Abstract
purpose. To evaluate risk factors for local recurrence, regional and distant metastases, and mortality associated with conjunctival melanoma.
methods This was a retrospective study of 194 patients with histologically confirmed conjunctival melanoma diagnosed between 1950 and 2002 in the Netherlands. Data were collected from all university centers and many nontertiary hospitals, using the National Pathology and the Leiden Oncologic Registration Systems. Based on the number of incidences, this study included 70% of the conjunctival melanomas in The Netherlands. Clinical and histopathological data for conjunctival tumors were reviewed and compared with data reported in the literature. Risk factors for local, regional, and distant metastases and survival were analyzed using the Kaplan-Meier and Cox regression analyses.
results. Of 194 patients with conjunctival melanoma, 112 had a local recurrence (median, 1; range, 1–9) during follow-up (median, 6.8 years; range, 0.1–51.5). Location was the most important risk factor for development of local recurrence, and significantly more occurred with nonepibulbar (log rank, P = 0.044) tumors. Significantly fewer local recurrences occurred with tumors initially treated with excision and adjuvant brachytherapy rather than with excision only (log rank, P = 0.008) or with excision and cryotherapy (log rank, P < 0.038). Forty-one (21%) patients had regional lymph node metastases, mostly to the parotid or preauricular lymph nodes (n = 26; 13%). Risk factors for regional metastases were tumor thickness (log rank, P < 0.001) and tumor diameter (log rank, P = 0.010). Forty-nine (25%) patients (mean, 4.37 years) had development of distant metastases, mainly in the lung, liver, skin, and brain. Tumor-related survival was 86.3% (95% confidence interval [CI], 81.0–91.6) at 5 years, 72% (95% CI, 79.7–64.4) at 10 years, and 67% (95% CI, 58.9–76.1) at 15 years. The main mortality risk factors were nonepibulbar location (log rank, P < 0.0001) and tumor thickness (log rank, P = 0.0004).
conclusions. Nonepibulbar tumors more often recur locally and are associated with a shorter survival independent of other risk factors. Tumor thickness is also an important predictor of regional and distant metastases, as well as survival. A prospective study is needed to compare the effect of excision with radiotherapy and excision with cryotherapy on the number of local recurrences, exenteration rate, and survival.
Conjunctival melanoma is a rare tumor
1 2 3 with an incidence of 0.02 to 0.08 per 100,000 in a white population,
4 5 6 accounting for some 1% to 3% of all ocular malignancies in adults. This malignancy normally occurs at approximately the age of 60 years and only rarely before the age of 40 (10%). Conjunctival melanomas may be associated with sun exposure, as is skin melanoma,
7 although they can occur at non–sun-exposed sites.
6 In contrast to uveal melanoma, the incidence of conjunctival melanoma is increasing.
6 8 9
Local recurrence is reported to be 30%–50% at 5 years, 38%–51% at 10 years, and 65% after 15 years, depending on treatment.
10 11 12 13 14 15 16 17 18 19 20 21 Excision without additional treatment is associated with more local recurrences.
22 Main risk factors for patient mortality are thickness and size (basal diameter) as well as a nonepibulbar location for the primary tumor or one of its recurrences. A contributing factor for prognosis is the origin of the tumor—that is, in 55% primary acquired melanosis (PAM) and in 25% melanoma de novo, with a worse prognosis for melanoma de novo.
23 Conjunctival nevi rarely develop into melanoma.
24 The mortality rate is 12% to 20% at 5 years and up to 30% at 10 years.
10 11 12 13 14 15 16 17 18 19 20 21 Conjunctival melanomas are known to spread through the lymph system, although distant metastases are also found without regional lymph node metastasis.
25
In this report, data from 194 patients with conjunctival melanoma collected from all university hospitals and many nontertiary centers in the Netherlands were analyzed to investigate differences in treatment and surgical approach, as well as the main risk factors for recurrence, metastasis, and survival.
