Traumatic iridial extrusion mimicking a conjunctival melanocytic

Pablo Zoroquiain1, 2, Maria SB Ganimi3, Sarah Alghamdi1, Julia V Burnier1, Sultan S Aldrees1, 5 and Miguel N Burnier1, 4

1Department of Pathology, Henry C Witelson Ocular Pathology Laboratory, McGill University, 1001 Boul Decarie, Montreal H4A 3J1, Canada 2Department of Pathology, School of Medicine, Pontificia Universidad Catolica de Chile, Marcoleta 377, Santiago 8330024, Chile 3Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Suprema, Alameda Salvaterra, 200 - Salvaterra, Juiz de Fora - MG 36033-003, Brazil 4Department of Ophthalmology, McGill University, 5252 Boul de Maisonneuve ouest, Montreal H4A 3S5, Canada 5Department of Ophthalmology, College of Medicine, King Saud University, PO Box 245, Riyadh 11411, Saudi Arabia

Correspondence to: Pablo Zoroquiain. Email: [email protected]

Abstract

Conjunctival is a rare malignant tumour of the eye. Its diagnosis represents a challenge for general pathologists due to low exposure to ocular biopsies and a broad differential diagnosis. In addition, conjunctival samples are often small and are associated with a high frequency of artefacts due to their processing. Here, we present the first case to date of a traumatic iridial extrusion masquerading as a conjunctival melanocytic neoplasm. An 83-year-old Asian man presented with a conjunctival-pigmented nodule surrounded by an area of diffuse pigmentation. Histopathology revealed in the nodule a well-demarcated lesion composed of spindle shaped melanocytes with thick-walled blood vessels. At higher magnification, the blood vessels were composed of thick walls with collagen fibres in an onion-skin-like Case Report arrangement. The histological findings were consistent with extruded iridial tissue. The map biopsies of the flat, pigmented lesion showed melanocytic cell proliferation with dendritic processes restricted to the lamina propria without any epithelial involvement, consistent with ocular melanocytosis. The diagnosis of conjunctival melanocytic lesions is challenging, and non-neoplastic conditions should always be included in the differential diagnosis. Pathologists should correlate clinicopathological findings and be familiar with the normal histology in order to achieve the correct diagnosis.

Keywords: conjunctival melanoma, iridial extrusion, ocular melanosis

Published: 12/02/2016 Received: 25/10/2015 ecancer 2016, 10:620 DOI: 10.3332/ecancer.2016.620

