Acquired Melanocytic Naevus
Nevi are noted in
either the skin or the conjunctival surface of the eyelids, particularly
along the lid margin. Junctional and compound type of melanocytic naevi
are the most common types.
Naevus of OtaNevus of
Ota included congenital and acquired cases. Skin lesions mainly occurred
in adolescence for the acquired cases. The main colours of lesions were
brown and blue. The most local lesions were zygomata, temporal regions,
and lower eyelids.
Nevus of Ota.
Presentation of a case associated with a cellular blue nevus with
suspected malignant degeneration and review of the literature.Pathologica.
1997 Apr;89(2):168-74.
BACKGROUND:
Nevus of Ota is a melanotic pigmentary disorder ("dermal
melanocytosis"), mostly congenital or acquired, involving the skin
innervated by the first and the second branch of the trigeminal
nerve, hence its descriptive label of "nevus fuscus coerulaeus
ophthalmic and maxillaris". In more than half of patients this
condition is associated with "ocular melanocytosis" ("melanosis
oculi") involving the conjunctiva, the sclera, the uveal tract and
possibly the optic nerve. In some cases a condition of "orbital
melanocytosis" with involvement of orbital fat and periosteum by
dendritic melanocytes is on record as well as in some other patients
an analogous condition of "leptomeningeal melanocytosis" is present.
At histology tissues from the above sites are seen infiltrated by
dendritic melanocytes which can vary in number from so scarce up to
so numerous that a diagnosis of a blue nevus of the common type is
warranted. Sometimes the finding of a variously pigmented typical
cellular blue nevus in the skin and alternatively that of heavily
pigmented melanocytoma in the eye ("nevus magnocellularis") or in
the meninges (so-called "melanotic meningioma") are respectively
observed. MATERIALS AND METHODS: A case of cellular blue nevus with
histologically uncertain malignant potential in a nevus of Ota of 30
years duration in a white female patient aged 59 is described. The
lesion which was surgically totally removed grossly appeared nodular
shaped and 2 cm sized. Histologically it consisted of a fairly
well-circumscribed proliferation of melanocytic spindle-shaped cells
growing in a vaguely fascicular pattern. On the basis of random
nuclear atypicalities and pleomorphism and additionally by virtue of
the presence of a few scattered mitoses (one of which was atypical)
but in absence of frank necrosis a diagnosis of unpredictable
biologic behaviour seemed to be warranted. The patient was closely
followed-up but no adjunctive therapy given. Four years after the
excision and diagnosis no local recurrence or distant metastasis has
been discovered. A computerized search of previously recorded cases
of melanomas in nevus of Ota was made. CONCLUSIONS: Forty-eight
cases of malignant melanomas complicating this clinico-pathological
setting are on record, mostly in the uveal tract, followed by
locations in central nervous system, skin, and retro-orbital fatty
tissue. Melanomas arising in nevus of Ota tend to be low grade
lesions that do infiltrate locally but rarely metastasize. The
importance of a closely dermatological and ophthalmic surveillance
of patients with nevus of Ota is emphasized.
Melanosis
Oculi :
(Ocular
melanocytosis)- A rare congenital anomaly. It is characterized by
hyperpigmentation of conjunctiva, episclera, sclera, uveal tract and
rarely the optic nerve.
Clinicopathologic
features and behavior of cutaneous eyelid melanoma. Ophthalmology.
2002 May;109(5):901-8.
OBJECTIVE: To
study the clinical and histopathologic features of cutaneous eyelid
melanomas and identify prognostic factors in the behavior of such
tumors. DESIGN: Retrospective observational case series.
PARTICIPANTS: Twenty-three patients with cutaneous eyelid melanomas
without conjunctival involvement. METHODS: Patients' charts were
reviewed for clinical information, treatment procedure, and disease
course (updated at the time of study). Histopathologic sections from
all surgical procedures were reviewed. MAIN OUTCOME MEASURES:
Histologic type of melanoma, tumor growth phase, Clark's level of
invasion, tumor thickness, and other microscopic features were
evaluated in each case. The width of excision margins was considered
and measured histologically when possible. RESULTS: There was no
gender predilection. The lower eyelid was more frequently involved
than the upper eyelid or canthi. Seventeen cases (74%) were
invasive, and six (26%) were in situ melanomas. Lentigo maligna
melanoma was the most common histologic type, accounting for 61% (14
cases) of all melanomas and 53% (9 cases) of invasive melanomas.
