Conjunctival myxoma, Zollinger-Ellison syndrome and abnormal thickening of the inter-atrial septum: a case report and review of the literature

Conjunctival myxoma: A case report and review of a rare tumor

RATIONALE

Conjunctival myxoma is a rare benign tumor, which can mimic more common conjunctival lesions such as a cyst, lymphangioma, amelanotic nevus, neurofibroma, amelanotic melanoma, or lipoma. We describe a patient with the conjunctival myxoma, who was initially misdiagnosed as a conjunctival cyst. This case report includes intraoperative photographs and various immunohistochemical staining images.

PATIENTS CONCERNS

A 55-year-old woman presented with a painless mass in the superotemporal conjunctiva of the left eye, which she had noticed 1 month ago. The patient had no previous history of trauma or eye surgery. Slit-lamp examination revealed a well-circumscribed, freely movable, pinkish, semi-translucent mass on the temporal bulbar conjunctiva, suggestive of a conjunctival cyst.

DIAGNOSES

Histopathological analysis showed stellate- and spindle-shaped cells within the loose myxoid stroma, confirming a diagnosis of conjunctival myxoma.

INTERVENTIONS

The conjunctival lesion was completely excised under local anesthesia.

OUTCOMES

After 4 months of follow-up, the patient remained in good health without recurrence of the conjunctival lesion and no evidence of any systemic abnormality.

LESSONS

Myxoma is an extremely uncommon benign tumor derived from primitive mesenchyme. Considering the rarity of the tumor and its similarity to other conjunctival tumors, diagnosis can be challenging. Ophthalmologists should consider myxoma as a possible differential diagnosis when encountering conjunctival lesions. Surgical excision is essential to confirm the diagnosis and careful systemic evaluation is required to prevent potentially life-threatening underlying systemic conditions.

Bilateral synchronous conjunctival myxoma and review of the literature

PURPOSE

The purpose of this study was to report the clinicopathological features and management of the first case of bilateral synchronous conjunctival myxoma.

METHODS

This study was a case report and literature review.

RESULTS

A 66-year-old Chinese male with past ocular history of uncomplicated bilateral phacoemulsification and intraocular lens (IOLs) 3 years ago prior to presentation presented with bilateral red and swollen conjunctiva for over a year. On examination his corrected distance visual acuity (CDVA) was 25/20 in the right eye 20/20 in the left eye. Slit lamp examination revealed swollen temporal conjunctiva bilaterally which appeared as painless, well-circumscribed, salmon-pink, fleshy patches. The lesion in the right eye was subsequently excised, followed by excision of the lesion in the left eye at 3-week interval. Microscopically, histopathological examination of both excised specimens revealed hypocellular conjunctival mucosa covered by non-dysplastic epithelium, with presence of myxoid degeneration in the subepithelial stroma and immunostaining findings consistent with conjunctival myxoma. At his latest follow-up at 24 months, there were no recurrences of the conjunctival masses and the CDVA was the same as preoperatively.

Conjunctival myxoma masquerading as conjunctival lymphoma: A case report

INTRODUCTION AND IMPORTANCE

Ocular myxomas are very rare and can involve the orbit, eyelids, and conjunctiva. Conjunctival myxoma can be misdiagnosed as amelanotic nevus, conjunctival cyst, or ocular surface squamous neoplasia, among others. They can appear as an isolated lesion or can be associated with systemic manifestations as part of the Carney complex or Zollinger-Ellison syndrome.

CASE PRESENTATION

We describe a 64-year-old healthy male who presented with a right eye painless peri-limbal salmon-colored patch lesion in the infero-temporal bulbar conjunctiva over a period of 2 years. There was no of ocular trauma or surgery and no effect on vision. The mass was not tender, raised, and mobile with fine intrinsic vascularity. Excisional biopsy with the presumed diagnosis of lymphoma revealed a typical sub-conjunctival myxoma.

DISCUSSION

The recognition of ocular myxoma necessitates systemic evaluation to rule out possible associated cardiac myxoma in Carney complex, thus can prevent life-threatening events. The excised mass in our patient showed an area of pseudo-elastotic degeneration, which has further complicated the clinical appearance of the lesion, however, the color, and consistency of the mass were highly suspicious of lymphoma. The diagnosis of myxoma by histopathology was helpful especially in presence of atypical appearance such as in our case.

