Documenta Ophthalmologica 42,2 : 321 - 328, 1977 CONJUNCTIVAL MELANOMA, A RETROSPECTIVE STUDY J. A. TEN NAPEL
(A msterdam/Zaandarn ) ABSTRACT During the period 1954 to 1974 inclusive, fourteen patients with melanoma of the conjunetiva were observed in the Department of Ophthalmology, University of Amsterdam. Frequency, etiology and treatment are discussed. No statistically proven conclusions may be drawn from this investigation; not at any rate, in regard to the treatment due to lack of homogeneity of the approaches used in recent years.
FREQUENCY As Table 1 shows, 14 patients have been hospitalized in 20 years. This is less than one patient per year, but if we only consider the last ten years, the frequency is just one patient a year. In the last ten years, an average of 1350 patients have been hospitalized annually, while our policlinic received approx. 10,000 new patients annually (first consultations and first-aid patients).
Table 1 i
Frequency of conjunctival melanoma 1954 to 1964 inclusive: 1964 to 1974 inclusive: last 5 years: total 1954 to 1974 inclusive:
3 11 8 14
In the literature, as a rule only a few cases are reported per paper. Reese is the only one who has reported several larger series. At the major international congresses of the period 1 9 6 0 - 1 9 7 0 , no large series have been described, either (Sehlieter, 1972). A few figures from the literature: Institute of Pathology, London: 104 cases in 13 years (Jay, 1965) Lederman (radiotherapist, London 1958): 63 melanomas in 18 years Balestrazzi (1971): 4 melanomas in 14 years among 30,000 patients. -
-
-
321
Mansehot (1974) unverifiably but probably more or less accurately stated that an ophthalmologist in The Netherlands in all the years of his practice may be expected to see only one or two eases of conjunctival melanoma. Table 2 lists the patients' age and sex and the eye involved. It should be mentioned in this connection that in most cases, the time o f onset of the melanoma could not be determined. The mean duration of interval between the time when the ophthalmologist saw the patient with a melanoma for the first time, and when the patient was first seen in our policlinic, was three months. One patient, a woman, who was subjected by her own ophthalmologist to ten local excisions in 12 years, was not included. Certain ophthalmologists immediately refer the patient to the clinic, others first perform local excision or excision biopsy.
Table 2
average age at time of admission R. eye L. eye
Male
Female
Total
6 56.5 3 3
8 69.4 3 5
14 63.5 6 8
As can be seen, this is mostly a disease of the more advanced age groups. The youngest patient was 30, the oldest, 90 years old. In my opinion, the figures are too small to justify an age distribution for the three different etiologies. ETIOLOGY Table 3 lists the etiologies as far as these could be ascertained from the (mostly scanty) anamnestic data or/and from the histologic preparation. Obviously, the condition is so infrequent that in most cases in our clinic the anamnesis contained too few data. That histologie examination cannot contribute much to reconstruct the etiology of a somewhat far advanced melanoma has been stated by Zimmerman (1964). The ultimate distribution, based on predominantly anamnestic data (presence of a brown spot for many years, etc.) is: from a naevus, 3 times; from a precancerous melanosis, 4 times and de novo, 7 times. There is complete agreement in the literature concerning one fact, viz. that 507. of the cases occur de novo. The ratio for the frequencies of the two other etiologies vary from equally frequent to
322
Table 3 Etiology 1) from a naevus 2) from a precancerous melanosis 3) de novo
3 4 7
one twice as frequent as the other. Below, we shall present an example of malignant degeneration of a precancerous melanosis. The patient was a bulb grower born in 1939, first seen in our policlinic in March 1970 (at the age of 30). The anamnesis included the presence for as long as eight years of numerous pigmented spots, some of them flat. Our clinical diagnosis was: precancerous melanosis. An excision biopsy was made from one of the elevated spots. The pathologist's diagnosis was: a naevus. Subsequently, three more naevi were removed (because of patients's dis~ comfort). Our ophthalmo-pathologist confirmed the diagnosis. The patient then stayed away for four years. In May 1974 he returned with several large elevated pigmented spots. Excision biopsy from an amelanotic area resulted in the diagnosis of melanoma. Orbital exenteration was performed. At the time of writing, over 18 months later, the patient is in good condition and shows no signs of recurrence and/or metastasization. Re-examination of our 1970 preparations revealed precancerous areas (with pronounced naevus elements), but distinctly malignant regions as well.
