Prognosis of conjunctival melanomas in relation to histopathological features

Malignant Transformation of Reese's Melanosis: A Case of Conjunctival Melanoma and Related Therapeutic Modalities

Conjunctival melanoma is a rare but aggressive condition that can arise from healthy conjunctiva, pre-existing nevi, or precancerous conditions like Reese's melanosis. This acquired primary conjunctival melanosis can significantly impact an individual's quality of life due to its potential for recurrence and metastasis. Effective treatment typically requires a multidisciplinary approach to optimize outcomes. We present the case of a 56-year-old patient with recurrent Reese melanoma who underwent multiple surgeries. During the last intervention, a malignant transformation into melanoma was discovered. Due to the absence of brachytherapy facilities, the patient received local treatment with mitomycin C eye drops. Despite this limitation, the patient showed no signs of recurrence one year post-treatment. Given the high risk of local recurrence after surgery alone, additional radiotherapy is recommended and should be systematically discussed. Regular monitoring and timely intervention are essential to prevent disease progression. Notably, the frequent BRAF (B-Raf proto-oncogene, serine/threonine kinase) mutation in conjunctival melanoma opens possibilities for targeted therapies, such as BRAF inhibitors, offering promising options for management alongside traditional surgical approaches.

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.

Vascular-Associated Muc4/Vwf Co-Localization in Human Conjunctival Malignant Melanoma Specimens-Tumor Metastasis by Migration?

PURPOSE

To investigate whether vascular differentiation marker von Willebrand factor (vWf) and proliferation marker KI67 expression correlate with MUC4 localization around stromal tumor vascularization in human conjunctival malignant melanoma (CMM).

MATERIALS AND METHODS

For the purposes of this study, we analyzed samples from human CMMs (n = 4), conjunctival compound nevi (n = 7), and samples from healthy conjunctiva (n = 7) for MUC1, 4, and 16 by immunohistochemistry. To test CMM vessel association of MUC4, we investigated the co-localization of MUC4 with vWf or KI67 in human CMM specimens (n = 10) by immunohistochemistry. Also, we investigated the MUC4 localization around vessels of healthy conjunctiva (n = 10).

RESULTS

The immunohistochemical analysis demonstrated membrane-associated mucin expression in epithelia of CMM, nevi and healthy conjunctiva, whereas only MUC4 was localized perivascular in CMM tissue in this preliminary analysis. Co-staining analysis with vWf and KI67 demonstrated MUC4 localization around stromal vessels in human CMM specimens. In contrast, no MUC4 localization has been seen around healthy conjunctiva stroma vessels.

CONCLUSIONS

MUC4 was detected around vWf/KI67-positive CMM stromal vascular tissue, but not around healthy conjunctival stroma vessels. Therefore, we assume that MUC4 might play a role in tumor cell migration toward vessels inducing metastasis.

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.

Parotidectomy and neck dissection in the management of conjunctival melanoma: are they necessary?

OBJECTIVES/HYPOTHESIS

The objectives of this study were to review traditional techniques for the management of conjunctival melanoma and assess the need for parotidectomy and neck dissection in the management of conjunctival melanoma.

STUDY DESIGN

Retrospective review.

METHODS

This study was a retrospective review conducted in a tertiary academic medical center of patients diagnosed with conjunctival melanoma over a 20-year period

RESULTS

There were 39 patients diagnosed with conjunctival melanoma identified from January 1990 to December 2010. Follow-up varied from 2 to 201 months (median, 25 months). Of the patients, 16 (41%) had local recurrences at the primary site, two (13%) of whom later presented with parotid disease. One patient with parotid recurrence had a subsequent neck dissection for confirmed metastatic spread. No patient in this series had metastatic cervical disease without initial spread to the parotid. The probability of disease-free survival at 1, 2, and 5 years was 77%, 68%, and 50%, respectively. The probability of parotid free progression at 1, 2, and 5 years was 100%, 96%, and 90%, respectively.

CONCLUSIONS

Conjunctival melanoma is a rare malignancy traditionally managed with aggressive treatment to optimize local control. The role for staging parotidectomy with or without neck dissection has been heavily debated. Based on our review, parotidectomy only needs to be undertaken when high suspicion for metastatic spread is present, such as a palpable or radiographically evident mass. In addition, without documented parotid disease, neck dissection is not required.

