doi:10.1111/j.1750-3639.2010.00423.

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CASE OF MONTH JUNE 2010 bpa_423 989..992

“POSTERIOR FOSSA LESION 45 YEARS AFTER

OCULAR TRAUMA”
Contributed by Julio César Gutiérrez Morales, MD, PhD1; Sandra Eugenia Gutiérrez Morales, Biol. Sci.1,2;
Aurora Astudillo González, MD, PhD3
1
Department of Neurosurgery, Hospital Universitario Central de Asturias, Oviedo, Spain
2
Faculty of Biological Sciences, University of Oviedo, Spain
3
Department of Clinical Neuropathology, Hospital Universitario Central de Asturias, Oviedo, Spain

view of those findings, the patient was consented for surgery. He

CLINICAL HISTORY underwent total microsurgical resection via paramedian supracer-
In October 2008, a 72-year-old man was referred to us with a three ebellar approach in sitting position. During the operation, the
week history of dizziness and unsteady gait. tumor was found to be a blackish soft, suckable mass with poorly
In 1963, at the age of 27 years, he suffered an ocular impact by defined boundaries. The surgical appearance was typical for a
coal stones at work. After the event, a residual dark spot (probably a pigmented metastasis. A small piece of tumor was submitted to
“coal tattoo” by inclusion) persisted in the conjunctiva. In 2004, he perform histopathological examination. He had an uneventful post-
began to feel discomfort in the “tattooed eye”. Owing to progres- operative period and the postoperative CT did not show residual
sive growth of the old lesion close to limbus-sclera border his tumour. He underwent whole brain radiotherapy and adjuvant
ophthalmologist decided to resect it. Malignant melanoma com- chemotherapy. The patient was neurologically symptom-free on
pounded by epithelioid and spindle cell was confirmed histopatho- follow-up after 3 months.
logically. The laminar specimen measured 0.7 ¥ 0.5-cm and the
initial intraoperative impression about the tumor extended to the
peripheral and deep margins was not confirmed after the histo- PATHOLOGICAL EXAMINATION
pathological exam. Further conservative management with local
Conjunctival specimen: A review of the primary conjunctival
chemotherapy (mitomycin in drops) was indicated. The patient has
lesion, obtained from other hospital, showed a slide section, with
undergone periodic ophthalmic and systemic evaluation. Systemic
a transversal representation of 1.3 ¥ 0.8 cm. The microscopic
evaluation included palpation of lymphatic chains, routine hemato-
examination showed conjunctiva with an intraepithelial pigmented
logical and biochemical examinations, chest x-ray and abdominal
lesion, formed by invasive epithelioid cells invading 2 mm in depth
ultrasound study. He did not show local relapse but an impairment
of the stroma (Figures 3–5). The lateral and deeper borders
of visual function secondary to chemotherapy was observed. The
were seemingly free of tumor, with partial squamous metaplasia
patient did not give any history of systemic complaints until
(Figure 6). There was no evidence of a benign Otás nevus.
October 2008 when he developed unsteady gait and dizziness.
Brain specimen: Brain lesion on macroscopic examination was
At the admission in October 2008, neurological examination
a grayish soft mass, measuring 1.5 ¥ 0.9 ¥ 0.7 cm. The microscopy
revealed mild dysmetria and hypotonia in left limbs. Cranial MRI
showed a compact tumor, formed by epithelioid anaplastic cells,
detected a 3 ¥ 2.5 ¥ 2.5-cm-sized intraaxial lesion, hyperintense on
organized in perivascular aggregates. There was a high mitotic
T1 and T2-weighted images, with heterogenous enhancing. It was
index and some cytoplasmic melanin (Figures 7–9).
located on the tentorial surface of the left cerebellar hemisphere
What are the diagnoses?
(left paraculminal area) showing mild perilesional edema
(Figures 1–2). The preoperative evaluation was completed with a
whole body-CT, which did not reveal any evidence of metastasis. In

Figure 1. Figure 2.

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© 2010 The Authors; Journal Compilation © 2010 International Society of Neuropathology
Correspondence

Figure 3.

