Saudi Journal of Ophthalmology (2012) 26, 137–144

Ophthalmic Pathology Update

Ocular melanoma

Bertil E. Damato, MD, PhD, FRCOphth a,⇑; Sarah E. Coupland, MBBS, PhD, FRCPath b,1

Abstract

Ocular melanomas comprise uveal and conjunctival sub-types, which are very different from each other. A large majority of uvealmelanomas involve the choroid, with less than 10% being confined to the ciliary body and iris. They tend to metastasize haemat-ogenously, almost always involving the liver. Therapeutic methods include various forms of radiotherapy, surgical resection andphototherapy, which are often used in combination. Conjunctival melanomas show many similarities to their cutaneous counter-parts, often metastasizing by lymphatic spread. Treatment consists of excision of invasive melanoma with adjunctive radiotherapyand/or cryotherapy and topical chemotherapy for intra-epithelial disease. The management of patients with ocular melanomasdemands a good understanding of the pathology of these tumours. Pathological examination of the tumour indicates the prog-nosis and hence the need for further investigation and treatment. The scope of the pathologist is enhanced thanks to advances inmolecular biology.

Keywords: Melanoma, Eye, Uvea, Conjunctiva, Pathology

� 2012 Saudi Ophthalmological Society, King Saud University. All rights reserved.doi:10.1016/j.sjopt.2012.02.004

Introduction

Ocular melanomas are rare, especially in countries suchas Saudi Arabia. Nevertheless, it behoves clinicians to havesome knowledge of this disease so that when they encoun-ter individuals with this condition they can offer thestandard of care that these patients deserve. Even thoughsuch patients may be referred to an ocular oncology centreoverseas, the success of their management dependsgreatly on the care that is provided at the home hospital,which would include diagnosis, counselling and long-termfollow-up.

As with any disease, a good understanding of theunderlying pathology is fundamental to patient care. Thereare many excellent sources of information on the pathol-ogy of ocular melanomas; however, some articles have

Peer review under responsibilityof Saudi Ophthalmological Society,King Saud University

Received 31 January 2012; accepted 5 February 2012; available online 15 Febr

a Liverpool Ocular Oncology Service, Royal Liverpool University Hospital, Liveb Pathology, Dept. of Molecular & Clinical Cancer Medicine, University of Liv

⇑ Corresponding author. Address: Ocular Oncology Service, Royal Liverpoo3973; fax: +44 151 706 5436.e-mail addresses: Bertil@Damato.co.uk (B.E. Damato), s.e.coupland@liverpoo

1 Honorary Consultant in Pathology, Dept. of Molecular & Clinical Cancer Medicine, UnivTel.: +44 151 706 5885; fax: +44 151 706 5859.

become outdated because of rapid advances that haveoccurred in recent years, and other texts are not easilyaccessible.

The aims of this article are to provide a succinct yet prac-tical overview of the pathology of ocular melanomas, with aguide to the more detailed literature on the subject. It ishoped that this review will be relevant not only to patholo-gists but also to ophthalmologists and oncologists.

Uveal melanoma

Introduction

Uveal melanomas account for approximately 98% of allocular melanomas. More than 90% of intraocular melanomas

j Production and hosting by ElsevierAccess this article online: www.saudiophthaljournal.comwww.sciencedirect.com

uary 2012

rpool, UKerpool, Liverpool, UK

l University Hospital, Prescot St., Liverpool L7 8XP, UK. Tel.: +44 151 706

l.ac.uk (S.E. Coupland).ersity of Liverpool, 6th Floor Duncan Building, Daulby Street, Liverpool L69 3GA, UK.

138 B.E. Damato, S.E. Coupland

arise in the choroid, with about 3–4% developing in the irisand the remainder in the ciliary body.1

In Caucasians, uveal melanomas have an incidence ofapproximately 7 per million per year.2 Presentation peaksat the age of sixty years and is rare before adulthood. Malesand females are affected in equal numbers, although iris mel-anomas tend to be slightly more common in women whereaschoroidal melanomas are more common in men.1

Risk factors for uveal melanoma include: light skin, blueeyes, tendency to cutaneous naevi, congenital ocular melan-ocytosis, uveal melanocytoma and neurofibromatosis. Therole of sunlight is uncertain but it is noteworthy that most irismelanomas occur inferiorly, where there is less protectionfrom the upper eyelid.