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1 with extrudediridialtissueandocularmelanocytosis. diagnosed was patient the obtained, information clinical the with along findings immunohistochemical and histopathological the on Based any epithelialinvolvement( without propria lamina the to restricted processes, dendritic with melanocytes benign showed lesion pigmented flat, the of biopsies Map The seen. were melanocytic cells were positive for Melan-Anecrosis and negative for HMB-45. The nuclear positivity index for the KI-67 antigen was less than or 1%. figures mitotic No 1D). (Figure arrangement onion-skin-like an in fibres collagen with walls thick had lesion the accompanying of vessels blood composed The was 1C). (Figure lesion features the nuclear bland magnification, and prolongations higher dendritic At with 1B). melanocytes spindle-shaped (Figure stroma the and lesion the between observed be could clefts areas, some In 1A). (Figure vessels blood thick-walled with lesion melanocytic well-demarcated a revealed nodule the from biopsy excisional An Results Ki-67. and Melan-A, HMB45, against performed were tissue examined. were lesion formalin-fixed-paraffin-embedded in surrounding studies flat the from Immunohistochemical biopsies map and nodule the from sections E)-stained & (H eosin and Haematoxylin Materials andmethods malignancy. PAMof made.Excisionalwas biopsies nodule mapthebiopsyandflat-pigmentedthefromof lesionanyobtainedoutwererule orderto in diffuselysuperficially.also pigmented was eye. surrounding left The the of conjunctiva area Aan within CM of diagnosis clinical taneouslypresentation.monthspriorsixtosuperior pigmented theexamination, mmmedialonOn seennodule well-defined was5 a × 10 spon- resolved that trauma ocular and melanocytosis ocular included history patient’seye. medical The left the of conjunctiva the on lesion An 83-year-old Asian man was referred to the ophthalmology department by an optometrist for the evaluation of an asymptomatic pigmented Case presentation a conjunctivalmelanomaandhistopathologicallybluenevus. conjunctival melanoma, which further obscures the diagnosis. Herein, we present a case of a as traumatic iridial masquerade extrusion mimicking to clinically known are tumours non-melanocytic several addition, In stroma. the in deep figures mitotic and nucleoli, of presence the pleomorphism, are features Cytological nevus. a of diagnosis the favours cyst epithelial an of presence the contrast, in malignancy; and the lack of maturation. However, the lack of an epithelial inclusion cyst within the melanoma is asymmetry specific, melanoma: but skin in not found sensitive, those as to same the conjunctival are lesion melanocytic conjunctival a in malignancy a indicating features tectural As with other melanocytic lesions in different parts of the body, the diagnosis of conjunctival melanoma (CM) is a challenge. The main archi- non-melanocytic, andnon-neoplasticentitiesknownaspseudomelanosis. novo de are cases noma mela- conjunctival as such malignant (PAM)or melanosis atypia, acquired with primary as such tumours premalignant atypia; Conjunctival melanocytic neoplasms can be classified into benign neoplasms, such as nevi and primary acquired melanosis (PAM) without Introduction [1]. About 75% of conjunctival arise from primary acquired melanosis with atypia, 5% arise from nevi, while the remaining . Furthermore, many conjunctival lesions can simulate a melanoma, including benign or malignant, melanocytic or melanocytic malignant, or benign including melanoma, a simulate can lesions conjunctival many Furthermore, [2]. Figures 1EandF). 2 ecancer www.ecancer.org 2016,10:620

Case Report infiltrates thestroma,itisreferredtoasconjunctivalmelanoma spread pagetoid show However,cells atypia. these grade when PAMto refers atypia high-grade with as enlarged, hyperchromatic, and irregular nuclei. When these atypical cells remain in the basal layer, the condition is called PAM with low- surroundings keratinocytes is seen the to transfer and pigmentation of amount the in increase an or keratinocytes) basal 6 by melanocyte 1 than (more epithelium In cases of PAM without atypia, a benign lesion is characterised as either hyperplasia of melanocytes in the basal layer of the conjunctival melanoma conjunctival not but melanoma, uveal a deeper melanosis that may affect the periorbital skin (oculodermal melanocytosis). This condition harbours an increased risk of developing hamartomatous lesion in which pigmented melanocytes are found in the rather than in the conjunctiva. Clinically, it is observed as a necrosis and atypia lack epithelium. typically overlying They the respecting fibres, collagen surrounding the Blue nevi, which were part of the differential diagnosis in this case, are composed of spindle and dendritic melanocytes that run parallel to pseudocysts epithelial associated with nodules yellow-brown as area interpalpebral the in occur to tend and conjunctiva the of stroma and PAM without atypia. Conjunctival nevi, similar to their skin melanosis, counterpart, ocular are case), circumscribed this melanocytic in proliferations nevus in blue the (including epithelium nevi or are lesions melanocytic benign of Examples entities. non-melanocytic as well as proliferations, melanocytic malignant and benign encompassing broad, is lesion conjunctival pigmented a differentialfor The diagnosis led toamisdiagnosisofbluenevus. vessels (Figure characterisedirisTheis presencetheby dendritic of melanocytes withinloosestroma,a withsurrounding characteristic thick-walled blood conjunctivalmelanoma;however,correctdiagnosis. towardsthe usguided histopathological iridial andtissuethe an typicalof picture was histology ocular is sometimes to limited among general Exposure pathologists and reviewed. dermatopathologists. In the being present case, are a biopsy was specimens requested to ophthalmic rule out when histology ocular in peculiarities the with familiar be to important is It Discussion parallel tothesurfaceepithelium.(F) At highmagnification,nodysplasticchangeswerenoticed.Noatypicalintraepithelialcellsareseen. adjacent tothenodule(EandF):(E)Theflat,pigmentedlesionmicroscopicallyshowedspindle-shaped melanocytes are foundinthestroma.(D)Collagenfiberswithonion-skin-likeconfigurationthick-wallbloodvesselsobserved.Flat pigmentedlesion (2×). (B) At higherpower, acleftbetweenthetumorandstromaisseen(10×).(C)Spindle-shapedmelanocyteswithoutdysplasticfeatures Figure 1.Conjunctivalmelanocyticnodule(A,B,CandD):(A) A well-circumscribed,non-necrotic,pigmentedtumorisseenwithinthestroma 2 ). In this particular case, the presence of dendritic melanocytes running in parallel without epithelial involvement could have [3]. However, in cases of PAM with atypia, a premalignant lesion, melanocytes show a degree of atypia . PAM, as the name implies, is an acquired condition seen in fair-skinned people. fair-skinned in seen condition acquired PAM,an 5]. is [3, implies, name the as [7, 8]. 3 . Finally,[6]. process neoplastic the if . Ocular melanocytosis is a is melanocytosis Ocular [4]. ecancer www.ecancer.org 2016,10:620 [3].

