Separate Primary Melanomas of the Bulbar Conjunctiva and Eyelid Skin: Clinical Implications of Multiple Primary Melanomas

Abstract

Purpose: We report a patient with previous in situ melanoma of the forehead skin who was referred for treatment of a bulbar conjunctival melanoma and a separate superficially invasive melanoma of the eyelid skin, and we offer a review of the biological and clinical implications of patients who have multiple primary melanomas.

Methods: This article offers a clinicopathological correlation with a review of the relevant literature.

Results: An 80-year-old white man was referred for evaluation of a suspicious conjunctival tumor and a lower-eyelid lesion. Excisional biopsies revealed that both were primary melanomas arising within in situ disease. Over the span of 25 years, the patient had three separate foci of in situ melanoma, two of which spawned invasive melanoma.

Conclusion: Separate melanomas arising from the bulbar conjunctiva and eyelid skin have rarely been reported. Multiple primary melanomas of the skin, however, are not uncommon. Based on studies of persons with multiple cutaneous melanomas, the prognosis is best predicted by the tumor with the greatest depth of invasion. Patients with multiple melanomas should be examined for dysplastic nevi, additional cutaneous melanomas, and screened periodically for future lesions. Ongoing studies enrolling patients with multiple primary melanomas are attempting to generate insights into low-penetrance susceptibility genes.

Keywords: Conjunctival melanoma; Eyelid; Melanoma.

Fig. 1

Few lashes remain in a tan 4 × 1.8 mm plaque on the right lower lid margin. A deep brown nodule of the bulbar conjunctiva fixed to underlying tissue wraps around the limbus from 8 to 12 o'clock. It is surrounded by diffuse hyperpigmentation of the bulbar conjunctiva and cornea.

Fig. 2

The conjunctival nodule consists of sheets of malignant cells filling the substantia propria (HE; bar = 275 µm). Inset Higher magnification showing atypical melanocytes in the epithelium and similar cells replacing the substantia propria (HE; bar = 150 µm).

Fig. 3

The epithelial surface of the lid margin is partially replaced by atypical melanocytes that have spread into a duct which is dilated distally (*). Neoplastic melanocytes lining the duct have expanded into the surrounding dermis (HE; bar = 75 µm).

Fig. 4

MART-1 stain of the posterior lid margin shows atypical melanocytes lining a follicle on the right. Neoplastic melanocytes spread no further posteriorly than the epithelium above the tarsus on the left (bar = 75 µm). There was no involvement of the palpebral conjunctiva.