Superficial spreading melanoma accounted for 22% (5 cases) and
nodular melanoma for 17% (4 cases) of all melanomas. Surgical
excision, as the treatment of choice, was incomplete in nine cases,
two thirds of which were lentigo maligna melanoma (in situ or
invasive). Tumor reappeared in 77.8% of these cases. Fourteen
patients had initial narrow excisions, and three of them (21.4%) had
local recurrences. Although recurrence occurred in one each of our
"in situ," "thin," and "thick" melanomas, it proceeded to distant
metastases and death only in the "thin" one. Adjuvant radiotherapy
was used in six patients with successful disease control in two
cases. CONCLUSIONS: Eyelid skin melanomas have a relatively good
clinical prognosis. The histologic type and thickness of the primary
melanoma were not clearly related to the clinical behavior once they
were completely excised. The use of very narrow excisions of 5 mm or
less was associated with greater frequency of local recurrence.
Lentigo maligna melanomas were the largest tumors at presentation
and, despite being thinner, were a greater surgical challenge. This
type of melanoma is almost certainly underdiagnosed by
ophthalmologists.
Prognostic factors for survival in malignant melanoma of the eyelid
skin.Ophthal
Plast Reconstr Surg. 2000 Jul;16(4):250-7
PURPOSE: This
study aimed to determine the prognostic factors for survival and
disease-free interval for malignant melanoma of the eyelid skin.
METHODS: This was a retrospective, nonrandomized, clinical review.
Twenty-four patients with eyelid skin melanoma were identified
through a search of the tumor registry at M. D. Anderson Cancer
Center. Patients were treated between 1953 and 1994. The follow-up
ranged from 3 to 18 years (mean = 9.6 years). Primary treatment in
all cases entailed wide local excision of the tumor. Patients in
whom regional lymph node metastasis developed underwent
parotidectomy or neck dissection, with or without adjuvant
chemotherapy or external beam radiation. Descriptive statistics were
used to characterize the patients. Survival analysis in terms of
disease-free survival and recurrence-free survival was performed
using age, sex, location of tumor (upper lid, lower lid, or both),
histologic type of melanoma, Breslow thickness, and Clark's level as
independent variables for survival. RESULTS: Age, sex, location, and
the histologic type of tumor were not significant prognostic
indicators for survival in this cohort. Clark's level > or = IV by
itself was a statistically significant predictor of decreased
survival. In addition, tumors with either Clark's level > or = IV or
Breslow thickness > or = 1.5 mm were associated with increased
mortality. CONCLUSION: Clark's level > or = IV or Breslow thickness
> or = 1.5 mm are poor prognostic indicators for malignant melanomas
of the eyelid skin. Clinicians should have a high level of suspicion
for occult regional lymph node metastasis when treating patients
with these tumor features.
Congenital
divided compound nevi of the eyelids.Klin
Monatsbl Augenheilkd. 1999
Oct;215(4):263-5
BACKGROUND:
Congenital divided nevi of the eyelids are a rare melanocytic
lesion. Only 30 patients are reported in literature. We report on a
6-year-old boy and a 41-year-old male with this lesion and give a
short overview of the literature. CASE REPORTS: Patient 1: A
6-year-old boy presented with a pigmented divided nevus of the left
eye involving the upper and lower lid naselly. The lesion had
increased in size in the last one year. Otherwise the results of
ophthalmological examination were unremarkable. The divided nevus
was completely excised. Histopathological studies revealed a
melanocytic compound nevus. Patient 2: A 41-year old male presented
in our department with a divided pigmented nevus on his left eye
involving the upper and lower lid laterally. The lesion had
gradually increased since birth. Otherwise the results of
ophthalmological examination were unremarkable. A subtotoal excision
and debulking procedure was performed. The defect in the lower
eyelid was covered using a transposition flap from the upper eyelid.
