Amelanotic Malignant Melanoma of the Eyelid referred for treat¬ A 38-year-old ment of suspected basal cell carcino¬ man was
a
of the right lower eyelid. The tumor had been present for 2 months and appeared to arise from previously normal skin based on clinical history and review of old ma
photographs. A firm, slightly erythematous, ill-defined nodule involving the lateral half of the right lower lid was ulcerated to the conjunctival mucosa (Fig 1). Results of a wedge biopsy revealed a high-grade malignant tumor. The diagnosis of malignant melanoma was established using results of immunohistochemical stains, which were strongly posi¬ tive for S100 protein and HMB-45 and negative for low- and high-molecularweight cytokeratins. He had no evidence of regional or systemic metastasis (stage I). The tumor was excised using rush perma¬ nent sections to determine the adequacy of the surgical margins.1 After the margins were deemed tumor-free, the surgical de¬ fect was closed using a Hughes procedure and rotational musculocutaneous flap. Histopathologic examination of the ex¬ cised tumor revealed a predominantly nodu¬ lar pattern of growth extending 1.5 mm into the ulcerated surface (Figs 2, 3, and 4). Consultants recommended an ipsilateral neck dissection. No tumor was found in 33 lymph nodes from the anterior neck or in the parotid gland. COMMENT
The eyelid skin is an uncommon loca¬ tion for malignant melanoma. Only 32
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such cases were reported in the two largest series investigating the sub¬ ject.2,3 Although pigmentation is con¬ sidered
a hallmark of cutaneous mela¬ half of the lid melanomas reported by Garner et al2 were clinical¬ ly nonpigmented. The prognosis for patients with cutaneous melanoma is closely correlated with the melanoma's depth of invasion/ Tumors more than 1.5 mm deep are usually associated with a poor prognosis.
noma,
Lessner, MD Sexton, MD Curtis E. Margo, MD Gainesville, Fla
Alan Mack
References 1. Dhawan SS, Wolf DJ, Rabinowitz HS, Poulos E. Lentigo maligna: the use of rush permanent sections in therapy. Arch Dermatol. 1990;126:928\x=req-\ 930. 2. Garner A, Koornneef L, Levene A, Collin JRO. Malignant melanoma of the eyelid skin: histopathology and behaviour. Br J Ophthalmol.
1985;69:180-186.
3. Naidoff MA, Bernadine VB, Clark WH Jr. Melanotic lesions of the eyelid. Am J Ophthalmol.
1981;82:371-382.
4. Breslow A. Tumor thickness, level of invasion and lymph node dissection in stage I cutaneous melanoma. Ann Surg. 1975;182:572-581.
Fig over
1 .—A 4-mm ulcerated nodule of the right lower eyelid grew rapidly 2 months.
Fig 3.—The tumor was composed of pleomorphic cells with abundant cytoplasms, large hyperchromatic nuclei, and promi¬ nent nucleoli (hematoxylin-eosin, original magnification 390).
Fig 4. —Tumor cells at upper left stained positive with HMB-45 antimelanoma antibody. Inflammatory cells at lower right were nonreactive (immunoperoxidase, original magnification 390).
Fig 2. —Full-thickness cross section of the eyelid demonstrates tumor invading deep into the tarsus. The ulcerated skin surface faces the right (hematoxylin-eosin, original
magnification 24).
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/20/2015
a
of the right lower eyelid. The tumor had been present for 2 months and appeared to arise from previously normal skin based on clinical history and review of old ma
photographs. A firm, slightly erythematous, ill-defined nodule involving the lateral half of the right lower lid was ulcerated to the conjunctival mucosa (Fig 1). Results of a wedge biopsy revealed a high-grade malignant tumor. The diagnosis of malignant melanoma was established using results of immunohistochemical stains, which were strongly posi¬ tive for S100 protein and HMB-45 and negative for low- and high-molecularweight cytokeratins. He had no evidence of regional or systemic metastasis (stage I). The tumor was excised using rush perma¬ nent sections to determine the adequacy of the surgical margins.1 After the margins were deemed tumor-free, the surgical de¬ fect was closed using a Hughes procedure and rotational musculocutaneous flap. Histopathologic examination of the ex¬ cised tumor revealed a predominantly nodu¬ lar pattern of growth extending 1.5 mm into the ulcerated surface (Figs 2, 3, and 4). Consultants recommended an ipsilateral neck dissection. No tumor was found in 33 lymph nodes from the anterior neck or in the parotid gland. COMMENT
The eyelid skin is an uncommon loca¬ tion for malignant melanoma. Only 32
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/20/2015
such cases were reported in the two largest series investigating the sub¬ ject.2,3 Although pigmentation is con¬ sidered
a hallmark of cutaneous mela¬ half of the lid melanomas reported by Garner et al2 were clinical¬ ly nonpigmented. The prognosis for patients with cutaneous melanoma is closely correlated with the melanoma's depth of invasion/ Tumors more than 1.5 mm deep are usually associated with a poor prognosis.
noma,
Lessner, MD Sexton, MD Curtis E. Margo, MD Gainesville, Fla
Alan Mack
References 1. Dhawan SS, Wolf DJ, Rabinowitz HS, Poulos E. Lentigo maligna: the use of rush permanent sections in therapy. Arch Dermatol. 1990;126:928\x=req-\ 930. 2. Garner A, Koornneef L, Levene A, Collin JRO. Malignant melanoma of the eyelid skin: histopathology and behaviour. Br J Ophthalmol.
1985;69:180-186.
3. Naidoff MA, Bernadine VB, Clark WH Jr. Melanotic lesions of the eyelid. Am J Ophthalmol.
1981;82:371-382.
4. Breslow A. Tumor thickness, level of invasion and lymph node dissection in stage I cutaneous melanoma. Ann Surg. 1975;182:572-581.
Fig over
1 .—A 4-mm ulcerated nodule of the right lower eyelid grew rapidly 2 months.
Fig 3.—The tumor was composed of pleomorphic cells with abundant cytoplasms, large hyperchromatic nuclei, and promi¬ nent nucleoli (hematoxylin-eosin, original magnification 390).
Fig 4. —Tumor cells at upper left stained positive with HMB-45 antimelanoma antibody. Inflammatory cells at lower right were nonreactive (immunoperoxidase, original magnification 390).
Fig 2. —Full-thickness cross section of the eyelid demonstrates tumor invading deep into the tarsus. The ulcerated skin surface faces the right (hematoxylin-eosin, original
magnification 24).
Downloaded From: http://archopht.jamanetwork.com/ by a Monash University Library User on 06/20/2015
