An audit of conjunctival melanoma treatment in Liverpool

Adjuvant Brachytherapy with Ruthenium-106 to Reduce the Risk of Recurrence of Conjunctival Melanoma after Excision

Introduction

Local recurrence of conjunctival melanoma (CM) is common after excision. Local radiotherapy is an effective adjuvant treatment option, and brachytherapy with ruthenium-106 (106Ru) is one such option. Thus, herein, we aimed to describe our experience with and the clinical results of post-excision adjuvant 106Ru plaque brachytherapy in patients with CM.

Methods

Nineteen patients (8 men and 11 women) received adjuvant brachytherapy with a 106Ru plaque after tumor excision. The mean adjuvant dose administered was 109 Gy (range, 80-134 Gy), and a depth of only 2.2 mm was targeted because the tumor had been excised. A full ophthalmological examination including visual acuity testing, slit-lamp examination, and indirect ophthalmoscopy was performed before therapy and at every postoperative follow-up. The mean follow-up period was 62 months (range, 2-144 months).

Results

Three patients developed a recurrence in a nontreated area, at either the conjunctiva bulbi or the conjunctiva tarsi. None of the patients developed a recurrence in the treated area. The local control rate was 84% (16/19).

Conclusion

106Ru plaque brachytherapy is an effective adjuvant treatment to minimize the risk of local recurrence after excision of a CM. Patients have to be followed up regularly and carefully for the early detection of recurrence.

Conjunctival melanoma: Insights into classification, outcomes, and biomarkers

Conjunctival melanoma is quite rare, estimated at approximately 0.5 incidence per 1 million persons per year. This malignancy arises from a pre-existing nevus (7%), primary acquired melanosis (74%), or de novo without pre-existing condition (19%) and develops most often in patients with Fitzpatrick skin types I (23%) and II (62%). At initial presentation, the tumor size is approximately 13 mm in cross-sectional diameter and has 3-mm thickness, involving the bulbar (97%), forniceal (30%), tarsal (28%), or caruncular (11%) regions, often with corneal (54%) and rarely with orbital (4%) involvement. According to the eighth edition of the American Joint Committee on Cancer (AJCC), the tumor is classified as T1 (63%), T2 (18%), T3 (20%), and T4 (0%). Outcomes depend on several factors including patient age, AJCC classification, orbital invasion, and type of initial surgery, whereas tumor origin and Fitzpatrick skin type do not appear to impact outcomes. Older patients (≥70 years of age) demonstrate larger tumors, greater recurrence, and greater vision loss. Analysis of 425 patients by AJCC classification (T1 versus T2 versus T3) revealed increasing T category with greater lymph node metastasis (3% versus 13% versus 25%; P < .001), tumor-related systemic metastasis (13% versus 45% versus 40%; P < .001), and tumor-related death (8% versus 22% versus 37%; P < .001). Data of patients with orbital invasion revealed significantly greater 10-year rates of exenteration (P < .001), distant metastasis (P = .0005), and death (P = .001). Studies have demonstrated biomarkers related to conjunctival melanoma include mutations in BRAF, NRAS, ATRX, and NF1. Future therapies might be directed against these mutations or with small-molecule inhibitors and/or immunotherapy. In summary, conjunctival melanoma is a rare but ominous malignancy, imparting moderate risk for lymph node and systemic metastasis as well as death, depending on tumor features and classification. The first surgery is highly important in prevention of tumor seeding, recurrence, and metastasis.

Factors affecting recurrence and metastasis in conjunctival melanoma

PURPOSE

To evaluate clinical and demographic characteristics and factors affecting recurrence, metastasis, and survival in conjunctival melanoma (CM).

METHODS

The clinical records of 45 patients who were treated for CM between October 1998 and June 2022 were retrospectively evaluated. Age, gender, presence of underlying conjunctival nevus-primary acquired melanosis (PAM), tumor stage according to the 8th edition of the American Joint Committee on Cancer (AJCC) staging system, tumor basal diameter, tumor thickness, lymph node (LN) involvement, metastasis, presence of tumor at the surgical margin, treatment method, need for adjuvant therapy, local tumor control, recurrence, and survival were recorded.

RESULTS

Twenty-one (46.7%) patients were female and 24 (53.3%) patients were male. The mean age at diagnosis was 53.2 ± 16.1 years. Median follow up time was 12 (1-300) months. Fifteen (33.3%) patients had conjunctival PAM; 2 (4.4%) patients had conjunctival nevus. The tumor stage was T1 in 24 (55.8%), T2 in 13 (30.2%), and T3 in 6 (14.0%) of the cases. The T stage in 2 cases could not be determined. For stage T1 and T2 CM, in addition to excisional biopsy (EB) and cryotherapy, alcohol epitheliectomy (AE) was performed in 17 cases (37.8%), superficial sclerectomy (SS) was performed in 7 (15.6%), and amnion membrane transplantation (AMT) due to a large conjunctival defect in 9 (20.0%). Six (14.0%) T3 cases underwent primary exenteration. Positive surgical margins were observed in 23 (51.1%) of the excised tumors at histopathologic examination. Adjuvant topical mitomycin-C (MMC) was used in 7 (30.4%) and strontium-90 episcleral brachytherapy in 4 (17.4%) of the 23 cases with tumor-positive borders. During the follow-up, recurrence was seen in 14 (31.1%) cases. According to Kaplan Meier analysis, the mean time to recurrence development was 90.5 ± 16.1 months and the 5-year recurrence free rate was 52.0%. Fourteen of the recurrent cases underwent EB + cryotherapy, 3 underwent AE + SS, and 3 underwent secondary exenteration. Metastasis and LN involvement occurred in 11 (24.4%) and 8 (17.8%) of the cases, respectively. Four (8.9%) cases expired during follow-up. According to Kaplan-Meier analysis, the mean time to metastasis was 106.2 ± 17.3 months and the 5-year metastasis free rate was 52.0%. While recurrence was more frequent in CM developing from PAM/nevus, metastasis was more frequent in men and those with LN involvement.

CONCLUSION

Conjunctival melanoma was a malignant tumor with high recurrence and metastasis rates. Precursor nevus/PAM is a risk factor for recurrence, while male gender and regional LN involvement were risk factors for metastasis in this study.

Malignant lesions of the caruncle

Caruncle malignancy is rare, but signs of disease can be easily missed by both patients and clinicians. There is significant potential for significant morbidity and even mortality from delayed diagnosis and treatment. Clinical features of primary malignant cancer include rapid growth, pigment deposition, ulcerated surface and bleeding. Malignant diagnoses include lymphoproliferative disease, basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma and malignant melanoma. Increased pigmentation is associated with melanoma, yellow coloured deposition with sebaceous carcinoma and a salmon-pink hue with lymphoproliferative disease. Treatment involves excision with margin control which may necessitate exenteration. Metastases to cervical and preauricular lymph nodes has been reported.

