Conjunctival Leiomyosarcoma, a Rare Neoplasm Always Originating at the Limbus? Report of a New Case and Review of 11 Published Cases.

PURPOSE OF THE STUDY: To describe the differential diagnosis and management of a rare conjunctival malignancy. PROCEDURES: A 79-year-old man presented with a conjunctival mass at the limbus. Excisional biopsy revealed a malignant mesenchymal tumor with myogenic differentiation. Six months later, three suspect lesions developed at the border of the previous excision. Pathological diagnosis pointed to a leiomyosarcoma. Adjuvant radiotherapy with strontium-90 brachytherapy was applied. After 3 years, there was neither recurrence nor distant metastases. A literature review revealed 11 cases of conjunctival leiomyosarcoma. RESULTS: All 12 cases seemed to originate at the limbal conjunctiva. Scleral invasion was found only in one patient with multiple previous resections. Corneal invasion was reported in two patients. Four patients had a globe-sparing resection. In two of them, margins were not tumor free and additional brachytherapy gave a tumor-free follow-up of 1 and 3 years. Four cases underwent an exenteration. CONCLUSION AND MESSAGE: Primary conjunctival leiomyosarcoma is a rare tumor with a favorable prognosis due to early detection and consequently limited size. Diagnosis involves histopathological investigation including immunohistochemistry. If possible, complete resection has the best prognosis. Adjunctive radiotherapy can be effective when the margins are not free and should be considered.

Chromosomal aberrations in iris melanomas.

BACKGROUND: Uveal melanomas can develop in the choroid, ciliary body and iris. In choroidal and ciliary body melanomas, specific chromosomal changes correlate with metastatic disease. Iris melanomas have a better prognosis than choroidal melanomas, and it would be interesting to know if they share chromosomal changes. In addition, iris melanomas might harbour UV-induced mutations of tumour suppressor genes, such as PTEN and CDKN2A. METHODS: Twenty iris melanomas were analysed for chromosome 1p, 3, 6, 8, 9p and 10q abnormalities using fluorescence in situ hybridisation. These results were correlated to clinical follow-up data using statistical analyses. RESULTS: (Partial) loss of chromosome 3 was observed in nine iris melanomas, and gain of 8q was present in seven tumours. Loss of chromosome 9p was demonstrated in seven tumours, but no deletions of the PTEN region on chromosome 10 were found. Three patients died of metastatic disease, and one patient developed liver metastases, but is still alive. Univariate analysis indicated a lower disease-free survival for patients with diffuse growing melanomas (p=0.01), melanomas that lost a copy of chromosome 3 (p=0.03), or invading the ciliary body (p=0.01). In a multivariate analysis, none of the correlations were significant. CONCLUSION: Loss of chromosome 3 as well as loss of chromosomal region 9p21 (that entails tumour suppressor gene CDKN2A) plays a role in iris melanoma. A firm correlation with disease-free survival could not be established, possibly due to the small sample size.

Epistaxis or epiphora as a sign for extension of a conjunctival melanoma. A series of six patients with nasolacrimal recurrence.

PURPOSE: To characterise malignant conjunctival melanomas with extension and recurrence in the nasolacrimal system. METHODS: Localisation of the primary tumour and recurrences of 210 conjunctival melanomas treated in The Netherlands were reviewed for orbital and nasal tumours (1978-2008). Based of these cases and literature data, characteristics for nasolacrimal system extension and metastasis were reviewed. RESULTS: Six patients (3%) showed a recurrence of the primary conjunctival melanoma in the nasolacrimal system. Two of the six primary tumours were limbal tumours; the other four were diffuse tumours involving the fornix. In all six patients, the primary conjunctival melanomas were associated with primary acquired melanosis. During the follow-up period (11.6±3 years, range 3.4-28.5 years, median 8.7 years) two patients developed metastases and died. CONCLUSIONS: Patients should be advised to contact their treating ophthalmologist in the case of symptoms of epiphora, nose obstructions and epistaxis, especially non-bulbar and diffuse cases associated with primary acquired melanosis.

Cutaneous allergy testing in patients suspected of an allergic reaction to eye medication.