"Posterior fossa lesion 45 years after ocular trauma"

We describe a patient who developed an isolated brain metastasis four years after his right eye was treated for conjunctival melanoma by excision and local chemotherapy. He had a history of ipsilateral ocular trauma by coal stuff while working in a mining industry. Conjunctival melanoma represents only 1.6% of all non-cutaneous melanoma. Metastasis of this kind of neoplasm to brain is a rare event, especially without evidence of prior or concurrent regional lymph node involvement.

Cutaneous Melanomas of the Eyelid

Cutaneous eyelid melanomas are very rare lesions. The lentiginous subtypes are the most frequent melanocytic lesions of the eyelid and can be likened to conjunctival melanocytic lesions like PAM, PAM with atypia and conjunctival melanoma. Compared to melanomas elsewhere on the body, eyelid melanomas have special considerations. Eyelid skin is very thin, the mucocutaneous junction at the lid margin can affect prognosis, the lymphatic drainage pattern is very variable and there is an inherent difficulty to excise wide margins without sacrificing important structures. A customized excision approach, using tissue-sparing "Slow-Mohs" technique, is suggested. Sentinel lymph node dissection has an evolving therapeutic role but remains controversial.

Malignant melanoma of the conjunctiva

BACKGROUND

Conjunctival melanoma is a relatively rare ocular malignancy with substantial associated morbidity and mortality.

METHODS

More than 100 articles on conjunctival melanoma were reviewed, including most of the relevant recent publications cited in a current MEDLINE search. The author's experience with conjunctival melanomas is also incorporated in this review.

RESULTS

Recognition of their precursor lesions at an early stage is important. Staging of the disease by sentinel lymph node biopsy is now advocated in some centers. Surgical excision with adjuvant cryotherapy and alcohol corneal epithelialectomy is usually effective in eradicating most of these lesions. Extensive cases of flat primary acquired melanosis with atypia may be managed with mitomycin C. Multifocal and advanced melanoma, especially in cases showing intraocular or orbital invasion, may require exenteration and/or radiotherapy to adequately extirpate the neoplasm locally. However, systemic metastases already may have occurred in these patients with advanced disease.

CONCLUSIONS

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.

Immunophenotypic markers to differentiate between benign and malignant melanocytic lesions

BACKGROUND/AIMS

The authors investigated the expression of S100A1, S100A6, S100B, MelanA, and CEA in conjunctival naevi, primary acquired melanosis (PAM), conjunctival melanoma, and uveal melanoma in order to assess their potential usefulness in the pathological differential diagnosis of these entities.

METHODS

Paraffin embedded sections of 18 conjunctival naevi, 14 PAM, 16 conjunctival melanomas, and 20 uveal melanomas were immunostained for S100A1, S100A6, S100B, MelanA, and CEA, and expression was scored semiquantitatively.

RESULTS

Expression of S100A1 differed significantly between conjunctival naevi and conjunctival melanoma, with percentages of positive cells of 30.6% and 71.4%, respectively. Conjunctival melanomas had high average scores for S100A1 and S100B (71.4%, 62.9%, respectively), while uveal melanomas also had high S100A1 but low S100B scores (88.5%, 18.5%, respectively). MelanA was highly variable; naevi and uveal melanoma had higher average scores than conjunctival melanoma. CEA was hardly detectable in all four groups.

CONCLUSION

S100A1 seems to be a possible candidate to differentiate conjunctival naevi from conjunctival melanoma. S100B seems to differentiate between uveal melanoma and conjunctival melanoma. However, the study size was small and therefore the data have to be confirmed by others.

Proton radiotherapy as an alternative to exenteration in the management of extended conjunctival melanoma

BACKGROUND

Diffuse and multifocal patterns of conjunctival melanoma may not be treatable with standard eye-sparing methods. The purpose of this study was to evaluate the usefulness of proton beam radiation therapy as an alternative to exenteration.

