NF1 mutations in conjunctival melanoma.

BACKGROUND: Conjunctival melanoma is a potentially deadly eye tumour. Despite effective local therapies, tumour recurrence and metastasis remain frequent. The genetics of conjunctival melanomas remain incompletely understood. METHODS: A large cohort of 63 conjunctival melanomas was screened for gene mutations known to be important in other melanoma subtypes by targeted next-generation sequencing. Mutation status was correlated with patient prognosis. RESULTS: Frequent mutations in genes activating the MAP kinase pathway were identified. NF1 mutations were most frequent (n = 21, 33%). Recurrent activating mutations were also identified in BRAF (n = 16, 25%) and RAS genes (n = 12, 19%; 11 NRAS and 1 KRAS). CONCLUSIONS: Similar to cutaneous melanomas, conjunctival melanomas can be grouped genetically into four groups: BRAF-mutated, RAS-mutated, NF1-mutated and triple wild-type melanomas. This genetic classification may be useful for assessment of therapeutic options for patients with metastatic conjunctival melanoma.

[Patient-Centred Care of Ocular Graft-vs-Host Disease in Germany]. / Versorgungsstrukturen der okulären Graft-versus-Host Disease in Deutschland.

BACKGROUND: Ocular GvHD is a severe complication following allogenic blood stem cell transplantation leading to massive reduction in quality of life and ocular pathologies including corneal perforation. Interdisciplinary patient-centred care needs to be performed in specialized ophthalmic centers that provide all diagnostic and therapeutic options, however, only few clinics have the necessary infrastructure. In addition there is a lack of transparency and easily accessible information for the patients regarding ophthalmic care and specialized centres. For this reason the "Ocular GvHD working group" within the Cornea Section of the German Society of Ophthalmology has been founded to evaluate and improve patient-centered care in ocular GvHD within Germany. METHODS: A survey was performed among the members of the Cornea Section of the German Society of Ophthalmology and the Directors of Departments of Ophthalmology in Germany that evaluated the number of annual examinations, presence of specialized GvHD outpatient clinics and eye screenings prior to allogenic blood stem cell transplantation (aBSCT). RESULTS: 25 clinics (19 university hospitals, 6 general hospitals) responded to the survey. In 18 clinics aBSCT are performed. Between 5 and 200 patients after aBSCT are examined per year per clinic. Larger institutions are associated with departments of haemato-oncology and other specialised disciplines to facilitate an interdisciplinary patient care. Three clinics are associated with GvHD competence centres. The major challenge in establishing an appropriate infrastructure for better patient-centered care is the limited or lacking reimbursement by health insurances. CONCLUSIONS: Within Germany only few ophthalmic centres exist that provide state-of-the-art patient-centered care for ocular GvHD. The present structures are not sufficient to treat all patients undergoing aBSCT following existing guidelines. Joint efforts are necessary to establish more and accessible competence centers for ocular GvHD with sufficient personnel and structural resources. In addition, ocular GvHD should be included as a mandatory topic in medical training and transparent and easily accessible information needs to be provided for patients and health-care professionals.

TERT promoter mutations in ocular melanoma distinguish between conjunctival and uveal tumours.

BACKGROUND: Recently, activating mutations in the TERT promoter were identified in cutaneous melanoma. We tested a cohort of ocular melanoma samples for similar mutations. METHODS: The TERT promoter region was analysed by Sanger sequencing in 47 uveal (ciliary body or choroidal) melanomas and 38 conjunctival melanomas. RESULTS: Mutations of the TERT promoter were not identified in uveal melanomas, but were detected in 12 (32%) conjunctival melanomas. Mutations had a UV signature and were identical to those found in cutaneous melanoma. CONCLUSION: Mutations of TERT promoter with UV signatures are frequent in conjunctival melanomas and favour a pathogenetic kinship with cutaneous melanomas. Absence of these mutations in uveal melanomas emphasises their genetic distinction from cutaneous and conjunctival melanomas.

[Malignant epibulbar tumours: new strategies in diagnostics and therapy]. / Maligne epibulbäre Tumoren: Neue Strategien in Diagnostik und Therapie.