Figure 4.

990 Brain Pathology 20 (2010) 989–992

© 2010 The Authors; Journal Compilation © 2010 International Society of Neuropathology
 Correspondence

Figure 5. Figure 8.

Figure 6. Figure 9.

Figure 7.

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© 2010 The Authors; Journal Compilation © 2010 International Society of Neuropathology
Correspondence
DIAGNOSIS
Metastatic epithelioid and spindle cell conjunctival melanoma
DISCUSSION
Malignant melanoma is a potentially fatal tumor that arises from
melanocytes, most often in the sun exposed skin (1). Less com-
monly, melanoma originates from other tissues and mucous mem-
branes such as conjunctiva. Conjunctival melanoma represents
only 1.6% of all non-cutaneous melanoma, being the most infre-
quent of the ocular melanomas (8). It is proposed to originate
from preexisting conjunctival nevus (as Ota’s nevus) or primary
acquired melanosis (PAM) or melanoma de novo (10). On the other
hand, ooccupational skin cancers resemble skin tumors found in
non-occupational subjects (including melanoma) and have particu-
larly been due to industrial exposure of human beings to chemical
carcinogens such as arsenic, ionizing radiation such as X-rays and
polycyclic hydrocarbons (e.g. from coal tar products). Besides, an
uncommon but well-recognized cause of occupational skin cancer
is that which results from scar formation following an industrial
burn(5). Some of that mechanism might have promoted the appear-
ance of the initial conjunctival lesion in our case. The most impor-
tant factors that affect patient outcome include greater tumor thick-
ness and base, epithelioid cell type, and, if PAM is present along
with the melanoma, then the following factors are significantly
related to patient death: the presence of atypical melanocytes, pag-
etoid invasion, in situ growth pattern, caruncular and palpebral
involvement, rarity of small polyhedral cell, lack of inflammation
and high mitotic activity (4, 9). Recurrence has been related to
tumors not touching the limbus (extralimbal) (7, 10), extension to
the margins on histopathology (10) development of metastasis and
treatment modality of the primary tumour (7). Therefore, proper
surgical planning with wide tumor free margins is important (7,
10). Usually, conjunctival melanomas, like those of the skin, first
metastasize to draining regional lymph nodes, being the preauricu-
lar chain the most commonly involved (3), although distant
metastasis in lung, liver, digestive tract, brain, bones, glands and
skin have been reported (3, 7, 10). Development of metastasis has
been related to tumors not touching the limbus (extralimbal) (10),
extension to the margins on histopathology (10), tumour thickness
over 2mm (7) and multilocular tumors (7). Isolated distant
metastases (without evidence of prior or concurrent regional lymph
node involvement) have been reported, especially in patients with
history of local recurrence. The presence of more aggressive histo-
logical features in recurrent melanoma could enable tumor cells to
skip the lymph nodes. On the other hand, hematogenous spreading
to distant organs may occur following multiple surgical interven-
tions for recurrence (2, 3). Based on it, our patient did not show
perioperative evidences to become a candidate for isolated distant
992
© 2010 The Authors; Journal Compilation © 2010 International Society of Neuropathology
metastases. The diagnosis of metastatic conjunctival melanoma
requires close ophthalmological and systemic follow up at regular
interval. High index of suspicion along with typical MRI findings
help to confirm the diagnosis. Melanin produces stable free radi-
cals, causing paramagnetic effect that shortens T1 and T2 relaxion
values on MRI. This results in hyperintensity of the lesion on T1
and T2-weighted images (6).
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ABSTRACT
We describe a patient who developed an isolated brain metastasis
four years after his right eye was treated for conjunctival melanoma
by excision and local chemotherapy. He had a history of ipsilateral
ocular trauma by coal stuff while working in a mining industry.
Conjunctival melanoma represents only 1.6% of all non-cutaneous
melanoma. Metastasis of this kind of neoplasm to brain is a rare
event, especially without evidence of prior or concurrent regional
lymph node involvement.
Brain Pathology 20 (2010) 989–992