Conjunctival Melanoma in 430 Cases: Comparative Analysis of the Impact of Orbital Invasion on Tumor Recurrence, Metastasis, and Death

PURPOSE

To compare the clinical features at presentation and treatment outcomes of conjunctival melanoma by absence/presence of orbital invasion.

METHODS

A retrospective review of patients with conjunctival melanoma managed at a single tertiary referral center from April 18, 1974, to September 9, 2019.

RESULTS

Of 430 patients with conjunctival melanoma, 21 (5%) had orbital invasion at presentation. A comparison between the 2 groups (orbital invasion absent vs. present) revealed that the orbital invasion group had a higher frequency of prior eyelid incisional biopsy (5% vs. 24%, P = 0.006), greater tumor basal diameter (12.2 vs. 17.3, P = 0.009), greater tumor thickness (2.4 vs. 7.0, P < 0.001), more quadrants involved (1.8 vs. 2.5, P = 0.002), and more clock hours involved (4.4 vs. 5.8, P = 0.037). In addition, those with orbital invasion were more likely to undergo exenteration as primary treatment (1% vs. 24%, P < 0.001). Multivariate relative risk regression analysis revealed that variables predictive of orbital invasion included greater tumor thickness (P < 0.001) and greater involvement of the fornix (P = 0.031) and tarsus (P = 0.033). Outcomes revealed orbital invasion group with greater 5-year/10-year distant metastatic rate (16%/21% vs. 63%/63%, P = 0.005), and greater melanoma-related death rate (7%/13% vs. 38%/53%, P = 0.001).

CONCLUSIONS

Conjunctival melanoma with orbital invasion at presentation demonstrate larger, more extensive tumors involving the fornix or tarsus, and with greater rate of melanoma-related metastasis and death.

Publication trends of research on conjunctival melanoma during 1997–2022: A 25-year bibliometric study

Background

Conjunctival melanoma (CM) is a life-threatening ocular tumor with a high rate of local recurrence and metastasis. Our objective is to analyze research trends in CM field and compare contributions from different countries, institutions and authors.

Methods

We extracted all CM-related publications published from 1997 to 2022 from the Web of Science database and applied Microsoft Excel and VOSviewer to review publication data, analyze publication trends, and visualize relevant data.

Results

A total of 708 publications were identified. The United States contributed the most publications (280) and citations (8,781 times) with the highest H-index value (47). The Ophthalmic Plastic and Reconstructive Surgery, British Journal of Ophthalmology, American Journal of Ophthalmology and Cornea were the most productive journal concerning CM, and Shields CL, Shields JA, Jager MJ as well as Finger PT had published the most papers in the field. Keywords were classified into three clusters: clinical research, management-related research and genetic research. The keywords “primary acquired melanosis”, “metastasis” and “BRAF mutations” were most frequently emerged. According to the average appearing year (AAY), targeted therapy (AAY of 2019.0) and nivolumab (AAY of 2018.7) were identified as the main focuses of the field in the near future.

Conclusion

In the past 25 years, the United States, Germany, England and the Netherlands held the leading position in the CM research. A group of scholars made important contributions to CM research and will continue to guide cutting-edge research. Treatments that have been shown to be effective for advanced cutaneous melanoma, such as targeted therapy and immunotherapy, are potential focuses for future CM research.

Bindehautdegenerationen und -neoplasien

Erhabenheiten der Bindehaut entstehen durch Gewebevermehrung, die entweder degenerativ oder neoplastisch, aber auch entzündlich sein können. In diesem Artikel werden degenerative (Pterygium und Pinguecula) sowie benigne und maligne neoplastische Bindehautveränderungen (epitheliale, melanozytäre und vaskuläre Tumoren, Choristome sowie Metastasen) bezüglich der Pathogenese, Symptome, Diagnostik und aktuellem Stand der Behandlung dargestellt.

[Conjunctival Degeneration and Neoplasia]

Conjunctival tumors result from gain of tissue, which can be either degenerative or neoplastic, but also inflammatory. In this article, degenerative (pterygium and pinguecula) as well as benign and malignant neoplastic conjunctival changes (epithelial, melanocytic and vascular tumors, choristomas as well as metastases) are discussed with regard to pathogenesis, symptoms, diagnostics and current status of treatment.

Second Primary Malignancies following a Diagnosis of Conjunctival Melanoma

BACKGROUND

Although incidence of second primary malignancies (SPMs) has been investigated in patients with cutaneous melanoma and uveal melanoma, limited studies have investigated their occurrence subsequent to conjunctival melanoma (CM). We conducted a retrospective observational study to assess incidence of SPMs in patients with primary CM and to identify associated risk factors.

METHODS

Cases of first primary CM diagnosed from 2000 to 2018 were extracted from the national cancer database Surveillance, Epidemiology, and End Results Program. Standardized incidence ratios (SIR) and excess absolute risk (EAR) of SPMs were calculated compared to a matched cohort from the general population with similar sex, race, age group, and calendar year. EAR was per 10,000 individuals, and a P-value of <0.05 was considered significant.

RESULTS

A total of 471 patients met inclusion criteria, 57 (12.1%) of whom developed second primary malignancies (excluding eye and orbit melanomas) over an average (±SD) follow-up period of 6.8 (±5.0) years. Average age at diagnosis for the overall cohort was 60.2 (±18.6) years. Patients with CM demonstrated a significantly increased risk for overall SPMs relative to the general population, even after excluding eye and orbit melanomas (SIR 1.52; 95% confidence interval [CI], 1.15-1.97; EAR 67.58). Specific sites and malignancy types with increased risk were cutaneous melanoma (SIR 7.95; 95% CI, 4.45-13.12; EAR 45.34), ophthalmic non-melanoma malignancies (SIR 80.92; 95% CI, 2.05-450.84; EAR 3.41), and non-intrahepatic biliary malignancies (SIR 11.72; 95% CI, 1.42-42.32; EAR 6.32). Risk of overall SPMs (excluding eye and orbit melanomas) was significantly increased 5-10 years from diagnosis date.

CONCLUSIONS

Patients with CM had an increased incidence of SPMs compared to the general population. Specifically, these patients developed more cutaneous, ophthalmic non-melanoma, and non-intrahepatic biliary malignancies. These second neoplasms could be due to shared pathophysiology or mutual risk factors. Patients with CM may benefit from surveillance for SPMs, such as annual age-appropriate screenings in the first 10 years after diagnosis.