Histology

According to the modified Callendar classification, uvealmelanoma cytomorphology is categorized as: spindle; epi-thelioid; and mixed. Spindle cells are long and narrow, withlarge nuclei and nucleoli.3 They were previously called ‘spin-dle-B’ cells to differentiate them from Spindle A cells with fur-rowed nuclei, which are now considered to be benign.Epithelioid cells are larger, with eosinophilic cytoplasm andcan be poorly cohesive (Fig. 1a). Rarely, the tumour is entirelynecrotic so that the cytomorphology is unclassifiable. Immu-nohistochemistry staining of proteins such as Heat Shock Pro-tein 27 (HSP-27) may be used for prognostic purposes(Fig. 1b).4 Conventionally, mitoses are counted per fortyhigh-power fields using sections stained with haematoxylinand eosin. (Fig. 1c). Other methods can be deployed, usingstains such as Ser-10 (also known as PHH3).5

Uveal melanomas often contain lymphocytes and macro-phages, which are mentioned in reports because of their

Figure 1. Histopathology of uveal melanoma (a) haematoxylin and eosin slidea good prognosis; (c) mitoses, stained with Ser-10 (PHH3)⁄; and (d) ‘‘closed’(2011).15

prognostic significance, greater numbers of such cells corre-lating with increased mortality.

There are a variety of extravascular matrix patterns, bestshown using the periodic-acid schiff (PAS) reagent, withoutcounter-staining. The most significant are the so-called‘closed loops’ (Fig. 1d), which correlate with aggressivebehaviour.6

Molecular biology

Uveal melanomas tend to show a variety of non-randomchromosomal abnormalities. The most important of theseare: chromosome 3 loss, which can be partial or total (the lat-ter being referred to as ‘monosomy 3’); chromosome 8qgains, occurring either as isodisomy 8q or trisomy; and gainsin 6p, usually developing as a result of isochromosome for-mation. These abnormalities tend to occur as a result of chro-mosomal instability, with the abnormal separation of sisterchromatids during cell division. Chromosome 3 loss and 8qgain are associated with a poor prognosis whereas chromo-some 6p gain correlates with an improved survivalprobability.7,8

On the basis of gene expression profiling, uveal melano-mas have been categorized as ‘‘Class 1’’ and ‘‘Class 2’’, thelatter being associated with a high-risk of metastaticdisease.9

Mutations of guanine nucleotide-binding protein G(q) sub-unit alpha (GNAQ) and GNA11 occur in a mutually-exclusivepattern in about 80% of uveal melanomas.9 Mutations of theBRCA1-associated protein (BAP1) on chromosome 3p21.1are also common and these are associated with metastaticdisease.9,10

showing epithelioid cells⁄; (b) staining for HSP-27, which is associated with’ loops⁄. ⁄From Damato BE et al., Progress in Retinal and Eye Research

Figure 2. Fundus photographs of choroidal melanomas showing: (a) a small tumour with overlying lipofuscin pigment; (b) a large, dome-shaped tumourwith serous retinal detachment; (c) an amelanotic collar-stud melanoma; and (d) a diffuse melanoma.

Ocular melanoma 139

Pathophysiology

Choroidal melanomas initially form a dome-shapedtumour (Fig. 2 a and b). There is an overlying retinal pig-ment epitheliopathy, with the multilayering of retinalpigment epithelial cells, lipofuscin accumulation, drusenand retinal pigment epithelial detachment. In Caucasians,most choroidal melanomas are amelanotic or only lightlypigmented and it is the retinal pigment epithelial (RPE) pro-liferation that gives choroidal melanomas their dark colour(Fig. 2c). This RPE dysfunction causes retinal degenerationand atrophy, inducing symptoms such as metamorphopsia,blurring, visual field loss and photopsia. Many choroidal mel-anomas rupture Bruch’s membrane and the retinal pigmentepithelium to prolapse into the sub-retinal space (Fig. 2c).Strangulation of the herniated tumour by the rigid Bruch’smembrane causes venous congestion and interstitial oede-ma so that the tumour develops a collar-stud or mushroomshape, which is virtually pathognomonic for choroidalmelanoma. Some tumours invade the retina, eventuallyperforating this structure to reach the vitreous, possiblyresulting in vitreous haemorrhage and, rarely, seeding oftumour cells around the eye. Intraocular spread of tumourcan occur anteriorly to involve the ciliary body, iris andangle, as well as posteriorly, towards the optic disc, whichhowever is only rarely invaded.