TREATMENT In the course of years, nearly all treatments proposed in the literature have been applied in our clinic. Various methods have been recommended in the literature to prevent migration of tumor cells. None of these methods has given statistically verifiable results (Schlieter, 1972).
IRRADIATION Only preoperative irradiation was administered in our clinic. One patient was subjected to pre-irradiation only. Irradiation as treatment was administered to two patients. In both cases, more radical surgical treatment had to be performed later.
323
According to Lederman (1961) who has the greatest experience of irradiation of melanomas of the conjunctiva, irradiation is equivalent to other methods of treatment, although the radiosensitivity of a melanoma depends on a number of factors (not specified here). All ophthalmologists are familiar with the complications of irradiation of an eye. Irradiation with fast electrons may give rise to vascular lesions after a long latent period. The radio-immunity that may occur constitutes a problem in itself. An element that causes the greatest discomfort to the patient is the actinic keratoconjunctivitis. The cases of two patients serve as an example: The first patient, a man born in 1889, was seen for the first time in our policlinic in 1967 (78 years old). One year previously he had noted a small brown spot in the right eye. Preoperative irradiation was decided upon. The patient was given 2000 r, but refused local excision. The irradiation was continued to a total dose of 4000 r. However, the tumor growth could not be arrested. Bulbar enucleation with conjunctivectomy was carried out in December 1967. A local recurrence was seen one year later. Further treatment was of no avail and the patient died in December 1969. An interesting element in the anatomical preparation was the rare aspect of invasion (into the cornea) beneath Bowman's membrane. The second patient was a woman born in 1903, who visited our policlinic in 1970. A small brown tumor of the left eye had been present for 6 months. Visual acuity of the right eye was 1/6 because of an operated glaucoma with defects of the visual field. Fast-electron irradiation (6000 r) of the left eye was decided upon. The tumor size decreased only slightly, and the patient was greatly troubled by the actinic keratoconjunctivitis. Six months later, visual acuity in the left eye decreased acutely: 1/300; central scotoma. Cause: obliterating angiopathy. A little over a year after the irradiation, it was decided to perform exenteration after all. At present, over 31/2 years later, the patient is in good condition.
BULBAR ENUCLEATION This is mostly a faulty therapy because the sedes morbi (Manschot, 1974) are left in situ. In two patients bulbar enucleation was performed; both patients died from metastases.
NO THERAPY The patient was a woman aged 82 years with diabetic retinopathy O.D. Visual acuity O.D. 3/60. Left, a clinically certain melanoma of the con-
324
junctiva. Nevertheless, in 1968, the appearance was not regarded as proof of malignancy and a policy of wait and see was decided upon. Four years later, the patient died, possibly from a diabetic complication (according to the general practitioner). LOCAL EXCISION The last ten years are characterized by a change of the previously prevailing views concerning the treatment of melanoma, viz. that it had to be rapid and radical (Schlieter, 1972). It appears that local excision may be adequate in itself. In our patients, local excision was applied eight times (Table 8). In four cases, the results were inadequate and subsequently more radical treatment had to be carried out. Table 4 lists the results in the four patients in whom only double excision was performed. The patient who has died had been the first in the series; his case dates from 1954/55. The patient with the longest survival in this group was a man who was 67 years old in 1971 and who had 'always had a broken vein' in O.D.; for the last six months, the lesion had been increasing. An ample local excision was carried out with kerato-sclereetomy. Up till now, there have been no signs of recurrence or metastasization.
Table 4 Results local excision: 4 Patients deceased lymph-node metastases recurrence good duration of follow-up
1 1 (later hemiparotidectomy) 1 1 5 years
The third patient was a man born in 1920 who at the age of 53 was operated on for a peptic ulcer. The small, brown conjunctival tumor was discovered at that time. Local excision was performed after preoperative irradiation (2000 r) in November 1973. A symblepharon was corrected one year later. Three months later, there was manifestation of a pre-audcular lymph-node metastasis, as proved by pathological examination of the gland. Radical neck dissection with hemiparotidectomy on the left was performed in March 1975. The sections of these tissues showed no signs of malignancy. At present, over one year later, there are no signs of renewed metastasization.
