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      Excision with Corneoscleral Lamellar Keratoplasty and Amniotic Membrane Transplantation of a Corneal Displaced Recurrent Conjunctival Melanoma

      case-report

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          Abstract

          An 81-year-old woman with a raised pigmented nodule over her left cornea for 7 months duration was examined. Dark conjunctival pigmentation was observed in the upper bulbar fornix conjunctiva. She had previously undergone primary surgical excision of a malignant conjunctival melanoma four years earlier. The tumor separated easily from the corneal surface, but remained slightly attached to the corneoscleral surface. A corneoscleral lamellar dissection of 3 mm in width and 2 mm in depth as well as a corneoscleral lamellar keratoplasty for the reconstruction of the corneoscleral defect were performed. The wide upper bulbar and fornix conjunctiva were excised, and an amniotic membrane transplantation was performed. Biopsy revealed an invasive melanoma with a depth of 1 mm. Left, right, and inferior tumor margins of the corneoscleral lesion and the pigmentary lesion in the conjunctiva were free of the tumor. After surgery, 0.04% mitomycin was administered topically 4 times daily for 4 weeks. There was no recurrence 2 years after surgery, and systemic evaluation revealed no metastasis.

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          Most cited references19

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          Treatment of conjunctival squamous cell carcinoma with topical 5-fluorouracil.

          To evaluate the efficacy of topical 5-fluorouracil (5-FU) alone, without concurrent surgery or radiotherapy, for the treatment of conjunctival squamous cell carcinoma. Eight patients affected by conjunctival squamous cell carcinoma (three recurrent cases, three incompletely excised, and two untreated cases) were treated with 1% 5-FU eye drops. Topical 1% 5-FU was administered four times daily for 4 weeks (one course). Clinical examination (biomicroscopy and photography) and morphological evaluation of conjunctival cytological specimens were used to monitor the efficacy of local chemotherapy, side effects, and recurrences. All patients showed clinical regression of conjunctival carcinoma after topical 1% 5-FU treatment. Neoplastic conjunctiva was completely replaced by normal epithelium within 3 months. Mean follow up was 27 months. One patient needed two courses of local chemotherapy for recurrent disease. An acute transient toxic keratoconjunctivitis was observed in all treated cases; it was easily controlled with topical therapy. No long term side effects were found. Topical 1% 5-FU is effective in the treatment of recurrent, incompletely excised, and selected untreated conjunctival squamous cell carcinomas. Topical 1% 5-FU has no major complications. This study suggests that topical conjunctival chemotherapy with 1% 5-FU may be useful, at least as adjunctive therapy, in the treatment of conjunctival squamous cell carcinoma.
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            Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients.

