Benign conjunctival melanocytic lesions. Clinicopathologic features

Conjunctival Nevus

Purpose of Review

To provide an up-to-date review of the epidemiology, presentation, diagnosis, and treatment options for conjunctival nevi (CN).

Recent Findings

Around 17.2%-42% of all conjunctival tumors have been found to be CN, which most frequently present in White individuals between the first to early third decade of life, with equal distribution between males and females. CN commonly occur in the interpalpebral bulbar conjunctiva with pigmentation ranging from amelanotic to dark. Diagnosis is typically made through slit lamp examination, visualized by a well circumscribed, variably elevated, variably pigmented, solitary lesion with clear cysts distributed throughout the pigment. In ambiguous cases, anterior segment optical coherence tomography (AS-OCT) can highlight the presence of sub-clinical cysts, whose presence points to a diagnosis of nevus. However, excisional biopsy with histopathology examination is the gold standard for identifying CN.

Summary

CN are benign, variably pigmented lesions. They are the most common of the conjunctival melanocytic tumors. Due to the extremely low risk of transformation to malignant melanoma (MM), CN are usually managed with routine observation and photo documentation.

PRAME/MELAN-A double immunostaining as a diagnostic tool for conjunctival melanocytic lesions: A South American experience

INTRODUCTION

PRAME (PReferentially expressed Antigen in Melanoma) is an antigen that is predominantly expressed in human melanomas. In cutaneous melanocytic lesions, PRAME expression is associated with malignancy. The objective of this study was to evaluate the co-expression of PRAME and Melan A to evaluate their diagnostic value in different conjunctival melanocytic lesions (CML).

METHODS

37 CML (23 nevi, 9 primary acquired melanosis (PAM), and 5 conjunctival melanomas) were evaluated by immunohistochemistry for PRAME and Melan-A. The percentage of melanocytic cells co-expressing PRAME and Melan-A was qualitatively evaluated as follows: negative, 0%; 1 + , 1-25%; 2 + , 26-50%; 3 + , 51-75% and 4 + , ≥ 76%.

RESULTS

Of the invasive melanoma cases, 80% showed a 4 + pattern of marking, whereas 20% showed a 3 + pattern. 11% of the PAMs showed a 4 + pattern and 88.9% showed a 1 + pattern. All the nevi showed a 1 + pattern. The sensitivity and specificity of PRAME 4 + for differentiating high-grade CML from the benign and low-grade grouped CML are 93% and 100%, respectively.

CONCLUSION

PRAME/MELAN-A double immunostain is particularly useful to differentiate benign from malignant conjunctival melanocytic lesions.

[Conjunctival tumors in children : Histopathological diagnoses in 262 cases]

BACKGROUND

The spectrum of conjunctival tumors in children and adolescents significantly differs from that of adults.

OBJECTIVE

The aim of this study was to show the distribution of histopathological diagnoses of pediatric conjunctival tumors.

MATERIAL AND METHODS

Retrospective case series including all conjunctival tumors of children and adolescents under 18 years of age examined histologically over a period of 25 years (1990-2015) at the Eye Center in Freiburg, Germany.

RESULTS

Among the 262 conjunctival specimens, the most common diagnoses were conjunctival nevi (148, [56%]), most often with junctional activity (106/148, [72%]), pyogenic granulomas (26, [10%]), and dermolipomas (18, [7%]). In one case a malignant tumor (conjunctival melanoma) was detected (1, < 1%).

CONCLUSION

The results suggest that pediatric conjunctival tumors are benign in most cases. Most of them were of melanocytic origin, with a junctional conjunctival nevus being the most common diagnosis.

Clinical and histopathological profile of primary caruncular lesions

Purpose

To provide a retrospective analysis of lesions of the caruncle which have been very rarely reported in the literature.

Methods

A retrospective review of all the caruncular lesions between January 2000 and January 2020 was done at a single tertiary eye care hospital. The lesions were classified as benign and malignant lesions. Clinicopathological correlation was done for the excised lesions.

Results

A total of 87 caruncular lesions were included in the study. Males (59%) were affected more than females (41%). The mean age at presentation was 44 ± 20 years. The mean duration of complaint was 36 ± 62 months. A total of 36 patients underwent surgical excision whereas the rest opted for conservative management. Recurrence was noted in five patients. Fifteen different types of lesions were identified histopathologically. Benign lesions (78%) were far more common than malignant ones (22%). Epithelial inclusion cyst was the most common benign lesion and sebaceous gland carcinoma was the most common malignant lesion. Correct clinicopathological correlation was seen in 52.7% of the cases. Caruncular tuberculosis, oncocytoma, and basosquamous cell carcinoma were some of the rare lesions.

