Conjunctival melanoma - Risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients

Objective: To identify the risk factors of conjunctival malignant melanoma that predict local tumor recurrence, orbital exenteration, distant metastas is, and tumor-related mortality. Design: The clinical parameters of the patient, tumor, and treatment were a nalyzed in a nonrandomized fashion for their relation to 4 main outcome mea sures using Cox proportional hazards regression models. Participants: One hundred fifty consecutive patients. Main Outcome Measures: Local tumor recurrence, orbital exenteration, distan t metastasis, and death from conjunctival melanoma. Results: The Kaplan-Meier estimates of local tumor recurrence was 26% at 5 years, 51% at 10 years, and 65% at 15 years. The mean number of recurrences per patient was 1 (median, 0 recurrences). There was no recurrence in 98 p atients (65%), 1 recurrence in 28 patients (19%), 2 recurrences in 11 patie nts (7%), 3 recurrences in 5 patients (3%), and 4 or more recurrences in 8 patients (5%). Using multivariate analysis, the factors correlated with loc al tumor recurrence were melanoma location (not touching the limbus) (P=.01 ) and pathological tumor margins (lateral margin involved) (P=.02). Multiva riate analysis for features correlated with ultimate exenteration included initial visual acuity (20/40 OU or worse) (P<.001), melanoma color red (P=. 01), and melanoma location (not touching the limbus) (P=.02). Tumor metastasis was present in 16% of patients at 5 years, 26% of patients at 10 years, and 32% of patients at 15 years. Metastasis was first located in the regional lymph nodes in 17 cases, the brain in 4 cases, the liver i n 3 cases, the lung in 2 cases, and was disseminated in 1 case. The risks f or metastases using multivariate analysis included pathological tumor margi ns (lateral margin involved) (P=.002) and melanoma location (not touching l imbus) (P=.04). Tumor-related death occurred in 7% patients at 5 years' follow-up and 13% a t 8 years' follow-up. The risk factors for death using multivariate analysi s included initial symptoms (lump) (P=.004) and pathologic findings (de nov o melanoma without primary acquired melanosis) (P=.05). The technique of in itial surgery was shown to be an important factor in preventing eventual tu mor recurrence (P=.07), metastasis (P=.03), and death (P=.006) in the univa riate analysis, but did not reach significance in the multivariate analysis . Conclusions: Conjunctival malignant melanoma is a potentially deadly tumor. In the present study, metastasis was detected in 26% of patients, and deat h occurred in 13% of patients at 10 years. Extralimbal melanoma and tumor i nvolvement of the surgical margins were especially poor prognostic factors. Meticulous surgical planning using wide microsurgical excisional biopsy wo rking with the "no touch" technique and supplemental alcohol corneal epithe liectomy and conjunctival cryotherapy is advised.