The Netherlands National Ocular and Orbital Tumor Committee, using the Netherlands Pathology Diagnosis System, helped identify 194 patients who had a diagnosis of malignant conjunctival melanoma between 1950 and 2002. Complete clinical and histopathological data were gathered from patients’ records and follow-up data were obtained from death certificates, general practitioners, local ophthalmologists, and the Oncologic Registration System of Leiden University Medical Center (LUMC). The mean follow-up was 9.2 years (SD, 8.1; median, 6.8). Only data for patients with histologically proven conjunctival melanoma were analyzed. Patients with a primary eyelid (cutaneous) melanoma were excluded, as were patients with PAM without an invasive component. The study was approved by the Institutional Review Board and adhered to the tenets of the Declaration of Helsinki.
Regional metastases developed in 41 patients (n = 9 regional, n = 32 regional and distant). Of these 41 patients, 32 were first thought to have only regional dissemination. The mean time between primary tumor diagnosis and regional metastasis was 4.37 years (SD, 4.2; median, 3.7). Mean survival time after metastasis was 8.1 years (SD, 8.7; median, 2.7) with regional dissemination only (six patients still living, three died of nonrelated causes) and 1.72 years (SD, 1.5; median, 1.3) with both regional and distant metastases. Regional metastases were found in parotid or preauricular (n = 26), cervical (n = 13), submandibular (n = 9), and axillary (n = 2) lymph nodes. Both patients with positive axillary lymph nodes also had parotid positive lymph nodes.
A univariate Cox regression analysis
(Table 4)indicated that tumor thickness (HR 2.8,
P < 0.001) and basal diameter (HR 1.6,
P = 0.010) were the best predictors of regional metastases. In a multivariate Cox model, only tumor thickness reached statistical significance.
Distant metastases developed in 49 patients, of whom 17 showed no regional (skipping) metastases. In 37 patients, the distant metastasis was localized. Metastasis occurred in the lungs (n = 18 cases), liver (n = 15), skin (n = 13), brain (n = 11), spinal cord (n = 5), ileum (n = 3), mesentery (n = 3), skeletal bones (n = 3), thyroid gland (n = 2), and jaw bone (n = 2).
Mean survival was 1.72 years (SD, 1.5; median, 1.3) for both regional and distant and 0.42 years (SD, 0.34; median, 0.44) for hematogenous metastases. Analysis
(Table 5)showed that nonepibulbar lesions were significantly more likely to give rise to a distant metastasis (HR 4.0,
P < 0.001). A univariate Cox analysis showed that increasing tumor diameter was associated with an increasing risk of distant recurrences (HR 2.1,
P < 0.001).
Predictors of poor survival were a nonepibulbar location, tumors thicker than 2 mm, and multifocal location. Survival may be improved by early diagnosis of regional metastases. The long survival rate of some patients with regional metastases also suggests that a sentinel lymph node biopsy may increase survival in high-risk patients (e.g., especially in patients with multiple local recurrences, a Breslow tumor thickness of >2 mm and a tumor diameter greater than 10 mm). Adjuvant brachytherapy may reduce the number of local recurrences. A prospective study is needed to compare the effect of excision in combination with radiotherapy and excision with cryotherapy on the number of local recurrences, exenteration rate, and survival.
Supported by The Netherlands Cancer Society.
Submitted for publication March 28, 2004; revised July 10 and September 20, 2004; accepted September 30, 2004.
Disclosure:
G.S. Missotten, None;
S. Keijser, None;
R.J.W. De Keizer, None;
D. De Wolff-Rouendaal, None
The publication costs of this article were defrayed in part by page charge payment. This article must therefore be marked “
advertisement” in accordance with 18 U.S.C. §1734 solely to indicate this fact.
Corresponding author: Guy S. O. A. Missotten, Department of Ophthalmology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands;
[email protected].