Small but Challenging Conjunctival Melanoma: New Insights, Paradigms and Future Perspectives

Although its incidence has increased over the last decades, conjunctival melanoma (CM) remains a rare but challenging periocular malignancy. While there is currently no recognized standard of care, "no-touch" surgical excision followed by adjuvant treatments is usually recommended. Despite its small size, managing CM is challenging for clinicians. The first challenge is the high risk of tumour local recurrence that occurs in about one third of the patients. The management of locally advanced CM (≥T2) or multiple recurrences may require mutilating surgeries such as orbital exenteration (OE). The second challenge is the metastatic spread of CM that occurs in about one quarter of patients, regardless of whether complete surgical excision is performed or not. This highlights the infiltrative and highly aggressive behaviour of CM. Recently, attention has been directed towards the use of eye-sparing strategies to avoid OE. Initially, wide conservative surgeries followed by customized brachytherapy or radiotherapy have appeared as viable strategies. Nowadays, new biological insights into CM have revealed similarities with cutaneous melanoma. These new findings have allowed clinicians to reconsider the management of locally advanced CM with "medical" eye-sparing treatment as well as the management of metastatic spread. The aim of this review was to summarize the current and future perspectives of treatment for CM based on recent biological findings.

Construction and validation of a novel prognostic signature for uveal melanoma based on five metabolism-related genes

BACKGROUND

Uveal melanoma (UM) is the most aggressive intraocular tumor worldwide. Accurate prognostic models are urgently needed. The present research aimed to construct and validate a prognostic signature is associated with overall survival (OS) for UM patients based on metabolism-related genes (MRGs).

METHODS

MRGs were obtained from molecular signature database (MSigDB). The gene expression profiles and patient clinical data were downloaded from The Cancer Genome Atlas (TCGA) database. In the training datasets, MRGs were analyzed through univariate Cox regression analyses and least absolute shrinkage and selection operator (LASSO) Cox analyses to build a prognostic model. The GSE84976 was treated as the validation cohort. In addition, time-dependent receiver operating characteristic (ROC) and Kaplan-Meier survival curve analyses the reliability of the developed model. Then, gene set enrichment analysis (GSEA) was used for gene enrichment analysis. Nomogram that combined the five-gene signature was used to evaluate the predictive OS value of UM patients.

RESULTS

Five MRGs were identified and used to establish the prognostic model for UM patients. The model was successfully validated using the testing cohort. Moreover, ROC analysis demonstrated a strong predictive ability that our prognostic signature had for UM prognosis. Multivariable Cox regression analysis revealed that the risk model was an independent predictor of prognosis. UM patients with a high-risk score showed a higher level of immune checkpoint molecules.

CONCLUSION

We established a novel metabolism-related signature that could predict survival and might be therapeutic targets for the treatment of UM patients.

Analysis of Clinical Characteristics and Prognosis of Patients With Periocular Malignant Melanoma in Korea

OBJECTIVE

To report the clinical features of 20 patients with malignant melanoma and to evaluate the survival and prognosis of patients with malignant melanoma in Korea.

METHODS AND ANALYSIS

The medical records of 20 patients with malignant melanoma treated between March 2004 and March 2020 were reviewed retrospectively. The demographic data, clinical characteristics, and outcomes were also reviewed. Outcome measures included local recurrence, metastasis, and tumor-related mortality. Prognostic factors associated with recurrence, metastasis, and survival were analyzed using a Cox proportional hazards model.

RESULTS

Among the 20 patients with periocular malignant melanoma, 4 (20%) showed local recurrence during follow-up (6.61 ± 6.36 years). The 1-, 5-, and 10-year recurrence rates were 5%, 10.3%, and 24.1%, respectively. 10 (50%) patients developed distant metastasis, mainly involving lung, brain, parotid gland and spine. The 1-, 5-, and 10-year rates of metastasis were 5%, 10.9%, and 35.7%, respectively. Significantly fewer metastases were detected following initial extensive surgical excision (P = 0.04). 8 (40%) patients died of malignant melanoma. The main risk factor for mortality was tumor thickness (HR: 3.88, P < 0.01). Based on Kaplan-Meier survival estimates, the 1-, 5-, and 10-year tumor-related survival rates were 75.8%, 55.6%, and 55.6%, respectively.

CONCLUSION

Tumor thickness is a significant prognostic factor affecting the survival rate. It is important to reduce the metastatic rate via extensive resection without leaving any residual tumor in the margin during surgery.

Conjunctival melanoma: New insights in tumour genetics and immunology, leading to new therapeutic options

Recent developments in oncology have led to a better molecular and cellular understanding of cancer, and the introduction of novel therapies. Conjunctival melanoma (CoM) is a rare but potentially devastating disease. A better understanding of CoM, leading to the development of novel therapies, is urgently needed. CoM is characterized by mutations that have also been identified in cutaneous melanoma, e.g. in BRAF, NRAS and TERT. These mutations are distinct from the mutations found in uveal melanoma (UM), affecting genes such as GNAQ, GNA11, and BAP1. Targeted therapies that are successful in cutaneous melanoma may therefore be useful in CoM. A recent breakthrough in the treatment of patients with metastatic cutaneous melanoma was the development of immunotherapy. While immunotherapy is currently sparsely effective in intraocular tumours such as UM, the similarities between CoM and cutaneous melanoma (including in their immunological tumour micro environment) provide hope for the application of immunotherapy in CoM, and preliminary clinical data are indeed emerging to support this use. This review aims to provide a comprehensive overview of the current knowledge regarding CoM, with a focus on the genetic and immunologic understanding. We elaborate on the distinct position of CoM in contrast to other types of melanoma, and explain how new insights in the pathophysiology of this disease guide the development of new, personalized, treatments.

Iatrogenic Ocular Surface Diseases Occurring during and/or after Different Treatments for Ocular Tumours

Simple Summary

The ocular surface represents a finely regulated system that allows the protection of the eye. It can be affected by therapies used for the treatment of various intraocular tumours, particularly conjunctival cancers and uveal melanoma. In these conditions, treatments are chosen according to the characteristics of the lesion, and include a combination of selective surgery, anticancer eye drops, and/or radiotherapy delivered through different mechanisms. Possible side effects affecting the ocular surface range from transient dry eye or keratitis up to more severe complications such as corneal melting and perforation. These complications deserve careful evaluation for the risk of permanent sight-threatening sequelae. Physicians involved in the management of patients affected by ocular tumours should be aware of this risk in order to reach an early diagnosis and promptly set up an adequate treatment. The present review summarizes acute and chronic complications affecting the ocular surface following different therapies for the treatment of conjunctival cancers and uveal melanoma, and also reports clinical cases of representative patients who experienced these complications.