            To identify the risk factors of conjunctival malignant melanoma that predict local tumor recurrence, orbital exenteration, distant metastasis, and tumor-related mortality. The study group consisted of 150 consecutive patients with a diagnosis of conjunctival melanoma. The clinical parameters of the patient, tumor, and treatment were analyzed in a nonrandomized fashion for their relation to 4 main outcome measures using Cox proportional hazards regression models. The Kaplan-Meier estimate of local tumor recurrence was 26% at 5 years, 51% at 10 years, and 65% at 15 years. The mean number of recurrences per patient was 1 (median, 0). Ninety-eight patients (65%) had no recurrences, 28 patients (19%) had 1, 11 patients (7%) had 2, 5 patients (3%) had 3, and 8 patients (5%) had 4 or more recurrences. According to multivariate analysis, the factors that predicted local tumor recurrence were the location of the melanoma (not touching the limbus) (P = .01) and tumor-margin pathology (lateral margin involved) (P = .02). Multivariate analysis for features predictive of ultimate exenteration included initial visual acuity (20/40 or worse) (P = .0007), melanoma color (red) (P = .01), and melanoma location (not touching the limbus) (P = .02). Tumor metastasis occurred in 16% of patients at 5 years, 26% at 10 years, and 32% at 15 years. Metastasis was initially in the regional lymph nodes in 17 cases, brain in 4, liver in 3, lung in 2, and disseminated in 1 case. Risks for metastases with use of multivariate analysis included tumor-margin pathology (lateral margin involved) (P = .002) and melanoma location (not touching limbus) (P = .04). Tumor-related death occurred in 7% of patients at 5 years and 13% at 8 years. Risk factors for death with use of multivariate analysis included initial symptoms (lump) (P = .004) and pathologic findings (de novo melanoma without primary acquired melanosis) (P = .05). In a series of univariate analyses, the technique of initial surgery was shown to be an important factor in preventing eventual tumor recurrence (P = .07), metastasis (P = .03), and death (P = .006). Patients who were managed with excisional biopsy using the "no-touch technique" plus alcohol corneal epitheliectomy and supplemental cryotherapy fared far better than those treated with excisional biopsy alone. In addition, the surgical technique used before referral to us was critical. Those patients who had an incisional diagnostic biopsy prior to referral were at risk for more than 1 recurrence (P = .04), and those who had excisional biopsy alone without supplemental cryotherapy were at risk for eventual exenteration (P = .0006) and death (P = .04). Conjunctival malignant melanoma is a potentially deadly tumor. In this study, metastasis was detected in 26% of patients and death occurs in 13% at 10 years. The surgical technique of tumor management was found to be possibly related to tumor metastases and death. Meticulous surgical planning, use of wide microsurgical excisional biopsy with the no-touch technique, and supplemental alcohol corneal epitheliectomy and conjunctival cryotherapy performed by experienced surgeons are advised. Incisional biopsy should be avoided.
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              Prognostic value of clinical and histopathological parameters in conjunctival melanomas: a retrospective study.

              To determine prognostic factors for recurrence of disease and tumour related mortality in patients with conjunctival melanoma. A retrospective analysis of clinical and histopathological data of 69 patients with histologically verified conjunctival melanoma. As univariate analysis showed, significant risk factors for the development of recurrence were: irregular pigmentation (RR = 2.0, p = 0.0007), incomplete surgical excision (RR = 3.5, p = 0.008), tumour invasion deeper than in substantia propria (RR = 3.9, p = 0.008), and presence of epithelioid tumour cells (RR = 2.9, p = 0.05). For tumour related mortality a significantly increased risk was found for tumour location in palpebral conjunctiva, caruncle, plica, or fornices (RR = 5.9, p = 0.001), for tumour infiltration deeper than the substantia propria (RR = 5.5, p = 0.001), for incomplete surgical excision (RR = 4.4, p = 0.05), and for nodular or mixed (nodular and superficial) growth pattern of the tumours (RR = 1.2, p = 0.002). The use of an adjuvant therapy for the surgical excision of the melanomas had no statistically significant influence upon the development of recurrent disease nor upon the tumour related mortality. These data present similar clinical and histopathological risk factors for patients with conjunctival melanoma as reported previously. The present study also addresses the failure of retrospective studies on conjunctival melanoma to prove the efficacy of a supplementary therapy to surgical excision.
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                Author and article information

                Journal
                Korean J Ophthalmol
                Korean J Ophthalmol
                KJO
                Korean Journal of Ophthalmology : KJO
                The Korean Ophthalmological Society
                1011-8942
                2092-9382
                October 2012
                24 September 2012
                : 26
                : 5
                : 383-387
                Affiliations
                Department of Ophthalmology & Visual Science, The Catholic University of Korea College of Medicine, Seoul, Korea.
                Author notes
                Corresponding Author: Nam Yeo Kang, MD. Department of Ophthalmology, Bucheon St. Mary's Hospital, #327 Sosa-ro 327beon-gil, Wonmi-gu, Bucheon 420-717, Korea. Tel: 82-32-340-2125, Fax: 82-32-340-2661, nyeokang@ 123456hanmail.net
                Article
                10.3341/kjo.2012.26.5.383
                3464323
                23060726
                7ce1f952-57ba-4260-b917-3999f640c5bc
                © 2012 The Korean Ophthalmological Society

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 30 November 2010
                : 09 March 2011
                Categories
                Case Report

                Ophthalmology & Optometry
                lamellar keratoplasty,malignant melanoma,amniotic membrane
                Ophthalmology & Optometry
                lamellar keratoplasty, malignant melanoma, amniotic membrane

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