PURPOSE: Our aim was to determine the usefulness of allergy testing in patients with possible allergic reactions to an eye medication. METHODS: This retrospective study analyzed the usefulness of allergy testing in 90 patients who on the basis of their complaints were under suspicion of having an allergic response to eye medication. RESULTS: Among the 90 patients suspected of an allergic reaction to eye medication, the most common complaint was itching, while hyperemic conjunctivae were the most common symptom. Skin testing revealed an allergy to eye medication in 32 (36%) of the patients tested, which seemed to be the causal factor of the complaints in 22 cases (24%). The most frequent medication-associated allergies were directed against tobramycin, neomycin sulfate and thimerosal. Clinically relevant non-drug-related allergies occurred in 26 cases and were directed against nickel sulfate, Myroxylon pereirae and fragrance mix. Twenty-three patients were atopic and had positive skin prick tests against inhalation allergens such as house dust mites or dogs. CONCLUSION: Allergy testing was helpful to obtain a diagnosis of a clinically relevant allergy in 48 of the 90 patients who were referred under suspicion of having a contact allergy to eye medication.

IL-10 promotor haplotypes associated with susceptibility to and severity of bacterial corneal ulcers.

Interleukin-10 plays an important role in modulating inflammation and antimicrobial defences. In animal models for bacterial corneal ulcers, high IL-10 levels were associated with a better clinical outcome. We investigated whether IL-10 promotor haplotypes, known to determine IL-10 expression in vitro, are associated with susceptibility to and/or clinical outcome of bacterial corneal ulcers in patients. IL-10 promotor polymorphisms C-819T, G-1082A, A-2763C, and A-2849G for 83 patients with bacterial corneal ulcers and 115 healthy controls were determined by restriction fragment length PCR analysis. For 63 patients and all healthy controls the most frequently occurring IL-10 promotor haplotypes were inferred from these data using the program SNPHAP. A significant underrepresentation of the A-2849A genotype was observed in patients as compared to healthy controls. Both the -2763A allele and the IL-10.1 promotor haplotype were associated with a poor clinical outcome, whereas a favourable clinical outcome was seen in patients carrying the IL-10.2 promotor haplotype. Together, IL-10 promotor haplotypes associated with low IL-10 levels seem to protect against the onset of bacterial corneal ulcers. Once a corneal ulcer has developed, patients carrying IL-10 haplotypes associated with a high IL-10 expression may have a favourable outcome.

[Nonfunctioning pituitary macroadenomas: diagnosis, treatment and follow-up]. / Niet-functionerende macroadenomen van de hypofyse: diagnostiek, behandeling en follow-up.

*Nonfunctioning pituitary adenomas are benign tumours characterised by the absence of hormone overproduction. *Clinical symptoms are caused by the mass effects of the tumour. The main symptoms are pituitary insufficiency, visual field defects, vision impairment and headache. *Treatment is unnecessary for tumours less than 1 cm, and an expectative approach can be used for some patients with larger tumours but no visual field defects. *Transsphenoidal surgery is indicated for patients with visual field defects. *Because nonfunctioning adenomas can recur, lifelong follow-up after treatment is necessary. *Poor quality of life has been reported in treated patients with nonfunctioning pituitary adenomas, which may be due to the intrinsic imperfections of hormonal replacement therapy.

Angiosarcoma of the eyelid and periorbital region. Experience in Leiden with iridium192 brachytherapy and low-dose doxorubicin chemotherapy.

AIM: To report on the use of iridium(192) brachytherapy and doxorubicin chemotherapy as adjuvant therapy in 6 patients with angiosarcoma of the eyelid and periorbital region. MATERIAL AND METHODS: Tumor localization and diameter, signs of inflammation, histology and treatment are discussed in this retrospective study of 6 patients (age 46-87 yrs.) presenting with primary angiosarcoma in the eyelid. RESULTS: Six patients (4 elderly) with angiosarcoma localized in one or more eyelids, the face or multilocular were seen between 1987 and 2000. In one patient, a small nodular tumor did not recur within 4 years after radical excision. In another patient, the tumor was treated with surgery and iridium(192) wire brachytherapy and did not recur in 17 years of follow-up. In four patients with large diffuse tumors that were treated with doxorubicin, partial regression was achieved. The follow-up was >3 years (median 5 years). CONCLUSION: If radical surgery for angiosarcoma of the eyelid and periorbital region is not possible, adjuvant iridium(192) wire brachytherapy may prove beneficial. For widespread, diffusely growing tumors, and in elderly patients, low-dose (slowly, 20 mg i.v.) doxorubicin can be used weekly as adjuvant therapy, resulting in partial regression and longer survival rates than previously published by other authors.

Cytotoxic effect of sodium hypochlorite 0.5% (NaOCl) on ocular melanoma cells in vitro.

