Advances in the management of malignant tumors of the eyelid and conjunctiva: the role of sentinel lymph node biopsy

Conjunctival melanoma: a review of conceptual and treatment advances

The aim of this study was to review the available literature and identify recent advances in the classification and management of conjunctival melanoma (CM) for clinicians working in this field. English-based articles were identified using the MEDLINE^® database, and additional cited works not detected in the initial search were also obtained. Articles were assessed according to the Australian National Health and Medical Research Council levels of evidence criteria. Review of the literature indicated that the current classification and management of CM is predominantly based upon primarily nonrandomized, single-institution, retrospective case series. While these studies provide the basis for the recent seventh edition of the tumor node metastasis staging classification, this classification more accurately reflects the current knowledge of prognostic factors for CM. Application of this revised classification system together with prospective trials will provide the opportunity for future consistent and comparable data collection across centers, and it will improve the quality of evidence upon which current classification and management of CM is based. Furthermore, the high risk of local recurrence with current standard management suggests that adjuvant therapy, particularly mitomycin C and/or brachytherapy, may improve outcomes regardless of clinical staging. Finally, the use of sentinel lymph node biopsy may have significant benefit for a select group of CM patients.

Treatment and Outcomes of Malignant Melanoma of the Eyelid

PURPOSE

To review the treatment and outcomes of malignant melanoma (MM) of the eyelid skin.

DESIGN

Retrospective case series review.

PARTICIPANTS

All consecutive patients who had MM arising from eyelid skin treated by 2 regional tertiary referral oculoplastic surgeons were included.

METHODS

Patient charts were reviewed to collect information on the main outcome measures.

MAIN OUTCOME MEASURES

Demographics, clinical and histological features of the lesion, treatment, and outcomes.

RESULTS

Twenty-nine patients between 22 and 88 years old (mean, 65) were included. The most common site of MM occurrence was the lower eyelid. Seventeen cases arose in an area of pigmentation, 4 arose de novo, and 8 were of unknown origin. The most common histopathological types were lentigo maligna melanoma (19 cases), followed by superficial spreading MM (8 cases). Fourteen patients had in situ disease and therefore had no Breslow thickness. Another 7 patients had Breslow thickness of <0.76 mm. Thirteen patients had Clark level II or higher. According to the American Joint Committee on Cancer staging system for cutaneous melanoma, 14 patients were clinically stage 0 and 6 patients were stage IA, with thickness < or = 1 mm and no ulceration. Treatment included wide excision in all cases, one of which underwent anterior exenteration. Pathological techniques used included mapped serial excision with standard or overnight paraffin sections or Mohs' micrographic surgery. Most patients had a good outcome, although 2 died of the disease. Five patients had local recurrence, and 4 had distant metastases. Median postoperative follow-up was 3 years (range, 1 month-9 years, 9 months).

CONCLUSIONS

Lentigo maligna melanoma compared with other forms of MM was relatively more common in the periocular region than in other body locations. Our pathologists preferred paraffin sections to frozen section for accurate assessment of melanocytic atypia and margin status. Initial wide excision margins of 10 mm from the macroscopic edge of the tumor are suggested, as histological margins may be less than this. Margin control by mapped serial excision or a modified Mohs' micrographic surgery using paraffin sections is a useful technique to ensure complete excision and minimization of local recurrence.

Sentinel node biopsy and head and neck tumors—Where do we stand today?

BACKGROUND

Sentinel lymph node sampling may be studied profitably in series of patients with 1 tumor type, such as breast carcinoma, in 1 anatomic locale. The present work analyzes the efficacy of sentinel node sampling in a pathologically diverse group of lesions from an anatomically diverse region such as the head and neck; however, there are risks conflating the findings in different tumors with radically different behaviors, in the process producing muddled data. This report reviews the head and neck experience with sentinel sampling and concludes that certain tumor types that have a known propensity for aggressive behavior are the best candidates for trials employing sentinel node sampling; candidates include many cutaneous melanomas of the head and neck, oropharyngeal squamous carcinomas, and selected thyroid carcinomas. Despite the growing popularity of sentinel node sampling in a variety of regions of the body, however, at this juncture this technique remains an investigational procedure, pending demonstration of a tangible improvement in patient outcome through its use. It is recommended that studies of the efficacy of this technique strive, whenever possible, to segregate results of different tumor types in different head and neck locales from one another so as to produce more focused findings for discrete types of malignancies, and not group together tumor types that may in reality exhibit different biological behaviors.

Clinical follow-up of conjunctival malignant melanoma

PURPOSE

To investigate the clinical features and course of conjunctival malignant melanoma in Korea.

METHODS

The medical records of 15 patients, 5 males and 10 females, diagnosed with conjunctival malignant melanoma who had been treated at Severance Hospital from May 1991 to March 2004 were reviewed retrospectively. The clinical parameters of the patients, tumors, and treatment were analyzed for their relation to outcome measures.

RESULTS

The mean age at the time of diagnosis was 53.4 years (+/- 11.7 years). In all cases, the disease was unilateral and all patients had experienced at least one recurrence. Local lymph node metastasis was found in 3 patients (20%) and the mean time to metastasis was 3.5 years. Systemic metastasis was found in 6 patients (40%) and the mean time to metastasis was 9.3 years. There were 5 cases of tumor-related death (33.3%), 4 of which were attributed to systemic metastasis. The Kaplan-Meier estimates of cumulative survival rate were 90% at 30 months and 56.6% at 70 months.