METHODS

Twenty patients with extended conjunctival melanoma were treated by proton beam irradiation. Most cases were T3 tumours which were not accessible to brachytherapy due to their extension, localisation with fornical or caruncular involvement. Only 2 patients had a tumour limited to the bulbar conjunctiva. Both were recurrent tumours with multiple lesions. Sixteen cases were recurrences after various pre-treatments. The area of the conjunctiva which was suspected to have microscopic disease was treated by 31 Gy in 6 fractions. The "high risk" areas with a clinically detectable tumour (primary target volume) were treated by an additional boost using a smaller beam size and applying 2 fractions up to 45 Gy. An individually shaped compensator was brought into the beam to modify the range of the protons so that the eye was irradiated only at a depth of 2 mm.

RESULTS

The mean follow-up time was 38.1+/-26.6 months (median 34 months). Recurrent disease occurred in 6 cases (30%); 2 of them outside the irradiated volume, 3 within the target volume treated by 31 Gy, and just one in the primary target volume treated by 45 Gy. An exenteration followed only in two patients (10%). 6 patients (30%) suffered from metastatic disease and 4 (20%) of them have died by now. During follow up we found no statistically significant association between the occurrence of local recurrence after proton radiotherapy and the development of metastases. Best corrected visual acuity remained stable in 12 cases (60%); in 14 patients the best corrected visual acuity was 0.25 or better. A sicca-syndrome developed in 19/20 patients. However, only 10/20 patients used artificial tears more than 5x/d. A focal cataract developed in 7 patients (35%). There was eyelash loss in the area of irradiated eyelids. In 4 cases a limbal stem cell deficiency occurred with the consequence of corneal vascularisation.

CONCLUSIONS

Proton radiotherapy may serve as an alternative to exenteration in case of T3 and diffuse T1 or T2 conjunctival melanomas.

Conjunctival Melanoma: The Role of Conservative Surgery and Radiotherapy in Regional Metastatic Disease

OBJECTIVE

To evaluate prognostic factors and determine the role of conservative surgery and radiotherapy in managing metastatic conjunctival malignant melanoma (MM) involving preauricular/submandibular lymph nodes.

METHOD

A retrospective analysis (1990-2003) of clinical and histopathologic data from 12 patients presenting with regional metastases after failed local treatment for conjunctival MM. Patients received a common, multispecialty, conservative management approach: wide local excision, topical cryotherapy or radiotherapy to conjunctival MM (orbital exenteration for more advanced local disease), lumpectomy, and adjuvant "ring" radiotherapy of regional metastases, with chemotherapy for distant metastases.

RESULTS

Median age at primary diagnosis was 51 (range 28-86) years with equal sex predilection. Six of the 12 patients had primary tumors of the bulbar conjunctiva; the remainder arose in the palpebral conjunctiva, the caruncle, or the fornix. Of 11 originating in primary acquired melanosis (PAM), 2 were amelanotic. Epithelioid tumor cells were noted histologically in seven of eight specimens in which cell type could be determined. Eight tumors metastasised to preauricular nodes, three to submandibular and one to both, with a median interval of 23 (range 12-108) months after primary diagnosis. After conservative surgery and "ring irradiation," 7 of 12 patients remained free of regional nodal relapse at median interval of 16 (range 3-126) months. Five patients developed regional nodal recurrence at median interval of 11 (range 6-13) months, 3 of whom were within radiotherapy portals. Eight patients developed distant metastasis at median interval of 44 (range 22-138) months. Eleven patients had tumor-related death. The mean Kaplan-Meier adjusted survival time after primary diagnosis was 76 months with death ensuing postregional metastasis within a median 18 (range 4-127) months. The sole survivor's follow-up duration was 56 months.

CONCLUSION

Locoregional metastasis after treatment for conjunctival MM is associated with a poor prognosis. Both epithelioid tumor cells and PAM are associated with disseminating disease and poorer outcome. Literature review has failed to demonstrate advantages of mutilating radical surgery over a conservative approach in this rare disease.

Expression of cell adhesion molecules and tumour infiltrating leucocytes in conjunctival melanoma

AIM

Very little is known about the immunology of conjunctival melanoma. We investigated the expression of cell adhesion molecules and the grade of tumour infiltration with lymphocytes and macrophages as important members for the communication between tumour cells and the immune system.