Conclusion

Caruncular lesions are uncommon and very diverse, which makes clinical diagnosis challenging. Epithelial inclusion cyst and sebaceous gland carcinoma were the most common benign and malignant lesions respectively. Correct clinicopathological correlation was seen in more than half of the cases.

Conjunctival Melanocytic Lesions

CONTEXT.—

Conjunctival melanocytic lesions consist of a variety of neoplastic and nonneoplastic conditions. These include benign processes such as primary intraepithelial hypermelanosis and melanocytic hyperplasia, secondary forms of intraepithelial hypermelanosis and melanocytic hyperplasia, melanocytic nevi, melanocytic proliferations with malignant potential, and melanoma.

OBJECTIVE.—

To provide a concise yet comprehensive resource regarding the histopathologic diagnosis of conjunctival melanocytic lesions. We aim to detail and clarify the numerous classification schemes that exist for junctional melanocytic proliferations of the conjunctiva (known as primary acquired melanosis or PAM; also termed conjunctival melanocytic intraepithelial neoplasia or C-MIN). Although not uniformly adopted, C-MIN is classified by using a numeric system based on a defined set of criteria. A less complex scheme (conjunctival melanocytic intraepithelial lesion or CMIL) has recently been proposed by the World Health Organization. Additionally, we aim to update the reader regarding molecular features and prognostic indicators.

DATA SOURCES.—

Peer-reviewed literature and archived cases for illustration.

CONCLUSIONS.—

Accurate histologic classification is essential, as PAM/C-MIN/CMILs that have a significant potential to progress to invasive melanoma may be clinically indistinguishable from low-risk lesions. Conjunctival melanoma (CM) more closely resembles cutaneous melanoma in terms of its pathogenesis and molecular features, compared to melanoma arising at other mucosal sites or to uveal melanoma. Depth of invasion and ulceration status, among other factors, have emerged as important prognostic indicators in CM. Sentinel lymph node biopsy may provide further prognostic information. Lastly, integration of pathologic and clinical findings is essential at this anatomically sensitive location to determine appropriate clinical management.

Conjunctival Balloon Cell Nevus in a Young Child: A Case Report

Background:

Conjunctival balloon cell nevus is rare and often presents in young adults to middle-aged patients with a longstanding history of melanocytic lesion, suggestive of benign pathology. The main treatment modality is excisional biopsy. Tumor recurrence is very rare. Malignant transformation has never been reported.

Objective:

This study aimed to report a case of conjunctival balloon cell nevus with an atypical presentation in a preschooler.

Methods:

We describe a case of a 5-year-and-9-month-old girl who presented with a rapidly growing melanocytic conjunctival mass, which she had since birth. Ophthalmic examination showed two prominent feeder vessels, and the lesion straddled the limbus to overlie the peripheral part of the cornea. These findings raised an index of suspicion of malignant transformation. The lesion was completely excised with a 2-mm resection margin, superficial keratectomy, ethyl alcohol epitheliectomy, and cryotherapy.

Results and Discussion:

The histopathological examination and immunohistochemical study showed a compound conjunctival nevus of the conjunctiva with most of the cells as balloon cell type. There were no malignant changes found. Moreover, there were no signs of tumor recurrence at the last follow-up of 6 months.

Conclusion:

Clinically malignant characteristics have never been reported in balloon cell nevi in a preschooler of this age. Thorough physical examination, well-planned surgical procedure, and careful pathological examination all play vital roles in the management of patients with these lesions.

Management of Inflamed Conjunctival Nevus with Topical Antiallergic Medications: Case Series

Purpose

To report our findings in three cases of an inflamed conjunctival nevus whose size and degree of pigmentation were reduced by topical antiallergic and immunosuppressive ophthalmic solutions.

Methods

Observational case series. Three patients with inflamed conjunctival nevus were examined by slit-lamp biomicroscopy, and the findings before and after the treatments were compared.

Results

All three patients had a slightly pigmented and edematous conjunctival tumor at the corneal limbal area. The tumors were hyperemic, and papillae and follicles were present on the superior conjunctiva in all patients. All of the patients had an allergic predisposition. The antiallergic treatment not only resolved the hyperemia and edema of the palpebral conjunctiva, but also reduced the tumor size. In one case, the topical antiallergic agent alone led to a reduction of the tumor size. A combination of topical antiallergic agent and topical immunosuppressant was effective in reducing the tumor size and degree of pigmentation in the other two patients.

Conclusion

The hyperemia and pigmentation in eyes with inflamed conjunctival nevus can be resolved by topical antiallergic agent and topical immunosuppressant without resection of the tumor.