Abstract

The ocular surface represents a finely regulated system that allows the protection of the eye. It is particularly susceptible to different treatments for intraocular tumours, such as uveal melanoma and conjunctival cancers. Traditionally, the management of ocular tumours depends on the characteristics of the lesion, and is based on a combination of selective surgery, topical chemotherapy, and/or radiotherapy delivered through different mechanisms (e.g., charged-particle radiotherapy or brachytherapy). Possible complications involving the ocular surface range from transient dry eye disease or keratitis up to corneal melting and perforation, which in any case deserve careful evaluation for the risk of permanent sigh-threatening complications. Clinicians involved in the management of these patients must be aware of this risk, in order to reach an early diagnosis and promptly set up an adequate treatment. The present review of the literature will summarize acute and chronic complications affecting the ocular surface following different therapies for the treatment of ocular tumours.

Conjunctival Melanoma: Features and Outcomes Based on the Fitzpatrick Skin Type in 540 Patients at a Single Ocular Oncology Center

PURPOSE

To determine the association of Fitzpatrick skin type (FST) with conjunctival melanoma.

METHODS

Retrospective case series of 540 patients with conjunctival melanoma to assess clinical features and outcomes per FST.

RESULTS

The FST was Type I (n = 126, 23%), II (n = 337, 62%), III (n = 56, 10%), IV (n = 8, 2%), V (n = 12, 2%), and VI (n = 1, <1%). A comparison (FST I vs. II vs. III, IV, V, and VI) revealed Types I and II associated with older mean patient age (63.9 vs. 60.7 vs. 51.1 years, p < 0.001), greater percentage of female patients (68% vs. 44% vs. 42%, p < 0.001), lower frequency of complexion associated melanosis (1% vs. 2% vs. 13%, p < 0.001), smaller tumor thickness (2.1 vs. 2.8 vs. 3.6 mm, p = 0.01), and less eyelid involvement (13% vs. 13% vs. 28%, p = 0.02). Kaplan-Meier estimates for 5-year risk showed no difference by Types for visual acuity loss ≥3 lines, local tumor recurrence, exenteration, metastasis, or death.

CONCLUSION AND RELEVANCE

Most patients with conjunctival melanoma show FST I or II, and this demonstrated no association with 5-year rate of vision loss, tumor recurrence, exenteration, metastasis, or death.

Incidence and Survival of Patients With Conjunctival Melanoma in Europe

Importance

Conjunctival melanoma (CM) is a rare ocular tumor. Estimates of incidence and survival of patients with CM are important to researchers and policy makers.

Objective

To estimate incidence and survival of patients with CM in Europe.

Design, Setting, and Participants

This population-based cohort study used data from 41 European cancer registries adhering to the RARECAREnet project. All individuals diagnosed as having malignant CM from January 1995 to December 2007 coded according to the International Classification of Diseases for Oncology, Third Edition codes C69.0 (conjunctiva) and 8720-8780 (melanoma) were included. Analysis began March 2019.

Main Outcomes and Measures

Trend estimates for incidence and for 5-year relative survival (the ratio of the measured survival of patients to the expected survival in the general population for the same country, age, sex, and calendar year). Crude, age-standardized, and bayesian incidence rates were calculated. Five-year relative survival was calculated by the Ederer II method with the cohort and period approach.

Results

A total of 724 patients 15 years or older (512 [70.7%] were 55 years or older; 366 [50.6%] were female) were analyzed with an overall crude incidence of CM (per 1 000 000 person/y) of 0.46 (95% CI, 0.42-0.49). Crude incidence was similar in men and women (0.48; 95% CI, 0.44-0.54 and 0.46; 95% CI, 0.41-0.51, respectively) and increased with age. Age-standardized incidence increased over time only in men and was the highest in Norway and the Netherlands (more than 0.70). Only 1 case in 14 years was estimated to occur in Iceland vs about 20 cases per year in large countries such as France and Germany. Percentage of 5-year survival (83.5 overall; 95% CI, 78.6-87.3) was not different between adult and elderly patients but showed large geographical disparities across European regions (range, 66-89) and improved markedly in male patients (from 76 in 1995-1998 to 86 in 2003-2007, with a difference of 10.2 [95% CI, 1.3-19.2]; P < .05) becoming similar to that of women in the last period.

Conclusions and Relevance

Although these data are only available through 2007 and based on registries not uniformly covering the European population, the study provides the first Europe-wide estimates of the incidence and relative survival of patients with CM using population-based data. Geographical differences in survival indicate room for outcome improvement in Southern, Northern, and Eastern European countries.

Conjunctival melanoma: Risk factors for recurrent or new tumor in 540 patients at a single ocular oncology center

PURPOSE

To investigate risk factors for recurrent or new tumor in patients with conjunctival melanoma.

METHODS

Retrospective review of patients with conjunctival melanoma managed on the Ocular Oncology Service, Wills Eye Hospital from 1974 to 2019.

RESULTS

There were 540 patients with mean follow-up of 57.6 months, of whom 176 (33%) had recurrent or new tumor formation. Risk factors for recurrent or new tumor on univariate analysis included presentation at older age (OR: 1.02 [1.01-1.03] per 1-year increase in age, p = 0.002), history of prior conjunctival surgery (OR: 1.62 [1.05-2.49], p = 0.03), worse visual acuity at presentation (OR: 1.76 [1.04-2.98] per 1 log-unit increase, p = 0.04), more advanced AJCC clinical T-subcategory (OR: 1.08 [1.02-1.14] per 1 subcategory increase, p = 0.01), tumor primary location in tarsal conjunctiva (OR: 1.80 [1.09-2.98], p = 0.02), and secondary tumor involvement of the fornix (OR: 1.68 [1.06-2.65], p = 0.03), and eyelid (OR: 1.92 [1.07-3.43], p = 0.03). Risk factors on multivariate analysis using all demographics, clinical features, and tumor location included presentation at older age (OR: 1.02 [1.00-1.03], p = 0.01), history of prior conjunctival surgery (OR: 1.84 [1.16-2.94], p = 0.01), and more advanced AJCC clinical T-subcategory (OR: 1.07 [1.01-1.13] per one subcategory increase, p = 0.03).

CONCLUSION

On multivariate analysis, the strongest predictors of recurrent or new tumor formation following treatment of conjunctival melanoma included older age, history of prior conjunctival surgery, and advanced AJCC T-subcategory. These results suggest that earlier detection and the first surgery in conjunctival melanoma management are critical for prevention of recurrent or new tumor, and we recommend prompt referral to an experienced surgeon.

