Possible dissemination of conjunctival melanoma along tear flow path.

Case report

A 60-year-old woman presented with conjunctival melanoma arising from pigmented primary acquired melanosis (PAM) located in the temporal upper bulbar conjunctiva of her right eye. The tumor had a diameter of 16 mm and height of 11 mm (Fig. 1A and Fig. 2A). Magnetic resonance imaging did not reveal tumor growth in the lacrimal sac (Fig. 2B) and pigmented PAM was not detected in other areas of the conjunctiva. Complete tumor resection was performed using the no-touch technique. At 34 months after the initial visit, conjunctival melanoma dissemination was observed in the lower bulbar conjunctiva (Fig. 1B), and was resected in the same manner. At 66 months after the initial visit, melanoma involvement was observed in the lacrimal sac (Fig. 1C and Fig. 2C), and was treated using proton beam radiotherapy. Histological examination of the lesions from the conjunctiva lacrimal sac revealed that both showed the same cytological and immunohistochemical features (Fig. 3).

Fig. 1

Conjunctival melanoma was detected at the upper temporal forniceal conjunctiva at the patient's initial visit (A), at the lower temporal epibulbar conjunctiva approximately 3 years after the initial visit (B), and in the lacrimal sac approximately 5 years after the initial visit (C).

Fig. 2

Magnetic resonance images at the patient's initial visit, showing a mass lesion at the upper temporal forniceal conjunctiva (A), but no visible lesion in the lacrimal sac (B). Computed tomography image showing a mass lesion in the lacrimal sac at approximately 5 years after the initial visit (C).

Fig. 3

Histological examination revealing that the tumor cells comprise epithelioid and plump spindle cells (A, hematoxylin-eosin staining; original magnification, 200 × ). Immunostaining reveals that tumor cells are positive for HMB-45 (B) and S100 (C). Original magnification 400 × .

Discussion

Conjunctival melanomas occasionally exhibit recurrences in the lacrimal drainage. However, typically several conjunctival recurrences occur first, and nasolacrimal recurrences appear at a median of five or six years after initial treatments,, along with recurrences at the nasal passage terminus. Most cancers have hematogenous and lymphatic dissemination patterns, and the lacrimal sac melanoma may have developed within the PAM. However, melanoma cells have been detected in tears in patients with conjunctival melanoma, and thus it is possible that conjunctival melanoma may have another dissemination pattern along tear flow path.

Conclusion

Ophthalmologists should be aware that conjunctival melanoma may have a dissemination pattern along the tear flow path.

Author conflicts of interest

None.

Authorship

All authors attest that they meet the current ICMJE Criteria for Authorship.

Funding

None.

Patient consent

Written consent to publish was obtained from the patient.