Primary orbital melanoma associated with orbital melanocytosis

Unexpected recurrence and rapid progression of lacrimal gland adenoid cystic carcinoma during pregnancy: a case report

Adenoid cystic carcinoma (ACC) is the most common malignant neoplasm involving the lacrimal glands, with high rates of recurrence and metastasis. During the pregnancy, reports of recurrence of ACC of the salivary glands and trachea have previously been published, but no lacrimal gland ACC recurrence has been reported. We present a 35-year-old woman with lacrimal gland ACC who was initially treated by surgical resection and adjunctive radiotherapy, but her cancer recurred during pregnancy, with rapid progression to cavernous sinuses and brain. Estrogen and progesterone receptors have been detected on lacrimal glands and ACCs of salivary glands. Thus, hormonal changes during pregnancy might contribute to the recurrence of ACC. However, the inherent invasive and recurrent nature of ACC could also account for the regrowth in this patient and further molecular studies can provide more accurate explanations.

Primary orbital melanoma: A report of a case and comprehensive review of the literature

Purpose: To review the clinical features and treatment-associated outcomes of primary orbital melanoma among cases reported in the literature and to present a case treated with orbital exenteration and post-operative radiotherapy.Methods: Case reports and case series on primary orbital melanoma published in the literature between 1980 and 2020 were reviewed. Data collected included patient demographics, presenting ocular symptoms, diagnostic imaging, histology, management, and outcomes.Results: Eighty-eight cases of primary orbital melanoma were reviewed. The average age at presentation was 45 years and 58% of patients were male. The most common presenting symptoms and signs were proptosis (73%), decreased visual acuity (32%), pain (14%), diplopia (15%), and palpable mass (9%). Imaging frequently showed a well-circumscribed enhancing lesion. Diagnosis was made by histology in all cases, and orbital blue nevus was identified in 42%. In the majority of cases, treatment consisted of orbital exenteration (54%) or excision (38%). Adjuvant radiotherapy was given in 47% of cases. For the 72 patients with reported outcomes, 36% had metastases, 15% had local recurrence, and 32% died of metastatic disease. Patients who received surgery and radiotherapy had improved survival compared to those who received surgery alone (p = .01). There was no difference in survival between those who underwent orbital exenteration or excision (p = .16).Conclusions: Primary orbital melanoma is a rare malignancy and should be considered in patients with a history of unilateral proptosis and a well-defined orbital mass on imaging. Surgery remains the mainstay of treatment. Adjuvant radiotherapy may improve patient survival.

Primary Orbital Melanoma: An Investigation of a Rare Malignancy Using the National Cancer Database

OBJECTIVES

Primary orbital melanoma (POM) is a rare disease with limited data on survival and best treatment practices. Here we utilize the National Cancer Database (NCDB) to determine the overall survival (OS) and covariates that influence mortality.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients diagnosed with POM from 2004 to 2016 were identified in the NCDB. Patient and oncologic data were analyzed using the Kaplan-Meier method and multivariate models for the primary outcome of OS.

RESULTS

A total of 129 patients were identified. Median OS was 36.9 months (95% confidence interval [CI] 24.1-78.7 months) with mean 5-year survival of 42.0% (CI 33.2%-53.2%). Treatments received included surgery alone (43.4%), radiation alone (23.3%), and surgery followed by radiation (20.2%). The multivariate model demonstrated an increased risk of death associated with age over 80 years (hazard ratio [HR] 3.41, CI 1.31-8.86, P = .012), a Charlson-Deyo comorbidity score of 2 or greater (HR 5.30, CI 1.87-15.03, P = .002), and no treatment (HR 2.28, CI 1.03-5.06, P = .042). For every 1 cm increase in tumor size, there was an increased risk of death (HR 1.06, CI 1.00-1.13, P = .039). When compared to surgery alone, no other treatment modality had an effect on OS.