325
The last patient in this group is a woman who at present is 92 years old. She presented a t u m o r situated nasally on the limbus O.D. which, in 1974, allegedly had been present for three m/3nths, although the clinical picture of the tumor suggested a longer duration. Control examination carried out in February 1976 (18 months after the local excision) revealed recurrence in a medio-superior position. ORBITAL EXENTERATION The most radical method of treatment is orbital exenteration. (Tables 5 and 6). Exenteration was carried out in 7 patients. In only 2 cases did it constitute the primary treatment. The first time was in 1958, in a woman with malignant degeneration of a precancerous melanosis, on Reese's written recommendation. This clinical diagnosis was confirmed by the pathological examination. The second case was one of recent de novo development of a melanoma. At present, both patients are in good condition, after 18 and 3 years, respectively.
Table 5 Orbital exenteration: 7 patients primary: secondary:
2 5 once after irradiation four times after local excision
Table 6 Results of orbital exenteration deceased metastases good duration of follow-up
1 1 (after 3 years) 5 18, 5, 3, 2, 11/2 years
In 5 cases, exenteration had to be performed after a less radical therapy. The first patient was a woman born in 1896 who visited her ophthalmologist in October 1964 because of unilateral lacrimation. Excision biopsy was performed, foUowed after some time by total excision. In May 1965, we
326
saw her with two melanomas, one in the superior fornix and one on the inferior bulbar conjunctiva of the left eye. Exenteration was decided upon. The patient returned to her own ophthalmologist for the follow-up examinations; she died a few years later from the consequences of metastasization. One patient is suffering at present from hepatic metastases. This case will be demonstrated separately (and probably published elsewhere) because of a very rare intra-ocular spread. Two other patients in this group have been discussed before. The last patient in the secondary exenteration group is a woman born in 1916 who in 1961, at the age of 45 years, visited her ophthalmologist with a tumor of the bulbar conjunctiva on the right which had been present for approximately one year. Local excision was performed. The pathologist's diagnosis read: naevus with junction activity; no definite malignancy but regular checks indicated. In the subsequent 12 years, some l 0 further local excisions were carried out. Starting with the second preparation, the diagnosis constantly read: melanoma. Another recurrence was seen in 1973. Ultimately, exenteration was carried out on December 3rd, 1973. At present, after a follow-up of two years, the patient is in good condition. Now let us consider the results of the various methods of treatment, coUectively~ (Table 7). Of the 7 patients who currently exhibit no signs of recurrence or metastasization, two belong to the local excision group and 5 to the exenteration group. In three patients, the duration of the follow-up exceeds 5 years, in the others, it has been shorter than 3 years. Table 7 Results of all methods of treatment combined: 14 patients deceased metastases good recurrence duration of follow-up
5 (1 case unknown) 1 7 1 18, 5, 5, 3, 2, 11/2, 1 years.
To recapitulate, I regard the following conclusions from this retrospective study as justified: the etiology of a conjunctival melanoma is difficult to ascertain; the pattern of behavior of the tumor varies greatly; the treatment should be considered separately for each individual case; in other words, no single optimal treatment of conjunctival melanoma exists. Possibly, a combination of forces by tumor experts in The Netherlands may result in a prospective investigation.
