Conjunctival melanoma arising from diffuse primary acquired melanosis in a young black woman

Clinical profile of melanocytic lesions of the ocular surface in a Hispanic population

PURPOSE

To determine the prevalence, clinical characteristics, and demographic factors of melanocytic lesions of the ocular surface, such as racial melanosis, primarily acquired melanosis, conjunctival nevus, and conjunctival melanoma in a Hispanic population.

MATERIALS AND METHODS

A cross-sectional and observational study was undertaken in a tertiary referral ophthalmological center in northern Mexico from December 2020 to April 2021. All patients attending an ophthalmology specialty clinic were screened during their first visit in order to detect melanocytic lesions of the ocular surface. Demographic factors, clinical characteristics, and diagnosis and treatment were recorded.

RESULTS

227 patients were screened for melanocytic lesions. Melanocytic lesions were identified in 114 patients (50.2%). The prevalence of the different melanocytic lesions in the screened population was racial melanosis, 45.3%; primary acquired melanosis, 3.5%, and conjunctival nevus 1.3%. No conjunctival melanoma was identified in the screened population. Primary acquired melanosis was more common in the fifth to sixth decade of life and in females. Racial melanosis showed no gender predilection and was also more common in the fifth to sixth decade of life. Only 1 melanocytic lesion (a primary acquired melanosis) required medical treatment with excisional biopsy and cryotherapy.

CONCLUSION

The prevalence of racial melanosis is remarkably high in the Hispanic population. While less prevalent, primary acquired melanosis is also present in a considerable percentage of Hispanic patients. Both melanocytic lesions exhibit demographic characteristics that match those previously reported in the medical literature.

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.

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

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

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

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

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

Current appraisal of conjunctival melanocytic tumors: classification and treatment

Conjunctival melanocytic tumors represent a spectrum of pigmented tumors that include benign, premalignant and malignant tumors. Conjunctival nevi are the most common pigmented tumors and are typically found in the interpalpebral bulbar conjunctiva. These lesions usually contain fine clear cysts on slit lamp biomicroscopy. Primary acquired melanosis includes lesions from increased melanin pigmentation without proliferation of melanocytes to melanoma in situ. In the new classification system, the idea is to use the term 'primary acquired melanosis' only as a clinical description, highlighting the fact that the biologic behavior of acquired melanotic lesions cannot be predicted solely based upon clinical grounds without histopathologic examination. Conjunctival melanoma represents only 5% of all melanomas arising in the ocular region and is associated with a high mortality rate. The management of primary acquired melanosis, nevi and conjunctival melanomas involves various modalities used either alone or concomitantly depending on the size and extent of the lesion.

Recurrent primary acquired melanosis with atypia involving a clear corneal phacoemulsification wound

PURPOSE

To report a case of corneal primary acquired melanosis (PAM) with atypia after cataract surgery.

METHODS

Retrospective case report with literature review.

RESULTS

Excision of an elevated pigmented conjunctival lesion was performed at the time of cataract extraction by clear corneal phacoemulsification by an outside surgeon. Histopathologic examination revealed PAM with atypia. Three months after the initial surgery, recurrent melanosis involving the peripheral corneal epithelium was noted, with extension of pigment into the corneal stroma through the paracentesis site. Excision of the involved corneal epithelium and the adjacent conjunctiva was performed, and microscopically recurrent PAM with atypia was confirmed. Adjuvant cryotherapy was applied at the time of surgery, and topical mitomycin C was given postoperatively. Repeat biopsies revealed no remaining malignancy, and the intrastromal pigment has disappeared during 18 months of follow-up.

CONCLUSION

We present this case to illustrate the importance of complete evaluation and treatment of potentially atypical melanocytic conjunctival lesions before proceeding with elective intraocular surgery.

Boston Ocular Surface Prosthesis for persistent epitheliopathy after treatment of conjunctival melanoma

PURPOSE

To report two cases of persistent epitheliopathy after treatment of conjunctival melanoma and review management options for this condition.

METHODS

Case report and literature review.

RESULTS

Persistent epitheliopathy, presumably resulting from limbal stem cell deficiency, is an uncommon complication of treatment of conjunctival malignant melanoma with surgical excision, cryotherapy, and mitomycin C. The Boston Ocular Surface Prosthesis was successful in improving vision, comfort, and epithelial status in our patients.

CONCLUSION

Persistent epitheliopathy is a rare complication of treatment of conjunctival melanoma. The Boston Ocular Surface Prosthesis is a viable treatment option in this situation.

Population-based incidence of conjunctival melanoma in various races and ethnic groups and comparison with other melanomas

PURPOSE

To investigate racial and ethnic differences in the incidence of conjunctival melanoma in a large population-based study.

DESIGN

Observational cross-sectional study.

METHODS

Using data from 1992 through 2003 provided by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program, we calculated age-adjusted incidence rates of conjunctival melanoma in various racial and ethnic groups (Black, American Indian, Asian and Pacific Islander, Hispanic, and non-Hispanic White). In addition, we calculated the standard incidence ratios (risk ratios) and 95% confidence intervals to describe the differences within these racial and ethnic groups.

RESULTS

From 1992 through 2003, there were a total of 168 conjunctival melanomas diagnosed in 13 SEER registries with known racial and ethnic groups. The annual age-adjusted incidence rates (per million population) of conjunctival melanoma was 0.18 (Blacks), 0.17 (American Indians), 0.15 (Asians), 0.33 (Hispanics), and 0.49 (non-Hispanic Whites). The difference in the incidence of conjunctival melanoma between Whites and Blacks or Asians was statistically significant, but was not significant between Blacks and Asians.

CONCLUSIONS

The overall White-to-Black incidence ratio in conjunctival melanoma was 2.6:1, which is much less than that of uveal melanoma (18:1) and cutaneous melanoma (13:1 to 26:1), but is similar to that of mucosal melanoma (2.2:1 to 2.3:1). The cause and significance of this difference of racial and ethnic incidence in various melanomas are discussed.

[Conjunctival melanoma at corneoscleral limbus on primary acquired melanosis. A case report]

A 51-year-old Caucasian man consulted for a visual loss in the left eye due to corneal extension of a conjunctival melanoma. This conjunctival melanoma arose from primary acquired melanosis with atypia at the temporal corneoscleral limbus. The patient was treated using a combination of surgical excision with physical treatment by ocular proton therapy. Progression remained under control 11 months after treatment: no local tumour recurrence or metastasis was observed. Primary acquired melanosis with atypia must be regarded as a premalignant melanocytic lesion. Based on this case report, the authors focus on primary acquired melanosis and its risk of transformation to a conjunctival malignant melanoma.

Topical medical therapies for ocular surface tumors

We review the use of three topical medications for the therapy of ocular surface tumors: mitomycin C, 5-fluorouracil, and interferon alpha-2B. One hundred sixty patients with histologically or cytologically proven epithelial and melanocytic tumors were identified in the literature. Side effects occurred most often with mitomycin C, followed by 5-fluorouracil, and interferon alpha-2B. Patients most frequently experienced transient keratitis, redness, and irritation. Topical agents were used as both primary and adjuvant therapy. Rates of tumor regression for CIN and squamous cell carcinoma ranged from 80 to 96%, and 70% of pigmented tumors regressed after an average follow-up of 27 months.