Histopathological examination revealed a melanocytic compound nevus.
CONCLUSION: Divided nevi of the eyelids may be disfiguring and
include the possibility of deprivation amblyopia when reaching a
certain size in childhood. Malignant changes of this lesion were not
observed so far. Total excision or subtotal excision and a debulking
procedure may be helpful.
Cutaneous
melanomas of the eyelid.Semin
Ophthalmol. 2006 Jul-Sep;21(3):195-206
Cutaneous
eyelid melanomas are very rare lesions. The lentiginous subtypes are
the most frequent melanocytic lesions of the eyelid and can be
likened to conjunctival melanocytic lesions like PAM, PAM with
atypia and conjunctival melanoma. Compared to melanomas elsewhere on
the body, eyelid melanomas have special considerations. Eyelid skin
is very thin, the mucocutaneous junction at the lid margin can
affect prognosis, the lymphatic drainage pattern is very variable
and there is an inherent difficulty to excise wide margins without
sacrificing important structures. A customized excision approach,
using tissue-sparing "Slow-Mohs" technique, is suggested. Sentinel
lymph node dissection has an evolving therapeutic role but remains
controversial.
Treatment and
outcomes of malignant melanoma of the eyelid: a review of 29 cases
in Australia.Ophthalmology. 2007
Jan;114(1):187-92.
PURPOSE: To
review the treatment and outcomes of malignant melanoma (MM) of the
eyelid skin. DESIGN: Retrospective case series review. PARTICIPANTS:
All consecutive patients who had MM arising from eyelid skin treated
by 2 regional tertiary referral oculoplastic surgeons were included.
METHODS: Patient charts were reviewed to collect information on the
main outcome measures. MAIN OUTCOME MEASURES: Demographics, clinical
and histological features of the lesion, treatment, and outcomes.
RESULTS: Twenty-nine patients between 22 and 88 years old (mean, 65)
were included. The most common site of MM occurrence was the lower
eyelid. Seventeen cases arose in an area of pigmentation, 4 arose de
novo, and 8 were of unknown origin. The most common
histopathological types were lentigo maligna melanoma (19 cases),
followed by superficial spreading MM (8 cases). Fourteen patients
had in situ disease and therefore had no Breslow thickness. Another
7 patients had Breslow thickness of <0.76 mm. Thirteen patients had
Clark level II or higher. According to the American Joint Committee
on Cancer staging system for cutaneous melanoma, 14 patients were
clinically stage 0 and 6 patients were stage IA, with thickness < or
= 1 mm and no ulceration. Treatment included wide excision in all
cases, one of which underwent anterior exenteration. Pathological
techniques used included mapped serial excision with standard or
overnight paraffin sections or Mohs' micrographic surgery. Most
patients had a good outcome, although 2 died of the disease. Five
patients had local recurrence, and 4 had distant metastases. Median
postoperative follow-up was 3 years (range, 1 month-9 years, 9
months). CONCLUSIONS: Lentigo maligna melanoma compared with other
forms of MM was relatively more common in the periocular region than
in other body locations. Our pathologists preferred paraffin
sections to frozen section for accurate assessment of melanocytic
atypia and margin status. Initial wide excision margins of 10 mm
from the macroscopic edge of the tumor are suggested, as
histological margins may be less than this. Margin control by mapped
serial excision or a modified Mohs' micrographic surgery using
paraffin sections is a useful technique to ensure complete excision
and minimization of local recurrence.
Benign
pigmented lesions of the eyelids.
J Fr Ophtalmol. 2005Oct;28(8):889-95.
We describe
benign pigmented tumors of the lids, including benign lesions of the
epithelium such as papillomas, seborrheic keratosis, and inverted
follicular keratosis; precancerous lesions of the epithelium such as
xeroderma pigmentosum and actinic keratosis; melanocytic lesions
such as Ota nevus, lentigo, and lentigo maligna; and nevi and other
lesions simulating a melanoma such as pigmented hidrocystoma,
angiomas, and epithelial cyst. For each of these lesions, we
describe the clinical and histopathological aspect as well as the
therapeutic guidelines..