327
REFERENCES Allen, A.C. & Spitz, S. Malignant melanoma. Cancer 6 : 1 (1953). Balestrazzi, E. Malignant melanoma of palpebral conjunctiva. Ophthalrnologica 162: 183(1971). Elsas F.J., Green, W.R. & Ryan, S.J. Benign pigmented tumors arising in acquired conjunctival melanosis. Amer. J. Ophthal. 7 8 : 2 2 9 (1974). Elsas, F.J. & Green, W.R. Epibulbar tumors in childhood.Amer. J. Ophthal. 79:1001 (1975). Greer, C.H. Ocular pathology. Oxford, Blackwell (1963). Henkind, P. & Friedman, A. Pigmented tumors. In: Ocular pathology. Int. Ophthal. Clinics, vol. 11, nr. 3. Boston, Little, Brown & Co. (1971). Jay, B. The pathology of surface melanomata of the eye. Trans. Ophthal. Soc. U.K. 84: 337 (1964). Jay, B. Naevi and melanomata of the conjunctiva. Brit. J. Ophthal. 4 9 : 1 6 9 (1965). Lederman, M. Radiotherapy of cancerous and precancerous melanosis. Trans. Ophthal. Soc. U.K. 7 8 : 1 4 7 - 1 6 4 (1958). Lederman, M. Radiotherapy of malignant melanomata of the eye. Brit. J. Radiol. 34: 21 (1961). Manschot, W.A. Therapie van melanoma conjunctivae. Ned. T. Geneesk. 1 1 8 : 1 1 0 9 (1974). Ophthalmic pathology; an arias and textbook; ed. by M.J. Hogan & L.E. Zimmerman; 2nd ed. London, Saunders (1962). Reese, A.B. Precancerous melanosis and diffuse malignant melanoma of the conjunctiva.Arch. Ophthal. 19:354 (1938). Reese, A.B. Precancerous melanosis and the resulting malignant melanoma (cancerous melanosis) of the conjunctiva and skin of lids.Arch. OphthaL 2 9 : 7 3 7 (1943). Reese, A.B. Pigmented tumors. Amer. J. Ophthal. 3 0 : 5 3 7 (1947). Reese, A.B. Tumors of the eye; 2nd ed. New York, Hoeber (1963). Reese, A.B. Precancerous and cancerous melanosis. Amer. J. Ophthal. 6 1 : 1 2 7 2 (1966). Schlieter, F. Konservative Therapie des malignen Melanoms der Bindehaut, entstanden auf dem Boden einer melanotischen Pr~blastomatose Dubreuilh. Klin. Mbl. Augenheilk. 161:416 (1972). Symposium on ocular and adnexal tumors; ed. by M. Boniuk. Saint Louis, Mosby (1964). Author's address: J uliana Ziekenhuis Zaandhm
328
(A msterdam/Zaandarn ) ABSTRACT During the period 1954 to 1974 inclusive, fourteen patients with melanoma of the conjunetiva were observed in the Department of Ophthalmology, University of Amsterdam. Frequency, etiology and treatment are discussed. No statistically proven conclusions may be drawn from this investigation; not at any rate, in regard to the treatment due to lack of homogeneity of the approaches used in recent years.
FREQUENCY As Table 1 shows, 14 patients have been hospitalized in 20 years. This is less than one patient per year, but if we only consider the last ten years, the frequency is just one patient a year. In the last ten years, an average of 1350 patients have been hospitalized annually, while our policlinic received approx. 10,000 new patients annually (first consultations and first-aid patients).
Table 1 i
Frequency of conjunctival melanoma 1954 to 1964 inclusive: 1964 to 1974 inclusive: last 5 years: total 1954 to 1974 inclusive:
3 11 8 14
In the literature, as a rule only a few cases are reported per paper. Reese is the only one who has reported several larger series. At the major international congresses of the period 1 9 6 0 - 1 9 7 0 , no large series have been described, either (Sehlieter, 1972). A few figures from the literature: Institute of Pathology, London: 104 cases in 13 years (Jay, 1965) Lederman (radiotherapist, London 1958): 63 melanomas in 18 years Balestrazzi (1971): 4 melanomas in 14 years among 30,000 patients. -
-
-
321
Mansehot (1974) unverifiably but probably more or less accurately stated that an ophthalmologist in The Netherlands in all the years of his practice may be expected to see only one or two eases of conjunctival melanoma. Table 2 lists the patients' age and sex and the eye involved. It should be mentioned in this connection that in most cases, the time o f onset of the melanoma could not be determined. The mean duration of interval between the time when the ophthalmologist saw the patient with a melanoma for the first time, and when the patient was first seen in our policlinic, was three months. One patient, a woman, who was subjected by her own ophthalmologist to ten local excisions in 12 years, was not included. Certain ophthalmologists immediately refer the patient to the clinic, others first perform local excision or excision biopsy.
