|Year : 1984 | Volume
| Issue : 1 | Page : 37-40
Multifocal primary malignant melanoma of conjunctiva
Akhauri Shashi Bhushan Sahai, C Choudhary, RK Sharan
Patna Medical College and Hospital, Patna, India
Akhauri Shashi Bhushan Sahai
AS.B., 146, Srikrishna Nagar, Patna-800 013
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Akhauri Shashi Bhushan Sahai, Choudhary C, Sharan R K. Multifocal primary malignant melanoma of conjunctiva. Indian J Ophthalmol 1984;32:37-40
The incidence of Malignant Melanoma in Orient is less, of the conjunctiva is still less, being multifocal least. This young proband had three loci of naevi to wit, upper & lower palpebral conjunctiva and the limbus. He was aware only about the latter. All three were possibly present from the childhood till one located at the limbus started growing which necessitated consultation. Of the three, the upper palpebral and one at the limbus were established histologically as primary melanocarcinoma arising out of the pre-existing naevi. The one located in the lower palpebral conjunctiva though excised later did not exhibit malignant deterioration histologically. The uncommon presentation has occasioned the present write up.
| Case report|| |
V. Singh; A Hindu male aged 20 years was admitted in the eye department of Patna Medical College Hospital, Patna, for pigmented growth which was fast, growing for the last six months in the right eye. [Figure - 1].
On further questioning he revealed that a pigmented mole which was present since childhood on the conjunctiva started showing activity for the last one year. Local examination showed a dark brownish lobulated growth on the temporal side of the limbus at 9' o clock meridian covering one third of the temporal side of the cornea. The size. of ibis growth was measured to be 10X 10X2 mm. Slit lamp examination revealed that two blood vessels were approaching the growth from the lateral side. The growth was sessile.
No abnormality was detected through systemic and ophthalmic examination. Vision and visual fields were normal (6/6) in both eyes. Skiagrams, haemogram & liver function tests did not show any sign of metastasis. This was further substantiated by the absence of melanin pigment in the urine of the patient.
Upper lid also showed a similar growth from the palpebral conjunctiva & was of 10X6 m.m. size. The lower fornix was having a flat growth of 6X2 m.m. size. All three growths were removed one by one at the interval of one week and were subjected to histopathological examination. Firstly the growth from upper palpebral conjunctiva was removed with wide excision. This was histologically confirmed and was labelled as malignant melanoma [Figure - 2]. the growth from the lower fornix was of intradermal naevus [Figure - 3]. Lastly the bigger timbal growth was removed with wide excision, partial keratectomy and superficial lame llar sclera1resection. Some difficulties were experienced while removing some of the deeper pigment of the growth at limbus. Heat cautery was applied to destroy the deeper pig ment the conjunctiva was stitched with 6/0 silk suture and this growth was found to be malignant melanoma. Radiologist did not administer radiotherapy on account of normal vision of the patient & radio-resistant nature of the growth. Patient -was kept on follow up & he regularly visits the eye department of Patna Medical College Hospital for examination.
No adverse effect of the surgery on the patient locally as well as systemically has been observed [Figure - 4]. Nine months after the removal of the growth two pin head size growths was noticed during follow up of the patient, one on the bulbar conjunctiva away from the limbus & another from the lower fornix, from where it was removed previously. Both of these small nodules like growth were removed. Histopathological examination of these nodules confirmed malignancy. The patient was otherwise healthy with perfect vision. When persuaded to part with eye due to the incurable nature of the disease, he was found reluctant.
He came with secondaries in the right preauricular lymph node after one year. Biopsy of the gland further confirmed malignant melanoma with infiltration in soft tissues of pre-auricular region. Subsequently radical neck dissection & radical parotidectomy were done at All India Institute Of Medical Science, New Delhi to remove secondaries. Consequently the patient developed facial paralysis. Lateral tarsorrhaphy was done to prevent exposure keratitis. There was no evidence of other metastasis. It is surprising that the eye ball is still functioning normally. The patient was kept on follow up, but now he has lost contact with us.
| Discussion|| |
Malignant melanoma of the conjunctiva may arise DE novo or from acquired melanosis and lastly a pre-existing naevus (Zimmerman). Acquired melanosis on the other hand which is considered as a pre-cancerous lesion has definite and greater predisposition to malignant deterioration. On the other hand naevi which was histologically very similar to those seen in skin seldom becomes malignant (Reese). Melano carcinoma arising out of neavus usually afflicts young or middle aged adult with a very suggestive history of a preexisting lesion, usually since childhood. In .Iay's senses, out of 48 cases of Malignant Melanoma at limbus, according to him preexisting naevus changes its character above the age of 45. In this context it is surprising that the malignant deterioration has set in very early age. He is only 22 at that time. Another most fascinating feature of this proband is only the rarity of the condition with regard to naevus transforming in to malignant lesion. As much as it has two foci at different topographical site of the conjunctiva which had histological evidence of melano carcinoma, that the tumour arose from the pre-existing naevi, beside the history the histological support either. Further corroboration was provided when the 3rd site of tissue was examined from the fower fornix of the right eye. It had feature of benign naevi with no malignant stigmata. Melano carcinoma primarily have haematogenous spread. Some time it maybe via lymphatics. Neither of these mechanism can adequately provide grounds for such type of dissemination. In absence of only plausible explanation, one is constrained to reconcile with the fact it just happened. The one which appeared following operation on the bulbar conjunctiva may be haematogenous spread. Because another three months after he developed nodules in the pre-auricular region.
The behaviour of such tumour have been reported difficult to predict. According to Smith, particularly pedunculated lesion have neither recovered no metastasised even through removed by simple excision. Others have produced multiple recurrences (Lewis & Zimmerman). And according to them atleast one had even metastasised killing the patient According to Zimmerman melanosis of the conjunctiva carry a guarded prognosis regardless of its histogenetic derivation. He suggests when localised and confined to limbal zone simple excision, but when involving the conjunctiva more diffusely invading the eye lids, caruncle and canthi exenteration is the rule. And this had exactly been done in this instant. Das et a1 has reported similar case with local excision of the tumour which does not show sign of systemic metastasis in five years of follow up.
Recent trends of treating melano carcinoma by immuno-chemotherapy await further work-up and general acceptance.
| Summary|| |
An interesting case of multifocal malignant melanoma of conjunctiva is reported in a young male.
| References|| |
Zimmerman Z.E. 1966, Arch ophthalmol 70:307.
Reese. AB. 1963. Tumours ofthe Eye, 2nd Edition, New York.
Jay, B.J. 1965, Brit. J. Ophthalmol 49:169.
Lewis, P.M. and Zimmerman Z.E. 1958. Amer J. f Ophthalmol 45:536.
Das Rita and Roy I.S. 1982. Ind. J. Ophthalmol, 30:477
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]