Approximately, 5% of choroidal melanomas are diffuse,spreading thinly around the uvea without forming any thicknodules (Fig. 2d).

Ciliary body melanomas behave in a similar fashion to cho-roidal tumours. Indeed, it is often difficult to determinewhether a choroidal melanoma has invaded the ciliary bodyor vice versa. These tumours tend to impinge on the lens tocause astigmatism, cataract and subluxation. The overlyingepiscleral vessels tend to become dilated and tortuous (i.e.,

‘sentinel vessels’). Anterior spread often occurs into the ante-rior chamber (Fig. 3a). There also tends to be circumferentialspread around the ciliary body, iris and angle (i.e., ‘ring mel-anoma’). Such circumferential spread can be diffuse and ini-tially sub-clinical so that when treating such anteriortumours it is necessary to apply very wide lateral safetymargins.

The secondary retinal detachment can become bullousand, eventually, total. As with other causes of serous retinaldetachment, there is no proliferative vitreoretinopathy sothat the retina is smooth and mobile. Detached retina tendsto be ischaemic and produces vasoproliferative factors,which, together with those emanating from the tumour, in-duce rubeosis and neovascular glaucoma. Infarction of the tu-mour can occur, causing uveitis, which can be severe enoughto amount to panophthalmitis, with orbital cellulitis and eye-lid swelling.

Iris melanomas can be nodular or diffuse or mixed(Fig. 3b–d). Some have a multinodular appearance (i.e., ‘tap-ioca melanoma’). The nodular melanomas tend to cause adja-cent sectorial cataract and keratopathy if they come intocontact with a large area of the endothelium. Diffuse melano-mas spread widely, and if they extend around the angle theytend to cause secondary glaucoma. Seeding of tumour cellsaround the iris and angle can occur (Fig. 3d). Iris melanomascan spread posteriorly into the ciliary body, some reachingthe choroid.

If left untreated, intraocular melanomas result in a blind,painful, and unsightly eye.

Extraocular spread

At any stage, uveal melanomas can spread extra-ocularly.Such spread tends to occur through pre-existing channels forciliary arteries, vortex veins and drainage vessels.11 Extraocu-

Figure 3. Slit-lamp appearances of anterior uveal melanomas, showing: (a) a ciliary body melanoma extending into anterior chamber; (b) a pigmented,nodular iris melanoma; (c) an amelanotic, nodular iris melanoma⁄; and (d) a diffuse iris melanoma with seeding. ⁄From Ocular Tumours, B Damato.Butterworth Heinemann (2000).

140 B.E. Damato, S.E. Coupland

lar tumour can be nodular, and apparently encapsulated byTenon’s fascia, or diffuse. If neglected, orbital spread canbecome extensive enough to cause proptosis. Before thetwentieth century, it was not uncommon for uveal melanomato spread through the optic canal into the cranial cavity to in-volve the brain.

Metastatic disease

Almost 50% of all patients with uveal melanoma developmetastatic disease, which usually becomes manifest from thesecond post-operative year onwards.12 Only about 2% of allpatients have detectable metastases when their ocular tumouris diagnosed and treated. Metastatic disease almost always in-volves the liver, less common sites being the lungs, skin andbone. Regional lymph nodes are rarely involved, even whenthe tumour shows extraocular spread. Most patients withmetastases die within a year of the onset of symptoms, butlong-term survivors are becoming more common thanks to ad-vances such as partial hepatectomy, ipilimumab, selectiveinternal radiotherapy with yttrium beads, and intra-hepaticchemotherapy, particularly using systems for isolated liver per-fusion. These developments have increased the scope ofscreening for metastatic disease by a variety of imaging meth-ods, such as hepatic magnetic resonance imaging, and bloodtests, such as liver function tests and circulating melanomacells.13,14

Prognostication

As with other cancers, prognostication is an important as-pect of patient care, identifying high-risk patients requiringspecial care while allowing low-risk patients to be reassured

of their good survival prospects. The pathologist is well-placed to play a valuable role in this process. This is becausehistological grade of malignancy and genetic type of mela-noma profoundly influence prognosis.15

The clinical features associated most strongly with an in-creased risk of metastatic disease from posterior segmentmelanoma are: largest basal tumour diameter; tumourheight; ciliary body involvement; and extraocular spread.These form the basis of the 7th edition of the TNM stagingsystem (i.e., Tumour, Node, Metastasis system developedby the American Joint Committee on Cancer).16 With iris mel-anomas, risk factors for metastasis include diffuse spread, an-gle involvement and secondary glaucoma.17

Histological predictors of metastasis include: melanomacytomorphology; mitotic count; and the presence of closedloops. There is no consensus as to the proportion of mela-noma cells that need to show epithelioid cytomorphologybefore the melanoma is termed ‘‘epithelioid’’. We reportthe approximate percentage of epithelioid cells within amelanoma.