Table 2
average age at time of admission R. eye L. eye
Male
Female
Total
6 56.5 3 3
8 69.4 3 5
14 63.5 6 8
As can be seen, this is mostly a disease of the more advanced age groups. The youngest patient was 30, the oldest, 90 years old. In my opinion, the figures are too small to justify an age distribution for the three different etiologies. ETIOLOGY Table 3 lists the etiologies as far as these could be ascertained from the (mostly scanty) anamnestic data or/and from the histologic preparation. Obviously, the condition is so infrequent that in most cases in our clinic the anamnesis contained too few data. That histologie examination cannot contribute much to reconstruct the etiology of a somewhat far advanced melanoma has been stated by Zimmerman (1964). The ultimate distribution, based on predominantly anamnestic data (presence of a brown spot for many years, etc.) is: from a naevus, 3 times; from a precancerous melanosis, 4 times and de novo, 7 times. There is complete agreement in the literature concerning one fact, viz. that 507. of the cases occur de novo. The ratio for the frequencies of the two other etiologies vary from equally frequent to
322
Table 3 Etiology 1) from a naevus 2) from a precancerous melanosis 3) de novo
3 4 7
one twice as frequent as the other. Below, we shall present an example of malignant degeneration of a precancerous melanosis. The patient was a bulb grower born in 1939, first seen in our policlinic in March 1970 (at the age of 30). The anamnesis included the presence for as long as eight years of numerous pigmented spots, some of them flat. Our clinical diagnosis was: precancerous melanosis. An excision biopsy was made from one of the elevated spots. The pathologist's diagnosis was: a naevus. Subsequently, three more naevi were removed (because of patients's dis~ comfort). Our ophthalmo-pathologist confirmed the diagnosis. The patient then stayed away for four years. In May 1974 he returned with several large elevated pigmented spots. Excision biopsy from an amelanotic area resulted in the diagnosis of melanoma. Orbital exenteration was performed. At the time of writing, over 18 months later, the patient is in good condition and shows no signs of recurrence and/or metastasization. Re-examination of our 1970 preparations revealed precancerous areas (with pronounced naevus elements), but distinctly malignant regions as well.
TREATMENT In the course of years, nearly all treatments proposed in the literature have been applied in our clinic. Various methods have been recommended in the literature to prevent migration of tumor cells. None of these methods has given statistically verifiable results (Schlieter, 1972).
IRRADIATION Only preoperative irradiation was administered in our clinic. One patient was subjected to pre-irradiation only. Irradiation as treatment was administered to two patients. In both cases, more radical surgical treatment had to be performed later.
323
According to Lederman (1961) who has the greatest experience of irradiation of melanomas of the conjunctiva, irradiation is equivalent to other methods of treatment, although the radiosensitivity of a melanoma depends on a number of factors (not specified here). All ophthalmologists are familiar with the complications of irradiation of an eye. Irradiation with fast electrons may give rise to vascular lesions after a long latent period. The radio-immunity that may occur constitutes a problem in itself. An element that causes the greatest discomfort to the patient is the actinic keratoconjunctivitis. The cases of two patients serve as an example: The first patient, a man born in 1889, was seen for the first time in our policlinic in 1967 (78 years old). One year previously he had noted a small brown spot in the right eye. Preoperative irradiation was decided upon. The patient was given 2000 r, but refused local excision. The irradiation was continued to a total dose of 4000 r. However, the tumor growth could not be arrested. Bulbar enucleation with conjunctivectomy was carried out in December 1967. A local recurrence was seen one year later. Further treatment was of no avail and the patient died in December 1969. An interesting element in the anatomical preparation was the rare aspect of invasion (into the cornea) beneath Bowman's membrane. The second patient was a woman born in 1903, who visited our policlinic in 1970. A small brown tumor of the left eye had been present for 6 months. Visual acuity of the right eye was 1/6 because of an operated glaucoma with defects of the visual field. Fast-electron irradiation (6000 r) of the left eye was decided upon. The tumor size decreased only slightly, and the patient was greatly troubled by the actinic keratoconjunctivitis. Six months later, visual acuity in the left eye decreased acutely: 1/300; central scotoma. Cause: obliterating angiopathy. A little over a year after the irradiation, it was decided to perform exenteration after all. At present, over 31/2 years later, the patient is in good condition.