Case Report clinically simulating a conjunctival extension from a primary (data not published). analogues, and suture reactions melanoma, including aluminium silicate material, mascara deposits, graphite from injury withelements afungal pencil,the of wall adrenochromethe in melanin of depositspresence the to from adrenalin due fungi dematiaceous of cases of number a in melanoma conjunctival clinically mimic to reported been has Mycosis inflammation. chronic pathologist when reviewing a case with the clinical diagnosis of conjunctival melanocytic lesion. These include infections, foreign bodies, and Thereisgroupa ofreactive non-neoplastic conditions, which are clinically referred toas pseudomelanosis and should beconsidered bythe melanocytosis) (oculodermal skin the involving sometimes and conjunctiva entire the in diffuse clinically being childhood, early in arises or congenital is latter the while demarcated, well clinically is and adolescents in appears generally former the that are differences main The picture. cal None. Conflict ofinterest with associatedocularmelanosis,clinicallymasqueradingas conjunctivalmelanomaarisinginaprimaryacquiredmelanosis. ings is essential to achieve the correct diagnosis. To the best of our knowledge, this is the first reported case of a traumatic iridial extrusion teamwork to obtain detailed medical history, perform clinical examination, and interpret tissue biopsies in light of the clinicopathological find- The differential diagnosis for a pigmented conjunctival lesion is broad. In spindle melanocytic lesions of the conjunctiva, a multidisciplinary Conclusion in summarised as In the map biopsies, the presence of spindle melanocytic cells led us to the diagnosis of spindle cell melanocytic lesion of the conjunctiva, Figure 3.Differentialdiagnosisofspindle-shapedmelanocyticlesions.Morphologicalfeaturesdescribedintheentitiesred overlaps. fibres canbeseeninvesselwall. Figure 2.Irisfromahumandonor’s eye.Notethesimilaritywithlesionshowedin Figure1D.Onion-skin-likeconfigurationofthecollagen [9, 10].Forthisreason,correctdiagnosisofthesetumoursrequiresclinicopathologicalcorrelation. Figure . It is important to highlight that blue nevus and ocular/oculodermal melanocytosis share the same morphologi same the share melanocytosis ocular/oculodermal and nevus blue that highlight to important is It 3. [12–15] . Moreover, in our practice, we have encountered conjunctival chronic inflammation with siderophages [11 ] . Foreign. bodies havealso been reported clinicallyto simulate conjunctival 4 ecancer www.ecancer.org 2016,10:620 -

Case Report

10.

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Case Report