Metastatic disease occurs almost exclusively with melano-mas showing chromosome 3 loss and/or class 2 gene expres-sion profile, which correlate strongly with each other.9 Thesurvival prognosis is especially poor when chromosome 3 lossand chromosome 8q gain occur together.8,18 Conversely,chromosome 6p gain is associated with a better prognosis,partly because chromosome 3 loss is less common in thepresence of 6p gain and also because the survival time islonger.19

Chromosomal testing with fluorescence in situ hybridisa-tion has largely been superseded by more sensitive methodssuch as multiplex ligation-dependent probe amplification(MLPA), microsatellite analysis (MSA), array comparative

Figure 4. Kaplan–Meier survival curves showing survival according to thepresence or absence of chromosome 3 loss, determined by multiplexligation-dependent probe amplification.

Ocular melanoma 141

genomic hybridisation (aCGH), and gene expression profil-ing.8,20–24 At present, we use MLPA as a first-line test, withMSA if the tumour sample is small or has a low DNA concen-tration (Fig. 4).

We have developed mathematical tools for estimating thesurvival prognosis after treatment of the choroidal mela-noma.15 These integrate the pathological grade of malig-

Figure 5. Personalised prognostication integrating pathological findings withby subtracting the all-cause mortality of the general population (upper curve)

nancy with TNM clinical stage and with chromosome 3 loss,also taking age and sex into account (i.e., normal life expec-tancy) (Fig. 5). Our method adjusts for competing risks andgenerates survival curves that are accurate enough to berelevant to individual patients. This program is availableonline, free of charge (www.ocularmelanomaonline.com).

Conjunctival melanoma

Introduction

Conjunctival melanomas comprise about 2% of all ocularmelanomas and are therefore very rare, even in Caucasians.As with uveal melanomas, they occur in adulthood, particu-larly in later life, and the incidence is similar in both sexes.25

Risk factors include: fair skin; tendency to sunburn and tohave a relatively-high number of cutaneous naevi.

Histology

Conjunctival melanomas arise from intra-epithelial mela-nocytes, which are normally located in the basal layer of theepithelium and which have long dendritic processes supply-ing melanin pigment to adjacent epithelial cells. On malig-nant transformation, melanocytes lose their dendrites anddemonstrate atypical features such as epithelioid morphol-ogy, with a large nucleus and prominent nucleolus (Fig. 6).In addition, they increase in number and invade the moresuperficial layers of the conjunctival epithelium, forming sep-arate and confluent cells nests and increasing in density untilmost of the epithelium is replaced by atypical melanocytes.The rate of cellular proliferation by the neoplastic melano-

genetic results and clinical tumour stage. The metastatic risk is estimatedfrom that of the patient population (lower curve).

Figure 6. Histological grading of conjunctival melanocytic intra-epithelial neoplasia (C-MIN). From Damato B and Coupland SE. Management ofconjunctival melanoma. Expert Rev. Anticancer Ther. 2009;9:1227–39.

142 B.E. Damato, S.E. Coupland

cytes increases so that mitotic figures are seen more readily.Eventually, the surface of the epithelium becomes ‘‘ulcer-ated’’. Previously, this condition was referred to as ‘primaryacquired melanosis (PAM) with atypia’26; however, suchterminology is imprecise because it subsumes two patholog-ical processes: both (a) melanin over-production (i.e., ‘hyper-melanosis’) and (b) proliferation of atypical melanocytes (i.e.melanocytosis). We prefer the term ‘conjunctival melanocyticintra-epithelial neoplasia (C-MIN)’, which we describe asoccurring with and without atypia, according to whether ornot the melanocytes show atypical cytological features andwhether they demonstrate particular radial and verticalgrowth patterns.27 We have developed a system for scoringthe degree of atypia according to these features (Fig. 5), withthe maximum score being 10.27 We have also introduced theterm ‘conjunctival melanoma in situ’, which refers to the moresevere grades of C-MIN (i.e., score > 5).