Case of a Giant Conjunctival Melanocytic Nevus

A 78-year-old female experienced extraocular extension of a giant conjunctival melanocytic mass. The clinical diagnosis was conjunctival malignant melanoma. We performed local excision and histopathological examination. The result of hematoxylin-eosin staining disclosed multiple intralesional mucosal cysts and nevus cell nests with abundant melanin. Immunohistochemical examination revealed expression of S-100, melan-A, and HMB-45 and no expression of Ki-67. Histopathological examination showed no evidence of malignancy. Giant conjunctival melanocytic nevi can be diagnostically confused with conjunctival malignant melanoma.

Melanocytoma of the Conjunctiva: Clinicopathologic Features of Three Cases

Background

Melanocytoma (magnocellular nevus) is a jet-black benign lesion histologically composed of polygonal tumor cells with small, inconspicuous nuclei and abundant cytoplasm. Melanocytomas in general are rare. Most cases occur in the optic nerve head. Conjunctival melanocytoma (magnocellular nevus) is extremely rare, and only 3 lesions of the ocular surface have been reported.

Objectives

To describe the clinical and histological spectrum of conjunctival melanocytoma and discuss differential diagnoses of this rare lesion.

Method

Four heavily pigmented conjunctival lesions were excised for slight tumor growth and histologically processed. The specimens were routinely stained with hematoxylin and eosin and periodic acid-Schiff. Sections were bleached and immunohistochemical stains were performed for CD68, HMB-45, S100, melanin, and Ki-67.

Results

Histological examination revealed findings of a conjunctival melanocytoma in 3 cases. The fourth case was diagnosed histologically as a combined melanocytic lesion with a compound nevus and an inverted type A nevus. None of the lesions exhibited transition towards malignancy. The differential diagnoses included conjunctival melanoma, granular cell nevus, compound nevus with reactive changes, and blue nevus.

Conclusions

Conjunctival melanocytic lesions suspicious for melanocytoma should be bleached to evaluate their cytologic features. CD68 can be helpful in identifying heavily pigmented melanomacrophages which may mimic a melanocytoma. As conjunctival melanocytomas are extremely rare, their pathogenesis may be different from that of other conjunctival nevi.

Inflammatory juvenile compound nevi: A melanoma is not all that it appears to be

An 11 year-old girl presented with a recent growth pigmented conjuntival lesion in the bulbar conjunctiva of left eye. Due to the the biomicroscopic and ultrasound findings, an excisional biopsy was performed on the lesion using the «no touch» technique, as well as cryo-coagulation of surgical margins. Histopathological examination revealed an inflammatory compound nevus. Melanotic conjunctival tumours are mostly benign. However, the recent growth of a lesion, its vascularisation, irregularities of the margins, and colour change must suggest it has turned malignant. In such case, excision of the lesion is mandatory. Despite all the clinical changes, especially in young patients, it can still be an inflammatory compound nevus.

Blue Nevi of the Ocular Surface: Clinical Characteristics, Pathologic Features, and Clinical Course

PURPOSE

Blue nevus is a melanocytic tumor that is commonly found in the skin. Extracutaneous presentations, including the ocular surface, are rare. As such, the purpose of this study was to characterize the clinical features and clinical course of congenital melanocytic tumor (blue nevus) of the conjunctiva.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Twenty-one patients with 23 blue nevi of the ocular surface that were excised surgically between 2000 and 2016.

METHODS

Chart review of patients identified from a database search of the Florida Lions Ocular Pathology Laboratory records. Pathologic diagnoses were confirmed by 2 pathologists (S.R.D. and G.E.). All specimens were bleached and, tissue permitting, stained using SOX10 (MilliporeSigma, Darmstadt, Germany) and CD68 (Leica Biosystems, Nussloch, Germany).

MAIN OUTCOME MEASURES

Clinical characteristics, pathologic features, and clinical course.

RESULTS

Mean age of the population was 55±15 years; 71.4% (n = 15) were white and 57.1% (n = 12) were men. One patient had 3 lesions, for a total of 23 lesions examined. Clinically, 13 lesions were on the bulbar conjunctiva, 3 were on the tarsal conjunctiva, 3 were in the fornix, 2 were caruncular, 1 was episcleral, and 1 was at the limbus. Before excision, 8 patients were thought to have primary acquired melanosis, 4 with concern for primary conjunctival melanoma, and 1 thought to have metastatic disease from a plantar melanoma. Five lesions were thought to be benign, and in 8 patients, the lesions were identified incidentally after other ocular surgeries, with no diagnosis of the lesions before excision. Pathologic features were consistent with simple blue nevi in 21 lesions and cellular blue nevus in 2 lesions. No malignant transformations were noted in any patient over the mean 20.2-month follow-up period (range, 2 weeks-103 months).