Conjunctival Melanoma with Ipsilateral, Non-Contiguous Eyelid Involvement: A Case Report and Comprehensive Review of the Literature

While the majority of cases of conjunctival melanoma (CM) involve the bulbar conjunctiva, concurrent pigmentation of the ipsilateral eyelid can be seen in up to 15% of cases. Although extension of conjunctival melanoma into the eyelid (AJCC cT3b) occurs in 1% of cases, non-contiguous lesions are very rare with only 5 clearly documented reports in the English literature. Several pathophysiological mechanisms have been proposed, including separate primary melanomas, patchy involvement from primary acquired melanosis (which may be sine pigmento) and exfoliation of malignant tumour cells into the tear film. Herein we present a case of eyelid melanoma arising in a patient previously treated for CM at a non-contiguous site and provide a comprehensive review of the relevant literature.

Current Management of Conjunctival Melanoma Part 1: Clinical Features, Diagnosis and Histopathology

Conjunctival melanoma is a rare disease which makes up approximately 5% of ocular melanomas. The lesion may occur de novo or originate from a pre-existing nevus or primary acquired melanosis. Biomicroscopy is of paramount importance in diagnosis and follow-up of the disease, while other diagnostic modalities serve as supplementary tools. Many clinical and histopathological risk factors have been reported for prognosis. This review aims to address the clinical findings, differential diagnosis, diagnostic tools, prognostic factors, and staging of this disease.

Prognostic value of TERT promoter mutations in conjunctival melanomas in addition to clinicopathological features

AIMS

To evaluate the prognostic value of clinical, histopathological and molecular features and to relate different treatment modalities to clinical outcome in conjunctival melanomas (CM).

METHODS

Retrospective review of clinical, histopathological and BRAF V600E and telomerase reverse transcriptase (TERT) promoter mutation status and treatment modalities, correlated to recurrence and metastasis in 79 patients with CM, diagnosed between 1987 and 2015 in three tertiary referral centres in the Netherlands and Belgium.

RESULTS

Out of 78 evaluable patients, recurrences occurred in 16 patients and metastasis in 12 patients (median follow-up time 35 months (0-260 months)). Tumour thickness >2 mm, pT status, the presence of epithelioid cells, ulceration and mitoses was significantly correlated with metastasis (p value 0.046, 0.01, 0.02, 0.001 and 0.003, respectively). Furthermore, CM frequently harbour BRAF V600E and TERT promoter mutations (29% and 43%, respectively). TERT promoter mutations were correlated to shorter metastasis-free survival (p value 0.002). No significant correlation was found for clinical parameters and metastatic disease. Palpebral, forniceal and caruncular melanomas were more prone to develop recurrences (p value: 0.03). Most CM were treated with excision with adjuvant therapy.

CONCLUSION

In line with the recommendations in the Eighth Edition of the American Joint Committee on Cancer Staging for CM, the pathology report should include information about pT status, tumour thickness, presence of epithelioid cells, ulceration and mitoses. Furthermore, information about the presence of a TERT promoter mutation and BRAF V600E mutation is of interest for therapeutic decision making. The presence of a TERT promoter mutation is correlated to metastatic disease.

Lacrimal drainage apparatus melanoma remotely following treatment and resolution of conjunctival melanoma

Lacrimal drainage apparatus melanoma is a rare entity that may arise primarily or, more commonly, as secondary involvement from melanoma originating elsewhere. Conjunctival melanoma may involve the lacrimal drainage apparatus (LDA) via spread along the canalicular epithelium, separate in situ processes, or direct invasion. Only seven cases exist in the literature where conjunctival melanoma remotely recurred in the LDA. We report three additional patients, two with invasive conjunctival melanoma and one with primary acquired melanosis (PAM) with severe atypia/melanoma in situ, who developed LDA melanoma at 5, 8, and 16 years after initial treatment of conjunctival melanoma. This report confirms the ability of conjunctival melanoma to give rise to spatially and temporally remote LDA melanoma despite adequate local treatment, and reviews the proposed mechanisms and associated characteristics of LDA recurrence in conjunctival melanoma.

[Diagnosis and Therapy of Benign and Malignant Tumors of the Conjunctiva]

The aim of this paper is to give an overview of different benign and malignant epibulbar tumors. Categories can be made of the age of manifestation (paediatric tumors versus tumors of adults), the originating cell types (squamous cell tumors, melanocytic tumors, lymphomas or germ cell tumors) or genesis (proliferative, infectious or degenerating tumors). Most epibulbar tumors show lesions on the conjunctiva or the cornea. These can be flesh coloured or pigmented efflorescences with leucoplakias or hyperkeratosis. Especially malignant tumors show atypical growth of blood vessels, are often prominent and can have ulcerations or bleeding. In case of tumor growth, change in pigmentations or atypical bleedings a malign tumor can be suspected. The diagnosis should be confirmed using histopathological evaluation after an incisional or excisional biopsy. Molecular pathologic techniques extend the diagnostic tools and have an implication on the therapy of metastatic tumors. Therapeutic options of the malignant tumors (apart from lymphomas) are chirurgical excision preferably with a no touch technique and afterwards an adjuvant therapy consisting of radiation or cryotherapy. A topical chemotherapy with Mitomycin C, 5-Fluorouracil or Interferon α2b can be effective to reduce persisting precancerosis and reduce recurrences. In case of a suspected malignant tumor it is advisable to refer the patient to an ophthalmo-oncologic center to plan and ensure interdisciplinary therapy.

Benigne und maligne Bindehauttumoren in Diagnostik und Therapie

Bindehauttumoren betreffen in Diagnostik und Therapie alle Bereiche der augenärztlichen Praxis. Das beginnt mit der klinischen Kontrolle von Bindehautnävi und anderen benignen Tumoren, der Einschätzung von entzündlichen Pseudotumoren und ihrer Abgrenzung zu Präkanzerosen oder vernarbenden Erkrankungen und mündet in der hochspezialisierten und interdisziplinären Führung onkologischer Patienten mit Lymphomen, hochmalignen Melanomen oder invasiven Plattenepithelkarzinomen.

Conjunctival Melanoma: Current Treatments and Future Options

Conjunctival melanoma is a rare tumor of the conjunctival epithelium with a heterogenous clinical presentation and a propensity for regional and distant metastatic spread. Guidelines for the treatment of local conjunctival melanoma are well-established, but there are no standard efficacious therapies for metastatic disease. Given that conjunctival melanoma is genetically similar to cutaneous melanoma and mucosal melanomas, targeted therapies effective in the treatment of these diseases, such as BRAF inhibitors and KIT inhibitors, may be effective in the treatment of patients with metastatic conjunctival melanoma. Other targeted small-molecule drugs in the drug development pipeline for the treatment of more prevalent melanomas could also be applicable to conjunctival melanoma. Furthermore, systemic immunotherapy treatments that are now a mainstay in the treatment of cutaneous melanoma, such as programmed cell death-1 and cytotoxic T lymphocyte-associated antigen-4 inhibitors, could also stand to benefit patients with metastatic conjunctival melanoma. Limited case reports provide clues about the effectiveness of both targeted small-molecule inhibitors and immunotherapy in patients with advanced local and metastatic conjunctival melanoma and give credence to the argument that conjunctival melanoma patients should be included in major trials studying new therapies in both cutaneous and mucosal melanomas where applicable.