PURPOSE: Excision with or without adjuvant cryotherapy or brachytherapy is the treatment of choice in conjunctival melanoma. Adjuvant rinsing with alcohol or sodium hypochlorite peroperatively (Dakin's solution) is used in some centers to prevent seeding of melanoma cells. The purpose of this research is to compare the cytotoxicity of sodium hypochlorite (NaOCl) with other potential cytotoxic solutions in the treatment of conjunctival melanoma. METHODS: Three uveal melanoma cell lines (OCM8, Mel285, and Mel270) and one conjunctival melanoma cell line (CM2005.1) were tested in a proliferation test (CellTiter 96 AQueous One Solution Cell Proliferation Assay, Promega, Madison, WI). The 96-well plates were coated with melanoma cells and treated with sodium hypochlorite 0.5%, sodium bicarbonate (1.4% and 8.4%), ethanol 99%, or sodium chlorite during 3, 5, or 15 minutes. Each solution was tested in several dilutions. RESULTS: In all cell lines, no surviving cells were observed after treatment of 3 minutes with sodium hypochlorite. Ethanol 99% had a similar effect. A reduction of 70% of viable cells could be reached using sodium bicarbonate 1.4% or 8.4%. Water reduced the amount of viable cells by 40%. CONCLUSIONS: Sodium hypochlorite is cytotoxic for melanocytic cells in vitro. Its use may reduce local seeding of tumor cells and may decrease metastasis after extirpation of an extended ocular tumour. Further in vivo evaluation of sodium hypochlorite is required.

Lactoferrin Glu561Asp polymorphism is associated with susceptibility to herpes simplex keratitis.

Lactoferrin plays an important role in the defense against infections, including herpes simplex virus (HSV) keratitis. We studied the impact of three single nucleotide polymorphisms in the human lactoferrin gene on the susceptibility to HSV infections of the eye and the severity of such infections. Lactoferrin gene polymorphisms were determined by PCR combined with restriction fragment length analysis in 105 HSV keratitis patients and 145 control subjects. Bilateral tear samples were harvested from 50 patients and 40 healthy controls and tear lactoferrin concentrations were determined by ELISA. Patients' records were used to acquire information about the severity of the HSV keratitis. The frequencies of the Glu561Asp polymorphism, but not those of the Ala11Thr and Lys29Arg polymorphisms, differed significantly between patients and control subjects with an under-representation of the Asp561 allele in the patient group. Furthermore, the values for best corrected visual acuity, frequency of recurrences since onset, and average duration of clinical episodes did not differ among patients with various lactoferrin genotypes. In addition, tear lactoferrin concentrations were the same in patients with HSV keratitis and healthy controls and also did not differ among patients with various lactoferrin genotypes. Lactoferrin Glu561Asp polymorphism is associated with the susceptibility to HSV keratitis with a protective role for lactoferrin variants comprising Asp561. However, no beneficial effects of this lactoferrin variant on the clinical outcome of ocular HSV keratitis were noted.

Merkel cell carcinoma of the eyelid review of the literature and report of patients with Merkel cell carcinoma showing spontaneous regression.

PURPOSE: To evaluate the clinical and histopathologic characteristics of Merkel cell carcinoma (MCC) of the eyelid. DESIGN: Retrospective case series and literature review. PARTICIPANTS: Three consecutive patients with MCC of the eyelid who were referred to the Ocular Oncology Unit of Leiden University Medical Center, Netherlands. METHODS: Clinical records and histopathologic material of patients with eyelid MCC were reviewed. The clinical presentation and treatment were evaluated. MAIN OUTCOME MEASURES: Clinical and histopathologic description of eyelid MCC, with histologic proof of spontaneous regression of the tumor. RESULTS: Three patients with MCC of the eyelid were included. Diagnosis was made by pathologic investigation and immunohistochemistry (S100, cytokeratin 20, epithelial membrane antigen, chromogranin). Two of the patients showed histologically proven complete spontaneous regression after nonradical excision of the tumor. After local excision, none of the MCCs demonstrated local recurrence, without regional or distant metastases. Mean clinical follow-up was 50 months. CONCLUSIONS: Nonocular MCC is known to recur in 66% of patients and to be lethal in almost 33%. Merkel cell carcinoma of the eyelid is a rare malignancy that can not be recognized clinically. Clinical differential diagnosis must be made with a chalazion, and histopathologic differential diagnosis must be made with small cell carcinomas. Close follow-up of these patients is advised because of the potential high recurrence rate and lymphatic spread. The immunologic phenomenon of spontaneous regression points out the importance of the immune system in this disease.