CONCLUSIONS

Blue nevus is a rare deeply pigmented congenital melanocytic lesion with a benign clinical course that can appear clinically similar to primary acquired melanosis or melanoma.

Update on conjunctival pathology

Conjunctival biopsies constitute a fairly large number of cases in a typical busy ophthalmic pathology practice. They range from a single biopsy through multiple mapping biopsies to assess the extent of a particular pathological process. Like most anatomical sites, the conjunctiva is subject to a very wide range of pathological processes. This article will cover key, commonly encountered nonneoplastic and neoplastic entities. Where relevant, sections will include recommendations on how best to submit specimens to the ophthalmic pathology laboratory and the relevance of up-to-date molecular techniques.

Giant Conjunctival Nevus in a 12-Year-Old Child

We describe a case of a giant conjunctival nevus presented in a 12-year-old girl with suspicious clinicomorphological appearance. The lesion was noticed by the parents at the age of 3 years as a “fleshy spot” on the bulbar conjunctiva. The lesion remained unchanged until approx. 6 months before recent admission. On slit-lamp examination, a large conjunctival lesion with variegate pigmentation and indistinct margins was detected on the superonasal part of the bulbar conjunctiva of the left eye. Intralesional cysts and vessels were detected with AS-OCT examination. Wide excision and cryotherapy to the scleral bed were performed and amniotic membrane graft was used to restore the ocular surface. Histopathological examination revealed compound type conjunctival nevus and disclosed any sign of malignancy. Although giant conjunctival nevus is a rare entity, precise diagnosis and adequate management are very important as it can be confused with malignant melanoma.

Spontaneous regression of a conjunctival naevus

Conjunctival naevi are one of the most common lesions affecting the conjunctiva. While benign in the vast majority of cases, the risk of malignant transformation necessitates regular follow-up. They are well known to increase in size; however, we present the first photo-documented case of spontaneous regression of conjunctival naevus. In most cases, surgical excision is performed due to the clinician's concerns over malignancy. However, a substantial proportion of patients request excision. Highlighting the potential for regression of the lesion is important to ensure patients make an informed decision when contemplating such surgery.

Conjunctival malignant melanoma in Denmark: epidemiology, treatment and prognosis with special emphasis on tumorigenesis and genetic profile

Conjunctival malignant melanoma is a rare disease associated with considerable mortality. Most published data have been based on case reports or series of referred patients. In addition, very little is known about the genetic and epigenetic profile of conjunctival melanoma and the resemblance to uveal, cutaneous and mucosal melanoma. The aim was to determine the incidence rate of conjunctival melanoma, and to relate clinicopathological features and treatment to prognosis. A further aim was to determine the prevalence of BRAF mutations in conjunctival melanoma, to determine whether BRAF mutations are early events in pathogenesis, and relate clinicopathological features and prognosis to BRAF-mutation status. Finally, we wanted to identify tumour-specific and prognostic microRNAs in conjunctival melanoma, and to compare these with the microRNA expression of other melanoma subtypes. In order to investigate these rare tumours, we studied all the conjunctival melanomas that had been surgically removed in Denmark over a period of 52 years (1960-2012). Tissue samples, clinical files, pathology reports and follow-up data were collected and re-evaluated. Using droplet digital polymerase chain reaction and immunohistochemistry, we investigated BRAF mutations; and using microRNA expression profiling, we investigated differentially expressed microRNAs. The overall incidence of conjunctival melanoma was 0.5/1 000 000/year, and it increased in Denmark over 52 years. The increase was mainly caused by an increase in older patients (>65 years) and bulbar lesions. Clinicopathological features significantly associated with a poor prognosis were extrabulbar location, involvement of adjacent tissue structures, tumour thickness exceeding 2 mm and local tumour recurrence. Patients undergoing incisional biopsy and/or treatment involving excision without adjuvant therapy fared worse than patients treated with excision and any type of adjuvant treatment. We found that 35% (39/110) of conjunctival melanomas were BRAF-mutated, and the incidence of BRAF mutations was constant over time. BRAF-mutation status corresponded in conjunctival melanoma and paired premalignant lesions. BRAF mutations were more frequent in males, in young patients, and in tumours with a sun-exposed tumour location (bulbar conjunctiva or caruncle), with a mixed or non-pigmented colour, with absence of primary acquired melanosis, and with origin in a nevus. Immunohistochemistry was able to accurately detect BRAF V600E mutations. In univariate analysis, distant metastatic disease was associated with BRAF mutations. No prognostic associations with BRAF mutations were identified in multivariate analyses. MicroRNA expression analysis revealed 25 tumour-specific microRNAs in conjunctival melanoma. Five possibly oncogenic miRNAs (miR-20b-5p, miR-146b-5p, miR-146a-5p, miR-506-3p and miR-509-3p) were up-regulated. Seven microRNAs (miR-30d-5p, miR-138-5p, miR-146a-5p, miR-500a-5p, miR-501-3p, miR-501-5p and miR-502-3p) were significantly and simultaneously up-regulated in both stage T1 and stage T2 tumours, and were associated with increased tumour thickness. The expression of the 25 tumour-specific microRNAs did not differ significantly between conjunctival melanoma and oral or nasal mucosal melanoma. In conclusion, the incidence of conjunctival melanoma increased in the Danish population from 1960 to 2012. From our findings of a distinct pattern of BRAF mutations and differentially expressed microRNAs, it is evident that conjunctival melanoma is closely related to cutaneous and other mucosal melanomas and bears less resemblance to uveal melanomas. This means that conjunctival melanoma patients may benefit from therapies that are effective for cutaneous and mucosal melanoma. Additionally, the identification of several up-regulated microRNAs may prove to be useful as prognostic or therapeutic targets in conjunctival melanoma.