CONCLUSION

The histopathological characteristics of conjunctival myxoma can aid in the diagnosis. The lesion in our case was associated with focal severe pseudo-elastotic degeneration and prominent salmon-patch appearing area thus was initially misdiagnosed clinically as a conjunctival lymphoma.

Conjunctival myxoid stromal tumor of the palpebral conjunctiva: A case report

Purpose

To present the importance of considering conjunctival myxoid stromal tumors in the differential when evaluating eyelid lesions as these tumors could indicate undetected systemic syndromes including Zollinger-Ellison Syndrome, Carney complex, and other endocrine disorders.

Observations

We present the case of a 56-year-old Caucasian female who was evaluated for a solid cyst-like structure of the palpebral conjunctiva just temporal to, but not involving, the left lower eyelid punctum. The lesion was removed with histopathologic examination of the specimen revealing the lesion to be a myxoid spindle cell tumor, consistent with conjunctival myxoid stromal tumor.

Conclusions and Importance

Myxoid tumors are an abnormal proliferation of mesenchymal cells. These are most commonly found in the heart and less commonly in the bone, skin, and skeletal muscle. Myxoid tumors of the conjunctiva are a very rare reported finding and most reported cases involving the conjunctiva occur on the bulbar conjunctiva. Our patient was found to have a conjunctival myxoid stromal tumor of the palpebral conjunctiva. As these are rare lesions, we believe that considering this as a differential when evaluating eyelid margin lesions is important due to the association of these tumors with systemic conditions including Zollinger-Ellison Syndrome, Carney complex, and other Endocrine disorders.

A conjunctival myxoid stromal tumor (COMST) mimicking phlyctenulosis: A case report and brief review of the literature

Purpose

This is a case report of a patient with a conjunctival myxoid stromal tumor (COMST), mimicking a phlyctenulosis. Tumors of the conjunctiva and cornea occupy a large spectrum ranging from benign lesions of myxoma to aggressive, life-threatening malignancies. Phlyctenulosis and phlyctenular keratoconjunctivitis are hypersensitivity reactions to a foreign antigen.

Observations

A 64-year-old male presented with six-month history of non-painful lump in the conjunctiva of the left eye. It was a mobile, non-tender, non-ulcerated, non-hemorrhagic, non-pigmented lesion and was non-adherent to the sclera. The differential diagnosis of phlyctenulosis or a soft tissue tumor was considered. The lesion was completely excised. The microscopy showed an ill-defined hypocellular myxoid lesion composed of stellate and spindle-shaped cells with eosinophilic cytoplasm, containing round-ovoid and spindle-shaped nuclei with a vesicular chromatic pattern. The tumor cells were diffusely and strongly positive for vimentin and CD 34 and were negative for S100. The immunomorphological features were compatible with a conjunctival myxoid stromal tumor. Complete systemic evaluation excluded the possible association with systemic myxomas.

Conclusions and importance

Myxoid tumors of the conjunctiva are benign tumors, however, they can mimic other benign conditions like phlyctenulosis or more sinister lesions like malignant tumors. Therefore, it is important to do an excisional biopsy to ascertain the definitive pathology of an indeterminate conjunctival lesion. COMST may be the index presentation for the detection of previously undiagnosed myxoma syndromes. One such association is with cardiac myxomas, which can result in vascular embolic events. Therefore, it is important to do cardiac screening in all patients diagnosed with a COMST.

Conjunctival myxoma: A systematic review of a rare tumor

Conjunctival myxoma is an uncommon benign tumor that may develop as a localized disease or as part of the Carney complex, in which case it can cause significant morbidity and mortality. Conjunctival myxomas can mimic other pure or mixed tumors and are often overlooked in clinical practice. Histopathological studies are essential for diagnosis; however, controversy regarding their pathological and immunohistochemical features makes the diagnostic process more difficult. Because of the importance of correctly classifying these conjunctival tumors, as well as recognizing when a systematic screening is required owing to the possible association with life-threatening diseases, we comprehensively evaluate the literature on this rare entity based on a systematic approach.