CONCLUSIONS

This study leveraged multiyear data from the NCDB to provide prognostic and demographic information on the largest known cohort of POM cases. Increased age, increased comorbidities, not receiving treatment, and larger tumor size were associated with increased mortality. There was no clear survival advantage for specific treatments.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1790-1797, 2021.

Primary orbital melanoma: a case series and literature review

Primary orbital melanoma (POM) is a very rare condition. We report further four cases and review all previously reported cases. We present a multicentre retrospective review of patients with POM. Clinical, radiological, surgical, histological, and follow-up data is presented. Four patients with POM were identified between 2000 and 2013. All presented with proptosis and diplopia without reduced vision. Two had known pre-existing blue cell naevi. All were stage T1N0M0. All underwent exenteration with adjuvant radiotherapy. All are disease free at follow-up durations of 24-151 months. The present three cases and review of all cases in the literature suggest a higher likelihood of disease-free survival from primary exenteration (7/8 disease-free survival, 1/8 death from metastatic disease) than wide local excision (7/16 disease-free survival, 9 recurrence or metastasis of whom 4 died). Adjuvant radiotherapy may additionally improve outcomes.

Primary Orbital Melanoma: Presentation, Treatment, and Long-term Outcomes for 13 Patients

BACKGROUND

Periocular melanoma is a rare but often deadly malignancy that arises in the uvea (commonest origin), conjunctiva or orbit (rarest primary site). Melanoma accounts for 5-10% of metastatic/secondary orbital malignancies, but only a tiny proportion of primary orbital neoplasia. Primary orbital melanoma (POM) is exceedingly rare, with approximately 50 cases reported to date.

METHODS

All patients seen in the orbital unit at a tertiary referral hospital (1991-2016) with a biopsy-proven diagnosis of POM were identified from a diagnostic database and were studied. The case notes, imaging, surgical approach, and histology were reviewed.

RESULTS

Thirteen patients (five male; 38%) presented with isolated malignant melanoma of the orbit, for which no other primary site was identified at presentation or during an average follow-up of 44 months (median 22; range 0-13 years). The patients presented between the ages of 40 and 84 years (mean 55.5; median 48 years) and typically gave a short history of rapidly increasing proptosis and eyelid swelling. On the basis of history, a malignant lesion was suspected in most patients and all underwent incisional biopsy, with debulking of the mass in 10 (77%) patients, and skin-sparing exenteration in 3/13 (23%). Ten patients underwent orbital radiotherapy and the survival to date ranged from 9 months to 14 years (mean 55 months; median 23 months); two patients received solely palliative care for widespread disease and one patient refused orbital radiotherapy. Five of the 13 (38%) patients died from the disease.

DISCUSSION

POM is a very rare malignancy, but clinical analysis of this cohort gives insight into disease presentation and prognosis. The tumor typically presents with a rapidly progressive, well-defined mass that is, in some cases, amenable to macroscopically intact excision. Unusual for malignant melanoma, some of these patients can show an unusually long period of quiescent disease after surgical debulking and radiotherapy.

Dural Melanoma Associated with Ocular Melanosis and Multiple Blue Nevi

Background:

Primary meningeal melanomas of the central nervous system (CNS) are a rare malignant process with the majority originating from the leptomeninges. Primary dural melanomas have been reported to occur in isolation or in conjunction with Nevus of Ota. The association of primary dural melanoma with multiple cutaneous blue nevi has not been reported previously.

Objective:

To describe a case of a 41-year-old Asian woman patient with a primary dural melanoma that arose in association with ocular melanosis and multiple cutaneous blue nevi. The patient is alive almost more than 8 years after subtotal and subsequent total resection of her primary tumor. Primary dural melanomas, Nevus of Ota, and blue nevi are discussed in relation to their coexistence and potential for intracranial melanoma.