Efficacy of Pattern Scan Laser photocoagulation for superficial conjunctival nevi ablation

This study reports the efficacy and safety of Pattern Scan Laser (PASCAL) photocoagulation in the removal of superficial conjunctival nevi. Superficial conjunctival nevi were removed from 10 eyes of 10 patients using PASCAL. The laser spots were 200 μm in size, and the power delivered ranged from 250 to 300 mW. The duration of the laser pulse was kept at the minimum needed for adequate lesion removal. The duration of the laser pulse administered to the patients varied from 100 to 200 ms. Complete removal of the conjunctival nevus was observed in all the patients after PASCAL photocoagulation. Six months after treatment, complete re-epithelialization of the overlying conjunctiva was noted. No signs of recurrence or scarring were found in any of the patients during the follow-up period. Pure thermal denaturation is the main mechanism of PASCAL photocoagulation for removal of superficial conjunctival nevi. PASCAL can be considered as an alternative to conventional argon laser treatment or surgery.

Conjunctival Primary Acquired Melanosis: Is It Time for a New Terminology?

PURPOSE

To review the diagnostic categories of a group of conditions referred to as "primary acquired melanosis."

DESIGN

Literature review on the subject and proposal of an alternative diagnostic schema with histopathologic and immunohistochemical illustrations.

METHODS

Standard hematoxylin-eosin-stained sections and immunohistochemical stains for MART-1, HMB-45, microphthalmia-associated transcription factor (MiTF), and Ki-67 for calculating the proliferation index are illustrated.

RESULTS

"Melanosis" is an inadequate and misleading term because it does not distinguish between conjunctival intraepithelial melanin overproduction ("hyperpigmentation") and intraepithelial melanocytic proliferation. It is recommended that "intraepithelial melanocytic proliferation" be adopted for histopathologic diagnosis. Atypical proliferations are characterized either by bloated dendritic melanocytes with enlarged cell components (dendrites, cell bodies, and nuclei) or by epithelioid melanocytes without dendrites. Atypical polygonal or epithelioid pagetoid cells may reach higher levels of the epithelium beyond the basal layer. Immunohistochemistry defines the degree of melanocytic proliferation or the cellular shape (dendritic or nondendritic) (MART-1, HMB-45) or identifies the melanocytic nuclei (MiTF). Intraepithelial melanocytic proliferation without atypia represents increased numbers of normal-appearing dendritic melanocytes (hyperplasia or early neoplasia) that generally remain confined to the basal/basement membrane region. Intraepithelial nonproliferative melanocytic pigmentation signifies the usually small number of conjunctival basal dendritic melanocytes that synthesize increased amounts of melanin that is transferred to surrounding keratinocytes.

CONCLUSION

All pre- and postoperative biopsies of flat conjunctival melanocytic disorders should be evaluated immunohistochemically if there is any question regarding atypicality. This should lead to a clearer microscopic descriptive diagnosis that is predicated on an analysis of the participating cell types and their architectural patterns. This approach is conducive to a better appreciation of features indicating when to intervene therapeutically. An accurate early diagnosis should forestall unnecessary later surgery.

