Primary conjunctival melanomas
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Primary conjunctival melanomas. Patient profile. 7 patients. 5 females ; 2 males. The female age range was 39-77 (median age 62). The males were aged 44 and 74. All patients had unilateral disease. 4 right eyes and 3 left eyes were affected. 14 primary invasive melanomas

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Primary conjunctival melanomas.

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Primary conjunctival melanomas.


Patient profile

  • 7 patients.

    5 females ; 2 males.

    The female age range was 39-77 (median age 62).

    The males were aged 44 and 74.

    All patients had unilateral disease.

    4 right eyes and 3 left eyes were affected.


14 primary

invasive

melanomas

in 7 patients

3 patients

Multiple mm

4 patients

Solitary mm

2 juxta-limbal

bulbar conjunctiva;

2 inferior fornix

and

inferior tarsal conjunctiva.

1 juxta-limbal bulbar,

1 juxtalimbal bulbar and non-bulbar

1 juxtalimbal bulbar and plica involvement.


Melanoma thickness

  • 0.1mm to 1.4 mm

  • pT1a to pT2b

  • All cases associated with in-situ MM

  • One case had vascular invasion.


What’s the big deal?


18 months later………………


8 months later………………


2002

2010


19 nodules overall

7 patients

4 patients solitary

3 patients multiple

1-synchronous

2-metachronous


Location of nodules

6 patients

nodules

after primary

Conj mm diag.

1 patient

presented

with nodule

19 nodules

in 7 patients

11 NON-BULBAR

8 BULBAR

Nodule size range 3-9mm

Median-5mm


Nodules

3-102 months

after first primary

Conj mm

(median 10m)

7 patients

Systemic mets

8-37 m after

First nodule

5 free of systemic

mets

2 developed

systemic mets

Alive

level 1 and 2

neck lymph nodes

intra-parotid lymph node

lung.

Dead

Bone

Liver

Brain


Histology of these nodules?


Local conjunctival metastases(LCM)


Evidence that nodules are

Local METS?

2 cases

Developed

Systemic mets

Multiple

and synchronous

Nodules-behaviour

like mets.

Well defined

Cannon ball

1 nodule-necrosis

Eg. Skin mm

In-transits

Well defined Grenz zone

No overlying in-situ MM


Argument against mets.

  • New primaries with once-existent in-situ melanoma, with the latter regressed in response to Mitomycin C and the nodule having been ‘carved out’

    Unlikely

  • In one case, the LCM was the presenting feature with no history of prior topical chemotherapy or surgery.

  • Further primary tumours developed in some cases, while on topical chemotherapy and none of these further primary tumours exhibited a well-defined, nodular morphology.

  • One case, the LCM developed 8 years after the primary tumour had been treated and never received MMC.


Odd distribution of LCMs?

  • Local factors that promote arrest and growth of the LCMs.

  • Surgery scarring and inflammation -damming up of tumour cells-possible but in 1 case, LCM at presentation and some cases LCM remote from surgery site.

  • Seeding by surgery? But 1 case presentation with LCM with no prior surgery history and no nodules at edge of dissection lines.

  • Dormant micromets that disseminate early…grow..?

  • Circulating stem cells that find niche and expand ?


  • All of the LCM extravascular,

  • Always extravascular, or whether once intravascular and have exited?

  • Intrinsic blood supply

  • Associated with a lymphocyte cap. Host reaction?

    LCM selected a pre-existing lymphoid niche?

  • LCM associated with lymphatic vessels some cases. Intraymphatic spread? Lymphangiogenesis?


Systemic mets.

  • 2 cases.

  • Is LCM a proxy measure for what is happening systemically?

  • Indication for sentinel LN biopsy?

  • Should LCMs be regarded as ‘N’ status in pathological TNM classification (like large bowel adenoca)?


Thanks


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