Patient case: 34-year-old female with melanoma; genetic feature: NRAS (Q61L)

Clinical trial: In Vivo Confocal Microscopy Study of Pigmented Conjunctival Lesions

Summary: This study aims to validate the use of laser in vivo confocal microscopy as an early diagnostic and differentiation tool of pigmented conjunctival lesions, evaluate the efficacy of in vivo confocal microscopy for follow-up (as a visualizing tool) after tumor resection for early detection of tumor recurrence, and to evaluate the use of in vivo confocal microscopy in evaluation of response to treatment. The modified technique with Heidelberg Retina Tomography (HRT) confocal microscopy and anterior segment optical coherence tomography (OCT) are non-invasive, no-touch, imaging techniques that may help in differentiation of benign lesions like nevi or racial melanosis, from malignant lesions like primary acquired melanosis and malignant melanomas. The OCT will potentially allow to estimate tumor depth in vivo as preliminary studies have shown.

Detailed description: Conjunctival melanoma is a potentially lethal neoplasm, with an average 10-year mortality rate of 30%, and 15-year mortality rate of 45%. This condition occurs mainly in the white population, with rare reports in black and other non-white populations. Recent studies have indicated that like cutaneous melanoma, the incidence of conjunctival melanoma is increasing.
  Conjunctival Malignant Melanoma (MM) is also currently diagnosed based upon clinical grounds, through observation of the growth of the suspected lesions over regular intervals of time. Unfortunately simple slit lamp examination is currently the only clinical diagnostic visual instrument available in medical practice, and the early diagnosis of MM by slit-lamp examination is still rather poor. Further the diagnosis of invasive conjunctival MM is currently established by conjunctival excisional biopsy and defined by the invasion of the underlying substantia propria of the conjunctiva by atypical tumor cells, especially when there is loss of the maturation. Regarding the management of malignant melanoma, unfortunately the extensive horizontal and even vertical growth of this neoplasm does not always lend itself to simple excision leading to exenteration. As a vision-sparing alternative, local excision with cryotherapy has become the treatment of choice. Long-term follow-up has shown that local recurrences are common. More recently, topical chemotherapy with mitomycin C (MMC) has been used to treat cases with extensive PAM with atypia , because the pigmented margin is used as a guide for most conservative treatments, the tumor's edge may be missed.
  Recurrent conjunctival MM often presents as an amelanotic mass and may be mistaken for pyogenic granuloma in a patient who has had multiple previous excisions of conjunctival MM, even though the original tumor may have been pigmented. Because of the lack of pigment, these tumors can remain unrecognized and progressively enlarge, especially if the patient has had previous surgery and conjunctival scarring. In addition, the tumor margins of recurrent amelanotic conjunctival MM may be indistinct. These factors can lead to delayed recognition and the unnecessary need for exenteration. Despite these radical procedures, which usually lead to loss of vision or the eye, these patients have been shown to have a poor survival rate, suggesting that metastasis has already occurred at the time of treatment. This confirms that the extent of the disease at diagnosis is the most important factor to determine the outcome. Recurrence of conjunctival MM is reported at 26% at 5 years and, 51% at 10 years.
  MM of the conjunctival represents one of the greatest challenges in early or preventive detection. Whereas surgical excision in early stages of tumor development is almost always curative, delayed recognition puts the patient at risk of destructive growth and death once the tumor has progressed to competence for metastasis. Accurate diagnosis of pigmented lesions of the conjunctiva such as nevi, primary, and secondary acquired melanosis and MM present a challenge to both the ophthalmologist and the pathologist. It is not possible clinically to distinguish between PAM with and without atypia. The ability to detect early MM remains of paramount importance in our efforts to curtail deaths related to this malignancy. The implementation and utilization of in vivo imaging technologies in clinical practice would enhance our ability to detect MM while this cancer is in its early stages and curable. Further, accurate assessment of therapeutic tumor response is critical for evaluation of chemotherapy results in patients, and in clinical trials. Tumor response is also a guide for the clinician and patient or study. Early, accurate prediction of non-response would allow an early change to second-line treatment, thus sparing patient's unnecessary toxicity, psychological morbidity and delay of initiation of effective treatment. These are very few variables that investigators, as clinicians, can control regarding the management of conjunctival MM. However, early detection, technique and time of surgery may ultimate after tumor recurrence, need for orbital exenteration, tumor metastasis, and patient death. This non-invasive imaging technique that is now available for clinical studies might help in early detecting and preventing above mentioned problems.

Eligibility: Inclusion criteria:
  1. Age over 18 years
  2. The ability to provide informed consent for enrollment in the study
  3. Diagnosis of conjunctival nevus (Group 1 only)
  4. Diagnosis of racial melanosis (Group 2 only)
  5. Diagnosis or suspicion of primary acquired melanosis (PAM), scheduled for biopsy (Group 3 only)
  6. Diagnosis of possible MM scheduled for biopsy (Group 4 only)
  7. Confirmed diagnosis of MM based upon clinical and histopathological findings, and have already undergone resection(Group 4 only)
  8. Confirmed diagnosis of MM recurrence based upon clinical and histopathological findings(Group 4 only)
  9. Clear cornea (Group 5 only)
  10. No conjunctival lesions or recent conjunctival diseases(Group 5 only)
  11. No recent chemotherapy or radiotherapy(Group 5 only)
  Exclusion criteria:
  1. History of previous ocular surgery within last 3 months
  2. History of inflammatory eye diseases within last 3 months
  3. Current or history of glaucoma disease and on glaucoma medication
  4. Contact lens use within last 3 months
  5. Physical inability to cooperate for confocal microscopy
  6. Prior history of infectious keratitis within 3 months
  7. Suspicion for PAM or malignant melanoma (MM)(Groups 1,2,3)
  8. History of PAM or MM(Groups 1,2,3)
  9. Histopathology not confirmatory for MM (group 4 only)
  10. History of other ocular carcinoma or any recent ocular topical chemotherapy or radiotherapy (Group 5 only)
  11. History of cancer elsewhere in the body which is currently under systemic chemotherapy (group 5 only)

Relevance to patient case: not relevant