Cellular blue nevus of the conjunctiva

Conjunctival Melanocytic Lesions

CONTEXT.—

Conjunctival melanocytic lesions consist of a variety of neoplastic and nonneoplastic conditions. These include benign processes such as primary intraepithelial hypermelanosis and melanocytic hyperplasia, secondary forms of intraepithelial hypermelanosis and melanocytic hyperplasia, melanocytic nevi, melanocytic proliferations with malignant potential, and melanoma.

OBJECTIVE.—

To provide a concise yet comprehensive resource regarding the histopathologic diagnosis of conjunctival melanocytic lesions. We aim to detail and clarify the numerous classification schemes that exist for junctional melanocytic proliferations of the conjunctiva (known as primary acquired melanosis or PAM; also termed conjunctival melanocytic intraepithelial neoplasia or C-MIN). Although not uniformly adopted, C-MIN is classified by using a numeric system based on a defined set of criteria. A less complex scheme (conjunctival melanocytic intraepithelial lesion or CMIL) has recently been proposed by the World Health Organization. Additionally, we aim to update the reader regarding molecular features and prognostic indicators.

DATA SOURCES.—

Peer-reviewed literature and archived cases for illustration.

CONCLUSIONS.—

Accurate histologic classification is essential, as PAM/C-MIN/CMILs that have a significant potential to progress to invasive melanoma may be clinically indistinguishable from low-risk lesions. Conjunctival melanoma (CM) more closely resembles cutaneous melanoma in terms of its pathogenesis and molecular features, compared to melanoma arising at other mucosal sites or to uveal melanoma. Depth of invasion and ulceration status, among other factors, have emerged as important prognostic indicators in CM. Sentinel lymph node biopsy may provide further prognostic information. Lastly, integration of pathologic and clinical findings is essential at this anatomically sensitive location to determine appropriate clinical management.

Blue nevi of the palpebral conjunctiva: report of 2 cases and review of literature

PURPOSE

To describe two patients with blue nevi of the palpebral conjunctiva and to review the existing literature on common and cellular blue nevi of the conjunctiva.

METHODS

Report of two cases and literature review.

RESULTS

We present two cases of blue nevi in the palpebral conjunctiva: an atypical cellular blue nevus of the left upper eyelid and a common blue nevus around the lacrimal punctum of the left lower eyelid. Both patients underwent full thickness eyelid excision with wide margins. There was no tumor recurrence at 11 and 4 months postoperatively.

CONCLUSIONS

Blue nevi are a group of melanocytic tumors that rarely involve the ocular adnexa. They may arise in the palpebral conjunctiva and should be considered in the differential diagnosis of pigmented lesions in this location as they can mimic melanoma.

Intra-Scleral Blue Nevus Arising within Oculodermal Melanocytosis: Melanoma or Not?

We report a 61-year-old female who presented to our service with recent growth of a thickened, pigmented, sub-conjunctival lesion within an area of ocular melanocytosis in her left eye. Lamellar sclerectomy was performed. Histopathological assessment revealed a localized melanocytic proliferation with features of blue nevus arising within the area of ocular melanocytosis. There was a small zone of cells showing cytological atypia and expansion of the scleral stroma. We believe this case to be the first report of intrascleral blue nevus arising within an area of ocular melanocytosis. Given the cytological atypia, the blue nevus may perhaps represent an intermediate stage within a progression from ocular melanocytosis towards melanoma. Patients with oculodermal melanocytosis merit regular long-term surveillance for early detection of melanoma, not only in the uvea, but also in the orbit and potentially the ocular surface.

Blue Nevi of the Ocular Surface: Clinical Characteristics, Pathologic Features, and Clinical Course

PURPOSE

Blue nevus is a melanocytic tumor that is commonly found in the skin. Extracutaneous presentations, including the ocular surface, are rare. As such, the purpose of this study was to characterize the clinical features and clinical course of congenital melanocytic tumor (blue nevus) of the conjunctiva.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Twenty-one patients with 23 blue nevi of the ocular surface that were excised surgically between 2000 and 2016.

METHODS

Chart review of patients identified from a database search of the Florida Lions Ocular Pathology Laboratory records. Pathologic diagnoses were confirmed by 2 pathologists (S.R.D. and G.E.). All specimens were bleached and, tissue permitting, stained using SOX10 (MilliporeSigma, Darmstadt, Germany) and CD68 (Leica Biosystems, Nussloch, Germany).

MAIN OUTCOME MEASURES

Clinical characteristics, pathologic features, and clinical course.

RESULTS

Mean age of the population was 55±15 years; 71.4% (n = 15) were white and 57.1% (n = 12) were men. One patient had 3 lesions, for a total of 23 lesions examined. Clinically, 13 lesions were on the bulbar conjunctiva, 3 were on the tarsal conjunctiva, 3 were in the fornix, 2 were caruncular, 1 was episcleral, and 1 was at the limbus. Before excision, 8 patients were thought to have primary acquired melanosis, 4 with concern for primary conjunctival melanoma, and 1 thought to have metastatic disease from a plantar melanoma. Five lesions were thought to be benign, and in 8 patients, the lesions were identified incidentally after other ocular surgeries, with no diagnosis of the lesions before excision. Pathologic features were consistent with simple blue nevi in 21 lesions and cellular blue nevus in 2 lesions. No malignant transformations were noted in any patient over the mean 20.2-month follow-up period (range, 2 weeks-103 months).

