Eyelid and periorbital cutaneous malignant melanoma

Staged Excision Technique for Periocular Cutaneous Melanoma: Long-Term Outcomes of the Square Procedure

PURPOSE

To examine the long-term outcome of the staged excision via the square procedure for the treatment of periocular thin cutaneous melanoma.

METHODS

A retrospective chart review of 95 periocular cutaneous melanoma-in-situ and microinvasive melanoma tumors that were treated with the square procedure between April 1, 1994 and December 31, 2018 at the University of Michigan. Demographic and clinical data were evaluated.

RESULTS

Of 95 cases, 19 (20%) were atypical junctional melanocytic proliferation with features of early melanoma-in-situ, 63 (66.3%) were melanoma-in-situ and 13 (13.7) were microinvasive melanoma with Breslow depth less than 1 mm. Tumor-free margins were achieved with a median margin of 10 mm (range 5-40 mm). Most cases (68.4%) required multiple excision stages. Surgical revision was necessary in 17.9% of cases and was associated with larger defect size. Local recurrence was noted in 8 patients (8.4%) at a median of 42 months postreconstruction. No tumor characteristics were found to predict recurrence.

CONCLUSIONS

The square procedure for periocular melanoma offers an 8.4% recurrence rate, consistent with literature reports on similar staged excision approaches. The staged excision provides an excellent option for comprehensive margin review and tumor control with acceptable cosmetic results after reconstruction.

Long-term outcomes of margin-controlled excision for eyelid melanoma

OBJECTIVES

To provide evidence for long-term outcomes for margin-controlled excision of eyelid melanoma.

METHODS

Retrospective single-centre observational case series of patients treated for eyelid melanoma between 2007 and 2016, with a minimum of 5-year follow-up. Tumour excision involved rush-paraffin en face horizontal sections and delayed repair (Slow Mohs; SM).

RESULTS

Twenty-two cases were seen with a survival of 91% (two deaths from nodular and lentigo maligna melanoma) and seven with melanoma in situ (MIS). Invasive melanoma includes eight lentigo maligna melanoma, four nodular, two amelanotic and one desmoplastic. Mean Breslow thickness was 6 mm for invasive (range 0.5-26). Mean excision margin for MIS was 3 mm (range 2-5 mm) and for invasive was 5 mm (range 2-10). Further excisions were performed in nine (41%); two went on to recur. Local recurrence was 36%; six invasive (27%) at a mean of 24 months (range 1.5-5 years) and two for MIS at a mean of 15 months (range 1-1.5 years). Imaging occurred for suspected advanced disease. Sentinel node biopsy was not performed. Advanced melanoma therapy was performed in two cases. No vitamin D testing occurred.

CONCLUSIONS

Survival rates are in line with 90% overall survival in the UK. Prescriptive excision margins are not applicable in the periocular region and margin-controlled excision with a delayed repair is recommended, but patients need to know further excision may be needed to obtain clearance. Evidence recommending vitamin D therapy needs to be put into clinical practice. In addition, upstaging of MIS occurred advocating excision rather than observation of MIS. More studies are needed to determine the best management of eyelid melanoma.

Diseases of the Eyelids and Orbit

The eyelids and orbit encompass intricate bony and soft tissue structures that work harmoniously in concert to protect, support, and nourish the eye in order to facilitate and maintain its function. Insult to periorbital and orbital anatomy can compromise orbital and ocular homeostasis. This article provides a foundational overview of eyelid and orbital anatomy, as well as common and key disorders that may confront internists and medical subspecialists.

Epidemiology and Survival Outcomes for Eyelid Primary Malignant Melanoma: An Analysis of 1397 Cases in the SEER Database

Purpose

There has not been a recent population-based study regarding the epidemiological trend and survival of eyelid primary malignant melanoma (PMM). Our study aims to evaluate the updated incidence trends and discuss the factors affecting the survival outcomes of eyelid PMM.

Methods

A total of 1397 eyelid PMM cases diagnosed between 1975 and 2016 were retrospectively identified from the Surveillance, Epidemiology, and End Results (SEER) database. Age-adjusted incidence rates and annual percent changes (APC) were calculated. Kaplan-Meier and Cox proportional hazards regression models were used to calculate survival outcomes and identify potential prognostic factors.

Results

The overall age-adjusted incidence of eyelid PMM rose from 0.039 (95% confidence interval [CI], 0.012–0.088) in 1975 to 0.103 (95% CI, 0.070–0.143) per 100 000 population in 2016, with significant APC of 1.313% (p < 0.001). Male subjects showed a higher average age-adjusted incidence rate than female subjects (p < 0.001). Survival analyses showed that 5-year accumulative overall survival (OS) and disease-specific survival (DSS) for patients with eyelid PMM were 70.5% and 90.6%. Additionally, 10-year OS and DSS were 51.8% and 86.1%, respectively. Analyses of Kaplan-Meier survival curves with the log-rank test revealed that older age, White race, nodular melanoma, higher American Joint Committee on Cancer (AJCC) stage (II to IV), advanced stage, distant metastasis, and no-surgery treatment were associated with lower OS and DSS rates. Age, histology, AJCC stage, and stage at diagnosis were found to be independent predictors of OS and DSS in multivariate models.

