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ARTICLES |
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Year : 1978 | Volume
: 26
| Issue : 1 | Page : 43-46 |
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Malignant melanoma of the eye with secondaries in the breast (A case report)
EC Narasimhan, K Ananda Kannan
Govt. Ophthalmic Hospital, EGMORE, Madras 600008, India
Correspondence Address: E C Narasimhan Govt. Ophthalmic Hospital, EGMORE, Madras 600008 India
Source of Support: None, Conflict of Interest: None | Check |
PMID: 711277
How to cite this article: Narasimhan E C, Kannan K A. Malignant melanoma of the eye with secondaries in the breast (A case report). Indian J Ophthalmol 1978;26:43-6 |
The general incidence of malignant melanoma of the eye as per Duke Elder is 0.02 to 0.06% of all patients i.e. from 2 to 6 per 10,000; with regard to the part of the eye affected, the vast majority occurs in the choroid of about 85%[8]. Only one in 20 is situated within the conjunctiva[1].
The prognosis of malignant melanoma, particularly of the palpebral conjunctiva, even after the most effective treatment is poor, while arising from the bulbar conjunctiva carry a better prognosis. Here a case of malignant melanoma is presented arising from bulbar conjunctiva in a relatively young patient, and secondaries in the breast soon after exenteration.
Case History | | |
A 30 years old female was seen in October 1974 with the complaint of growth in the limbal region left eye, since two months. She gave history of having had biopsy six years ago for a mole. The slide was traced back and biopsy report was Pre Cancerous Melanosis. [Figure - 1]
On examination, she had a fleshy growth at 12 O'Clock position in the left eye with black pigmentation all around. It was hard in consistency attached to the deeper layers of the conjunctiva and also to the cornea. There was no enlargement of the lymph nodes. Visual acuity 6/9. Fundus was normal. Right Eye was normal. Diathermy excision of the mass was done on 19.10.1974 and sent for biopsy. The biopsy report showed the picture of malignant melanoma with invasion of the vessel wall. [Figure - 2] She was advised enucleation, but refused and went home against medical advice.
She came back after seven months with proptosis of the left eye and a fungating mass protruding with restricted movement of eye from the left orbit. With restricted movements of eye cornea was completely covered by the growth and the other details could not be made. There was no perception of light. There was no regional lymphadenopathy. Systemic examination showed no secondaries elsewhere in the body. She had so much pain that she volunteered for removal of the globe. An exenteration of the orbit was done under general anaesthesia [Figure - 3]. The biopsy report was malignant melanoma of epitheloid type [Figure - 4]. The post-operative period was uneventful and she was discharged with the advice to have post-operative irradiation.
She attended Barnard Institute of Radiology, General Hospital, Madras for irradiation. While she was on therapy, she developed nodules in the breast [Figure - 5]. Liver was palpable 3 fingers breadth below the costal margin. A simple mastectomy was done, the histopathological examination showed the presence of melanoma cells in the breast tissue [Figure - 6].
The irradiation was continued but the patient went home against medical advice. It was found out that she expired after one year of examination.
Discussion | | |
Melanoma of the conjunctiva arise in three ways:
1. From pre-existing naevus.
2. From a localised or widespread acquired melanosis.
3. `De novo' from apparently normal conjunctiva.
Conjunctival melanomas hardly ever occur under the age of 20 years. Widespread intraepithelial conjunctiva) melanoma is best managed by diagnostic biopsy followed by periodic observation. Exenteration is indicated only in cases of cancerous melanosis which are too extensive for excision and in cases of widespread recurrence after radiotherapy[1]. Authorities agree that biopsies do not influence prognosis and one should never hesitate to repeat them[1]. In this case, it took six years to notice malignant changes.