Conclusion:

CNS melanoma is regarded as an extremely aggressive disease with poor prognosis. This case and previous reports of dural melanomas occurring in isolation or with Nevus of Ota have demonstrated relatively prolonged survival after surgical intervention. We conclude that dural melanomas are less aggressive tumors requiring surgical extirpation only.

An Orbital Malignant Melanoma Arising in Cellular Blue Nevus in a Patient with Nevus of Ota

Melanomas arising from orbital melanocytic proliferations are exceedingly rare. Many questions remain regarding their development and malignant transformation. We report on a 45-year-old Caucasian woman with a nevus of Ota that presented with visual disturbances involving her right eye and was found to have a biopsy-proven cellular blue nevus in the orbital space. Five years later, she presented with proptosis and worsening symptoms. Biopsy at that time showed a cellular blue nevus with areas of melanoma. We conclude that patients with a nevus of Ota or an orbital cellular blue nevus, particularly Caucasians, should be monitored for ocular/orbital involvement and followed closely for signs of rapid growth. There may be a progressive evolution to melanoma from a blue nevus.  

Animal-type malignant melanoma associated with nevus of Ota in the orbit of a Japanese woman: a case report

We present a patient with an animal-type malignant melanoma associated with the nevus of Ota in the orbit who showed a good prognosis after a combination of orbital extirpation, chemotherapy, stereotactic radiotherapy, and gamma knife. A 42-year-old Japanese woman presented with two tumors, one pathologically diagnosed as right-sided intraconal animal-type malignant melanoma and the other intracranially, presumed to be of the same pathogenesis and both were considered to have arisen from the nevus of Ota. She underwent an extirpation of the orbit, chemotherapy (DAV therapy, which is a combination of dacarbazine, nimustine, and vincristine), stereotactic radiotherapy (54 Gy in 27 fractions), and gamma knife (marginal dose was 17 Gy, target volume was 0.2 ml). She has been alive for 33 months since the extirpation, with no sign of local recurrence, new metastasis, nor enlargement of the intracranial tumor. Not just combination therapy but also the low malignancy of animal-type melanoma may have contributed toward the good prognosis.

Primary orbital melanoma in association with cellular blue nevus

PURPOSE

To describe 3 cases of primary orbital melanoma associated with either known or subsequently discovered cellular blue nevus.

METHODS

The clinical records and surgical specimens of 3 patients who underwent orbital exenteration for primary orbital melanoma and who had a cellular blue nevus diagnosed before or after detection of the melanoma were retrospectively reviewed.

RESULTS

All 3 patients presented with signs and symptoms of an orbital mass. Subsequent biopsy revealed invasive melanoma. One patient had a known history of congenital cellular blue nevus of the eyelid from which the orbital melanoma originated. The other 2 patients had no known history of cutaneous pigmentation or blue nevus. In these 2 patients, the cellular blue nevus was detected on pathologic review of the orbital exenteration specimen (1 patient) or surgical biopsy specimen (1 patient). All 3 patients underwent total body positron emission tomography/computed tomography, and in all 3 results were negative for other sites of disease involvement. In the 2 patients without a previously known nevus a total body skin check was negative for other primary melanoma lesions. All 3 patients underwent orbital exenteration followed by postoperative radiation therapy.

CONCLUSIONS

Thorough evaluation of biopsy specimens of "primary" orbital melanoma is warranted to ensure identification of any associated blue nevus because blue nevi are precursor lesions for orbital melanoma, and the presence of a blue nevus would support a primary orbital melanoma rather than a metastatic lesion. Patients with a known blue nevus of the periocular skin and ocular adnexa should be monitored closely for signs of malignant transformation.

Primary malignant melanoma of the orbit in an African-American man

The authors report the third case of primary orbital melanoma in an African American. A 50-year-old black man presented with 1 year of progressive vision loss and swelling of the right lacrimal gland. His presentation, imaging, biopsy, histopathology, and management are presented and the poor prognosis of primary orbital melanoma reviewed.