METHODS

Archival material from 35 conjunctival melanomas was used for immunohistochemical detection of intercellular cell adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), neural cell adhesion molecule (NCAM), CD3 and CD68 using monoclonal antibodies. Histological and clinical data for these tumours were assessed.

RESULTS

ICAM-1 was expressed in 34 of 35 tumours; in 20 cases, more than 50% of the cells stained ICAM-1 positive. VCAM-1 was expressed in 21 of 34 tumours; in 17 cases, only a small proportion (1-25%) stained VCAM-1 positive. NCAM was expressed in 14 of 34 tumours; in 11 cases, only a small proportion (1-25%) stained NCAM positive. CD3-positive leucocytes were found in 26 of 32 tumours, whereas CD68-positive leucocytes were present in 33 of 34 tumours. Cox regression analysis revealed that patients with NCAM-positive tumours had a 6.4-fold higher risk of dying from conjunctival melanoma (P = 0.02). NCAM-positive tumours were preferentially (P = 0.03) located in prognostically 'unfavourable' areas (i.e. fornices, palpebral, caruncle) and had no or only a weak CD3-positive infiltrate (P = 0.03).

CONCLUSIONS

ICAM-1, VCAM-1 and NCAM are differentially expressed in conjunctival melanoma. Leucocytes were present in almost every tumour. The association between NCAM expression and prognosis may be related to the differential anatomical tumour location of NCAM-positive and NCAM-negative tumours, and should be considered a preliminary observation due to the limited statistical power of this study.

Prognostic value of clinical and histopathological parameters in conjunctival melanomas: a retrospective study

AIM

To determine prognostic factors for recurrence of disease and tumour related mortality in patients with conjunctival melanoma.

METHODS

A retrospective analysis of clinical and histopathological data of 69 patients with histologically verified conjunctival melanoma.

RESULTS

As univariate analysis showed, significant risk factors for the development of recurrence were: irregular pigmentation (RR = 2.0, p = 0.0007), incomplete surgical excision (RR = 3.5, p = 0.008), tumour invasion deeper than in substantia propria (RR = 3.9, p = 0.008), and presence of epithelioid tumour cells (RR = 2.9, p = 0.05). For tumour related mortality a significantly increased risk was found for tumour location in palpebral conjunctiva, caruncle, plica, or fornices (RR = 5.9, p = 0.001), for tumour infiltration deeper than the substantia propria (RR = 5.5, p = 0.001), for incomplete surgical excision (RR = 4.4, p = 0.05), and for nodular or mixed (nodular and superficial) growth pattern of the tumours (RR = 1.2, p = 0.002). The use of an adjuvant therapy for the surgical excision of the melanomas had no statistically significant influence upon the development of recurrent disease nor upon the tumour related mortality.

CONCLUSION

These data present similar clinical and histopathological risk factors for patients with conjunctival melanoma as reported previously. The present study also addresses the failure of retrospective studies on conjunctival melanoma to prove the efficacy of a supplementary therapy to surgical excision.

Clinical features predictive of orbital exenteration for conjunctival melanoma

PURPOSE

Conjunctival malignant melanoma can sometimes be difficult to control locally, and orbital exenteration may be necessary. To our knowledge, the risk factors that portend exenteration have not been previously identified. The purpose of this study was to review patients who underwent orbital exenteration for advanced disease and to identify retrospectively the clinical factors predictive of ultimate exenteration.

METHODS

The records of patients with conjunctival melanoma who were managed on the Oncology Service at Wills Eye Hospital from 1974 to 1997 were reviewed. Factors predictive of orbital exenteration were analyzed using Cox proportional hazards regression models.

RESULTS

Of 151 consecutive patients with conjunctival melanoma, 20 (13%) required orbital exenteration for advanced disease. The number of melanoma excisions performed before referral ranged from 0 to 11, with a mean of 2. The clinical factors predictive of orbital exenteration on multivariable analysis were visual acuity of 20/200 or worse, lack of tumor pigmentation, and extralimbal tumor location. All exenterations were performed using an eyelid-sparing technique. At mean follow-up of 51 months after exenteration, 4 patients (20%) had died of metastasis, 3 (15%) were alive with metastasis, and 13 (65%) had not developed metastasis.