Table 1. Patient and Tumor Characteristics of 194 Patients with Conjunctival Melanoma
Table 1. Patient and Tumor Characteristics of 194 Patients with Conjunctival Melanoma
Variables | Cases (n) | % |
Sex | | |
Male | 87 | 45 |
Female | 107 | 55 |
Location | | |
Fornix | 2 | 1 |
Caruncular | 5 | 2.5 |
Tarsal | 11 | 5.5 |
Limbal | 110 | 57 |
Epibulbar | 133 | 69 |
Diffuse | 43 | 22 |
Origin of melanoma | | |
Nevus | 3 | 2 |
Nevus and PAM | 9 | 4 |
PAM | 111 | 57 |
De novo | 50 | 26 |
Inconclusive | 21 | 11 |
| Cases (n) | Mean | SD |
Measurements | | | |
Basal diameter (mm) | 153 | 7.21 | 4.7 |
Thickness (mm) | 152 | 2.07 | 1.9 |
Table 2. Treatment of the Primary Tumor at Moment of Its Histological Diagnosis, and the Number of Patients with a Local Recurrence
Table 2. Treatment of the Primary Tumor at Moment of Its Histological Diagnosis, and the Number of Patients with a Local Recurrence
Treatment Modality | Cases | Patients with a Local Recurrence | |
| (n) | n | % |
Excision | 127 | 85 | 67 |
Excision and chemotherapy (MMC) | 4 | 4 | 100 |
Excision and cryotherapy | 17 | 11 | 65 |
External irradiation | 11 | 7 | 64 |
Excision and brachytherapy | 19 | 5 | 26 |
Excision and brachytherapy and cryotherapy | 1 | 0 | 0 |
Exenteration and irradiation | 1 | 0 | 0 |
Exenteration | 14 | 0 | 0 |
Table 3. Cox Regression Analysis of the Appearance of First Local Recurrence
Table 3. Cox Regression Analysis of the Appearance of First Local Recurrence
Variable | Coefficient (SE) | Wald2 | P | Hazard Ratio (95% CI) |
Univariate analysis | | | | |
Age at diagnosis* | 0.005 (0.005) | 0.897 | 0.344 | 1.005 (0.994–1.016) |
Nonepibulbar location | 0.412 (0.206) | 3.996 | 0.046 | 1.510 (1.008–2.263) |
Uni/multilocular | 0.087 (0.170) | 0.263 | 0.608 | 1.091 (0.782–1.522) |
Origin, † (referenced to melanoma), ¶ | | 1.768 | 0.622 | |
Nevus | −0.515 (0.732) | 0.495 | 0.482 | 0.598 (0.142–2.509) |
Nevus + PAM | −0.624 (0.532) | 1.374 | 0.241 | 0.536 (0.189–1.520) |
PAM | −0.120 (0.219) | 0.303 | 0.582 | 0.887 (0.578–1.361) |
Thickness, ‡ | 0.240 (0.130) | 3.433 | 0.064 | 1.271 (0.986–1.639) |
Basal diameter, § | 0.065 (0.115) | 0.320 | 0.571 | 1.067 (0.852–1.338) |
Therapy, ∥ (referenced to excision + brachytherapy), ¶ | | 8.065 | 0.045 | |
Excision | 1.251 (0.460) | 7.404 | 0.007 | 3.494 (1.419–8.606) |
Excision + cryotherapy | 1.129 (0.540) | 4.373 | 0.037 | 3.093 (1.073–8.911) |
Irradiation | 0.863 (0.588) | 2.151 | 0.142 | 2.370 (0.748–7.506) |
Multivariate analysis | | | | |
Model (−2 log likelihood 1006.905) | | | | |
Non-epibulbar location | 0.533 (0.211) | 6.376 | 0.012 | 1.704 (1.127–2.577) |
Therapy, ∥ (referenced to excision + brachytherapy), ¶ | | 9.667 | 0.022 | |
Excision | 1.331 (0.461) | 8.315 | 0.004 | 3.783 (1.531–9.347) |
Excision + cryotherapy | 1.236 (0.542) | 5.196 | 0.023 | 3.442 (1.189–9.963) |
Irradiation | 0.768 (0.590) | 1.699 | 0.192 | 2.156 (0.679–6.848) |
Table 4. Cox Regression Analysis for the Appearance of Regional Metastases in 194 Patients
