Melanotic Lesions of the Eye Charleen T. Chu, M.D., Ph.D. Division of Neuropathology University of Pittsburgh chu@np.awing.upmc.edu April 2002 Copyright ©2002 CT Chu Pigmented Cells of the Eye Eyelid and Conjunctiva – Neural crest derived melanocytes Uvea (“grape”) or tunica vasculosa – Middle layer of the globe – Iris, ciliary body, choroid – Epithelial and stromal compartments Uvea (“grape”) Evisceration specimen Melanin producing cells Embryology Pigmented epithelia – Neuroepithelium of embryonic optic cup Stromal melanocytes – Neural crest - similar to those found in skin Migration of neural crest derived stromal melanocytes continues after birth 2-4 weeks - Invagination of optic cup Images modified from Apple & Rabb, Ocular Pathology 5th ed, © 1998 Mosby-Year Book Iris © 2002 CT Chu © 2002 CT Chu Ciliary Body © 2002 CT Chu © 2002 CT Chu Retina and choroid © 2002 CT Chu RPE and Choroidal Melanocytes Pigment epithelium QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. Stromal melanocytes Modified from Yanoff & Fine, ©1996 Mosby-Times Mirror Int. Bruch’s membrane Case 1 58 year old man with serous detachment of the retina What might be the most relevant prognostic feature? A B C Case 1 © 2002 CT Chu © 2002 CT Chu Choroidal Melanoma, Spindle B Type with transcleral extension along an emissary channel (vortex vein) Choroidal Melanoma Most common intraocular tumor Classic mushroom shape - rupture into vitreous LIVER If metastatic - tend to go to _________. Prognosis – – – – Largest dimension, particularly along base Extension into canal of Schlemm, emissary channels Cytology Location DDx: Diffuse uveal thickening? DDx Diffuse Uveal Thickening Diffuse, flat melanoma of the choroid Metastatic carcinoma Lymphoid/leukemic infiltrates Sympathetic uveitis Vogt-Koyanagi-Harada syndrome Phacoanaphylactic uveitis << Modified from Yanoff & Fine, ©1996 Mosby-Times Mirror Int. Epithelioid Spindle A - grooves © 2002 CT Chu Spindle B - nucleoli © 2002 CT Chu Case 2 84 year old woman with blind eye and 2 week history of eye pain and inflammation. Mass detected by ultrasound FNA performed Case 2 © 2002 CT Chu © 2002 CT Chu © 2002 CT Chu Necrotic Choroidal Melanoma (with residual epithelioid and spindle A cells) and Transcleral Extension Choroidal Melanoma - cytology Spindle A, Spindle B, Epithelioid, Necrotic – Most are mixed – Significant epithelioid component - worse prognosis Spindle only - 22% death rate Necrotic, mixed, epithelioid - 62% death rate – Infarcted tumors can cause significant ocular inflammation >> misdiagnosis in “blind painful eyes” Uveal melanoma - location Tumors of the iris - ______ better prognosis Tumors of the posterior temporal pole better prognosis _______ Tumors of the ciliary body and the worse prognosis peripheral choroid - ______ Early detection Proximity to meshwork and related structures Anterior ciliary artery, venous drainage from meshwork, ciliary nerves Vortex vein © 2002 CT Chu Short and long posterior ciliary arteries Modified from Apple & Rabb, Ocular Pathology, © 1998 Mosby-Year Book Epibulbar Mass QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. Modified from Yanoff & Fine, ©1996 Mosby-Times Mirror Int. DDx of Pigmented Epibulbar Masses Conjunctival nevus or melanoma Extraocular extension of uveal melanoma Foreign body “Pigment spots of the sclera” – Recurrent nerve loop of Axenfeld Hematoma Images modified from Yanoff & Fine, ©1996 Mosby-Times Mirror Int. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. Nerve with associated melanocytes Melanoma exiting through anterior scleral canal Pigment spots of the sclera People with dark irises Located 3-4 mm from the limbus Collections of melanocytes associated with: – Anterior ciliary vessel – Intrascleral nerve loop of Axenfeld Conjunctiva remains freely mobile over the pigment spot and nerve remains painful after anesthesia Case 3 80 year old woman Corneal transplant Expulsive choroidal hemorrhage © 2002 CT Chu Case 3 © 2002 CT Chu Case 3 © 2002 CT Chu Your diagnosis? What if this was a 55 year old African American man? What if this lesion measured 16 x 10 mm? What if I told you this is then classic location for this tumor? QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. Modified from Yanoff & Fine, ©1996 Mosby-Times Mirror Int. Melanocytoma (Magnocellular Nevus) Bleached slide - H&E What special technique might be helpful for demonstrating benign cytology? Image courtesy of Bruce Shields, presented EOPS ‘99 Suspect melanocytoma Maximally pigmented Uniform, polyhedral cells Low N/C ratio Typically affect inferior temporal aspect of optic disc (but can occur anywhere in uvea and sclera) Skin tone of patient Melanocytoma - Clinical Characteristics 10 times more likely to occur in darkskinned individuals In contrast, uveal melanomas are 15 times more likely to occur in Caucasians Benign lesion with low malignant potential – 15% will enlarge over time, can locally infiltrate choroid and optic nerve beyond lamina cribosa Caveat: choroidal melanomas can invade optic disc QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. Modified from Yanoff & Fine, Ocular Pathology ©1996 Mosby-Times Mirror Int. Multiple iris nevi associated with NF2 (Lisch Nodules) Modified from Okazaki & Scheithauer, Slide Atlas of Neuropathology © 1991 Gower Medical Pub. Case 4 Orbital exenteration for morpheaform BCC © 2002 CT Chu © 2002 CT Chu RPE hypertrophy Melanotic RPE nevus, benign “melanoma” of the RPE of Reese and Jones Round or oval, jet black, flat lesion Can be surrounded by halo or contain punched out yellow, depigmented patches Hypertrophy of RPE cells, increase in size of melanosomes May be associated with Gardner’s syndrome - 4 or more RPE hamartomas early marker 5q21 © 2002 CT Chu © 2002 CT Chu Reactive hyperplasia of the RPE Reactive PE Proliferation Pseudoneoplastic proliferations – “Invasion” of neural retina – Intravitreal extension of papillary cords and nests of pigmented and nonpigmented epithelia with abundant BM material – “Fuchs’ adenoma” - of pars plicata Drusen Metaplasia – Fibrous - macular scarring in ARMD – Osseus Reactive PE Proliferation TRAUMA LONG-STANDING OCULAR INFLAMMATION LONG-STANDING DIABETES Retinitis pigmentosa Homocystinuria Ringschwiele or demarcation line © 2002 CT Chu © 2002 CT Chu Neoplastic transformation of uveal epithelia is very rare. What type(s) of neoplasms arise from pigmented uveal epithelia? Pleomorphic Adenoma, Adenocarcinoma of the ciliary body Tubulo-papillary or vacuolated solid pattern, Variable pigmentaion Nuclear atypia common, mitoses rare Vimenin, S-100, low MW keratins, Sparse stroma (BM and hyaluronic acid) CA - histologic dx, locally invasive, rare extrascleral extension, and no distant mets Images courtesy of Barbara Streeten (presented EOPS’99) PAS Pigment epithelia Stromal melanocytes Optic cup Neural crest Present at birth Develops after birth Cuboidal epithelial cells, tight Solitary, dendritic cells, jxns, coarse granules (melanin fine dusty granules and lipofuscin) Always darkly pigmented (except albinos) Reactive proliferations Vary in size, number, and melanin content Neoplastic proliferation Adenoma/adenocarcinoma Nevus, Melanoma Case 5 46 year old man with a cystic conjunctival lesion © 2002 CT Chu Compound cystic melanocytic nevus of the conjunctiva Modified from Yanoff & Fine, ©1996 Mosby-Times Mirror Int. Conjunctival Nevi Junctional Compound Subepithelial Blue Congenital melanocytosis (African & Asian) – Melanosis oculi - ipsilateral conj & uveal – Nevus of Ota - ipsilateral skin, conj & uveal Melanocytic nevus 50% associated with epithelial buds & cysts – Cysts may be so prominent to simulate lymphangioma clinically – Can have “feeder vessels” Inflammed nevus of puberty - nevus enlarges because of lymphoplasmacytic infiltration +/- germinal centers – DDx lymphoid tumor, regressing melanoma Warning signs Overwhelming majority of nevi stable But 20-25% melanomas arise from nevi – Nevi rare in palpebral and forniceal conj. – Base of nevus does not encroach the cornea – Cysts tend to be uniformly distributed; look closely are regions where solid tissue obliterates cysts at one end of lesion – Pagetoid spread of melanocytes –Junctional component should end with subepithelial component (except in children - early phase of maturation from junctional to compound) © 2002 CT Chu © 2002 CT Chu Case 5 © 2002 CT Chu 72 year old man with pigmented areas on the conjunctiva. Status post multiple biopsies © 2002 CT Chu Images modified from Yanoff & Fine, ©1996 Times Mirror Int. Primary Acquired Melanosis with Marked Atypia (Stage IB2) PAM IB vs. Junctional nevus May be identical histologically Basilar hyperplasia, basilar nesting, and intraepithelial nesting can be seen in both Pagetoid spread is not seen in nevus PAM - > 30 year old, mean age is 40-47 Caveat: Conjunctival melanomas can arise in teenagers PAM Unilateral, middle-aged or elderly white pts. Can wax and wane in size, pigmentation Need to evert eyelids to chart extent of involvement, does not respect cornea Extends beyond palpebral fissure, in contrast to lentigo/freckle (sun exposure) PAM Staging IA without atypia IB with atypical melanocytic hyperplasia – 1. Mild to moderate – 2. Severe (“melanoma in situ”) IIA with superficially invasive melanoma IIB with invasive melanoma (>1.5 mm) Primary acquired melanosis PAM without atypia (IA) – 8% recurrence – 0 progressed to melanoma PAM with atypia (IB) – 61% recurrence • incomplete excision, involvement of cornea – 46% progression to malignant melanoma • 20% if mild atypia, basilar hyperplasia pattern • 90% if atypical melanocytes distant from jxn (nests or pagetoid) • 75% if epithelioid cells Primary acquired melanosis PAM with superficially invasive melanoma (< 1.5 mm) (IIA) – Generally nonlethal if excised – Jakobiec et al. suggest cut off of 0.8 mm PAM with invasive melanoma (IIB) – Generally lethal • Pagetoid growth pattern - more sensitive than tumor thickness • Unfavorable location (palpebral, forniceal, caruncle, invasion of cornea) • > 5 mitoses/10 HPF, lack of inflammation © 2002 CT Chu © 2002 CT Chu © 2002 CT Chu © 2002 CT Chu Potential pitfalls for overcalling invasion Bulbous basilar nests simulating invasion Melanophages - central or eccentric nuclei without nucleoli after bleaching Tangential sectioning – surgeon may submit fixed on a cucumber slice – corneal margin, deep margin, other margins Pseudoglands and epithelial cysts – Goblet cells or compressed rim of keratinocytes Goblet cells can take up melanin Conjunctival melanomas 75% associated with PAM – Confused with nevus, SCC, can simultaneously involve conj and lid skin – Usually progress within 6 yrs. Not after 10. 20-25% associated with compound nevus Spread via ipsilateral preauricular, submandibular, or cervical lymph nodes DDX - extraocular extension of uveal tumor, metastasis © 2002 CT Chu • © 2002 CT Chu S-100 © 2002 CT Chu © 2002 CT Chu Secondary melanosis Radiation Addison’s, Pregnancy Arsenic, Thorazine Chronic conjunctivitis “Racial” melanosis Pathologically, how do these differ from primary melanosis? Nonproliferative conditions with increased melanin transfer to keratinocytes