Margins of excision
for cutaneous melanoma of the eyelid skin: the Collaborative Eyelid
Skin Melanoma Group Report.
Ophthal Plast Reconstr Surg
2003 Mar;19(2):96-101
PURPOSE: To
evaluate the practice patterns among surgeons who treat melanomas of
the eyelid skin with respect to margins of excision and to look for
possible correlation between margins of excision and the incidence
of local and regional recurrence and distant metastasis. METHODS: A
retrospective survey of the members of the American Society of
Ophthalmic Plastic and Reconstructive Surgery and the European
Society of Ophthalmic Plastic and Reconstructive Surgery yielded 44
cases. The patients' age, sex, date of diagnosis, histologic
classification of melanoma, Breslow thickness, Clark level, location
of melanoma, size of margins of excision, and findings of local or
regional recurrence or distant metastasis were recorded in each
case. Patients were stratified on the basis of margins of excision:
</=5 mm; >5 mm but <10 mm; and >/=10 mm. Patients were also
stratified by Breslow thickness. A Cox regression model was used to
evaluate the predictive value of each factor for recurrence. Main
outcome measures were the incidences of local and regional
recurrence and distant metastasis as a function of margins of
excision and Breslow thickness. RESULTS: The majority of patients
for whom reliable information was available had excision margins of
</=5 mm. The Breslow thickness of most of the tumors was </=1 mm.
Eleven patients (25%) had local recurrence. Five patients (11%) had
regional lymph node metastasis. All patients with regional nodal
metastasis were men. Distant metastasis developed in 3 patients
(7%)-2 men and 1 woman. The follow-up times ranged from 10 to 108
months (mean, 34 months; median, 21 months). The incidence of local
recurrence was higher among patients with melanomas at least 2 mm
thick and margins of excision </=5 mm than among patients with
melanomas at least 2 mm thick but with margins >/=10 mm, but this
difference was not statistically significant because very few
patients had melanomas at least 2 mm thick. Breslow thickness was
the only statistically significant predictor of local, regional, and
distant metastasis. Margins of excision did not have a statistically
significant effect on local, regional, or distant recurrence.
CONCLUSIONS: Breslow thickness is an important prognostic indicator
for eyelid skin melanomas. A 5-mm margin of excision may be adequate
for thin melanomas of the periocular skin, but because of the small
number of patients in this series who had >5-mm margins, a
definitive comparison of outcome with larger margins of excision
cannot be made. For melanomas >/=2 mm, wider margins of excision may
be prudent, and careful surveillance for local and regional
recurrence is indicated.
Periorbital
melanocytic lesions: excision and reconstruction in 40 patients.
Plast Reconstr Surg. 1998
Jul;102(1):19-27.
The treatment
of melanoma arising in the periorbital region is a difficult
reconstructive problem. The abundance of vital structures in close
proximity to one another makes the resection and subsequent
reconstructive procedures extremely challenging. Reported here is
experience with periorbital melanocytic lesions in 40 patients with
the emphasis on the types of reconstruction performed. Forty
patients with periorbital melanocytic lesions were treated between
1984 and 1995. The periorbital region was subdivided into five
zones. These zones are the following: zone I, upper eyelid; zone II,
lower eyelid; zone III, medial canthus; zone IV, lateral canthus;
and zone V, contiguous structures. Ocular melanomas were not
included in this study. The distribution of the lesions in our 40
patients was zone I (n = 1), zone II (n = 14), zone III (n = 1),
zone IV (n = 9), and zone V (n = 31). The ages of the patients
ranged from 3 to 84 years at the time of reconstruction, with an
average age of 57 years. Resection and reconstruction were performed
simultaneously in all patients. Thirty-six of the patients were
reconstructed with one procedure, three patients required two
procedures, and one patient required five procedures. The tumor type
was superficial spreading melanoma in 15 patients, melanoma in situ
in 17 patients, malignant spindle cell neoplasm in 2 patients,
desmoplastic melanoma in 2 patients, amelanocytic melanoma in 1
patient, epithelioid melanoma in 1 patient, and atypical melanocytic
nevus in 2 patients in which an early, evolving melanoma could not
be excluded. Elective lymph node dissection was performed in four
patients for intermediate thickness lesions (1.5 to 4.0 mm). The
types of reconstructions performed included full-thickness skin
grafts, upper lid myocutaneous flaps, cheek advancement flaps,
cervicofacial flaps, inferiorly based nasolabial flaps,
tarsoconjunctival flaps, frontalis muscle flaps, medial
transposition Z-plasty, and primary closure. The resection of
periorbital melanomas can be difficult because of the number of
important anatomic structures in the region. The challenge to the
surgeon in handling head and neck melanomas in general lies in the
need to provide the best functional and aesthetic result while still
resecting the primary lesion with the intent of effecting a cure. We
present our series to demonstrate that the adequacy of margins of
resection need not be compromised to facilitate reconstruction and
that excellent results are obtainable with reconstructive procedures
performed after adequate resections. Several different types of
flaps and grafts can be used, with the indications varying depending
on the location of the lesion and the extent of resection. The major
reconstructive options will be reviewed in detail.