Invasive melanoma is present when the conjunctival base-ment membrane has been breached by the neoplastic mela-nocytes resulting in invasion of the lamina propria. Thisdevelopment is of fundamental prognostic significance asthe tumour cells have gained access to lymphatic channelsand blood vessels, thereby giving rise to a possibility of met-astatic disease. Tumour-associated lymphangiogenesis corre-lates with increased mortality.28

Other notable histological features, which are of prognos-tic value, include lymphocytic infiltration, tumour thickness,surface ulceration, depth of invasion, and surgical clearance.The presence of pagetoid spread in the epithelium is also sig-nificant as it indicates an increased risk of local recurrence,thereby influencing ocular treatment.

Molecular biology

Conjunctival melanomas are biologically different fromtheir uveal counterparts and are more similar to cutaneousand mucous membrane melanomas. We and many othershave shown, for example, that conjunctival melanomas com-

monly show BRAF V600E mutations, which do not occur withintraocular melanomas.29 Such BRAF mutations are of clinicalsignificance because they indicate that the patient may re-spond to treatment with vemurafenib, should metastatic dis-ease develop.30 Other mutations include CDKN1A, RUNX2,MLH1, TIMP2, MGMT, ECHS1 and others.29 To our knowl-edge, none of these factors have yet been shown to haveprognostic value.

Pathophysiology

Conjunctival melanomas can be described as ‘in situ’ or‘invasive’. Invasive melanomas can arise de novo, from apre-existing naevus, or from pre-existing C-MIN (Fig. 7).Most invasive conjunctival melanomas arise in the bulbar con-junctiva, especially temporally, less common sites of originbeing the caruncle, plica and tarsal conjunctiva.31–33 Theycan be nodular, diffuse or mixed and single or multiple.The degree of pigmentation is highly variable between tu-mours, even within the same patient, so that clinically the col-our of the melanomas can be black, grey, brown, pink, red,yellow or white. Dilated conjunctival feeder vessels are com-monly present.

Local spread

Conjunctival melanomas can show pagetoid spread withinthe epithelium, seeding across the conjunctival surface andinto the nasolacrimal passages, and invasion within the con-junctiva as well as to the surrounding tissues. Such invasioncan occur circumferentially along the limbus and fornix, aswell as deeply into the eye, orbit, sinuses, and cranial cavity.They can also invade the adjacent skin. Intraocular spread ismore likely after inadequate surgery, especially if there is dis-ruption of the Bowman’s membrane, which serves as a natu-ral barrier.34 Seeding can be iatrogenic, with the transfer ofmalignant cells to healthy tissues by means of contaminatedsurgical instruments.

Figure 7. Slit-lamp photographs showing: (a) conjunctival melanocytic intraepithelial neoplasia; (b) diffuse, invasive conjunctival melanoma; (c) bulbarinvasive conjunctival melanoma; and (d) caruncular invasive conjunctival melanoma. From Damato B and Coupland SE. Management of conjunctivalmelanoma. Expert Rev. Anticancer Ther. 2009;9:1227–39.

Ocular melanoma 143

Metastatic disease

Metastases can occur via lymphatics to regional lymphnodes and haematogenously to other parts of the body.35,36

Risk factors predicting metastatic disease include:involvement of non-bulbar conjunctiva, particularly the carun-cle; tumour thickness; histological grade of malignancy; andhistological evidence of lymphatic invasion.37–39,39,40

Prognostication

The 7th edition of the TNM staging system categorizes theclinical stage of conjunctival melanomas according to circum-ferential spread, in terms of: (1) number of quadrants of con-junctiva involved; (2) location in bulbar or extra-bulbarconjunctiva; (3) caruncular involvement; and (4) invasion ofthe substantia propria, globe, eyelid, orbit, sinus and CNS.Approximately 20% of all patients with conjunctival mela-noma die of metastatic disease within ten years, but mortalityis much higher if the caruncle is involved.39,37

Conclusions

The management of patients with an ocular melanoma de-pends greatly on proper understanding of the pathology oftheir tumour. Pathological examination of ocular melanomasprofoundly influences patient care, not only confirming thediagnosis but also indicating prognosis and hence the needfor further investigation and treatment. The role of the pathol-ogist is growing thanks to advances in molecular biology andthe involvement of pathologists in this specialized field.

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