CONCLUSIONS

Blue nevus is a rare deeply pigmented congenital melanocytic lesion with a benign clinical course that can appear clinically similar to primary acquired melanosis or melanoma.

Conjunctival Blue Naevus in an Anophthalmic Socket

PURPOSE OF THE STUDY

To describe an unusual brown pigmented lesion of the conjunctiva in an anophthalmic socket in a 16-year-old male.

PROCEDURES

A 16-year-old male patient presented with socket irritation whilst wearing an artificial eye due to meibomian gland dysfunction. An area of flat, subepithelial, dark brown pigmentation with irregular and indistinct borders on the bulbar conjunctiva of the anophthalmic socket was seen. The patient believed it had been present for at least 2 years. His past ocular history was of childhood trauma to the right eye at the age of 9 years, and he underwent primary enucleation and hydroxyapatite orbital implant insertion at that time. Unfortunately, the implant extruded and was removed a year later.

RESULTS

An incisional biopsy of the pigmented lesion showed a conjunctival, subepithelial bland spindle cell melanocytic lesion, with uniform-sized and -shaped melanosomes. Immunohistochemistry showed the cells to express Melan A and HMB45 and they were negative for CD68 and pan-cytokeratins. The features were of a common blue naevus.

CONCLUSION

This is the first documentation of a post-enucleation conjunctival naevus in an anophthalmic socket. We propose a pathogenesis and suggest surveillance as there is a risk of transformation to melanoma.

Update on conjunctival pathology

Conjunctival biopsies constitute a fairly large number of cases in a typical busy ophthalmic pathology practice. They range from a single biopsy through multiple mapping biopsies to assess the extent of a particular pathological process. Like most anatomical sites, the conjunctiva is subject to a very wide range of pathological processes. This article will cover key, commonly encountered nonneoplastic and neoplastic entities. Where relevant, sections will include recommendations on how best to submit specimens to the ophthalmic pathology laboratory and the relevance of up-to-date molecular techniques.

Focal blue nevus of the eyelid margin (mucocutaneous junction): a report of a unique case with a review of the literature

PURPOSE

To describe the first isolated and focal benign blue nevus of the eyelid margin.

METHODS

Review of clinical, histopathologic, and immunohistochemical characteristics and relevant literature.

RESULTS

A 93-year-old Caucasian woman with a flat, irregular, and deeply pigmented black growth of the left upper eyelid margin of unknown duration underwent a full-thickness eyelid excisional biopsy. Microscopically, a population of loosely aggregated, mitotically inactive, heavily pigmented oval-to-elongated spindle dermal cells that paralleled the epithelium was seen. MART-1 and HMB-45 immunostaining of premelanosomes could not distinguish between melanocytes and melanophages. The more specific microphthalmia-associated transcription factor stained the nuclei of the subepithelial melanocytes before and after bleaching of the cytoplasmic melanin. The patient did not have Carney complex. No residual pigmentation or lesional recurrence has been noted during 6 months of follow up.

CONCLUSIONS

A blue nevus of the preorbicularis eyelid skin is extremely rare, and still more uncommon is such a lesion of the eyelid margin. Careful microscopic and immunohistochemical evaluation is necessary to establish the proper diagnosis. Wide local excision should be performed due to concern about a more common and serious melanomatous nodule. A differential diagnosis of other pigmented lesions in this location is offered.

Melanocytic Lesions of the Conjunctiva

Context—Melanocytic proliferations are among the most common neoplasms of the conjunctiva. They often represent challenging lesions for pathologists unfamiliar with unique histologic features of melanocytic proliferations in this location and with nomenclature used by ophthalmologists.

Objective—To comprehensively review clinical aspects, pathologic features, and management of melanocytic proliferations of the conjunctiva.

Data Sources—Review of the literature and personal experience of the authors.

Conclusions—Classification, state of the art, and practical aspects of pathology of melanocytic proliferations of the conjunctiva are discussed.

Recurrent blue nevus of the corneoscleral limbus

PURPOSE

To describe an unusual corneoscleral blue nevus.

METHODS

Review of clinical and histopathological characteristics and previous relevant literature supplemented with immunohistochemical studies.

RESULTS

A 13-year-old Pakistani girl presented with a 5 x 2-mm, superotemporal, nonmovable, recurrent, black, limbal nodule. The lesion had been incompletely removed two and a half years earlier. Nonfascicular, variably pigmented, banal, spindle melanocytes with bland nuclei were discovered histopathologically in the conjunctival substantia propria and superficial sclera in the original and recurrent specimens. HMB-45+ and MART-1+ immunostainings established that all the variably pigmented spindle cells were melanocytes. Dispersed plump melanophages displayed clumped melanin granules and were shown to have small nuclei after decolorization. The Ki-67 proliferation index was very low (0.05%), supporting a benign diagnosis. No residual pigmentation after excision and cryotherapy was observed in follow-up examinations during a year and a half.

