Current Management Of Conjunctival Melanoma

A review of conjunctival melanoma, both in its diagnosis in the context of conjunctival pigmented lesions and in its follow-up and treatment, based on a clinical case.

Raise the awareness of ophthalmologists in the management of these lesions as they can change the prognosis in the evolution of the lesions and thus of the patient, as many of them have suboptimal results due to iatrogenic tumour seeding, inadequate local tumour control and the morbidity of the surgery.

Conjunctival melanoma is rare but carries a poor prognosis. Its aetiology is unknown (UV?):75% come from a conjunctival PAM with atypia, 20-30% from a nevus and only 5-10% "de novo". There is a 50% local recurrence rate and 25% distant metastasis despite adequate treatment. The diagnosis is anatomopathological with an adequate surgical technique and extension study where the sentinel lymph node biopsy and PET/CT scan plays an important role. It may benefit from topical and/or systemic treatment.

A 29-year-old woman with a hyperemic and pigmented conjunctival bulbar temporal right eye lesion of one year's evolution. Suspicion of malignancy led to excision and pathological anatomy of the lesion. It was treated with Mitomycin-C 0.02% and Alcohol 20% intraoperatively (cryotherapy was not available). Recostruction of the defect with amniotic membrane graft. Topical treatment with Interferon alpha-2b was started. After inconclusive pathological examination for melanoma, the specimen was referred to the Royal Liverpool University Hospital where it was reported as invasive epithelioid cell melanoma of the conjunctiva with tumour presence very close to the medial and deep margin. Presence of melanoma in situ in the lateral conjunctiva. Three weeks postoperatively, pigmented cell niches appeared on the graft in the limbar area without affecting the cornea or sclera, so it was decided to add topical Mitomycin-C 0.02% to the topical treatment. During two years of follow-up and extension study with PET/CT scan there has been no evidence of local or distant recurrence.

Importance of proper early diagnosis and follow-up.

High recurrence and lethality.

At the slightest suspicion, perform biopsy.
Need for expert pathologists.

Complete treatment at an early stage decreases tumour seeding and improves outcomes.

Multidisciplinary management.

Local recurrence and distant metastasis may appear years after diagnosis and treatment.

Essential extension study: Sentinel lymph node biopsy and PET/CT scan.

Systemic treatments as a potential treatment option in metastatic conjunctival melanoma.

Psychological support.