndrome and dysplastic nevi: identification of populations at risk for developing melanoma - review article

Atypical Mole Syndrome is the most important phenotypic risk factor for developing cutaneous melanoma, a malignancy that accounts for about 80% of deaths from skin cancer. Because the diagnosis of melanoma at an early stage is of great prognostic relevance, the identification of Atypical Mole Syndrome carriers is essential, as well as the creation of recommended preventative measures that must be taken by these patients.

Cyclo-oxygenase-2 expression in photon-radiated and non-radiated uveal melanomas

PURPOSE

To determine and compare cyclo-oxygenase-2 (COX-2) expression in photon-radiated and non-radiated malignant uveal melanomas and to analyse the correlation between COX-2 expression and prognosis.

METHODS

Immunohistochemical staining for COX-2 was performed on 21 uveal melanomas that were endoresected after prior stereotactic radiotherapy with photons and on 22 tumours that were treated by endoresection without prior radiotherapy. COX-2 staining was further analysed in respect to cell type, maximal prominence, time interval between radiotherapy and surgery, apoptotic index (AI), proliferative index (PI) and the development of metastatic disease.

RESULTS

There was no difference in COX-2 expression between radiated and non-radiated melanomas (P>0.15). COX-2 staining correlated with neither the tumour prominence (P>0.40) nor the AI or the PI (both P>0.35). Tumours with high COX-2 expression were significantly more likely to develop metastasis (P=0.022).

CONCLUSION

Radiotherapy with photons does not induce COX-2 expression in malignant melanomas of the uvea. But high COX-2 expression may be a marker for poor prognosis.

Choroidal pigmented lesions imaged by ultra-wide-field scanning laser ophthalmoscopy with two laser wavelengths (Optomap)

Purpose:

Clinical differentiation of choroidal pigmented lesions is sometimes difficult. Choroidal melanoma is the most prevalent primary neoplasia among malignant ocular tumors, and metastasis often occurs before the primary tumor is diagnosed. Therefore, early detection is essential. We investigated the imaging properties of clinically diagnosed melanocytic choroidal tumors using a nonmydriatic ultra-wide-field scanning laser ophthalmoscope (SLO) with two laser wavelengths to distinguish benign from malignant lesions. Repeated standardized ultrasound (US) evaluation provided reference standard.

Methods:

In a consecutive series of 49 patients with clinically diagnosed melanocytic choroidal tumors in one eye, 29 had established melanoma (defined by proven growth on repeated US follow-up) and 20 had nevi (defined by no malignancy according to clinical, US, and growth characteristics for at least 2 years). All patients underwent clinical examination, undilated Optomap^® (Optos PLC, Dunfermline, Fife, Scotland, UK) imaging, standardized US examination, and standard retinal photography. Measurements of the tumor base using the Optomap software were compared with US B-scan measurements. Imaging characteristics from the SLO images were correlated with the structural findings in the two patient groups.

Results:

Measurements of tumor base correlated well between SLO and US with r = 0.61 (T-direction) and r = 0.51 (L-direction). On SLO imaging, typical malignant lesions appeared dark on the red laser channel and bright on the green laser channel. Based on those simple binary characteristics, a sensitivity of 76% at a specificity of 70% was obtained for a correct classification of lesions. When analogous to clinical examination lesion size, margin touching the optic disc, and existence of subretinal fluid were additionally considered, 90% sensitivity at 82% specificity was obtained.

Conclusions:

In this first, limited series, nonmydriatic SLO imaging with two laser wavelengths permitted to differentiate malignant ocular tumors from nonmalignant lesions with high diagnostic accuracy. Additional parameters may further enhance diagnostic properties, but larger patient series are required to validate our findings and prove the diagnostic properties.

The "dysplastic" nevus

Dysplastic nevi have become an increasing focus clinically, with evidence that they are associated with a higher risk of developing melanoma. However, there still is contention regarding the significance of dysplastic nevi. This contribution provides an overview of the history, epidemiology, genetics, clinical and histologic features, and procedures for clinical management of dysplastic nevi. Since dysplastic nevi were described originally in 1978, a great deal of research has examined the epidemiology of these lesions and the genetic factors related to the development of dysplastic nevi. However, there is disagreement regarding the clinical management of dysplastic nevi and the histologic definition of dysplastic nevi. Current recommendations include preventative measures, such as sun protection and careful surveillance and biopsies of suspicious lesions as needed. The advent of new technologies, such as computer-vision systems, have the potential to significantly change treatment of dysplastic nevi in the future.