Primary Acquired Melanosis: Clinical, Histopathologic and Optical Coherence Tomographic Correlation

AIM

To assess the use of anterior segment optical coherence tomography (OCT) as an adjuvant diagnostic tool in primary acquired melanosis (PAM) by correlating clinical, histopathologic and anterior segment OCT findings.

METHODS

Twenty-four patients (24 eyes) with PAM of the conjunctiva, cornea or both were imaged with an anterior segment OCT device (RTVue, model-RT100; Optovue Inc., Fremont, Calif., USA).

RESULTS

Histopathologic diagnosis following excisional or incisional biopsy was confirmed in 13 out of 24 patients (54.6%). OCT images showed a characteristic uniformly thick basal epithelial hyperreflective band (about 20 μm thick) and normal thickness of the overlying epithelial layer in all patients (100%). The hyperreflective band on OCT correlated with the basal epithelial melanocytic pigmentation noted on histopathologic examination but did not vary in thickness between cases with or without atypia.

CONCLUSIONS

The characteristic basal epithelial hyperreflective band with normal overlying epithelium in the absence of cysts observed in all cases by anterior segment OCT correlated with clinical and histopathologic features of conjunctival and corneal PAM. Anterior segment OCT may be helpful as a noninvasive diagnostic tool for PAM. Improvement in resolution is necessary to detect melanocytic hyperplasia and aytpia suggestive of malignant potential.

Unilateral Conjunctival in situ Squamous Carcinoma with Bilateral Conjunctival Chlorpromazine-Induced Secondary Melanosis Masquerading as in situ and Invasive Melanoma

PURPOSE

To describe the clinical and histopathological features of a 61-year-old male with a history of eczema, asthma and schizophrenia on long-term chlorpromazine medication, who developed a unilateral limbal tumour in association with bilateral melanosis.

PROCEDURES

The patient was referred for a routine cataract assessment, and an incidental pink gelatinous limbal lesion was detected on the left side, associated with bilateral speckled brown conjunctival pigmentation. The limbal lesion and brown pigmentation were biopsied. The tissue was fixed in standard buffered formalin and processed to paraffin wax, and sections were stained with haematoxylin and eosin. Tissue from the pigmented area was also processed for transmission electron microscopy.

RESULTS

The biopsy from the limbal lesion showed an in situ squamous carcinoma associated with prominent numbers of intra-epithelial eosinophils. The biopsy of the pigmented area showed bilateral melanosis without atypia. The latter was attributable to an increase in melanin production rather than to melanocyte hyperplasia. Melanophages were also present in the adjacent substantia propria. These pigment changes were entirely compatible with chlorpromazine-induced secondary melanosis.

CONCLUSIONS

This paper highlights the first documented occurrence of in situ squamous carcinoma with bilateral chlorpromazine-induced conjunctival secondary melanosis. This clinically masqueraded as in situ melanoma/primary acquired melanosis and invasive melanoma. Bilateral melanosis is rare, has many causes and, in this case, was drug induced. This highlights the importance of thorough history taking and illustrates that not all pigmented and amelanotic lesions are in situ melanomas, primary acquired melanosis or invasive melanomas. Lastly, atopy was a risk factor for the development of this in situ squamous carcinoma.

Handheld reflectance confocal microscopy for the diagnosis of conjunctival tumors

PURPOSE

To evaluate whether the handheld in vivo reflectance confocal microscopy that has been recently developed for the study of skin tumors is suitable for the diagnosis of conjunctival tumors.

DESIGN

Prospective study, observational case series.

METHODS

We prospectively evaluated the reflectance confocal microscopy features of 53 conjunctival lesions clinically suspicious for tumors of 46 patients referred to the University Hospital of Saint-Etienne (France) by using the handheld device. Twenty-three lesions were excised (3 nevi, 10 melanomas, 5 squamous cell carcinoma, 2 lymphomas, and 3 pinguecula/pterygium) while the other 30, presenting no reflectance confocal microscopy malignant features, were under follow-up for at least 1 year. Clinical reflectance confocal microscopy and histologic diagnosis were compared.

RESULTS

In vivo reflectance confocal microscopy diagnosis was in agreement with the histologic diagnosis in all cases and none of the lesions that were not excised show any clinical progression under follow-up.

CONCLUSION

In vivo reflectance confocal microscopy with a handheld dermatology-dedicated microscope can play a role in the noninvasive diagnosis of conjunctival lesions. Further studies should be performed to better define the diagnostic ability of this technique.