BULBAR ENUCLEATION This is mostly a faulty therapy because the sedes morbi (Manschot, 1974) are left in situ. In two patients bulbar enucleation was performed; both patients died from metastases.
NO THERAPY The patient was a woman aged 82 years with diabetic retinopathy O.D. Visual acuity O.D. 3/60. Left, a clinically certain melanoma of the con-
324
junctiva. Nevertheless, in 1968, the appearance was not regarded as proof of malignancy and a policy of wait and see was decided upon. Four years later, the patient died, possibly from a diabetic complication (according to the general practitioner). LOCAL EXCISION The last ten years are characterized by a change of the previously prevailing views concerning the treatment of melanoma, viz. that it had to be rapid and radical (Schlieter, 1972). It appears that local excision may be adequate in itself. In our patients, local excision was applied eight times (Table 8). In four cases, the results were inadequate and subsequently more radical treatment had to be carried out. Table 4 lists the results in the four patients in whom only double excision was performed. The patient who has died had been the first in the series; his case dates from 1954/55. The patient with the longest survival in this group was a man who was 67 years old in 1971 and who had 'always had a broken vein' in O.D.; for the last six months, the lesion had been increasing. An ample local excision was carried out with kerato-sclereetomy. Up till now, there have been no signs of recurrence or metastasization.
Table 4 Results local excision: 4 Patients deceased lymph-node metastases recurrence good duration of follow-up
1 1 (later hemiparotidectomy) 1 1 5 years
The third patient was a man born in 1920 who at the age of 53 was operated on for a peptic ulcer. The small, brown conjunctival tumor was discovered at that time. Local excision was performed after preoperative irradiation (2000 r) in November 1973. A symblepharon was corrected one year later. Three months later, there was manifestation of a pre-audcular lymph-node metastasis, as proved by pathological examination of the gland. Radical neck dissection with hemiparotidectomy on the left was performed in March 1975. The sections of these tissues showed no signs of malignancy. At present, over one year later, there are no signs of renewed metastasization.
325
The last patient in this group is a woman who at present is 92 years old. She presented a t u m o r situated nasally on the limbus O.D. which, in 1974, allegedly had been present for three m/3nths, although the clinical picture of the tumor suggested a longer duration. Control examination carried out in February 1976 (18 months after the local excision) revealed recurrence in a medio-superior position. ORBITAL EXENTERATION The most radical method of treatment is orbital exenteration. (Tables 5 and 6). Exenteration was carried out in 7 patients. In only 2 cases did it constitute the primary treatment. The first time was in 1958, in a woman with malignant degeneration of a precancerous melanosis, on Reese's written recommendation. This clinical diagnosis was confirmed by the pathological examination. The second case was one of recent de novo development of a melanoma. At present, both patients are in good condition, after 18 and 3 years, respectively.
Table 5 Orbital exenteration: 7 patients primary: secondary:
2 5 once after irradiation four times after local excision
Table 6 Results of orbital exenteration deceased metastases good duration of follow-up
1 1 (after 3 years) 5 18, 5, 3, 2, 11/2 years
In 5 cases, exenteration had to be performed after a less radical therapy. The first patient was a woman born in 1896 who visited her ophthalmologist in October 1964 because of unilateral lacrimation. Excision biopsy was performed, foUowed after some time by total excision. In May 1965, we
326
saw her with two melanomas, one in the superior fornix and one on the inferior bulbar conjunctiva of the left eye. Exenteration was decided upon. The patient returned to her own ophthalmologist for the follow-up examinations; she died a few years later from the consequences of metastasization. One patient is suffering at present from hepatic metastases. This case will be demonstrated separately (and probably published elsewhere) because of a very rare intra-ocular spread. Two other patients in this group have been discussed before. The last patient in the secondary exenteration group is a woman born in 1916 who in 1961, at the age of 45 years, visited her ophthalmologist with a tumor of the bulbar conjunctiva on the right which had been present for approximately one year. Local excision was performed. The pathologist's diagnosis read: naevus with junction activity; no definite malignancy but regular checks indicated. In the subsequent 12 years, some l 0 further local excisions were carried out. Starting with the second preparation, the diagnosis constantly read: melanoma. Another recurrence was seen in 1973. Ultimately, exenteration was carried out on December 3rd, 1973. At present, after a follow-up of two years, the patient is in good condition. Now let us consider the results of the various methods of treatment, coUectively~ (Table 7). Of the 7 patients who currently exhibit no signs of recurrence or metastasization, two belong to the local excision group and 5 to the exenteration group. In three patients, the duration of the follow-up exceeds 5 years, in the others, it has been shorter than 3 years. Table 7 Results of all methods of treatment combined: 14 patients deceased metastases good recurrence duration of follow-up
5 (1 case unknown) 1 7 1 18, 5, 5, 3, 2, 11/2, 1 years.