Conclusion

The incidence of eyelid PMM increased with significant APC and male predominance. Age, histology, AJCC stage, and stage at diagnosis might be independent predictors of prognosis, emphasizing the importance of improved diagnosis of eyelid PMM.

Melanoma of the eyelid and periocular skin: Histopathologic classification and molecular pathology

Cutaneous melanoma, a potentially lethal malignancy of the periocular skin, represents only a small proportion of the roughly 87,000 new cases of cutaneous melanoma diagnosed annually in the United States. Most of our understanding of melanoma of the eyelid skin is extrapolated from studies of cutaneous melanoma located elsewhere. Recent years have witnessed major breakthroughs in molecular biology and genomics of cutaneous melanoma, some of which have led to the development of targeted therapies. The molecular insights have also kindled interest in rethinking how cutaneous melanomas are classified and assessed for risk. We provide a synopsis of the epidemiology, histopathologic classification, and clinical experience of eyelid melanoma since 1990 and then review major advances in the molecular biology of cutaneous melanoma, exploring how this impacts our understanding of classification and predicting risk.

What's New in Eyelid Tumors

Eyelid malignancies represent between 5% and 10% of all skin cancers. Basal cell carcinoma is the most common, followed by squamous cell carcinoma, sebaceous cell carcinoma, Merkel cell carcinoma, and melanoma. The gold standard treatment for periocular epithelial malignancies is surgical excision. Given the constraints of the anatomy and function of the eyelids, excision with negative margins and reconstruction can be challenging. In cases of significant tissue invasion or metastasis, complete tumor removal may not be possible. This review examines the management of periocular skin cancer from diagnosis and staging, including the role of sentinel lymph node biopsy, to both surgical and nonsurgical treatment. The development of targeted drug therapy against specific genetic mutations in cutaneous malignancies has allowed for the treatment of specific cancer cells with less systemic toxicity than more traditional treatments.

CRB1: one gene, many phenotypes

Mutations in the CRB1 gene cause severe retinal degenerations, which may present as Leber congenital amaurosis, early onset retinal dystrophy, retinitis pigmentosa, or cone-rod dystrophy. Some clinical features should alert the ophthalmologist to the possibility of CRB1 disease. These features are nummular pigmentation of the retina, atrophic macula, retinal degeneration associated with Coats disease, and a unique form of retinitis pigmentosa named para-arteriolar preservation of the retinal pigment epithelium (PPRPE). Retinal degenerations associated with nanophthalmos and hyperopia, or with keratoconus, can serve as further clinical cues to mutations in CRB1. Despite this, no clear genotype-phenotype relationship has been established in CRB1 disease. In CRB1-disease, as in other inherited retinal degenerations (IRDs), it is essential to diagnose the specific disease-causing gene for the disease as genetic therapy has progressed considerably in the last few years and might be applicable.

The molecular genetics of eyelid tumors: recent advances and future directions

BACKGROUND

Unprecedented recent advances in the molecular genetics of cutaneous malignancies have markedly improved our ability to diagnose, treat, and counsel patients with skin tumors. This review provides an update on molecular genetics of periocular cutaneous basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma, Merkel cell carcinoma, and malignant melanoma and describes how the knowledge of molecular genetics is translated into clinical practice.

METHODS

A literature search of peer-reviewed and indexed publications from 1965 to 2012 using the PubMed search engine was performed. Key terms included: molecular genetics, eyelid, basal cell carcinoma, squamous cell carcinoma, sebaceous adenoma, sebaceous epithelioma, sebaceoma, sebaceous carcinoma, Merkel cell carcinoma, and melanoma. Seminal articles prior to 1965 were selected from primary sources and reviews from the initial search. Articles were chosen based on pertinence to clinical, genetic, and therapeutic topics reviewed in this manuscript.

RESULTS

We reviewed the literature regarding the advances in molecular genetics of cutaneous basal cell carcinoma, squamous cell carcinoma, sebaceous neoplasia, Merkel cell carcinoma, and malignant melanoma, and possible future directions towards diagnosing and treating cutaneous tumors at the genetic level. Cell culture experiments, animal models, and molecular genetic studies on the patients' tumor tissues helped to elucidate genetic aberrations in these lesions. Cell culture experiments, animal studies and, ultimately, clinical trials provided means to test and develop novel therapeutic strategies, namely targeted therapy directed at specific molecular genetic defects. While remarkable progress has been made in this process, the complexity of the molecular genetics of skin tumors makes complete elucidation of the genetic mechanisms and the search for ideal therapies challenging.

CONCLUSIONS

The recent studies focusing on molecular genetics of cutaneous malignancies show promising results, thereby improving our ability to diagnose, treat and counsel patients with these lesions. Future studies will hopefully help unravel further molecular mechanisms involved in cutaneous neoplasia and provide insights into novel preventative and therapeutic modalities.