eMedicine Specialties > Ophthalmology > Conjunctiva

Melanoma, Conjunctival: Differential Diagnoses & Workup

Author: Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Coauthor(s): Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic; C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Contributor Information and Disclosures

Updated: Dec 27, 2007

Differential Diagnoses

Melanoma, Choroidal
Melanoma, Ciliary Body
Melanoma, Iris
Squamous Cell Carcinoma, Conjunctival

Other Problems to Be Considered

Conjunctival nevi
Conjunctival melanosis
Conjunctival mycosis
Conjunctival seborrheic keratosis
Acquired melanosis (primary or secondary)
Foreign body (eg, graphite)
Drug toxicity (eg, epinephrine)
Conjunctival pseudomelanoma - iatrogenic secondary to scleral tunnel

Workup

Imaging Studies

  • Ultrasound biomicroscopy (UBM)
    • Extrascleral extension of a ciliary body melanoma can simulate a conjunctival melanoma in some cases. UBM of such eyes confirms the presence, character, and extent of the underlying ciliary body tumor and often reveals the route of access of the tumor to the surface by way of a scleral emissary canal.
    • UBM may serve as an additional diagnostic tool to estimate the tumor thickness before surgical resection of a conjunctival melanoma.

Procedures

  • Conjunctival excision biopsy: Conjunctiva is an easily accessible tissue source for diagnostic biopsy. A biopsy of a malignant melanoma does not seem to increase its lethality, and it may prevent unnecessary, mutilating surgery.

Histologic Findings

Invasive melanoma cells may be small polyhedral, epithelioid, spindled, or ballooned.

The Callender classification for melanoma does not apply to conjunctival melanomas (see Histopathologic Type). Melanoma cells are larger than nevus cells and grow as irregular nests or as individual cells in nodules that extend through all the layers of the epidermis and dermis. Typically, these cells have large nuclei with chromatin clumping at the periphery of the nuclear membrane and distinct eosinophilic nucleoli. The ascent of atypical melanocytes to the surface of the conjunctival epithelium is indicative of malignancy.

Staging

This classification applies only to melanoma. Histologic verification of the melanocytic lesion should occur.

Clinical staging: The assessment of the cancer is based on inspection; slit lamp examination; palpation of the regional lymph nodes; and, when indicated, radiologic (including computed tomography) and ultrasonographic examination of the orbit, paranasal sinuses, and chest.

Pathologic staging: Complete resection of the primary site is indicated. Histologic study of the margins and the deep aspect of resected tissues is necessary. Resection or needle biopsy of enlarged regional lymph nodes or orbital masses is desirable.

  • Clinical classification (cTNM)
    • Primary tumor (T)
      • TX - Primary tumor cannot be assessed.
      • TO - No evidence of primary tumor
      • T1 - Tumor(s) of bulbar conjunctiva occupying 1 quadrant or less
      • T2 - Tumor(s) of bulbar conjunctiva occupying more than 1 quadrant
      • T3 - Tumor(s) of conjunctival fornix and/or palpebral conjunctiva and/or caruncle
      • T4 - Tumor invades eyelid, cornea, and/or orbit
    • Regional lymph nodes (N)
      • NX - Regional lymph nodes cannot be assessed.
      • N0 - No regional lymph node metastasis
      • N1 - Regional lymph node metastasis
    • Distant metastasis (M)
      • MX - Distant metastasis cannot be assessed.
      • M0 - No distant metastasis
      • M1 - Distant metastasis
  • Pathologic classification (pTNM)
    • Primary tumor (pT)
      • pTX - Primary tumor cannot be assessed.
      • pT0 - No evidence of primary tumor
      • pT1 - Tumor(s) of bulbar conjunctiva occupying 1 quadrant or less and 2 mm or less in thickness
      • pT2 - Tumor(s) of bulbar conjunctiva occupying more than 1 quadrant and 2 mm or less in thickness
      • pT3 - Tumor(s) of the conjunctival fornix, and/or palpebral, and/or caruncle or tumor(s) of the bulbar conjunctiva, more than 2 mm in thickness
      • pT4 - Tumor invades eyelid, cornea, and/or orbit
    • Regional lymph nodes (pN)
      • pNX - Regional lymph nodes cannot be assessed.
      • pN0 - No regional lymph node metastasis
      • pN1 - Regional lymph node metastasis
    • Distant metastasis
      • pMX - Distant metastasis cannot be assessed.
      • pM0 - No distant metastasis
      • pM1 - Distant metastasis
  • Stage group: No stage grouping is recommended at this time.
  • Histopathologic type: This categorization applies only to melanoma of the conjunctiva.
  • Histopathologic grade: This grade represents the origin of the primary tumor.
    • GX - Origin cannot be assessed.
    • G0 - PAM
    • G1 - Malignant melanoma arises from a nevus
    • G2 - Malignant melanoma arises from a PAM
    • G3 - Malignant melanoma arises de novo

More on Melanoma, Conjunctival

Overview: Melanoma, Conjunctival
Differential Diagnoses & Workup: Melanoma, Conjunctival
Treatment & Medication: Melanoma, Conjunctival
Follow-up: Melanoma, Conjunctival
Multimedia: Melanoma, Conjunctival
References
[ CLOSE WINDOW ]

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  106. Zografos L, Uffer S, Chamot L. Unilateral conjunctival-corneal argyrosis simulating conjunctival melanoma. Arch Ophthalmol. Oct 2003;121(10):1483-7. [Medline].

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Further Reading

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Keywords

conjunctival melanoma, malignant melanoma of the conjunctiva, malignancy, tumor, exenteration, cryotherapy

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Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Manolette R Roque, MD, MBA, DPBO, FPAO is a member of the following medical societies: American Academy of Ophthalmic Executives, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic
Disclosure: Nothing to disclose.

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Brian A Phillpotts, MD, Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine
Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Hospital
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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