Management of conjunctival melanoma with local excision and adjuvant brachytherapy

BACKGROUND/OBJECTIVES

To evaluate the management of conjunctival melanoma with local excision and adjuvant brachytherapy.

SUBJECTS/METHODS

Data of all patients who received local excision and adjuvant brachytherapy for conjunctival melanoma between 1999 and 2016 in a Dutch national referral centre were reviewed. A protocol with Sr-90 was used until 2012, a protocol with Ru-106 was used hereafter. Local recurrence, metastasis, survival, visual acuity and treatment complications were assessed.

RESULTS

A total of 58 patients was identified: 32 patients were treated with Sr-90 and 26 with Ru-106. Mean follow-up time was 97.3 months (143.1 months after Sr-90, and 40.2 months after Ru-106). All lesions were epibulbar, the median tumour thickness was 0.9 mm. Local recurrence occurred in 13/58 cases (22%), with a 5-year recurrence rate of 21%. Local recurrence occurred equally often in both protocols, with 5-year recurrence rates of 19% (Sr-90) versus 23% (Ru-106) (p = 0.68). Metastasis developed in 3/58 cases (5%), with 2 cases after Sr-90, and 1 after Ru-106 (p = 1.00). The most reported complications were pain (29%), dry eyes (21%), symblepharon (9%), ptosis (12%) and cataract (9%). No severe corneal or scleral complications were observed. Median visual acuity was 1.00 pre-surgery, at the end of follow-up this was 1.00 (Sr-90) and 0.95 (Ru-106).

CONCLUSION

Local excision with adjuvant brachytherapy provides good tumour control with excellent visual outcome and mild side effects in patients with limited conjunctival melanoma. Results after Sr-90 or Ru-106 were comparable; a choice for either treatment may be based on experience of the clinician and availability of materials.

Conjunctival melanoma in patients with xeroderma pigmentosum: a series of four cases

PURPOSE

To study the demographic features, treatment, histopathology, and outcomes in patients of xeroderma pigmentosum (XP) with conjunctival melanoma.

METHODS

Retrospective case series.

RESULTS

The median age at presentation was 18 years (range 9-30 years). There were three females and one male patient presenting with a median duration of symptoms of 3 months (range 1-60 months). The tumor was located in the bulbar conjunctiva in all 4 patients. All patients had corneal involvement by the tumor. The median tumor basal diameter was 7 mm (range 4-15 mm). Wide tumor excisional biopsy with alcohol keratoepithelectomy, cryotherapy to the free margins, and amniotic membrane grafting was done in three patients. One patient underwent orbital exenteration for extensive tumor. One patient also received adjuvant plaque brachytherapy for microscopic residual tumor. Over a median follow-up of 22 months (range 2-101 months), there were no recurrences, metastasis, or death.

CONCLUSION

Conjunctival melanoma in XP is rare and manifests at a younger age.

Oncologic and visual outcomes after postoperative proton therapy of localized conjunctival melanomas

Introduction

conjunctival melanomas have high local relapse rates. Oncologic and visual outcomes can be improved with proton therapy and no-touch surgery.

Material and methods

a monocentric retrospective study of consecutive patients treated with surgery and proton therapy for conjunctival melanoma was conducted. Proton therapy was performed to a total dose of 45 Grays physical dose delivered in eight fractions over two weeks.

Results

Ninety-two patients were included. The mean age was 63-year-old. 65.2% of patients had primary acquired melanosis. The mean tumor thickness and diameter was 2.5 mm and 7.0 mm respectively. The clinical stage was T1 in 71.6% of cases, with a quadrangular involvement of more than 90° in 69% of cases. Conjunctival melanomas were of epithelioid cell-type in 40% of cases. Mean follow-up was 4.7 years. Five-year local failure rate was 33.2%. Of 25 local recurrences, 14 were marginal/out-of-field, 4 in-field, others were undetermined. First surgery at expert center resulted in 24.3% of local failure at 5 years versus 38.7% if performed elsewhere (p = 0.41). Salvage exenteration was performed in 13 patients. Tumor stage and quadrangular involvement were significant factors for local failure. Five-year progression-free survival and cause-specific death rates were 61.5 and 3.6%. Stage and epithelioid type were associated with poorer progression-free survival. Trophic toxicity occurred in 22.9% of patients and was treated locally, with grafts in 7 patients. Glaucoma and cataract occurred in 13 and 22 patients respectively. Prognostic factors for visual deterioration were age, tumor extent (multifocality, quadrangular involvement > 180°) and cryotherapy.

Conclusions

5-year local failure rate after postoperative proton therapy for conjunctival melanoma was of 33.2%. Radiation-induced complications were overall manageable.

Management Issues in Conjunctival Tumours: Conjunctival Melanoma and Primary Acquired Melanosis

Conjunctival melanoma is a rare malignant condition of the ocular surface. It is potentially lethal, with regional lymph node spread often preceding distant solid-organ metastasis. Due to its rarity and the long latency between treatment and local recurrence or the development of metastases, it is difficult to study. The literature is composed entirely of case series of varying quality, and there is significant variability in the management of this condition. This commentary attempts to distil the evidence base to provide practical management tips for the clinician.

[Conjunctival malignancies]

Conjunctival malignancies are rare. However, some of these tumors are among the most aggressive malignancies in ophthalmology and require radical forms of therapy that may lead to blindness or loss of the ipsilateral eye and tumor-associated death. The most relevant primary conjunctival malignancies for oncologists are squamous cell carcinoma, malignant melanoma and malignant lymphoma. Surgical therapy is the primary treatment for squamous cell carcinoma and malignant melanoma. An adjuvant therapy in the form of topical chemotherapy or radiation is necessary in most cases. The isolated malignant lymphoma of the conjunctiva is biopsied excisionally if possible. However, if an incisional biopsy was unavoidable, additional irradiation should be performed; malignant lymphoma generally responds very well to relatively low irradiation doses with a good prognosis quad vitam. More aggressive forms, such as diffuse large cell B‑cell lymphoma or mantle cell lymphoma, must also be treated systemically at an early stage.

Multicenter, International Assessment of the Eighth Edition of the American Joint Committee on Cancer Cancer Staging Manual for Conjunctival Melanoma

Importance

Eye cancer staging systems used for standardizing patient care and research need to be validated.

Objective

To evaluate the accuracy of the eighth edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual in estimating metastatis and mortality rates of conjunctival melanoma.