[Transsphenoidal resection of pituitary adenomas: long-term results from the Leiden University Medical Center]. / Transsfenoïdale resectie van hypofyseadenomen: langetermijnresultaten van het Leids Universitair Medisch Centrum.

OBJECTIVE: To evaluate the long-term outcome of transsphenoidal resection of pituitary adenomas at the Leiden University Medical Center (LUMC), The Netherlands. DESIGN: Retrospective, descriptive. METHOD: 416 consecutive patients undergoing surgery for pituitary adenoma at the LUMC between 1978 and 2004 were included; 174 patients with non-functioning macroadenomas (NFMA), 164 patients with acromegaly and 78 patients with Cushing's disease. RESULTS: Biochemical remission was achieved in 66% of patients with acromegaly, and 72% of patients with Cushing's disease; incidence of pituitary failure was low in these patients (5% and 18% respectively). In 82% of the patients with NFMA visual function improved whereas the percentage with any degree of pituitary failure increased from 85% (preoperatively) to 95% (postoperatively). During follow-up of 10-15 years, the recurrence rate for acromegaly and Cushing's disease was 9% and for NFMA it was 15%. CONCLUSION: Transsphenoidal resection is an effective treatment in most, but not all, patients with pituitary adenomas. The surgical results at the LUMC are comparable with those obtained in important international centres. All patients cured by surgery need lifelong follow-up, because of the real risk of recurrent disease.

Impression cytology of melanocytic conjunctival tumours using the Biopore membrane.

PURPOSE: To compare a new Biopore membrane impression cytology method with the routinely used exfoliative cytology in patients with a melanocytic lesion of the conjunctiva. METHODS: Sixty-eight consecutive patients with a conjunctival melanocytic lesion underwent Biopore membrane impression cytology as well as exfoliative cytology. A histologic sample was also available in 26 cases. All Biopore samples were stained immediately with RAL 555. Both Biopore and exfoliative cytology samples were assessed by two cytopathologists and graded into four different categories of atypia. RESULTS: Twenty-three out of 26 Biopores and 20 out of 24 for the exfoliative smears correlated with the corresponding histologic sample. Biopore cytology resulted in higher numbers of cells with a greater density compared to exfoliative cytology. CONCLUSIONS: Biopore cytology can be used for cytologic sampling of conjunctival melanocytic lesions. Because of the larger amount and higher density of cells obtained with the Biopore membrane, interpretation by a pathologist is easier and faster. Sampling of the fornix, caruncula, and ocular material in children is difficult with the Biopore method, and exfoliative cytology seems to be the favorable test in those situations.

The natural course of non-functioning pituitary macroadenomas.

OBJECTIVE: The natural history of non-functioning pituitary macroadenomas (NFMA) has not been completely elucidated. Therefore, we evaluated pituitary function, visual fields, and tumor size during long-term follow-up of non-operated patients with NFMA. DESIGN: Follow-up study. PATIENTS: Twenty-eight patients (age 55 +/- 3 years) with NFMA, not operated after initial diagnosis, were included. RESULTS: Initial presentation was pituitary insufficiency in 44%, visual field defects in 14%, apoplexy in 14%, and chronic headache in 7% of the patients. The duration of follow-up was 85 +/- 13 months. Radiological evidence of tumor growth was observed in 14 out of 28 patients (50%) after duration of follow-up of 118 +/- 24 months. Six patients (21%) were operated, because tumor growth was accompanied by visual field defects. Visual impairments improved in all the cases after transsphenoidal surgery. Spontaneous reduction in tumor volume was observed in eight patients (29%). No independent predictors for increase or decrease in tumor volume could be found by regression analysis. CONCLUSION: Observation alone is a safe alternative for transsphenoidal surgery in selected NFMA patients, without the risk of irreversibly compromising visual function.

Progressive improvement of impaired visual acuity during the first year after transsphenoidal surgery for non-functioning pituitary macroadenoma.