Selected
pigmented fundus lesions of children.J
AAPOS. 2005 Aug;9(4):306-14.
BACKGROUND:
Ocular cells that accumulate melanin pigment are derived from 1 of 2
sources, the optic vesicle or the neural crest. Migration and
distribution of pigment containing cells may go awry during fetal
development or these cells may be altered before or after birth
either by local or systemic stimuli. Specific recognition patterns
of pigment distribution often exist and may relate directly to a
single disease process. METHODS: Records of pediatric patients with
disorders of pigment distribution in the ocular fundi who had been
examined by the author were reviewed. RESULTS: Five disorders with
recognizable patterns of retinal pigment epithelium (optic vesicle
derivation) disturbance (congenital hypertrophy of the retinal
pigment epithelium, Gardner syndrome, chronic granulomatous disease,
preserved para-arteriole retinal pigment epithelium in (autosomal-recessive)
retinitis pigmentosa, and combined hamartoma of the retina and
retinal pigment epithelium), and 5 disorders of cells originating
from the neural crest (choroidal nevi, choroidal melanoma,
melanocytoma, ocular melanosis, and oculodermal melanosis), were
selected for illustration and discussion. CONCLUSIONS: These
arbitrarily selected groups of disorders affect or involve patterns
of pigment deposition in the ocular fundus. These patterns are
recognizable and distinguishable one from another but have different
implications for treatment and follow-up. Progress in recognizing
distinguishing characteristics, diagnostic implications,
understanding, and treatment of these disorders during the past 40
years is compared and contrasted between the 2 groups.
Pigmented
conjunctival and scleral lesions.Mayo
Clin Proc. 1994 Feb;69(2):151-61.
OBJECTIVE: The
multiple causes of pigmentations of the conjunctiva and sclera are
reviewed, and the recommended therapeutic modalities are discussed.
DESIGN: Information from personal experience and the recent
literature is summarized to determine the optimal diagnostic and
treatment approaches for suspicious pigmented conjunctival and
scleral lesions. MATERIAL AND METHODS: Clinical descriptions and
illustrations are presented to characterize these ocular lesions.
RESULTS: Pigmented lesions of the conjunctiva and sclera arise from
either melanocytes or nonmelanocytes and have a diverse differential
diagnosis. These lesions can be classified into congenital melanosis,
conjunctival nevi, acquired melanosis (secondary or primary), and
conjunctival melanomas. In secondary acquired melanosis, the
increased conjunctival pigmentation is caused by irradiation,
hormonal changes, chemical irritation, or chronic inflammatory
conjunctival disorders. The biologic behavior of primary acquired
melanosis of the conjunctiva is a controversial topic with important
implications because it may progress to melanoma. In patients with
primary acquired melanosis, a biopsy is recommended in order to
grade the disease, offer a prognosis, and direct further treatment.
Conjunctival melanomas may arise from primary acquired melanosis,
from nevi, or de novo, or they may be metastatic lesions.
CONCLUSION: Of the wide spectrum of melanocytic conjunctival
lesions, those with malignant potential are melanosis oculi, nevus
of Ota, junctional nevus, compound nevus, primary acquired melanosis,
and melanomas.