Design, Setting, and Participants

This international, multicenter, registry-based case series pooled data from 10 ophthalmic oncology centers from 9 countries on 4 continents. A total of 288 patients diagnosed with conjunctival melanoma from January 1, 2001, to December 31, 2013, were studied. Data analysis was performed from July 7, 2018, to September 11, 2018.

Interventions

Treatments included excision biopsy, cryotherapy, topical chemotherapy, radiation therapy, enucleation, and exenteration.

Main Outcomes and Measures

Metastasis rates and 5-year and 10-year Kaplan-Meier mortality rates according to the clinical T categories and subcategories of the eighth edition of the AJCC Cancer Staging Manual.

Results

A total of 288 eyes from 288 patients (mean [SD] age, 59.7 [16.8] years; 147 [51.0%] male) with conjunctival melanoma were studied. Clinical primary tumors (cT) were staged at presentation as cT1 in 218 patients (75.7%), cT2 in 34 (11.8%), cT3 in 15 (5.2%), and cTx in 21 (7.3%). There were no T4 tumors. Pathological T categories (pT) were pTis in 43 patients (14.9%), pT1 in 169 (58.7%), pT2 in 33 (11.5%), pT3 in 12 (4.2%), and pTx in 31 (10.8%). Metastasis at presentation was seen in 5 patients (1.7%). Metastasis during follow-up developed in 24 patients (8.5%) after a median time of 4.3 years (interquartile range, 2.9-6.0 years). Of the 288 patients, 29 died (melanoma-related mortality, 10.1%) at a median time of 5.3 years (interquartile range, 1.8-7.0 years). The cumulative rates of mortality among patients with cT1 tumors were 0% at 1 year, 2.5% (95% CI, 0.7%-7.7%) at 5 years, and 15.2% (95% CI, 8.1%-27.4%) at 10 years of follow-up; among patients with cT2 tumors, 0% at 1 year, 28.6% (95% CI, 12.9%-58.4%) at 5 years, and 43.6% (95% CI, 19.6%-77.9%) at 10 years of follow-up; and among patients with cT3 tumors, 21.1% (95% CI, 8.1%-52.7%) at 1 year of follow-up and 31.6% (95% CI, 13.5%-64.9%) at 5 years of follow-up. Patients with cT2 and cT3 tumors had a significantly higher cumulative mortality rate compared with those presenting with cT1 tumors (log-rank P < .001). Patients with ulcerated melanomas had significantly higher risk of mortality (hazard ratio, 7.58; 95% CI, 1.02-56.32; P = .04).

Conclusions and Relevance

This multicenter, international, collaborative study yielded evidence that the conjunctival melanoma staging system in the eighth edition of the AJCC Cancer Staging Manual can be used to accurately estimate metastasis and mortality rates. These findings appear to support the use of AJCC staging as a tool for patient care and research.

Conjunctival Melanoma in Asian Indians: A Study of 42 Patients

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

Conjunctival Melanoma in Childhood and Adolescence: A Systematic Review

Background

Conjunctival melanoma is rare in adults and rarer in children. We systematically reviewed the presentation, diagnostic and management strategies as well as outcomes for conjunctival melanoma in children and adolescents.

Methods

The following databases were searched: Medline, Embase, Web of Science and Scopus for cases of conjunctival melanoma occurring in children and adolescents < 18 years of age.

Results

Seventeen studies with 32 patients (18 males) were identified. The median age at presentation was 11 years (range 4-18 years). Most patients were white. Most patients presented with a conjunctival mass or naevus with a recent history of growth or change. Excision biopsy provided diagnosis and management for all cases. Adjuvant chemotherapy and radiotherapy were also used. One patient had metastatic disease at diagnosis and 3 developed metastatic disease (range 1-10 months). Two patients died from disease and one was alive with metastatic disease. Two patients had disease recurrence. Outcomes were observed to be better where diagnosis was made earlier and "no-touch" excision biopsy was performed in an appropriate specialist setting.

Conclusions

Conjunctival melanoma occurs rarely in children and adolescents. Surgery is the mainstay of management. The prognosis is guarded in metastatic disease due to the small sample size and limited follow-up.

Conjunctival melanoma copy number alterations and correlation with mutation status, tumor features, and clinical outcome

Relatively little is known about the genetic aberrations of conjunctival melanomas (CoM) and their correlation with clinical and histomorphological features as well as prognosis. The aim of this large collaborative multicenter study was to determine potential key biomarkers for metastatic risk and any druggable targets for high metastatic risk CoM. Using Affymetrix single nucleotide polymorphism genotyping arrays on 59 CoM, we detected frequent amplifications on chromosome (chr) 6p and deletions on 7q, and characterized mutation‐specific copy number alterations. Deletions on chr 10q11.21‐26.2, a region harboring the tumor suppressor genes, PDCD4, SUFU, NEURL1, PTEN, RASSF4, DMBT1, and C10orf90 and C10orf99, significantly correlated with metastasis (Fisher's exact, p ≤ 0.04), lymphatic invasion (Fisher's exact, p ≤ 0.02), increasing tumor thickness (Mann–Whitney, p ≤ 0.02), and BRAF mutation (Fisher's exact, p ≤ 0.05). This enhanced insight into CoM biology is a step toward identifying patients at risk of metastasis and potential therapeutic targets for systemic disease.

Treatment of conjunctival melanoma in a Dutch referral centre

AIMS

To evaluate the treatment of conjunctival melanoma at a large Dutch referral centre and to make recommendations for clinical management.

METHODS

A retrospective review was performed of clinical and histological data of 70 patients treated for a primary conjunctival melanoma between 2001 and 2014 at the Leiden University Medical Center, Leiden, the Netherlands. Detailed follow-up data were available for all patients.

RESULTS

The mean follow-up time was 70.2 months. The overall 5-year recurrence rate was 29%, the 5-year metastasis rate 12% and the 5-year melanoma-related survival 90%. Treatment with excision alone had a significantly higher 5-year recurrence rate than (the combination of) other treatments (HR 3.73,95% CI 1.19 to 11.6, P=0.02). Initial treatment in an ocular oncology centre was associated with fewer recurrences compared with initial treatment by a local ophthalmologist of a referring centre (HR 0.32,95% CI 0.11 to 0.94, P=0.04), despite similar tumour baseline characteristics.

CONCLUSION

Conjunctival melanoma is a rare disease with a high recurrence rate. A treatment strategy with local excision and adjuvant therapy gave a good clinical outcome, excision alone as a treatment should be considered obsolete. Initial treatment in a large referral centre improves clinical outcome, and patients should be referred to a specialised centre as soon as possible.