CONCLUSIONS

Careful histopathological and immunohistochemical evaluation of recurrent, incompletely excised, blue nevi can determine if they remain benign. Adjunctive cryotherapy was performed to prevent further recurrence, based on results from published data.

Incidence of Melanocytic Lesions of the Conjunctiva in a Review of 10 675 Ophthalmic Specimens

During the study period, 10 675 human ophthalmic specimens were received at The Henry C. Witelson Ophthalmic Pathology Laboratory and Registry, McGill University, Montreal, Canada. Of those, 271 were conjunctival lesions (2.5%), with 101 being classified as melanocytic: 50 (49.5%) nevi, 36 (35.6%) primary acquired melanoses, and 15 (14.9%) melanomas. After exclusion of referred cases, 85 lesions were included in the study: 44 (51.7%) nevi, 33 (38.8%) primary acquired melanoses, and 8 (9.4%) melanomas. The most prevalent location was the bulbar conjunctiva. Conjunctival melanomas were most commonly found in an older age group than primary acquired melanosis or nevi. Conjunctival nevi were subdivided into compound (32.9%), subepithelial (16.4%), and junctional (2.3%). Primary acquired melanosis were further classified into primary acquired melanosis with atypia (8.2%) and primary acquired melanosis without atypia (30.5%). Primary acquired melanoses was the predisposing lesion in 75% of the cases of melanoma. In our sample, referral bias could alter the distribution of conjunctival pigmented lesions, with a shift toward the malignant end.

Subungual blue nevus

Junctional or compound melanocytic nevus and melanoma may involve the nail apparatus and are usually discussed in the differential diagnosis of nail pigmentation. Blue nevus has been very rarely reported in this location. We report the second clinicopathologic study of a subungual blue nevus.

Amelanotic cellular blue nevus: a hypopigmented variant of the cellular blue nevus: clinicopathologic analysis of 20 cases

Blue nevus and its variants typically present as pigmented lesions. Dermal melanin is responsible for coloration and is an expected histologic finding. Herein, we report 20 cases of an unusual amelanotic variant of cellular blue nevus. Our series showed clinical demographics similar to pigmented counterparts. Thus, there was a predilection for young individuals with a mean age of 24 years (range 6-74 years). Both sexes were affected, with a female-to-male ratio of approximately 2:1. The lower back, distal extremities, and scalp were the most common sites of occurrence. Importantly, the lack of pigmentation resulted in an atypical clinical appearance. A diagnosis of blue nevus by the attending physician was not considered in any of the reported lesions. All of the tumors extended deep into the reticular dermis or subcutaneous fat with a mean thickness of 5.5 mm (range 1.7-11 mm). Ulceration was present in two lesions. Mild cytologic atypia and pleomorphism were present in five cases. Mitotic activity (up to 3 mitoses/mm ) was observed in 11 lesions. A brisk lymphocytic host response was present in only one lesion. Tumor necrosis was not observed. Most, but not all, tumors showed reactivity for S-100 and HMB-45. Clinical follow-up (mean 32 months) was consistent with a benign course. Local recurrence was not observed after complete excision. None of the cases was associated with clinical evidence of lymph node or distant metastases. Recognition of amelanotic cellular blue nevus is important because the lack of expected pigmentation may result in clinical and pathologic diagnostic difficulty. In particular, amelanotic cellular blue nevus must be distinguished from malignant cellular blue nevus and other variants of melanoma.

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.

Blue nevus: classical types and new related entities. A differential diagnostic review

Blue nevus is an uncommon pigmented lesion of dermal melanocytes. By convention, two well defined histologic variants, designated as "common" and "cellular", have been recognised. In the last few years, these lesions have attracted much attention due to the recognition of news entities and to its confusion with malignant melanoma. In the present review, we point out the more striking features of new related entities (combined nevus, deep penetrating nevus, compound blue nevus) and establish the differential diagnosis with conflictive lesions such as atypical blue nevus, locally aggressive blue nevus, congenital giant melanocytic nevus with nodular growth and melanocytic dermal tumor of unpredictable outcome. We also review the concept of malignant blue nevus and the significance of lymph node metastases. The blue nevus is an uncommon pigmented lesion consisting of dermal melanocytes that can appear in diverse forms: dendritic, spindle-shaped, oval-shaped, or polyhedral. Although it usually occurs in skin, it has been reported in other locations, such as oral mucosa, sclera, uterine cervix, vagina, prostate, spermatic cord, pulmonary hilus, orbit, conjunctiva, maxillary sinus, breast, and lymph nodes 3,8,42,49. Generally, it occurs in adults as a single, acquired, intensely pigmented lesion, although familial and multiple nevi have been reported 7,39. By convention, there are two well-defined histologic variants, designated as "common" and "cellular", but lesions often manifest intermediate features. In the last few years, blue nevus has attracted much attention due to the recognition of new (clinical and histologic) entities and to its confusion with malignant melanoma.(ABSTRACT TRUNCATED AT 250 WORDS)