Malignant melanoma presenting as amelanotic caruncular lesion in a child

Pediatric conjunctival melanoma: A comprehensive case report and literature review

Purpose

This case report aims to present a rare instance of conjunctival melanoma in a 5-year-old patient and contribute to the limited body of knowledge on pediatric conjunctival melanoma. The purpose is to understand the characteristics, diagnosis, and management of this uncommon malignancy in young individuals.

Observations

The case describes a 5-year-old female with a progressively growing pigmented conjunctival lesion. The lesion was observed to be located on the temporal conjunctiva of the right eye and displayed distinctive features, including feeder vessels. Imaging revealed specific dimensions of the lesion and ruled out deeper invasions. Histopathological examination revealed architectural and cytologic atypia, positive immunohistochemical staining for HMB-45, and a Ki67 proliferation index of 20 %, confirming the diagnosis of conjunctival melanoma.

Conclusions

Conjunctival melanoma, an uncommon malignancy even more so in pediatric patients, typically presents with pigmented growths and feeder vessels. This case underscores the need for thorough diagnosis and early intervention, as conjunctival melanoma can lead to devastating outcomes. The rarity of such cases limits our understanding of their etiology and progression. This case contributes to the literature on pediatric conjunctival melanoma and reinforces the importance of vigilance in detecting and managing ocular pigmented lesions in children.

TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface

Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.

Amelanotic conjunctival melanoma in a child

Purpose

Malignant melanomas of the conjunctiva are extremely rare in children. In this case report we present a conjunctival melanoma of a child.

Observations

We report a case of a 7 years old boy who presented with a rapidly growing reddish lesion measuring 8mm in base × 2.5 mm in thickness on the nasal conjunctiva in his right eye. The patient underwent resection of the lesion (with 4 mm margins of the surrounding clinically normal conjunctiva) and cryotherapy to the adjacent conjunctival margins. Histopathology confirmed the diagnosis of conjunctival melanoma. Pathology also can be challenging; a review of pathology is advisable as happened in this case. Systemic workup was negative for metastatic disease. On 73 months of follow up, the patient was stable without local recurrence or secondary systemic disease.

Conclusions and Importance

Malignant melanoma can present de novo as an amelanotic rapidly growing conjunctival lesion in children. This case should raise the awareness of the variable clinical presentations, the challenging diagnosis, treatment and follow up of pediatric conjunctival melanoma.

Fluorescent in situ hybridization (FISH): A useful diagnostic tool for childhood conjunctival melanoma

INTRODUCTION

Conjunctival melanoma is extremely rare in children and has low rates of resolution. Definitive histopathological diagnosis based exclusively on microscopic findings is sometimes difficult. Thus, early diagnosis and adequate treatment are essential to improve clinical outcomes.

CLINICAL CASE

We present the first case in which the fluorescent in situ hybridization (FISH) diagnostic technique was applied to a 10-year-old boy initially suspected of having amelanotic nevi in his right eye. Based on the 65% of tumor cells with 11q13 (CCND1) copy number gain and 33% with 6p25 (RREB1) gain as measured by the FISH analysis, and on supporting histopathological findings, the diagnosis of conjunctival melanoma could be made. Following a larger re-excision, adjuvant therapy with Mitomycin C (MMC), cryotherapy and an amniotic membrane graft, the patient has remained disease-free during 9 years of long-term follow-up.

CASE DISCUSSION

Every ophthalmologist should remember to consider and not forget the possibility of using FISH analyses during the differential diagnosis of any suspicious conjunctival lesions. Genetic techniques, such as FISH, have led to great advances in the classification of ambiguous lesions. Evidence-based guidelines for diagnosing conjunctival melanoma in the pediatric population are needed to determine the most appropriate strategy for this age group.

Conjunctival Melanoma in Childhood and Adolescence: A Systematic Review

Background

Conjunctival melanoma is rare in adults and rarer in children. We systematically reviewed the presentation, diagnostic and management strategies as well as outcomes for conjunctival melanoma in children and adolescents.

Methods

The following databases were searched: Medline, Embase, Web of Science and Scopus for cases of conjunctival melanoma occurring in children and adolescents < 18 years of age.

Results

Seventeen studies with 32 patients (18 males) were identified. The median age at presentation was 11 years (range 4-18 years). Most patients were white. Most patients presented with a conjunctival mass or naevus with a recent history of growth or change. Excision biopsy provided diagnosis and management for all cases. Adjuvant chemotherapy and radiotherapy were also used. One patient had metastatic disease at diagnosis and 3 developed metastatic disease (range 1-10 months). Two patients died from disease and one was alive with metastatic disease. Two patients had disease recurrence. Outcomes were observed to be better where diagnosis was made earlier and "no-touch" excision biopsy was performed in an appropriate specialist setting.

Conclusions

Conjunctival melanoma occurs rarely in children and adolescents. Surgery is the mainstay of management. The prognosis is guarded in metastatic disease due to the small sample size and limited follow-up.