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 Tumors: Review of Clinical Features, Risks, Biomarkers, and Outcomes--The 2017 J. Donald M. Gass Lecture

Conjunctival tumors encompass a broad range of diagnoses. The 3 most important malignant tumors include ocular surface squamous neoplasia (OSSN) (14%), melanoma (12%), and lymphoma (7%). Conjunctival malignancies are rarely found in children. Regarding OSSN, pre-disposing conditions include chronic solar radiation, immune deficiency (HIV), organ transplant, autoimmune conditions, xeroderma pigmentosum, and chronic exposure to cigarette smoke. OSSN is managed surgically or with topical/injection immunotherapy or chemotherapy. Metastasis occurs in <1%. Regarding melanoma, predisposing conditions include primary acquired melanosis (PAM), chronic nevus, and chronic solar radiation. Treatment of PAM or nevus can prevent melanoma. Melanoma management involves surgical resection with clean margins and avoidance of direct tumor manipulation ("no touch" technique). The first surgery is most important, to minimize tumor seeding. Biomarkers including BRAF, TERT, and PTEN provide information regarding risk for metastasis and allow for targeted antibiomarker therapies. Ten-year risk for melanoma metastasis is 25%. Tumors >2 mm thickness or those located in fornix, caruncle, or orbit are at highest risk for metastasis. Regarding lymphoma, predisposing conditions include benign reactive lymphoid hyperplasia, immune deficiency (HIV), immune dysfunction, and chronic inflammation/infection (Helicobacter pylori, Chlamydia psittaci). The 4 most important subtypes include extranodal marginal zone lymphoma (ENMZL), follicular lymphoma, mantle cell lymphoma (MCL), and diffuse large B-cell lymphoma. Treatment includes surgical resection, cryotherapy, radiotherapy, systemic chemotherapy, or targeted anti-B-cell therapy (rituximab). Lymphoma-related survival (5-year) depends on subtype and ranges from 97% (ENMZL) to 9% (MCL). Recognizing conjunctival tumors and understanding predisposing factors, biomarkers, and treatment strategies are vital to patient outcomes.

Ocular oncology: advances in retinoblastoma, uveal melanoma and conjunctival melanoma

BACKGROUND

Retinoblastoma, uveal and conjunctival melanomas are important malignancies within the remit of ocular oncology. Outlined are the diagnostic features and management principles, as well as advancements in the field and current challenges.

SOURCES OF DATA

Original papers, reviews and guidelines.

AREAS OF AGREEMENT

Most eyes with retinoblastoma (International Intraocular Retinoblastoma Classification (IIRC) Group A-D) are salvaged, whereas advanced cases (Group E) remain a challenge. Despite a high rate of local tumour control in uveal melanoma, metastatic spread commonly occurs. Conjunctival melanoma is treated by complete resection, but high rates of local recurrence occur, with the possibility of systemic relapse and death.

AREAS OF CONTROVERSY

Use of the IIRC in retinoblastoma, and systemic screening in melanomas.

GROWING POINTS

Utilization of novel treatment modalities in retinoblastoma and an increasing understanding of the genetic basis of melanomas.

AREAS TIMELY FOR DEVELOPING RESEARCH

Improvements in chemotherapy delivery in retinoblastoma and prognostic tests in melanomas.

[Operative therapy and irradiation of conjunctival melanoma]

BACKGROUND

Radiotherapy of conjunctival melanoma has gained in importance in recent years compared to less invasive therapeutic approaches. This is due to the high recurrence rates achieved by omitting adjuvant therapy and to the increasing availability of suitable radiotherapeutic methods, so that tumors formerly not amenable to organ-preserving therapy can now be treated.

OBJECTIVE

This article presents the current radiotherapeutic options for conjunctival melanoma. The aim is to describe the diagnostic and therapeutic strategies and the course of therapy of malignant conjunctival melanoma. It is the authors' intention to justify the necessity of the adjuvant therapy of conjunctival melanoma and to emphasize the need for interdisciplinary cooperation during the course of tumor therapy.

METHODS

The article is based on results published in the literature as well as on data collected and experience gained in our centre.

[Adjuvant therapy and interdisciplinary follow-up care of conjunctival melanoma]

BACKGROUND

Despite microscopically controlled tumor excision, malignant melanomas of the conjunctiva have a propensity for local recurrence, lymphatic spread and distant metastases.

OBJECTIVES

This review outlines the options of adjuvant therapy as well as the structure of interdisciplinary follow-up care for patients with conjunctival melanoma.

METHODS

The study provides a PubMed literature review and own clinical results.

RESULTS

In conjunctival melanoma complete tumor excision using a minimal touch technique should always be combined with adjuvant therapy, such as cryotherapy, radiotherapy, topical chemotherapy and/or immunotherapy. For locally circumscribed lesions of the bulbar conjunctiva adjuvant brachytherapy can be supplemented and for non-bulbar, extensive, diffuse or multilocular tumor growth, complementary adjuvant topical mitomycin C therapy or proton radiotherapy can be used. Novel adjuvant approaches include topical interferon alpha-2b immunotherapy, topical vascular endothelial growth factor (VEGF) inhibitors or in cases of BRAF mutations personalized therapy using selective BRAF inhibitors or in combination with mitogen-activated protein kinase (MAPK) and extracellular signal-regulated kinase (ERK), MAPK/ERK (MEK) inhibitors. All patients should be integrated into an interdisciplinary follow-up care program including quarter yearly checkups in the first 5 years and psycho-oncological healthcare.

CONCLUSION

Following microscopically controlled tumor excision, adjuvant treatment using cryotherapy, radiotherapy, topical chemotherapy and/or immunotherapy as well as interdisciplinary follow-up care are mandatory for the modern management of patients with conjunctival melanoma.

Systemic BRAF/MEK Inhibitors as a Potential Treatment Option in Metastatic Conjunctival Melanoma

AIM

In this review, we outline similarities between conjunctival and skin melanoma as well as the effectiveness of combined BRAF/MEK inhibition in melanoma, and discuss the applicability of these agents in conjunctival melanoma.

METHODS

The study provides a PubMed literature review.

RESULTS

Conjunctival melanoma and skin melanoma are genetically and phenotypically related. Both tumors typically harbor BRAF mutations in more than 50% of cases. New targeted therapies in metastatic skin melanoma include selective inhibition of BRAF and MEK. Combined BRAF/MEK inhibition has revolutionized the treatment of metastatic skin melanoma, significantly improving patients' prognoses. While these new substances have been investigated extensively in the treatment of skin melanoma, comparable studies in conjunctival melanoma do not exist owing to the rarity of the malignancy.

CONCLUSIONS

The application of combined BRAF/MEK inhibition in metastatic or unresectable conjunctival melanoma shows great potential for improving patients' prognoses. Future studies are needed to investigate the assumed benefit.

Advances in the management of conjunctival melanoma

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