Estimating the risk of malignant transformation of a choroidal nevus

PURPOSE

To estimate the risk of malignant transformation of a choroidal nevus in the white population.

DESIGN

Systematic literature review.

METHODS

A literature review was performed to obtain data on the prevalence of choroidal nevi in the white population. Data from studies that used indirect ophthalmoscopy or otherwise corrected data to include the entire fundus were selected. Only studies reporting on the United States population were included. The number of affected individuals was estimated using 2000 U.S. census data. The estimate of annual incident choroidal melanoma cases in the corresponding age- and race-matched population was calculated using the Surveillance, Epidemiology, and End Result database (1973-2000). Average annual age-specific incidence rates for 1973 to 2000 for each of the 5-year age groups (adjusted for the U.S. 2000 population) were calculated and applied to the corresponding census data. The ratio of numbers of affected individuals with choroidal melanoma and choroidal nevi gave the annual rate of malignant transformation of a choroidal nevus.

MAIN OUTCOME MEASURES

Annual rate of malignant transformation of a choroidal nevus in the white population of the U.S.

RESULTS

The prevalence of choroidal nevus in the white U.S. population ranged from 4.6% to 7.9%. It was estimated that, on average, 8864625 individuals in the U.S. had a choroidal nevus. The number of individuals with choroidal melanoma in the corresponding age- and race-matched population ranged from 989 to 1008 (mean, 1002). The annual rate of malignant transformation of a choroidal nevus was estimated to be 1 in 8845.

CONCLUSIONS

If it is assumed that all choroidal melanomas arise from preexisting nevi, then the published data suggest a low rate (1/8845) of malignant transformation of a choroidal nevus in the U.S. white population.

Pigmented conjunctival neoplasms

Pigmented lesions of the conjunctiva are not rare. They may be acquired, congenital, benign or malignant. In the present paper, the author provides a brief review, in a non-exhaustive manner, of the common melanocytic pigmentations, with more emphasis on the malignant and pre-malignant variants.

Genetic predisposition to ocular melanoma

Uveal melanoma is the most common primary intraocular malignancy, with an annual incidence of 6 per million. The environmental factors known to increase the risk of cutaneous melanoma appear to be less important in ocular melanoma and it is conceivable that host factors have a greater impact. The coexistence of ocular and cutaneous melanoma in some patients suggests a predisposition to both types and implicates mutations in the CDKN2A gene in a proportion of these cases. An association between ocular melanoma and breast and/or ovarian cancer has also been reported and recent studies of breast cancer families strongly implicate BRCA2 as a predisposition gene. Other more common genes predisposing to ocular melanoma may be of low penetrance. An example of a gene in this class is MC1R, which affects host response to ultraviolet radiation. Identification of genes conferring an increased risk of ocular melanoma should provide insights into the pathogenesis of this tumour. Furthermore, it offers an opportunity to identify individuals at a high risk who may benefit from targeted surveillance. At present the identification of such individuals is restricted to the small number belonging to BRCA2 families and those with the atypical mole syndrome.

Pigmented lesions of the conjunctiva

A careful examination of the conjunctiva and ocular adnexa should be performed as part of a complete dermatologic examination. This article reviews the clinical presentation and classification of pigmented lesions of the conjunctiva. The histologic features of these conjunctival lesions are compared with those of pigmented lesions of the skin.

Ocular melanomas and melanocytic lesions of the eye

This article describes several melanocytic lesions of the eye. Benign and malignant lesions will be discussed as well as a review of the dysplastic nevus syndrome and its proposed association with ocular melanoma. Ocular melanomas arise from the same embryologically derived melanocytes as their cutaneous counterparts. However, ocular and cutaneous melanomas differ in many respects. The diagnosis and management of these ocular tumors rely heavily on the ophthalmologist. However, knowledge of melanocytic lesions will aid the dermatologist in detection and in proper referral of these patients.

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.