OBJECTIVE: Improvement of visual field defects continues even years after the initial surgical treatment. Because this process of continuing improvement has not been documented for visual acuity, we audited our data to explore the pattern of recovery of visual acuity until 1 year after transsphenoidal surgery for non-functioning pituitary macroadenoma. DESIGN: Retrospective follow-up study. PATIENTS: Forty-three patients (mean age 56 +/- 14 years), treated by transsphenoidal surgery for non-functioning pituitary macroadenoma, were included in this analysis. RESULTS: Visual acuity improved significantly within 3 months after transsphenoidal surgery. The mean visual acuity increased from 0.65 +/- 0.37 to 0.75 +/- 0.36 (P < 0.01) (right eye), and from 0.60 +/- 0.32 to 0.82 +/- 0.30 (P < 0.01) (left eye). Visual acuity was improved 1 year after transsphenoidal surgery compared to the 3 months postoperative values. The mean visual acuity increased from 0.75 +/- 0.36 to 0.82 +/- 0.34 (P < 0.05) (right eye), and from 0.82 +/- 0.30 to 0.88 +/- 0.27 (P < 0.05) (left eye). CONCLUSION: Visual acuity improves progressively after surgical treatment for non-functioning pituitary macroadenomas, at least within the first year after transsphenoidal surgery.

Screening for conjunctival melanoma metastasis: literature review.

Local tumour control in conjunctival melanoma has improved in recent years. However the tumour-related death rate of these patients is still 14% at 5 years up to 33% at 15 years. With the introduction of sentinel node biopsies for conjunctival melanomas with a poor prognosis and screening for locoregional and distant metasases prognosis might be improved.

A new model for limbal transplantation using E-GFP for follow-up of transplant survival.

Limbal transplants in humans show a high rate of rejection even under local and systemic immunotherapy. In order to test immunomodulatory treatments a new limbal transplant model in the rat was developed using enhanced green fluorescent protein (E-GFP) as marker for follow-up. Sixty E-GFP-positive limbal transplants from Sprague-Dawley TgN(act-EGFP)Osb4 rats were transplanted onto 18 wild-type inbred Sprague-Dawley (isografts) rats, six wild-type litter mate Sprague-Dawley (sibling) rats, 18 Fischer 344 (allografts) rats, and 18 Fischer 344 rats depleted from monocytes and macrophages by subconjunctival treatment with clodronate liposomes. All rats were monitored three times a week with fluorescence microscopy, until fluorescence had disappeared. At postoperative days 6, 9, 12, and 15, three rats of all groups were killed for immunohistochemical analysis of infiltrating cells. Using a modified digital fluorescence microscope, we were able to monitor transplant behavior over time without disturbance of the ocular surface. The average days of rejection were 14 days in the isograft group, the sibling group, and the untreated allograft group. However, the average day of rejection in the allogeneic macrophage-depleted group was 27 days. Marked infiltration of macrophages and lymphocytes was seen in the untreated isografts and allografts. In the clodronate liposome-treated allografts infiltration was minor. A successful new limbal transplant model is described. The transplant can be accurately followed up in vivo by E-GFP labeling of the donor tissue without disturbing the corneal surface. Although E-GFP itself proved to be immunogenic, local clodronate liposome injections significantly increased graft survival. So the model seems to be useful for testing immunosuppressive or modulatory agents in limbal transplantation studies.

Immunophenotypic markers to differentiate between benign and malignant melanocytic lesions.

BACKGROUND/AIMS: The authors investigated the expression of S100A1, S100A6, S100B, MelanA, and CEA in conjunctival naevi, primary acquired melanosis (PAM), conjunctival melanoma, and uveal melanoma in order to assess their potential usefulness in the pathological differential diagnosis of these entities. METHODS: Paraffin embedded sections of 18 conjunctival naevi, 14 PAM, 16 conjunctival melanomas, and 20 uveal melanomas were immunostained for S100A1, S100A6, S100B, MelanA, and CEA, and expression was scored semiquantitatively. RESULTS: Expression of S100A1 differed significantly between conjunctival naevi and conjunctival melanoma, with percentages of positive cells of 30.6% and 71.4%, respectively. Conjunctival melanomas had high average scores for S100A1 and S100B (71.4%, 62.9%, respectively), while uveal melanomas also had high S100A1 but low S100B scores (88.5%, 18.5%, respectively). MelanA was highly variable; naevi and uveal melanoma had higher average scores than conjunctival melanoma. CEA was hardly detectable in all four groups. CONCLUSION: S100A1 seems to be a possible candidate to differentiate conjunctival naevi from conjunctival melanoma. S100B seems to differentiate between uveal melanoma and conjunctival melanoma. However, the study size was small and therefore the data have to be confirmed by others.