Nasal and orbital recurrence of conjunctival melanoma 21 years after exenteration.

Abstract

In our experience 5% of invasive malignant melanomas of the conjunctiva arising from areas ofprimary acquired melanosis with atypia spread to the ipsilateral nasal cavity and paranasal sinuses. Twenty one years after orbital exenteration for multicentric conjunctival melanoma an 82-year-old man was seen with an orbital recurrence, which had extended to the nasal cavity and paranasal sinuses through the nasolacrimal duct without invading the mucosa. This previously undescribed way of spread after the longest symptom-free interval following exenteration ever reported is illustrated. In 1985 a small, hard subcutaneous nodule, which was tethered to the periosteum superiorly in the right socket, was noted. The overlying skin was slightly pigmented. On observation the small mass remained unchanged.In 1990, 21 years after the exenteration, the 82-year-old patient complained of obstruction of the right nasal passage. Examination of the right orbit showed a large subcutaneous swelling at the medial edge of the right socket and the preexisting small nodule at the superolateral edge (Fig 1). Examination of the nasal cavity revealed a large ulcerating pigmented polyp obstructing the right nasal passage (Fig 2). There was no clinical involvement ofthe regional lymph nodes. Investigation for metastases, including liver ultrasound, liver function tests, and a chest x ray, was negative. There was no evidence of cutaneous malignant melanoma. A computerised tomography (CT) scan (Fig 3) showed the presence of tumour in the right anteromedial orbit, the nasolacrimal duct, invasion of the anterior ethmoidal cells, and a large intranasal mass. A diagnostic biopsy of the nasal lesion confirmed the clinical diagnosis of malignant melanoma. The patient's remaining eye showed lens opacities and age-related macular disease, reducing the visual acuity to 6/12.The patient was treated by right lateral rhinotomy. The skin overlying the medial orbital mass was excised. The anteromedial wall of the maxilla and the orbital floor were removed, and subsequently the tumour was cleared from the

Two Late Recurrences of Conjunctival Melanoma

“…In our case, the patient developed a recurrence 4 years after this procedure. To our knowledge, this kind of recurrence has only been reported once before in a patient who had undergone orbital exenteration 21 years before [6]. …”

Possible dissemination of conjunctival melanoma along tear flow path

“…However, typically several conjunctival recurrences occur first, and nasolacrimal recurrences appear at a median of five or six years after initial treatments, 2 , 3 along with recurrences at the nasal passage terminus 4 . Most cancers have hematogenous and lymphatic dissemination patterns, and the lacrimal sac melanoma may have developed within the PAM.…”

Sinonasal melanoma arising from conjunctival primary acquired melanosis

“…Paridaens et al 4 reported that 5% of invasive conjunctival melanomas arising from areas of PAM with atypia spread locally to the ipsilateral nasal cavity and paranasal sinus. Yet, the patient reported here was never found to have invasive melanoma of the conjunctiva.…”

“…Paridaens et al 4 reported that 5% of invasive conjunctival melanomas arising from areas of PAM with atypia spread locally to the ipsilateral nasal cavity and paranasal sinus. Distant metastasis occurs through lymphatic spread through channels in the conjunctival substantia propria or through haematogenous spread 5.…”