Risk of cutaneous melanoma in relation to the numbers, types and sites of naevi: a case-control study

The atypical mole syndrome (AMS) phenotype, characterised by a large number of common naevi as well as atypical naevi, has been described in families with a genetic susceptibility to melanoma. However, the importance of this phenotype for melanoma in the general population has not been conclusively determined. This study was designed to examine the types and distribution of naevi as well as the prevalence of the AMS phenotype in melanoma patients in England compared with controls. A total of 426 cutaneous melanoma cases (61% of all incident cases) aged 16-75 years were recruited between 1989 and 1993 from the north-east Thames region of the UK and 416 controls from the same age group were recruited over the same period and from the same region. Each subject answered a questionnaire covering demographic details, sun exposure history and other risk factors and underwent a skin examination with total body naevus count performed by a dermatologist. The AMS phenotype was defined using a scoring system. Atypical naevi gave the highest relative risk for cutaneous melanoma, with an odds ratio (OR) of 28.7 (P < 0.0001) for four or more atypical naevi compared with none. Many common naevi were also an important risk factor: the OR for 100 or more naevi 2 mm or above in diameter compared with 0-4 naevi was 7.7 (P < 0.0001). Melanoma was also associated with naevi on sun-exposed sites but also with naevi on non-sun-exposed sites such as the dorsum of the feet, buttocks and anterior scalp. Sixteen per cent of the cases had the AMS phenotype compared with 2% of the controls (OR 10.4, P < 0.0001). The AMS phenotype was more common in males than females (P = 0.008). The odds ratio for the presence of the AMS phenotype was dependent on age, with an odds ratio of 16.1 (95% CI 4.6-57.5) for the presence of the AMS phenotype if aged less than 40 compared with an odds ratio of 6.9 (95% CI 2.9-16.6) if aged 40 or more. The AMS phenotype was strongly predictive of an increased risk of melanoma outside the familial context.

Bilateral primary uveal melanoma. Bad luck or bad genes?

BACKGROUND

The occurrence of bilateral primary uveal melanoma has been assumed to be a rare, random event . Bilaterality of a primary cancer is suggestive of an inherited cancer predisposition. The authors therefore evaluated patients with bilateral primary uveal melanoma for such cancer predisposition.

METHODS

The charts of 4500 patients with uveal melanoma were reviewed for the presence of bilaterality. The clinical profile of patients with bilateral primary uveal melanoma was studied. The presence of ocular melanocytosis, familial atypical mole and melanoma syndrome, neurofibromatosis type 1, cutaneous melanoma, familial uveal melanoma, Li-Fraumeni syndrome, and second primary cancers also was investigated.

RESULTS

Of 4500 patients with primary uveal melanoma, 8 (0.18%) were identified to have bilateral primary uveal melanoma. Using the annual incidence rate (Shammas and Watzke) and normal approximation to the binomial, the expected number of patients with primary bilateral uveal melanoma in the authors' series was calculated to be less than one person. Observation of eight patients with bilateral primary uveal melanoma represented greater than expected occurrence (P<0.0001). The mean age at diagnosis in the first eye was 56 years. The interval between the diagnosis of uveal melanoma in the two eyes ranged from 2 to 32 years (median, 10.5 years). Two patients had bilateral ocular melanocytosis. Ocular melanocytosis was more common (2/8, 25%) in patients with bilateral uveal melanoma compared with those with unilateral uveal melanoma (60/4492, 1.3%). This difference was statistically significant (P = 0.001). No relation to familial atypical mole and melanoma syndrome, cutaneous melanoma, neurofibromatosis type 1, familial uveal melanoma, second primary cancers, or Li-Fraumenni syndrome was observed.

CONCLUSIONS

Bilateral primary uveal melanoma occurs more frequently than expected by chance, and may be associated with ocular melanocytosis. In the authors' series, there was no clinical evidence of an inherited genetic predisposition for bilateral primary uveal melanoma. Unidentified germ-line mutations may be involved in pathogenesis of bilateral uveal melanoma.

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.