In this article we discuss the complex diagnostic approaches and therapeutic options for the most important conjunctival malignancies. Conjunctival melanoma can be a diagnostic challenge as it can be difficult to distinguish from benign melanocytic conjunctival tumours. Complete surgical excision accompanied by a coherent adjuvant concept is the key for a curative therapy. Moderate and severe conjunctival intraepithelial neoplasias (CIN) are precancerous lesions and can progress to invasive squamous cell carcinoma. The involvement of large parts of the ocular surface can prevent an R 0-resection. Adjuvant therapeutic concepts are therefore especially important to gain tumour control and preserve the function of the affected eye. Lymphomas are the most common malignant primary tumours of the orbit and ocular adnexa. They can present as primary or secondary tumours of the conjunctiva, the lacrimal gland, the orbital fat, the eye lid or the lacrimal sac. The most common manifestation site of ocular MALT lymphoma is the conjunctiva with 20 - 33 % of all epibulbar lymphomas. More than 75 % of ocular lymphoma patients develop only one lymphomatous lesion. Immunophenotyping allows the exact differentiation between the lymphoma entities. Infectious agents (e.g., Chlamydia psittaci) seem to play a role in the pathogenesis. An overview over radiotherapeutic approaches that are conclusively applicable at the conjunctiva completes the article.

[Ocular graft versus host disease : Corneal complications]. / Okuläre Graft-versus-Host-Disease : Korneale Komplikationen.

BACKGROUND: Ocular graft-versus-host disease (GvHD) following allogeneic blood stem cell transplantation leads to immunologically induced alterations in many ocular tissues, particularly at the ocular surface. Within the framework of the main topic, this article focuses primarily on corneal complications in chronic ocular GvHD. OBJECTIVE: This article aims to promote understanding of the influencing factors, diagnostics, and therapeutic options pertaining to corneal complications in ocular GvHD. Furthermore, the possibilities for prevention are discussed. MATERIALS AND METHODS: This analysis is based on a literature review as well as on data from the Ophthalmology Clinic at the University Hospital Essen. RESULTS: Corneal complications often occur secondarily in ocular GvHD, as a consequence of severe inflammatory alterations of the conjunctiva or eyelid. Spontaneous corneal perforations associated with only mild symptoms are less common during the course of disease. From the ophthalmologist's perspective, it is important that the inflammatory activity of all the different ocular tissues is considered. Treatment may follow a stepwise scheme that includes substitution, immunosuppression, and surgical rehabilitation. CONCLUSION: Systematic diagnosis of ocular GvHD helps to prevent corneal complications or support early therapeutic intervention. An interdisciplinary approach to diagnosis and treatment planning is recommended, in order to optimize local and systemic immunosuppressive therapy.

[Analysis of ocular surface alterations following proton beam radiation in eyes with conjunctival malignant melanoma]. / Analyse der okulären Oberfläche nach Protonenbestrahlung bei malignem Melanom der Bindehaut.

BACKGROUND: In cases of large, diffuse or multilocular growth pattern of conjunctival melanoma, proton beam irradiation can serve as an alternative therapy to exenteration. In extended tumours, ocular surface problems can result after therapy. In this study we examined ocular surface integrity of ten patients who underwent proton beam radiation between 1996 and 2002. METHODS: The patients were examined during their follow-up. Eight of the ten cases who underwent proton radiotherapy were recurrent tumours, which were previously treated with other adjuvant therapies. We performed a standard ophthalmological examination and detailed tear film diagnostics. RESULTS: The follow-up was 17-87 months (mean: 40.9+/-20.1). In six cases more than 50% of the upper and lower eyelids were included in the radiation field. All of these cases showed moderate to severe sicca symptoms. The impression cytology revealed squamous metaplasia of conjunctival cells in nine of ten cases. CONCLUSIONS: Squamous metaplasia of conjunctival epithelia indicates a radiogenic, persisting disturbance of differentiation of the conjunctival epithelial cells. The tear film instability correlates with the loss of mucin-secreting goblet cells and meibomian gland dysfunction.

