Local conjunctival mets (LCMs) in 7 cases.

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Primary conjunctival melanomas.
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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.

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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.
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Melanoma thickness

• 0.1mm to 1.4 mm
• pT1a to pT2b
• All cases associated with in-situ MM
• One case had vascular invasion.

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Whats the big deal?
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18 months later
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8 months later
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2002
2010
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19 nodules overall 7 patients
4 patients solitary
3 patients multiple
1-synchronous
2-metachronous
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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
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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
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Histology of these nodules?
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Local conjunctival metastases(LCM)
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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
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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.

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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 earlygrow..?
• Circulating stem cells that find niche and expand
  ?

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• 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?

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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)?

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Thanks