Combined nevus of the tarsal conjunctival

We present an unusual case of combined nevus of the tarsal conjunctiva and eyelid margin in a pregnant woman who noticed morphological changes of the lesion during pregnancy. The patient underwent a wide full-thickness eyelid excisional biopsy including tarsal conjunctiva. Histopathologically, a subepithelial combined nevus (nevocellular and blue nevus) was observed. Conjunctival nevi are benign lesions with wide variation in clinical and histopathological features. Tarsal conjunctival involvement, as in the present case, is extremely rare (less than 1% of conjunctival nevi), especially the blue type nevus. Definitive diagnosis is possible only with excisional biopsy.

Cystic benign melanosis of the conjunctiva

PURPOSE

To report the clinical and histologic features of cystic benign melanosis.

METHODS

This case series reports on the clinical and histopathologic features of 3 patients with enlarging, cystic, brown, pigmented, conjunctival lesions.

RESULTS

Slit-lamp examination showed cystic melanotic lesions of bulbar conjunctiva. Histopathologic examination of the biopsy specimens showed epithelial lined cysts in the substantia propria, goblet cells, and secondary pigmentation of basilar keratinocytes.

CONCLUSIONS

Cystic benign melanosis, a unique conjunctival lesion, should be differentiated from cystic nevus and primary acquired melanosis.

Management of pigmented conjunctival lesions

Pigmented conjunctival lesions primarily include melanoma, nevus, primary acquired melanosis (PAM), and complexion-associated melanosis. The incidence of conjunctival malignant melanoma (CMM) has significantly increased in the USA and Europe over the years, and it carries a very serious risk for metastasis and melanoma-related death. Conjunctival melanoma can arise de novo or from precursor lesions, nevus, and PAM. PAM is histologically separated into two distinct forms: PAM with atypia and without atypia. PAM with severe atypia progresses to malignant melanoma in up to 50% of cases and PAM without atypia virtually never progresses. Nevus is a benign melanocytic tumor that only rarely undergoes malignant transformation. Complexion-associated melanosis is frequently seen in more darkly pigmented individuals and does not progress to melanoma, although it can become very large. A detailed literature review on the various pigmented conjunctival lesions together with a schematic approach to diagnosis and management is presented.

When narrative medicine helps in the diagnosis of conjunctival melanoma - an exceptional case report

Introduction: Conjunctival melanoma is a relatively rare ocular malignancy with substantial associated morbidity and mortality. It can arise in previously unblemished and unpigmented regions (approximately 10% of cases), from a preexisting nevus (approximately 20% of cases), or from the flat, spreading pigmentation of primary acquired melanosis with atypia (60–70% of cases), actually called conjunctival melanocytic intraepithelial neoplasia (C-MIN) with atypia (histopathologically more accurately term).

Purpose: The authors describe an extremely rare case of malignant conjunctival melanoma, with a long evolution, in a young black woman.

Results: Until now the patient has not shown any sign of relapse of this melanoma, after local excision.

Conclusion: Conjunctival melanoma is a condition of concern because of its rarity and lethal potential. Advances in the understanding and management of this neoplasm have markedly reduced the mortality and possibly the morbidity associated with this malignancy. We observe that there are some cases of conjunctival melanoma that might be cured with only a local excision with posterior cryotherapy without more aggressive methods. The practice of narrative medicine brings new possibilities in the diagnosis and collection of classical history.

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.

A clinicopathologic study of excised conjunctival lesions

Purpose:

This study was aimed at to determine the frequency of excised conjunctival lesions in a patient population treated over a 10-year period.

Materials and Methods:

The data of all excised conjunctival lesions with tissue diagnoses from 1998 to 2008 in the pathology department were analyzed.

Results:

The patient group comprised 192 conjunctival specimens; 106 (55.2%) obtained from male patients and 86 (44.8 %) from female patients. The age range was 75 years with a mean age of 27.07 ± 17 years. The most frequent excised lesions were pyogenic granulomas, which represented 30.7% (59 cases). Pigmented epithelial tumors were the second most common benign conjunctival lesions (44 cases, 22.9%). Out of these cases, compound nevus represented 86.4% (38 cases) and junctional nevus represented 6.8% (3 cases). Primary acquired melanosis and subepithelial nevus were reported in two cases (4.5%) and one case (2.3%), respectively. Cystic lesions represented 12% (23 cases). These were mostly ductal retention cysts in 16 cases (70%), occupying the fornix in eight cases. Ocular surface squamous neoplasia (OSSN) was detected in 21 cases (10.9%) significantly affecting an older age group as compared to other lesions (mean age 45.9 ± 16.7). Other less frequent lesions included papilloma (10 cases, 2.5%), dermolipoma (8 cases, 4.2%), solid dermoid (3 cases, 1.6%), hemangioma (15 cases, 7.8%), and benign reactive lymphoid hyperplasia (four cases, 2.1%).