Uveal melanoma and familial atypical mole and melanoma (FAM-M) syndrome

We conducted this study to determine whether occurrence of primary uveal melanoma in the setting of familial atypical mole and melanoma (F A M-M) syndrome (an autosomal dominant cutaneous preneoplastic syndrome) follows a pattern of a hereditary cancer predisposition syndrome. A retrospective review of 4600 consecutive patients with primary uveal melanoma revealed eight patients with biopsy-proven F A M-M syndrome. The clinical profile of these patients was studied and their kindreds analyzed. In patients with F A M-M syndrome, the uveal melanoma occurred at a relatively young age (mean 40 years; range 10-52 years). The diagnosis of F A M-M syndrome preceded or followed the diagnosis of uveal melanoma by as much as 10 years. None of the patients had an associated nonmelanocytic malignancy. Three of the eight patients had a positive family history of melanoma (cutaneous melanoma (2) and uveal melanoma (1). The authors conclude that the occurrence of primary uveal melanoma in the setting of F A M-M syndrome does not follow a clear pattern of a hereditary cancer predisposition syndrome.

Risk of ocular melanoma in relation to cutaneous and iris naevi

A case-control study was set up to assess the risk of eye melanoma in relation to the number and type of cutaneous melanocytic naevi and pigmented lesions of the iris. Cases comprised 211 unselected ocular melanoma patients attending the Ocular Oncology Clinic at Moorfields Eye Hospital, London, during November 1990 to October 1991 and diagnosed after August 1986. Hospital and general practice controls (416) were recruited in the North East Thames Region of the UK. Cutaneous naevi greater than or equal to 2 mm in diameter were counted on the skin. Clinically atypical and congenital naevi were recorded separately. Pigmented lesions of the iris were counted. The relative risk for ocular melanoma increased with numbers of atypical naevi and numbers of common naevi. Ten percent of cases but 3% of controls had at least 100 naevi of 2 mm or greater diameter. Seven percent of cases and 0.4% of controls had 4 or more atypical naevi. Pigmented lesions of the iris were significantly more common in cases than controls. Nine percent of cases had the Atypical Mole syndrome (AMS) phenotype compared with 1% of controls. Six cases had concurrent cutaneous melanoma primaries. We conclude that atypical and iris naevi are important risk factors for eye melanoma and that patients with eye melanoma are at increased risk of cutaneous melanoma. Dermatological examination for the AMS phenotype and cutaneous melanoma should be recommended in eye melanoma patients with large numbers of pigmented lesions of the skin or family history of melanoma.

Iris melanoma in a ten-year-old boy with familial atypical mole-melanoma (FAM-M) syndrome

A ten-year-old boy was referred with an enlarging amelanotic iris tumor and secondary glaucoma in the left eye. After excisional biopsy it proved histopathologically to be an iris melanoma. The patient also had multiple nevi on his trunk, scalp, and buttocks suggestive of familial atypical mole melanoma (FAM-M) syndrome and confirmed histopathologically. To the authors' knowledge, this is the first report of iris melanoma in association with FAM-M syndrome. The young age at tumor onset is suggestive of a predisposing condition such as FAM-M syndrome. The association of uveal melanoma with FAM-M syndrome is discussed.

Cytogenetic findings in primary uveal melanoma

We analyzed cytogenetic abnormalities in 10 cases of primary uveal melanoma. Clonal chromosomal abnormalities were present in nine cases. Chromosome 6 was most commonly affected (seven cases) and included gain of material from 6 and/or loss of material from 6q. Trisomy of chromosome 8 or gain in material from 8q, mostly in the form of an i(8q) resulting in three to five copies of the 8q segment was seen in six cases. Monosomy of chromosome 3 and rearrangements of chromosome 9 were less frequent and were altered in three cases each. Clinical, histopathologic, and cytogenetic abnormalities are correlated.

How common is the atypical mole syndrome phenotype in apparently sporadic melanoma?

BACKGROUND

Although patients from some families with the atypical mole syndrome (AMS) are predisposed to melanoma, it is not known how frequently this underlies the apparently sporadic presentation of melanoma.

OBJECTIVE

This study was designed to estimate the frequency of the AMS (dysplastic nevus or FAMMM syndrome) phenotype in a population-based study of patients with melanoma in the United Kingdom and to determine the prevalence of the phenotype in the relatives of the patients with AMS.

METHODS

The nevi of patients with melanoma and controls in a case-control study, and the nevi of some relatives of patients with AMS, were examined. An AMS scoring system was used to define the AMS phenotype. The familiarity of the AMS phenotype was then determined by screening first-degree relatives of persons with the AMS phenotype.