Primary Orbital Melanoma Associated With a Blue Nevus

A 43-year-old white woman presented with a sudden pain and protrusion of the right eye, along with decreased vision. Orbital CT revealed a well-demarcated lesion in the right intraconal space. After surgical excision, the histopathologic examination revealed a malignant melanoma with a predominant epithelioid cell type, probably arising in a blue nevus. The patient was treated with exenteration followed by radiotherapy.

Primary orbital melanoma masquerading as vascular anomalies

PURPOSE

To review two cases of primary orbital melanoma presenting like orbital vascular anomalies.

METHODS

Retrospective review of clinical presentation, treatment, radiology and pathology for two patients under the care of the Orbital Clinic at Moorfields Eye Hospital.

RESULTS

Both lesions presented with the appearance and behaviour of vascular anomalies. In one case, a spindle cell melanoma appeared to be a low flow vascular anomaly with a loculated secondary haemorrhage and, in the other case, a melanoma of soft parts was considered to be an arteriovenous malformation and responded partially to embolisation.

CONCLUSION

Primary malignant melanoma may present as a secondary vascular lesion of the orbit and this very rare tumour should be considered in the differential diagnosis of any vascular anomaly.

Primary orbital melanoma associated with oculodermal melanocytosis

A 29-year-old, otherwise healthy man presented with an approximately 5-months' history of left-sided exophthalmos. The patient had a bluish-black pigmentation on his left upper lid, and black pigmentation on the left conjunctiva and sclera, since birth. CT examination revealed a retrobulbar tumor in the left orbit, and the left medial rectus muscle was wider than the right one. The left orbital cavity and the superior orbital fissure were enlarged. All of the examinations were negative in respect of another primary tumor outside the orbit or of tumor dissemination. At surgery, a pigmented tumor was found and removed. The orbital tissues were darkly pigmented. Histological examination of the excised tumor showed it to be an encapsulated, circumscribed mass. The tumor was built up of fusiform and spindle-shaped cells containing black pigmentation, with very few mitoses and without necrosis. There has been no recurrence or metastasis in 3 years of follow-up. The consequences of the tumorous transformation of oculodermal melanocytosis as reflected in the published literature and the special clinical and histopathological characteristics of our case are discussed.

Periorbital cellular blue nevus leading to orbitopalpebral and intracranial melanoma

OBJECTIVE

To report the rare occurrence of orbitopalpebral and intracranial melanoma in patients with periorbital cellular blue nevus.

DESIGN

A case series.

INTERVENTION

The clinicopathologic records of two patients with periorbital cellular blue nevus were reviewed.

RESULTS

In case 1, a 32-year-old woman with congenital blue discoloration of her eyelids had gradual increase in nodularity of the eyelid tissue develop over the prior 20 years. The lesion enlarged to the point that the eyelids were almost completely closed from the massive tumor. Results from a biopsy disclosed orbitopalpebral melanoma arising from cellular blue nevus. Because of the diffuse infiltrative pattern of the lesion, she was treated by surgical debulking of the mass. She had a separate focus of ipsilateral intracranial melanoma develop at 40 years of age and eventually died of meningeal melanoma. In case 2, a 29-year-old man with blue discoloration of his left lower eyelid since 10 years of age had an anterior orbital mass develop. He underwent excisional biopsy, the results of which showed an orbitopalpebral melanoma arising from the periorbital cellular blue nevus. Orbital melanoma recurrence and ipsilateral lymph node metastasis were found 9 years later and treated with resection and chemotherapy. He was free of recurrence or metastasis 2 years later.

CONCLUSIONS

Patients with periorbital cellular blue nevus may present in the preteen years with a bluish eyelid discoloration. They are at risk of having orbitopalpebral and intracranial malignant melanoma develop.