CONCLUSIONS

Conjunctival melanoma can show aggressive local behavior, and orbital exenteration is necessary in up to 13% of cases at a tertiary referral center. Patients with risk factors such as poor visual acuity, amelanotic tumor, and extralimbal tumor location may require wider excision and radiation therapy to control the tumor and avoid orbital exenteration. It is hoped that modern surgical approaches will decrease the need for orbital exenteration.

Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients

OBJECTIVE

To identify the risk factors of conjunctival malignant melanoma that predict local tumor recurrence, orbital exenteration, distant metastasis, and tumor-related mortality.

DESIGN

The study group consisted of 150 consecutive patients with a diagnosis of conjunctival melanoma. The clinical parameters of the patient, tumor, and treatment were analyzed in a nonrandomized fashion for their relation to 4 main outcome measures using Cox proportional hazards regression models.

RESULTS

The Kaplan-Meier estimate of local tumor recurrence was 26% at 5 years, 51% at 10 years, and 65% at 15 years. The mean number of recurrences per patient was 1 (median, 0). Ninety-eight patients (65%) had no recurrences, 28 patients (19%) had 1, 11 patients (7%) had 2, 5 patients (3%) had 3, and 8 patients (5%) had 4 or more recurrences. According to multivariate analysis, the factors that predicted local tumor recurrence were the location of the melanoma (not touching the limbus) (P = .01) and tumor-margin pathology (lateral margin involved) (P = .02). Multivariate analysis for features predictive of ultimate exenteration included initial visual acuity (20/40 or worse) (P = .0007), melanoma color (red) (P = .01), and melanoma location (not touching the limbus) (P = .02). Tumor metastasis occurred in 16% of patients at 5 years, 26% at 10 years, and 32% at 15 years. Metastasis was initially in the regional lymph nodes in 17 cases, brain in 4, liver in 3, lung in 2, and disseminated in 1 case. Risks for metastases with use of multivariate analysis included tumor-margin pathology (lateral margin involved) (P = .002) and melanoma location (not touching limbus) (P = .04). Tumor-related death occurred in 7% of patients at 5 years and 13% at 8 years. Risk factors for death with use of multivariate analysis included initial symptoms (lump) (P = .004) and pathologic findings (de novo melanoma without primary acquired melanosis) (P = .05). In a series of univariate analyses, the technique of initial surgery was shown to be an important factor in preventing eventual tumor recurrence (P = .07), metastasis (P = .03), and death (P = .006). Patients who were managed with excisional biopsy using the "no-touch technique" plus alcohol corneal epitheliectomy and supplemental cryotherapy fared far better than those treated with excisional biopsy alone. In addition, the surgical technique used before referral to us was critical. Those patients who had an incisional diagnostic biopsy prior to referral were at risk for more than 1 recurrence (P = .04), and those who had excisional biopsy alone without supplemental cryotherapy were at risk for eventual exenteration (P = .0006) and death (P = .04).

CONCLUSIONS

Conjunctival malignant melanoma is a potentially deadly tumor. In this study, metastasis was detected in 26% of patients and death occurs in 13% at 10 years. The surgical technique of tumor management was found to be possibly related to tumor metastases and death. Meticulous surgical planning, use of wide microsurgical excisional biopsy with the no-touch technique, and supplemental alcohol corneal epitheliectomy and conjunctival cryotherapy performed by experienced surgeons are advised. Incisional biopsy should be avoided.

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.

Malignant melanoma of the conjunctiva: occurrence and survival following surgery and radiotherapy in a Danish population

PURPOSE

To describe patient characteristics, risk of recurrence, and survival in patients with premalignant and malignant melanocytic lesions of the conjunctiva.

METHODS

In a retrospective study, 55 cases with a minimum follow-up of 10 years were reviewed.