Clinical appearance and pathological findings of conjunctival myxoma: Case report and literature review

Purpose

To describe a case with a growing erythematous conjunctival mass in the left eye, diagnosed as conjunctival myxoma.

Observations

A 31-year-old lady had corrected visual acuity of 6/7.5 and normal intraocular pressure in both eyes. Congested left bulbar conjunctiva with one slightly elevated nodule at nasal area was noted for one year. Excisional biopsy was performed after failed treatment with topical eye drops. Pathology showed conjunctival myxoma with spindle- and stellate-shaped cells, which was a rare ocular surface neoplasia. There was no combined systemic disease found.

Conclusions and importance

We described the clinical and pathological features of conjunctival myxoma. Systemic evaluation should be considered before and after surgical excision.

Case Report with Review of the Literature: Uveal Melanoma in a Patient with Carney Complex - Another Rare Component of the Syndrome?

A 74-year-old woman with Carney complex (CNC) and complaints of poor vision was found, on ophthalmic examination, to have a pigmented tumor involving the peripheral choroid and ciliary body in her right eye. The eye was enucleated and showed a ciliochoroidal melanoma with marked pleomorphism. The tumor did not recur or metastasize after almost 10 years of follow-up, and the patient died of unrelated causes. Molecular studies revealed a complex genome with multiple whole-chromosome losses including monosomy of chromosomes 1, 2 (including loss of CNC2at 2p16), 14, 17 (including loss of a copy of PRAKA1 at 17q24.2), 18, 19, 21, 22, and X. No monosomy 3 was observed. This is only the second case of uveal melanoma in a patient with CNC, raising the possibility that this might represent a rare component of this syndrome.

Conjunctival Myxoid Lesions: Clinical-Pathologic Multiparametric Analysis, Including Molecular Genetics (An American Ophthalmological Society Thesis)

PURPOSE

To evaluate the clinical and pathologic characteristics of conjunctival myxoid lesions, with specific focus on PRKAR1A studies, in order to distinguish neoplastic conjunctival myxoma from other myxoid conjunctival lesions.

METHODS

A retrospective, interventional, multicenter study of all patients with conjunctival myxoma, conjunctival stromal tumor, or reactive fibromyxoid proliferation diagnosed during 1988-2018. Patient and family medical histories and clinical and pathologic characteristics of excised lesions were assessed.

RESULTS

There were 28 patients with conjunctival myxoid lesions diagnosed as myxoma (16/28), conjunctival stromal tumor (10/28), or reactive fibromyxoid proliferation (2/28). The patients with abundant myxoid matrix lesions (14/28, 50%) were younger (mean 49 [range 23-68] years) than those with scant-to-moderate myxoid matrix lesions (14/28, mean 61 [range 18-82] years; P = .04). Abundant myxoid matrix lesions more likely contained predominantly stellate cells (6/14 [43%] vs 0/14 [0%]; P = .05) and fibrillar collagen (13/14 [93%] vs 2/14 [14%]; P < .0001), conforming to the standard morphologic definition of myxoma. Absence of PRKAR1A protein expression was found in 2 lesions with morphologic features of myxoma (2/14, 14%), 1 of which demonstrated a pathogenic mutation in the PRKAR1A gene. There was no difference between the lesions with respect to other clinical and pathologic parameters.

CONCLUSIONS

PRKAR1A plays a role in the development of a subset of conjunctival myxomas, particularly in tumors fulfilling stringent morphologic criteria for myxoma. With the exception of PRKAR1A studies, current immunohistochemical panels cannot reliably distinguish between neoplastic conjunctival myxomas and other myxoid lesions, underscoring the importance of morphology in establishing accurate diagnosis.

Conjunctival myxoma: A case report with unique high frequency ultrasound (UBM) findings

A 39-year-old female presented with a painless yellow-pink tumor on her right eye. High-frequency ultrasound imaging revealed an epibulbar lesion with homogenous low internal reflectivity and no evidence of intraocular invasion. The patient underwent excisional biopsy leading to a pathology diagnosis of myxoma. Additional surgical margins as well as adjuvant cryotherapy margins were followed by extensive conjunctival repair. Herein, we report on a conjunctival myxoma with unique ultrasonographic findings.