To recapitulate, I regard the following conclusions from this retrospective study as justified: the etiology of a conjunctival melanoma is difficult to ascertain; the pattern of behavior of the tumor varies greatly; the treatment should be considered separately for each individual case; in other words, no single optimal treatment of conjunctival melanoma exists. Possibly, a combination of forces by tumor experts in The Netherlands may result in a prospective investigation.
327
REFERENCES Allen, A.C. & Spitz, S. Malignant melanoma. Cancer 6 : 1 (1953). Balestrazzi, E. Malignant melanoma of palpebral conjunctiva. Ophthalrnologica 162: 183(1971). Elsas F.J., Green, W.R. & Ryan, S.J. Benign pigmented tumors arising in acquired conjunctival melanosis. Amer. J. Ophthal. 7 8 : 2 2 9 (1974). Elsas, F.J. & Green, W.R. Epibulbar tumors in childhood.Amer. J. Ophthal. 79:1001 (1975). Greer, C.H. Ocular pathology. Oxford, Blackwell (1963). Henkind, P. & Friedman, A. Pigmented tumors. In: Ocular pathology. Int. Ophthal. Clinics, vol. 11, nr. 3. Boston, Little, Brown & Co. (1971). Jay, B. The pathology of surface melanomata of the eye. Trans. Ophthal. Soc. U.K. 84: 337 (1964). Jay, B. Naevi and melanomata of the conjunctiva. Brit. J. Ophthal. 4 9 : 1 6 9 (1965). Lederman, M. Radiotherapy of cancerous and precancerous melanosis. Trans. Ophthal. Soc. U.K. 7 8 : 1 4 7 - 1 6 4 (1958). Lederman, M. Radiotherapy of malignant melanomata of the eye. Brit. J. Radiol. 34: 21 (1961). Manschot, W.A. Therapie van melanoma conjunctivae. Ned. T. Geneesk. 1 1 8 : 1 1 0 9 (1974). Ophthalmic pathology; an arias and textbook; ed. by M.J. Hogan & L.E. Zimmerman; 2nd ed. London, Saunders (1962). Reese, A.B. Precancerous melanosis and diffuse malignant melanoma of the conjunctiva.Arch. Ophthal. 19:354 (1938). Reese, A.B. Precancerous melanosis and the resulting malignant melanoma (cancerous melanosis) of the conjunctiva and skin of lids.Arch. OphthaL 2 9 : 7 3 7 (1943). Reese, A.B. Pigmented tumors. Amer. J. Ophthal. 3 0 : 5 3 7 (1947). Reese, A.B. Tumors of the eye; 2nd ed. New York, Hoeber (1963). Reese, A.B. Precancerous and cancerous melanosis. Amer. J. Ophthal. 6 1 : 1 2 7 2 (1966). Schlieter, F. Konservative Therapie des malignen Melanoms der Bindehaut, entstanden auf dem Boden einer melanotischen Pr~blastomatose Dubreuilh. Klin. Mbl. Augenheilk. 161:416 (1972). Symposium on ocular and adnexal tumors; ed. by M. Boniuk. Saint Louis, Mosby (1964). Author's address: J uliana Ziekenhuis Zaandhm
328