RESULTS

The actuarial 5-and 10-year survival rates were 86% (95% Cl: 76-96%) and 73% (95% Cl: 60-87%) respectively. The 5-year risk of local recurrence was 35% (95% Cl: 21-49%), and the 10-year risk was 43% (95% Cl: 28-58%). Primary acquired melanosis with atypia was the first manifestation in 13 cases, malignant melanoma in 42 cases. No significant difference in survival and recurrence was found between the two groups or by gender, location of primary lesion, histological characteristics, or extent of surgical procedure. A minimum incidence of 0.052 cases a year per 100 000 in Denmark was calculated.

CONCLUSION

The results are estimated to represent a nationwide sample of patients. No prognostic factors of significance were identified.

DNA ploidy and S-phase fraction as prognostic factors in patients with uveal melanomas

In 96 patients with uveal malignant melanomas the tumours were investigated by DNA flow cytometry. Thirty-eight per cent of the melanomas were aneuploid. By univariate analysis significant correlations with survival were found for histological type, tumour size, DNA ploidy, evidence of 'blind eye' and S-phase fraction. By multivariate analysis, significant prognostic variables were found to be histological type (P = 0.0008), tumour size (P < 0.0001) and DNA ploidy (P = 0.0038). Evidence of 'blind eye' was not significantly correlated with survival after adjustments for the other variables mentioned above. The S-phase fraction could be estimated in all 60 diploid tumours and in 12 of 36 aneuploid melanomas. By univariate analysis this variable was found to be a significant prognostic factor, but did not remain so after adjustment for ploidy, histological type and tumor size. We further conclude that patients with small DNA diploid uveal melanomas of spindle cell type have a rather favourable prognosis.

Orbital exenteration in 95 cases of primary conjunctival malignant melanoma

The role of orbital exenteration in the management of malignant melanoma of the conjunctiva has been underexplored. The outcome in 95 patients with this condition, who underwent exenteration as a primary treatment (n = 36) or after failure of other treatment (n = 59) for early to advanced stages of the disease, was evaluated. The majority of treated cases had multicentric melanomas sited at prognostically unfavourable locations. In the group of tumours with a maximum thickness of 1.0 mm no melanoma related mortality was noted. Melanomas thicker than 1.0 mm were associated with a mortality varying between 33% and 50%, independent of whether exenteration was performed as primary or secondary treatment. An especially poor outcome was noted for the group of caruncular melanomas despite exenteration. These findings indicate that total eradication of tumour should be performed at an early stage. For this purpose, a combination of debulking surgery and adjunctive cryotherapy or beta radiotherapy is more appropriate than orbital exenteration which causes disfigurement and blindness. Exenteration of the orbit should be reserved as a palliative procedure for advanced stages of neoplastic disease.

Prognostic factors in primary malignant melanoma of the conjunctiva: a clinicopathological study of 256 cases

A series of 256 consecutive cases of invasive primary conjunctival malignant melanomas was examined to identify clinical and histopathological prognostic factors. The follow up period varied between 0.3 and 45.9 years (mean 9 years, median 6.3 years). The 5 year survival rate was estimated at 82.9%, the 10 year survival rate at 69.3%. Multiple regression analysis with the Cox proportional hazards model was used to assess sex, age, and a number of baseline features of conjunctival malignant melanoma as possible prognostic factors influencing melanoma related mortality. In assessing each potential prognostic factor, the effects of all other factors were taken into account in the modelling process. Tumours in unfavourable locations--that is, those involving the palpebral conjunctiva, fornices, plica, caruncle, and lid margins, were associated with 2.2 times higher mortality compared with (epi)bulbar melanomas. Patients with mixed cell type tumours had about three times higher mortality compared with those with pure spindle cell melanomas, and histological evidence of lymphatic invasion by tumour cells was also a prognostic feature, carrying a fourfold increase in the death rate. Multifocal tumours were associated with a fivefold increase in mortality among those with tumours in favourable (epi)bulbar locations, but were not prognostic in patients with melanomas in unfavourable sites. The death rate was significantly higher in those with initial tumour thickness of more than 4 mm, but only among patients with unfavourably located melanomas. Sex, age, and clinical origin of the tumour (primary acquired melanosis, pre-existing naevus, or de novo) were not useful prognostic indicators in this study.