Primary conjunctival myxoma: case series and review of the literature

AIMS

Myxomas are benign soft tissue tumours resembling primitive mesenchyme. They rarely involve ocular structures, and have been recognized in the conjunctiva, eyelids, cornea, and orbit. The aim of this study was to investigate the clinicopathological features of seven patients with primary conjunctival myxoma seen at Dr Luis Sánchez Bulnes Hospital, an ophthalmological referral centre in Mexico City.

METHODS AND RESULTS

We reviewed the clinical, histochemical and immunohistochemical studies of patients with documented myxoma of the conjunctiva diagnosed in our hospital. Seven conjunctival myxomas were retrieved from 5923 conjunctival biopsies (0.1%). The mean age of patients was 40 years, with a range of 27-51 years. Females were more frequently affected, and none of our patients had systemic disease. The left eye was involved in five cases, and most of the lesions were located in the bulbar conjunctiva. Histopathological examination revealed a benign tumour composed of spindle-shaped and stellate-shaped cells immersed within an abundant mucinous matrix with sparse vessels and reticulin fibres. Immunohistochemistry demonstrated positivity for vimentin and negativity for smooth muscle actin, SOX10 and GLUT1 in myxoma cells of all cases. S100 was found to be positive in four cases, and muscle-specific-actin in three cases.

CONCLUSIONS

Conjunctival myxomas are uncommon tumours. For accurate diagnosis, histopathological examination is mandatory. The treatment of choice is surgical removal, and the prognosis is excellent.

Conjunctival myxoma - atypical presentation of a rare tumour: case report and review of literature

Background

Conjunctival myxomas are rare, benign, connective tissue tumours that classically present as slow-growing, painless, well-circumscribed masses (Arch Ophthalmol 124:735-8, 2006; Case Rep Ophthalmol 3:145-50, 2012). There have been 29 cases reported in the literature (Arch Ophthalmol 124:735-8, 2006; Malays J Med Sci 20(1):92-4, 2013; Case Rep Ophthalmol 3:145-50, 2012; Middle East Afr J Ophthalmol 19(3):353-3, 2012). We present a case with atypical features, and emphasize the importance of excisional biopsies for diagnosing indeterminate conjunctival lesions.

Case presentation

A 32 year old Korean woman presented with a 5 mm × 7 mm × 3 mm pedunculated firm cystic lesion on the inferior palpebral conjunctiva of her right lower eyelid. The lesion had rapidly enlarged over the course of a week. She gave a history of uncomplicated bilateral epiblepharon correction performed in Korea three months prior. There were no systemic features, or family history of genetic conditions. The lesion was excised under local anaesthesia and reported to be a conjunctival myxoma.

The clinical and histopathological features of this lesion were consistent with previous reports on conjunctival myxoma (Arch Ophthalmol 124:735-8, 2006; Arch Ophthalmol 101:1416-20, 1983; Case Rep Ophthalmol 3:145-50, 2012; Am J Ophthalmol 102(1):80-84, 1986). The unusual features of this case were, the rapid growth of the lesion - with the previously documented mean time before presentation being 34 months (range 3 months - 24 years) (Arch Ophthalmol 124:735-8, 2006; Case Rep Ophthalmol 3:145-50, 2012); the location of the lesion in the inferior palpebral conjunctiva - 93 % of previously reported cases had occurred in the bulbar conjunctiva (Arch Ophthalmol 124:735-8, 2006; Case Rep Ophthalmol 3:145-50, 2012); and its occurrence in association with recent eyelid surgery - which has never been reported.