Lifetime prevalence of uveal melanoma in white patients with oculo(dermal) melanocytosis

OBJECTIVE

In the white population, an association between oculo(dermal) melanocytosis (ODM) and uveal melanoma is well recognized. However, the lifetime prevalence of uveal melanoma in the ODM population is not known. This study was designed to determine the lifetime prevalence of uveal melanoma among patients with ocular melanocytosis.

DESIGN

Fifty-six white patients manifesting ODM with uveal melanoma formed the basis of the study.

MAIN OUTCOME MEASURES

Published prevalence rates of ODM and uveal melanoma were used for calculations using Bayes' theorem.

RESULTS

The lifetime prevalence of uveal melanoma in white patients with ODM is estimated to be 2.6 x 10(-3). The median age at diagnosis of uveal melanoma in the ODM population was similar to a randomly selected population (60.5 years and 62.5 years, respectively). In the vast majority of patients (90%) with ODM-associated uveal melanoma, the uveal melanoma was diagnosed between the ages of 31 years and 80 years.

CONCLUSIONS

One of about 400 patients with ODM followed for life is estimated to develop uveal melanoma. Excessive melanocytes in the uveal tract in ODM may provide the biologic basis for susceptibility to the development of uveal melanoma. Patients with ODM should be monitored ophthalmoscopically, especially during the susceptible period, for the development of uveal melanoma. The authors suggest that a national registry of ODM patients be created and prospective data collected to better assess the risk of developing uveal melanoma.

Primary orbital melanomas

PURPOSE

Primary orbital melanomas are rare tumors with a poorly defined biologic course. Most recorded experiences concern single case reports. The authors evaluated the applicability of several of the histopathologic prognostic indicators used for uveal melanomas to a series of primary orbital melanomas with known clinical follow-up.

METHODS

Twenty-one primary orbital melanomas, each with at least a 1-year follow-up after diagnosis, were evaluated for (1) modified Callender cell type, (2) mitotic count per 40 high-power fields, (3) lymphocyte count (less than versus greater than 100/20 high-power fields), (4) blue nevus component, and (5) largest tumor diameter.

RESULTS

All patients for whom race was recorded were white. The mean age at diagnosis was 42 years (range, 15-84 years). There was an associated blue nevus in 19 patients (90 percent), and in 10 patients (47.5 percent) there was some form of congenital melanosis. With a mean follow-up period of 4.5 years (range, 1-13 years), mortality from metastatic tumor occurred in 8 (38 percent) of 21 patients. Of these eight patients, there were liver metastases in seven (88 percent) and brain metastases in one (12 percent). Indicators of poor prognosis were tumors of mixed cell type with high mitotic count and greater patient age with underlying congenital melanosis.

CONCLUSION

Most primary orbital melanomas occur in white patients and are associated with blue nevi. These tumors are similar to uveal melanomas with respect to prognostic indicators and pattern of metastasis.

A case of primary orbital melanoma treated by local excision

Images

Necrotic orbital melanoma arising de novo

A 76-year-old man with compressive optic neuropathy secondary to a retrobulbar mass was managed by orbitotomy and removal of the mass. The lesion proved histopathologically to be an unusual orbital melanoma with massive central necrosis. There was no histopathological evidence of congenital melanocytosis. Dermatological and systemic evaluation before and after orbital surgery revealed no evidence of primary melanoma elsewhere. The patient developed hepatic metastasis 2 years after excision of the orbital tumour. It appears that the melanoma was a primary orbital tumour and not a metastatic melanoma from an occult primary lesion.

Malignant melanoma of the optic nerve head in a case of oculodermal melanocytosis

Malignant melanoma of the uveal tract, orbit, and brain have been reported to occur in patients with oculodermal melanocytosis. A 60-year-old Caucasian man with oculodermal melanocytosis developed a malignant melanoma of the optic nerve head in the left eye. This case is the first reported example of a malignant melanoma developing in the optic nerve associated with oculodermal melanocytosis. After presentation the patient refused surgery for 19 months and the progression of the tumour necessitated an exenteration of the orbit.