Clinical predictive factors for development of recurrence and metastasis in conjunctival melanoma: a review of 68 cases

Sixty eight cases of histologically proved conjunctival melanoma were reviewed in order to determine the clinical factors that were predictive of local recurrence and distant metastasis. All patients were treated with surgical excision and most had supplemental cryotherapy. The mean follow up was 7.5 years. Histopathologically, the conjunctival melanoma arose from primary acquired melanosis in 56%, from naevus in 26%, and de novo in 18%. Of the 68 patients, 38 (56%) developed at least one local tumour recurrence and 22 (32%) developed more than one recurrence. The method of initial treatment and the eventual development of metastasis were the two parameters statistically associated with tumour recurrence. Those patients treated initially with tumour excision alone had a statistically significant higher recurrence rate than those treated initially with excision and supplemental cryotherapy (p = 0.001). Fourteen patients (21%) developed metastasis and the mean period between treatment and metastasis was 3.6 years. Twelve (18%) died from metastatic melanoma with a mean interval of 4.4 years from the time of initial surgery until death. The only clinical parameter that was statistically associated with distant metastasis was local tumour recurrence (p = 0.015). Based on these observations, the authors make recommendations regarding the treatment of conjunctival malignant melanoma. It appears that initial complete excision of the tumour with supplemental cryotherapy offers the patient the best chance of remaining free of recurrence and metastasis.

The morphologic characteristics of tumor blood vessels as a marker of tumor progression in primary human uveal melanoma: a matched case-control study

Nine morphologic patterns of tumor vessels were identified in eyes removed for ciliary body or choroidal melanoma by the examination of tissue sections stained with fluorescein-conjugated Ulex europaeus I using laser scanning confocal microscopy. This technique also highlights intravascular tumor invasion. Each of these nine morphologic patterns of tumor vessels also may be demonstrated by a modification of the periodic acid-Schiff reaction, viewed with a green narrow band pass filter, but this modified histochemical technique does not accurately identify intravascular tumor invasion. Most tumors have a heterogeneous distribution of vascular patterns. Melanomas in two groups of 20 tumors each were matched by tumor size and location (one group of tumors from patients who survived at least 15 years free of metastatic melanoma after enucleation and one group of tumors from patients who died of metastatic melanoma). A matched case-control analysis indicates that the presence of at least one closed vascular loop in a uveal melanoma is the most significant vascular pattern associated with death from metastatic melanoma after enucleation. Closed loops are associated with other histologic features that are predictive of an unfavorable outcome after enucleation: epithelioid cells and mitotic figures. In this preliminary study the formation of closed vascular loops is a marker of tumor progression in ciliary body and choroidal melanomas.

Malignant melanoma of the eyelid. A report of eight cases and a review of the literature

BACKGROUND

Because of the relatively rare occurrence of malignant melanoma (MM) of the eyelid, prognostic factors in relation to survival in these patients have not been established.

OBJECTIVE

Our purpose was to examine prognostic indicators in relation to survival in patients with MM of the eyelid.

METHODS

All patients seen at UCLA Medical Center with MM of the eyelid as well as all cases reported in the literature were reviewed retrospectively.

RESULTS

The data obtained from 47 total cases seen at UCLA Medical Center revealed a significant disadvantage in 5-year survival for those patients with MM involving the lid margins in comparison to those without lid margin involvement.

CONCLUSION

Our review suggests that melanoma involving the eyelid margin and conjunctiva has a worse prognosis than melanomas of the eyelid that do not involve the conjunctiva. We can make no predictions in regard to the benefits of narrow versus wide surgical margins in the treatment of these patients.

Conjunctival malignant melanoma in Sweden 1969-91

Clinical information, follow-up and histopathological parameters of the primary lesions were assessed for all (45) individuals with conjunctival malignant melanomas in Sweden presenting during a 22.5 year period (1969 to mid 1991). The annual incidence of conjunctival malignant melanoma in Sweden was 0.0240 per 100,000. On average, two new cases were diagnosed each year (population 8.6 million in 1991). Sixty-two per cent of the lesions recurred, but re-growth in itself was not correlated to reduced survival. The actuarial 10-year survival proportion using life-table analysis was 70%. A significantly reduced survival due to tumour-related death was noted in patients with tumours with high mitotic indices, many epithelioid cells and in lesions exceeding 10 mm in diameter. Other factors that may influence survival are presented in the context of previous reports. The present policy in Sweden for treating patients with malignant melanoma of the conjunctiva is outlined and discussed.