[Operative therapy and irradiation of conjunctival melanoma]. / Operative Therapie und Bestrahlung konjunktivaler Melanome.

BACKGROUND: Radiotherapy of conjunctival melanoma has gained in importance in recent years compared to less invasive therapeutic approaches. This is due to the high recurrence rates achieved by omitting adjuvant therapy and to the increasing availability of suitable radiotherapeutic methods, so that tumors formerly not amenable to organ-preserving therapy can now be treated. OBJECTIVE: This article presents the current radiotherapeutic options for conjunctival melanoma. The aim is to describe the diagnostic and therapeutic strategies and the course of therapy of malignant conjunctival melanoma. It is the authors' intention to justify the necessity of the adjuvant therapy of conjunctival melanoma and to emphasize the need for interdisciplinary cooperation during the course of tumor therapy. METHODS: The article is based on results published in the literature as well as on data collected and experience gained in our centre.

[Autologous transplantation of cultivated limbal epithelium]. / Autologe Transplantation von kultiviertem Limbusepithel.

OBJECTIVE: In this study the clinical outcome of ex vivo expansion of autologous limbal epithelial cells on intact amniotic membranes (AM) for ocular surface reconstruction in limbal stem cell deficiency (LSCD) was investigated. PATIENTS AND METHODS: A total of 30 eyes in 28 patients (22 male and 6 female) with total (n=18) or partial (n=12) LSCD were treated by transplantation of autologous limbal epithelial cells after expansion on intact AM. The causes of LSCD in the patients were chemical and thermal burns (n=16), pterygium (n=9), tumor excision (n=2), perforating injury, mitomycin C-induced LSCD and epidermolysis bullosa (each n=1). Only eyes with a follow-up time of at least 9 months were included in the analysis. The main outcome criteria were restoration of ocular surface integrity and improvement of visual acuity (VA). RESULTS: The mean follow-up time was 28.9±15.5 months. An entirely stable corneal surface was reconstructed in 23 (76.7%) eyes. Visual acuity increased significantly in 21 (70%) eyes, was stable in 8 (26.7%) eyes and decreased in 1 (3.3%) eye. The mean visual acuity increased significantly (p<0.0001) from a preoperative value of 1.58±0.97 LogMAR to 0.6±0.49 LogMAR. CONCLUSION: Transplantation of limbal epithelium cultivated on intact AM restores a stable corneal surface and results in a significant increase in visual acuity in most cases of LSCD. Autologous transplantation of cultivated limbal epithelium showed an excellent prognosis and outcome after long-term follow-up.

Differential chemokine expression in chronic GVHD of the conjunctiva.

In chronic GVHD after BMT, the conjunctiva represents a target organ. GVHD can lead to severe inflammation and dry-eye syndrome (sicca syndrome). The molecular mechanisms are largely unknown. We examined the expression of chemokines in the conjunctiva in cases of chronic GVHD. In this study, we included 10 patients with chronic GVHD and 10 healthy controls. Clinical data were collected and tear film analysis and conjunctival cytology were carried out. Conjunctival biopsies were taken from all participants. Gene expression profiles of chemokines and their corresponding receptors were evaluated by means of quantitative real-time PCR. Chemokine protein expression was analysed by immunohistochemical analyses. Expressions of the Th1-associated chemokines, chemokine (C-X-C motif) ligand (CXCL) 9 (Mig), CXCL10 (IP-10), and their receptor chemokine (C-X-C motif) receptor 3 (CXCR3) were significantly increased in GVHD patients. Immunohistochemical analysis confirmed marked expression of the inflammatory CXCR3 ligands. A total of six patients had a moderate or severe sicca syndrome. Impression cytology revealed a mild keratinisation, moderate keratinisation or severe squamous metaplasia in three patients, respectively. Chronic GVHD of the conjunctiva is characterised by the expression of Th1-associated chemokines. Taken together, our results confirm that the conjunctiva is a target organ in this T cell-mediated process and add to molecular understanding of conjunctival GVHD.