Duke-Elder[7] states that once the growth starts in an epibulbar tumour, it usually takes about a year to attain the size of a peanut. Exceptionally growth may be so rapid and extensive that the entire conjunctival sac including both fornices may be filled, the cornea covered and the globe hidden in neoplastic tissue[7]. This was what happened in the present case. Histologically, in early tumor and sometimes in well established cases derived from a naevus, anaplastic changes are seen in the junctional zone of the epithelium, the cells instead of being uniform become larger, rounder and separate themselves from each other. They show variations in size, shape and chromatin pattern of nuclei. Epitheloid cells, the most common type are large polygonal cells with round or oval nuclei and prominent nucleoli and an abundant cytoplasm containing fine melanin granules[2] [Figure - 4],[Figure - 5].
Sometimes the corneal involvement at an early stage is from a lesion at the limbus. The route appears to be direct between the epithelium and Bowman's membrane and along the superficial corneal nerves. Penetration of the globe is rare and late and extension may occur into the ciliary body and iris from the region of Schlemm's canal[7].
The development of metastatic spread is by the blood vessels and lymphatics, particularly to the lymph nodes-cervical, intra-abdominal and others. Extraocular metastasis has taken place in this case at a very early stage which is not an uncommon feature in malignant melanomas. The extraocular portion usually contains less pigment than the parent tumour. Extraocular metastasis usually causes the termination of malignant melanomata as it is in this case. The regional lymph nodes are not affected. Dissemination of the neoplastic cells into the blood stream is extremely common. The average interval between enucleation and the appearance of metastasis is 37 months. But in this case, this has been shortened dramatically to six months, possibly due to delayed therapy and the young age of the patient. Once metastasis commence, they tend to run on apace so that the death comes in six months or less in 85% of cases[6]. Again this has been confirmed in this case.
Of the 126 cases studied by Jensen[3] more fertile field for metastasis is the liver, and thereafter almost any organ in the body may be affected. (Liver alone 34%; Liver plus other organs 63%; other organs 3%.) Other organs include pleurae and lungs, pericardium, and myocardium, gastro-intestinal tract, lymph nodes, pancreas, skin, central nervous system, bones, spleen, suprarenal glands, thyroid gland, kidneys, ovaries, gall bladder, aortic adventitia and retroperitoneally[4]. An earlier report by Fuchs also enlists the same organs. But the presence of secondaries in the breast has not been noted previously in the Literature. So, this is probably the first case to be reported of secondaries in the breast following malignant melanoma of the eye. This has been confirmed by Biopsy [Figure 7],[Figure 8].
Summary | | |
A case of malignant melanoma of the eye, arising from the conjunctiva is presented because of its following rarities:
1: A relatively young patient;
2. The rapidity of its growth;
3. Non-response to the recommended line Of management;
4. The early occurance of secondaries;
5. Unique feature of developing secondaries i n the breast.
Acknowledgement | | |
We wish to thank Dr. N.S. Venugopal, M.S., D.O., Superintendent, Government Ophthalmic Hospital, Madras for permitting us to publish this paper; and to the Professor of Pathology, Madras Medical College, Madras for having helped us with the biopsy reports; to the Director, Barnard Institute of Radiology, General Hospital, Madras for having given the post-operative follow up[10].
References | | |
1. | Barrie, J., 1965, Brit. Jour. of Ophthal., 49, 169, |
2. | Brian Martin, 1973, Trans. of Ophthal. Soc., U.K., XCIII, 473. |
3. | Gwyn Morgan, 1973, Trans. of Ophthal. Soc., U.K., XCIII, 71. |
4. | Jensen, 1963, Acta Ophthal (Kbh)--Suppl. 75. |
5. | Reese A.B., 1966, Amer. J. of Ophthal., 61, 1272. |
6. | Reese A.B., 1963. Tumors of the Eye Second Edition. Herber Medical Division, London. |
7. | Sir Stewart Duke Elder 1965, Sys. of Ophthal. Vol. VIII, Part II, P., 1219-Henry Kimpton, London. |
8. | Sir Stewart Duke Elder 1965, Sys. of Ophthal. Volume IX, P, 841, Henry Kimpton, London. |
9. | William A. Manshort 1973, Trans. of Ophthal., U.K. XCIII, 733. |
10. | Zimmerman and Hogan, 1968, Ophthal., Pathology. 2nd Edition, Saunders Company, London. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
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