Orbital exenteration and conjunctival melanoma: a 14-year study at the Jules Gonin Eye Hospital

Abstract

Purpose To report our 14-year experience with orbital exenteration and assess risk factors for poor prognosis by focusing on conjunctival melanoma. Patients and method A retrospective study was conducted in our tertiary care centre (Jules Gonin Eye Hospital, Lausanne, Switzerland) between 2003 and 2017. Inclusion criteria were patients aged ≥18 years with a follow-up >12 months, without metastatic spread at the time of surgery. Data recorded were age, gender, tumour histology, surgical technique, postoperative complications, surgical margin status, local recurrence, postoperative radiation beam therapy and metastatic status. Results Twenty-five patients with a mean age of 63.2 years (38–92) were included. Conjunctival melanoma was the most frequently identified tumour ( n = 14, 56%) followed by conjunctival squamous cell carcinoma ( n = 4, 16%), sebaceous carcinoma ( n = 3, 12%), choroidal melanoma ( n = 2, 8%) and basal cell carcinoma ( n = 2, 8%). Eighteen tumours (72%) originated from the conjunctival tissue. Clear surgical margins were achieved in 21 (84%) patients. Fourteen (56%) patients experienced distant metastases and died from metastatic spread after a mean follow-up of 52.3 months (6–120). The 1-, 3- and 5-year overall survival (OS) was 96%, 72% and 60%, respectively. In the univariate analysis, positive surgical margins, local recurrence and metachronous metastases were associated with a decreased OS ( p = 0.002, p = 0.005 and p = 0.007, respectively). In the multivariate analysis, positive surgical margins and metachronous metastases were also associated with a decreased OS ( p = 0.02 and p = 0.042, respectively). Conjunctival melanoma was not associated with a poorer prognosis ( p = 0.280). Conclusion Free surgical margins are needed to increase OS. To achieve clearer surgical margins, neoadjuvant targeted therapies/immunotherapies may be considered.

New Targeted Therapies and Immunotherapies for Locally Advanced Periocular Malignant Tumours: Towards a New ‘Eye-Sparing’ Paradigm?

“…OE is a radical surgical procedure consisting of the removal of the entire orbital contents, including the eye and oculomotor muscles, in a subperiosteal fashion ( Figure 2 ) [ 5 ]. Historically, OE was first described in 1583 by Bartisch et al [ 6 ].…”

“…Cosmetic rehabilitation is better achieved with an orbital prosthesis retained by orbital implants, skin glue or glasses [ 4 ]. Cosmetic rehabilitation depends on orbital socket healing and is often delayed, especially in the case of orbital implant placement [ 5 ]. Although recent progress has been made in terms of reconstructive strategies and cosmetic rehabilitation [ 4 ], OE is associated with anxiety and depression [ 8 ].…”

Small but Challenging Conjunctival Melanoma: New Insights, Paradigms and Future Perspectives

“…OE is rarely performed with less than one hundred procedures performed yearly in France, corresponding to an annual incidence of 0.13/100,000 inhabitants [ 85 ]. In tertiary ocular oncology centres, CM is often the leading cause of OE [ 5 , 8 , 86 , 87 , 88 ]. OE is rarely performed as a first-line treatment for CM and is usually recommended in patients with an orbital involvement or multiple tumour recurrence [ 5 , 8 , 55 , 89 ].…”

“…In tertiary ocular oncology centres, CM is often the leading cause of OE [ 5 , 8 , 86 , 87 , 88 ]. OE is rarely performed as a first-line treatment for CM and is usually recommended in patients with an orbital involvement or multiple tumour recurrence [ 5 , 8 , 55 , 89 ]. A recent study has recommended the performance of early OE (i.e., before the occurrence of 4 local recurrences) to reduce the risk of metastatic spread [ 89 ].…”

“…Despite complete surgical excision, local recurrence and metastatic spread occur in about one third and one quarter of patients, respectively [ 5 , 6 , 7 ]. In some cases, radical and disfiguring surgeries such as orbital exenteration (OE) are needed to achieve tumour control [ 8 ]. Nevertheless, OE has failed to improve the overall survival.…”