Conclusion

This case of conjunctival myxoma adds to the small number of documented cases, by demonstrating an atypical presentation. Conjunctival myxomas can occur in association with the Carney Complex, which is an autosomal dominant syndrome associated with benign tumours, spotty mucocutaneous pigmentation, and endocrine overactivity (Ophthalmic Surg Lasers Imaging 39(6):514-6, 2008). Ophthalmic manifestations of the Carney Complex have been found to precede vascular embolic events secondary to cardiac myxoma, thus early diagnosis of conjunctival myxoma can prevent potentially devastating consequences (Ophthalmic Surg Lasers Imaging 39(6):514-6, 2008). The different presentations of this rare tumour emphasise the importance of excisional biopsies in diagnosing indeterminate conjunctival lesions; and its association with cardiac myxoma, highlights the need for cardiac investigations in all patients who present with conjunctival myxoma (J Ophthalmol (1);1-5, 2014; Ophthalmic Surg Lasers Imaging 39(6):514-6, 2008).

Conjunctival myxoma: a synopsis of a rare ocular tumor

Conjunctival myxoma is an exceptionally rare, slow-growing, benign neoplasm of primitive mesenchyme origin. Forty-one cases of conjunctival myxoma from a literature review, including the authors' case, are listed. The usual clinical history is a painless mass appearing during months to years. Grossly, the tumor is a well-circumscribed, cystlike, gelatinous, yellow-to-pink, translucent-to-solid mass. Microscopically, the hypocellular tumor contains stellate- and spindle-shaped cells in a mucoid stroma with abundant hyaluronic acid mucopolysaccharides. Vimentin and α-smooth muscle actin highlight the spindle and stellate cells. S100 protein and desmin are negative for the tumor cells. Treatment is complete surgical excision, with no recurrence reported in the follow-up period. Notably, conjunctival myxoma may be associated with Carney complex, an autosomal-dominant disorder associated with skin pigmentation, endocrine abnormalities, and myxoma of the heart and eye. Physicians should appreciate this unique ocular tumor because of its potential association with Carney complex.

A rare presentation of conjunctival myxoma with pain and redness: case report and literature review

BACKGROUND

Conjunctival myxoma is a type of rare, benign tumor of mesenchymal cells, with fewer than 30 reported cases in the English literature. It is mostly an isolated occurrence but can sometimes be associated with systemic diseases such as Carney complex or Zollinger-Ellison syndrome. It is necessary in clinical practice to differentiate it from other similar lesions, such as amelanotic nevus, lymphangioma, myxoid liposarcoma, spindle-cell lipoma, myxoid neurofibroma, and rhabdomyosarcoma.

CASE PRESENTATION

The usual presentation of conjunctival myxoma is a translucent, well-circumscribed, and painless conjunctival mass, but in this report we discuss an unusual case of conjunctival myxoma in a 47-year-old Taiwanese woman who presented initially with pain and redness. This atypical presentation complicated the diagnosis and the management at first. Surgical excision of the mass was performed. The mass was found to be a conjunctival myxoma. The patient subsequently underwent extensive evaluation but was found not to have any systemic diseases with known association with conjunctival myxoma.

CONCLUSIONS

In summary, we present a case of conjunctival myxoma in a 47-year-old Taiwanese woman. The initial presentation with pain and redness was atypical for conjunctival myxoma. The lesion was successfully managed with complete excisional biopsy.

A rare case of conjunctival myxoma and a review of the literature

BACKGROUND

To report on an 11-year-old boy with a painless slow-growing temporal bulbar conjunctival mass of his left eye.

METHODS

A case report and review of the literature.

RESULTS

An 11-year-old boy presented with a painless slow-growing mass in the temporal bulbar conjunctiva of his left eye, which had been noted for 1 year. After ophthalmic and systemic evaluations, the clinical differential diagnosis at the time included amelanotic naevus, amelanotic melanoma, myxoma, fibrous histiocytoma, reactive lymphoid hyperplasia and lipoma. This lesion was excised under local anaesthesia. From the histopathological features, conjunctival myxoma was confirmed. After 12 months, the patient remained healthy, with no recurrence or metastasis of the conjunctival lesion or evidence of a systemic abnormality.

CONCLUSION

We report this case to emphasize that conjunctival myxoma can appear as a well-circumscribed, translucent, yellow-pink conjunctival mass in teenage patients. Successful healing is usually achieved by complete surgical resection. Cardiac, endocrine, and family screening is required to reduce the risk of morbidity and mortality.