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

Primary conjunctival melanomas.


Patient profile

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.


Primary conjunctival melanomas

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

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

What’s the big deal?


Primary conjunctival melanomas

18 months later………………


Primary conjunctival melanomas

8 months later………………


Primary conjunctival melanomas

2002

2010


Primary conjunctival melanomas

19 nodules overall

7 patients

4 patients solitary

3 patients multiple

1-synchronous

2-metachronous


Location of nodules

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


Primary conjunctival melanomas

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

Histology of these nodules?


Local conjunctival metastases lcm

Local conjunctival metastases(LCM)


Primary conjunctival melanomas

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

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

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 ?


Primary conjunctival melanomas

  • 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

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

Thanks


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