Rare variants of malignant melanoma

The personal experience with 5 rare types of malignant melanoma is reviewed to point out some of the practical problems in the diagnosis and management of these tumors. The rare forms discussed are conjunctival, nasal, oral, vulvar, and penile melanomas. All pigmented lesions in the oral cavity, but not the penis or vulva, should be prophylactically excised as lesions in the mouth have a higher malignant potential. Local excision of all 5 forms of primary melanomas, no matter how locally advanced they may be, is the sole treatment. Nevertheless, anatomic constraints often preclude surgery with generous margins and consequently local recurrence, particularly for conjunctival, nasal, and oral primary lesions, is usually the major first failure in treatment. Lymph node dissection is only performed if the regional nodes are palpable at the time of first presentation. Elective lymph node dissections are not performed since the patients are often elderly, the lymphatic drainage is usually ambiguous or multiple, and the disease tends to spread hematogenously rather than lymphatically. Surgery still remains the cornerstone of treatment for these rare forms of melanoma but prognosis is very poor since surgery is often a palliative rather than a curative measure. Improved survival may depend on identifying more effective chemotherapeutic and immunologic agents.

Immunohistochemical evaluation of uveal melanocytic tumors. Expression of HMB-45, S-100 protein, and neuron-specific enolase

The authors compared the immunohistochemical reactivity of 13 uveal nevi and 20 uveal melanomas for HMB-45, S-100 protein, and neuron-specific enolase (NSE) in formalin-fixed, paraffin-embedded sections. All 33 of the lesions were positive for HMB-45. The false-negative rates for S-100 protein and NSE were 21% and 18%, respectively. If only strongly positive reactions were considered, more than 50% of the tumors would be interpreted as negative for S-100 protein and NSE. Nevi stained with less intensity than melanomas using all three antibodies. The expression of HMB-45 appeared to be greater in active nevi than in inactive nevi. There was a weak association between S-100 protein reactivity and the ability of the uveal melanomas to metastasize (P = 0.1); however, the standard deviation of nucleolar area was a much better predictor (P = 0.02). These results indicate that pathologists will find HMB-45 to be a useful tool in differentiating uveal melanoma from nonmelanocytic tumors.

Therapeutic outcome of patients suffering from malignant melanomas of the conjunctiva

Eighty-one cases of conjunctival melanoma treated between 1960 and 1988 were studied to determine factors that might affect outcome in patients with such lesions. The therapeutic procedures performed were local excision (16), local excision followed by brachytherapy with Sr-90/Y-90 (32), local excision followed by cryotherapy with liquid nitrogen (16), brachytherapy with Sr-90/Y-90 (12), local excision followed by external beam irradiation (3), and local excision followed by brachytherapy and cryotherapy (2). The median follow-up period was 5.5 years (longest 26, shortest 1 year). Sixty two patients (76.5%) showed a complete regression of the melanoma, 19 (23.5%) developed recurrences, and 15 (18.5%) died from metastases. The melanomas had developed with almost equal frequency from a pre-existing naevus (25.9%), from primary acquired melanosis (25.9%), and 'de novo' (30.9%). Small tumours had a higher chance of regressing (80.6%) than larger ones (68.6%). The cumulative survival rate was 76% after five years and 60% after 10 years from any causes of death and 87.6% after five years and 76.3% after 10 years from deaths caused by metastases. Most deaths from metastases occurred within 5 years. At 88.5%, the cumulative survival rate of patients with small tumours (less than one quadrant of the bulbar conjunctiva and less than 2 mm thickness) was significantly higher than that of patients with larger tumours (more than one quadrant of the bulbar conjunctiva and/or more than 2 mm thickness) with 65% after eight years. Local excision followed by beta ray irradiation (Sr-90/Y-90) or cryotherapy can be recommended as the treatment of choice. Nevertheless the behaviour of conjunctival melanomas remains unpredictable in individual cases.