RESULTS

Forty of 266 (15%) of patients with melanoma had the AMS phenotype compared with 7 of 305 (2%) of the controls (odds ratio 7.5, 95% confidence interval 3.4-16.8). Screening of relatives of patients with melanoma who had the AMS phenotype identified the same phenotype within the families, providing evidence that the AMS phenotype in patients with melanoma is predictive of the same phenotype in relatives, consistent with so-called type D1 AMS.

CONCLUSION

The AMS phenotype is a potent risk factor for cutaneous melanoma and is present in 15% of patients. Melanoma in the United Kingdom is more common in women than in men, but the AMS phenotype was more frequent in men in this study. It is our hypothesis that the effects of the putative AMS gene are diluted by environmental factors in U.K. women. Screening of relatives of patients with melanoma who have the AMS phenotype may identify persons at increased risk of melanoma.

Simultaneous occurrence of primary choroidal and cutaneous malignant melanoma and skin metastasis

This case report describes the clinical and histopathological findings in a 65-year-old woman enucleated for a malignant choroidal melanoma. Simultaneously, an excision was performed of a cutaneous melanoma together with a satellite nodule presumed to be a metastasis from the cutaneous, superficial spreading melanoma. Six months later, chemotherapy for liver metastasis was given without effect. There were no signs of dysplastic nevus syndrome. A 39-year-old cousin, however, had been enucleated for a malignant choroidal melanoma. This sporadic case might suggest a common etiologic factor in the pathogenesis of multicentric melanomas.

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.

Familial melanoma

The presence of large numbers of moles, atypical in appearance and distribution typifies the atypical mole syndrome. The syndrome may occur in one individual alone or in an autosomal-dominant fashion in his/her family. The presence of this phenotype indicates an increased risk of melanoma, although the risk varies according to the presence or absence of a family history. The classification devised by Kraemer et al. works well in estimating the risk of melanomas but is, as yet, not fully evaluated. The diagnosis of the syndrome is essentially clinical, necessitating the consideration of various aspects of phenotype such as total mole count, distribution, clinical appearance of the moles, the age of onset, site, and number of melanomas. It is always helpful to screen first-degree and second-degree relatives if there is a family history of moleyness or melanoma. Small numbers of clinically and, sometimes histologically dysplastic naevi may occur in normal individuals. The vast majority of these probably regress as do totally banal naevi, although a low percentage will result in a melanoma. Those patients should be questioned to establish the existence of a family history of increased numbers of moles and melanoma. They should also be thoroughly examined for the presence of other signs of the syndrome: increased total mole count, iris freckles etc. In the absence of either a family history or these additional clinical features it is unlikely that these individuals have 'the syndrome'. Common sense advice about sun avoidance and self-examination should be given. It is important to distinguish this from the atypical mole syndrome (AMS).(ABSTRACT TRUNCATED AT 250 WORDS)

Familial uveal melanoma

The cause of uveal melanoma is unknown. In a few cases, however, factors are found in association with the disease which may play some part in the aetiology. One such factor is inheritance. Twelve families have been reported with adequate documentation during the last century in which two or more members have had uveal melanomas. At least some of these may be the result of an inherited disorder. On available data inheritance is most likely autosomal dominant with partial expressivity or incomplete penetrance. This report describes two more families each of which have two members with uveal melanomas.

Epidemiologic aspects of uveal melanoma

Although the underlying cause or causes of uveal melanoma have yet to be elucidated, important insights may be gained by examining the epidemiologic features of the disease. Uveal melanoma is an uncommon cancer with an incidence of only six cases per million population per year. It is most often diagnosed in the sixth decade and is somewhat more common in males. Apart from sporadic reports of family clusters, uveal melanoma is not considered an inherited disease. Whether some environmental exposure triggers the development of uveal melanoma remains an open question. Sunlight has been proposed as an environmental risk factor because sunlight is known to cause melanoma of the skin and both diseases are rare in nonwhite races. Unlike cutaneous melanoma, however, rates have not been increasing over time and do not vary by latitude. This paper evaluates the available evidence for sunlight and other potential risk factors for uveal melanoma, highlighting areas requiring further research.

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.