CONCLUSIONS

Although conjunctival malignant melanoma is a rare disease, it is life-threatening and complete tumor excision at an early stage is mandatory, as is additional therapy to prevent local recurrence and systemic metastasis.

Patterns of regional and distant metastasis in patients with eyelid and periocular squamous cell carcinoma

PURPOSE

To determine the frequency and location of regional lymph node metastasis in patients with squamous cell carcinoma (SCC) of the eyelid and periocular skin. Patterns of distant metastasis were also investigated.

DESIGN

Retrospective case series.

PATIENTS

One hundred eleven patients treated at The University of Texas M. D. Anderson Cancer Center for SCC of the eyelid and periocular skin between 1952 and 2000.

METHODS

The clinical records of the 111 patients were retrospectively reviewed. The clinical characteristics analyzed included age, gender, location of lesion, treatment modalities, patterns of regional nodal and distant metastasis, and perineural invasion. Follow-up time ranged from 6 to 484 months (median, 76.6).

MAIN OUTCOME MEASURE

Incidence of regional lymph node metastasis.

RESULTS

The most common sites of SCC were the lower eyelid (54 patients [48.6%]), the medial canthus (40 patients [36.0%]), and the upper eyelid (25 patients [22.5%]). Local treatment of SCC consisted of wide local excision with frozen section analysis to ensure negative margins in 96 patients (86.4%), radiotherapy (without surgery) in 7 patients, and primary exenteration because of extensive tumor in 7 patients. Local recurrence occurred in 41 patients (36.9%). Twenty-seven patients (24.3%) had regional nodal metastasis during the study period. Sixteen of these patients had regional lymph node metastasis at the time of the initial presentation to M. D. Anderson Cancer Center. Eleven developed regional nodal disease later. Seven patients (6.2%) had distant metastasis during the study period. Nine patients (8.1%) had perineural invasion.

CONCLUSION

This study indicates that the overall rate of regional lymph node metastasis in patients with SCC of the eyelid or periocular skin may be as high as 24%. Thus, careful surveillance of the regional lymph nodes is an important aspect of the initial management of eyelid or periocular skin SCC. Consideration could be given to studying sentinel lymph node biopsy as a technique to stage SCC of the eyelid or periocular skin more accurately, especially in patients with recurrent, large, or highly invasive lesions or with perineural invasion.

Sentinel lymph node biopsy in head and neck cancer

In the past decade, the technique of sentinel lymph node biopsy (SLNB) has been applied to a vast array of primary neoplasms, ranging from head and neck melanoma to vulvar carcinoma. At present, experience with SLNB is greatest in patients with melanoma and breast cancer. In view of the well known complications associated with cervical node dissection, it has been suspected for some time that cervical SLNB, if successful, might reduce the morbidity associated with the definitive care of patients with head and neck cancers. This report assesses the current status of SLNB in the treatment of head and neck cancers; while formal investigations of the efficacy of this technique are recommended, SLNB has not yet been demonstrated to possess the same level of utility seen in SLNB in melanoma and breast cancer patients. As a consequence, the application of SLNB to head and neck cancers remains an experimental technique--one which has not yet acquired the status of the standard of patient care.

Feasibility of preoperative lymphoscintigraphy for identification of sentinel lymph nodes in patients with conjunctival and periocular skin malignancies

PURPOSE

To determine the feasibility of preoperative lymphoscintigraphy for identification of sentinel lymph nodes (SLNs) in patients with conjunctival and periocular skin tumors and to determine the patterns of lymphatic drainage from such tumors.

METHODS

We retrospectively reviewed the records of all patients with biopsy-confirmed conjunctival and periocular skin malignancies who underwent lymphoscintigraphy with or without SLN biopsy between January 1999 and June 2000. Patients underwent lymphoscintigraphy with 0.3 to 1 mCi of technetium Tc-99m sulfur colloid in a volume of either 0.2 mL or 1 mL. Images were taken as soon as the first SLNs were detected through the camera and every 15 minutes thereafter. Intraoperative mapping and SLN biopsy was performed 1 to 2 days after lymphoscintigraphy unless the patient refused or there were medical contraindications to the procedure.

RESULTS

The study included 7 patients with malignant melanoma of the conjunctiva or periocular skin and 1 patient with Merkel cell carcinoma of the eyelid. On lymphoscintigraphy, at least 1 SLN was identified in 7 of the 8 patients. Although all lesions located in the lateral half of the ocular adnexa drained to at least one SLN in the parotid (preauricular) area, there was some variability in the drainage patterns of lesions located in the medial half of the ocular adnexa. A smaller injection volume (0.2 mL) was adequate for detecting the nodes draining the area of injection and led to less spread of technetium to the surrounding areas. Six patients underwent SLN biopsy. In all but one, the nodes identified during surgery corresponded with those visualized on lymphoscintigraphy.

CONCLUSIONS

Preoperative lymphoscintigraphy successfully identifies SLNs in most patients with conjunctival and periocular skin malignancies. Smaller injection volumes (0.2 mL) appear to be adequate for identification of the sentinel nodes and lead to less spread to surrounding tissues.