Conclusion:

Benign lesions were the most frequent histologically diagnosed conjunctival lesions. The true malignant lesions were lower than what has been described in many reports. The significant proportion of precancerous OSSN can be attributed to sun exposure and ultraviolet light in Egypt.

Congenital melanocytic nevus of the oral mucosa: report of a rare pigmented lesion and review of the literature

Oral pigmented lesions are uncommon and congenital melanocytic nevi are especially rare. We report a case of a patient with multiple congenital melanocytic nevi including a palatal lesion. This is reported to add to the scant literature that exists on this subject. Prognosis and management are discussed.

Melanocytic Lesions of the Conjunctiva

Context—Melanocytic proliferations are among the most common neoplasms of the conjunctiva. They often represent challenging lesions for pathologists unfamiliar with unique histologic features of melanocytic proliferations in this location and with nomenclature used by ophthalmologists.

Objective—To comprehensively review clinical aspects, pathologic features, and management of melanocytic proliferations of the conjunctiva.

Data Sources—Review of the literature and personal experience of the authors.

Conclusions—Classification, state of the art, and practical aspects of pathology of melanocytic proliferations of the conjunctiva are discussed.

Conjunctival nevi: Clinical and histopathologic features in a Saudi population

BACKGROUND AND OBJECTIVE

Conjunctival nevi are benign lesions with wide variation in clinical and histopathological features. The differentiation between benign nevi and other pigmented lesions is essential. The aim of our study was to identify the distribution of the histopathologic types of conjunctival nevi among the Saudi population and to provide the basic knowledge needed for proper clinical diagnosis.

PATIENTS AND METHODS

This retrospective study of surgically excised benign conjunctival nevi was conducted at a tertiary care eye hospital from 1995 to 2006. Clinical data was collected from medical records and the histopathologic features reviewed by a single pathologist.

RESULTS

A total 105 conjunctival nevi were included from 104 consecutive patients (mean age, 26 years, 54 males and 50 females). The anatomical location was the bulbar conjunctiva in 83%, juxtalimbal in 12%, caruncle in 4% and palpebral in 1%. The lesion was removed for cosmetic reasons in 38% while 8% of the lesions were removed to rule out malignancy. The compound nevus was the commonest (72%) in all age groups, followed by subepithelial nevus (24%) and finally junctional nevus (3%).

CONCLUSIONS

The distribution of the histopathologic types of this tumor in our population matches the pattern in other areas of the world with the compound nevus being the commonest lesion. However, fewer lesions among our patients are removed to rule out malignancy.

Recurrent blue nevus of the corneoscleral limbus

PURPOSE

To describe an unusual corneoscleral blue nevus.

METHODS

Review of clinical and histopathological characteristics and previous relevant literature supplemented with immunohistochemical studies.

RESULTS

A 13-year-old Pakistani girl presented with a 5 x 2-mm, superotemporal, nonmovable, recurrent, black, limbal nodule. The lesion had been incompletely removed two and a half years earlier. Nonfascicular, variably pigmented, banal, spindle melanocytes with bland nuclei were discovered histopathologically in the conjunctival substantia propria and superficial sclera in the original and recurrent specimens. HMB-45+ and MART-1+ immunostainings established that all the variably pigmented spindle cells were melanocytes. Dispersed plump melanophages displayed clumped melanin granules and were shown to have small nuclei after decolorization. The Ki-67 proliferation index was very low (0.05%), supporting a benign diagnosis. No residual pigmentation after excision and cryotherapy was observed in follow-up examinations during a year and a half.

CONCLUSIONS

Careful histopathological and immunohistochemical evaluation of recurrent, incompletely excised, blue nevi can determine if they remain benign. Adjunctive cryotherapy was performed to prevent further recurrence, based on results from published data.

Bilateral conjunctival melanocytic nevi of simultaneous onset simulating conjunctivitis in a child

A healthy 10-year-old girl developed synchronous, bilateral, temporal redness of the eyes regarded as sectoral conjunctivitis for 5 years that was unresponsive to topical steroids and antihistamines. Finely vascularized, minimally elevated, amelanotic or faintly focally pigmented, epibulbar conjunctival lesions were present bilaterally. The lesions were completely excised. Histopathologic and immunohistochemical evaluations confirmed that they were both predominantly junctional nevi with conspicuous chronic inflammation. Juvenile conjunctival nevi frequently have atypical histopathologic traits that in an adult could be suggestive of melanoma. The differential diagnosis of much less likely disorders includes leukemia, lymphoid tumor (salmon patch), and conjunctival sarcoidosis, among other conditions. The patient has had no recurrence 3 years after surgery.