Table 4. Cox Regression Analysis for the Appearance of Regional Metastases in 194 Patients
Variable | Coefficient (SE) | Wald2 | P | Hazard Ratio (95% CI) |
Univariate analysis | | | | |
Age at diagnosis* | 0.011 (0.010) | 1.234 | 0.267 | 1.011 (0.992–1.031) |
Nonepibulbar location | 0.596 (0.321) | 3.456 | 0.063 | 1.815 (0.968–3.404) |
Uni/multilocular | 0.231 (0.228) | 1.027 | 0.311 | 1.259 (0.806–1.967) |
Origin† (referenced to melanoma)¶ | | 1.260 | 0.739 | |
Nevus | −12.241 (414.426) | 0.001 | 0.976 | 0.000 (NA) |
Nevus + PAM | 0.312 (0.652) | 0.229 | 0.632 | 1.366 (0.381–4.903) |
PAM | −0.281 (0.370) | 0.575 | 0.448 | 0.755 (0.366–1.560) |
Thickness‡ | 1.019 (0.238) | 18.363 | <0.001 | 2.770 (1.738–4.415) |
Basal diameter§ | 0.489 (0.189) | 6.660 | 0.010 | 1.631 (1.125–2.364) |
Therapy∥ (referenced to excision + brachytherapy)¶ | | 1.483 | 0.686 | |
Excision | 0.566 (0.732) | 0.597 | 0.440 | 1.761 (0.419–7.396) |
Excision + cryotherapy | −0.092 (1.001) | 0.008 | 0.927 | 0.912 (0.128–6.485) |
Irradiation | 0.741 (0.915) | 0.656 | 0.418 | 2.098 (0.349–12.602) |
Multivariate analysis | | | | |
Model 1 (−2 log likelihood 264.401) | | | | |
Thickness‡ | 0.874 (0.254) | 11.851 | 0.001 | 2.397 (1.457–3.942) |
Basal diameter§ | 0.192 (0.213) | 0.811 | 0.368 | 1.211 (0.798–1.839) |
Table 5. Cox Regression Analysis for the Appearance of Hematogenous Metastases in 194 Patients with Conjunctival Melanoma
Table 5. Cox Regression Analysis for the Appearance of Hematogenous Metastases in 194 Patients with Conjunctival Melanoma
Variable | Coefficient (SE) | Wald2 | P | Hazard Ratio (95% CI) |
Univariate analysis | | | | |
Age at diagnosis* | 0.425 (0.180) | 5.556 | 0.018 | 1.530 (1.074–2.179) |
Nonepibulbar location | 1.396 (0.289) | 23.269 | <0.001 | 4.039 (2.290–7.122) |
Uni/multilocular | 0.034 (0.057) | 0.343 | 0.558 | 1.034 (0.924–1.157) |
Origin† (referenced to melanoma)¶ | | 1.234 | 0.745 | |
Nevus | −12.305 (358.641) | 0.001 | 0.973 | 0.000 (0.000–8.544) |
Nevus + PAM | −0.007 (0.637) | 0.000 | 0.991 | 0.993 (0.285–3.461) |
PAM | −0.347 (0.331) | 1.100 | 0.294 | 0.707 (0.369–1.352) |
Thickness‡ | 0.743 (0.196) | 14.306 | <0.001 | 2.102 (1.430–3.089) |
Basal diameter§ | 0.322 (0.172) | 3.501 | 0.061 | 1.379 (0.985–1.932) |
Therapy∥ (referenced to excision + brachytherapy)¶ | | 3.121 | 0.373 | |
Excision | 0.711 (0.727) | 0.955 | 0.328 | 2.036 (0.489–8.471) |
Excision + cryotherapy | −0.818 (1.226) | 0.466 | 0.504 | 0.441 (0.040–4.876) |
Irradiation | 0.582 (0.918) | 0.401 | 0.526 | 1.789 (0.296–10.813) |
Multivariate analysis | | | | |
Model 1 (−2 log likelihood 333.378) | | | | |
Nonepibulbar location | 1.269 (0.331) | 14.694 | <0.001 | 3.557 (1.859–6.805) |
Thickness‡ | 0.533 (0.197) | 7.345 | 0.007 | 1.704 (1.159–2.505) |
Table 6. Cox Regression Analysis for Survival in 194 Patients with Conjunctival Melanoma
Table 6. Cox Regression Analysis for Survival in 194 Patients with Conjunctival Melanoma
Variable | Coefficient (SE) | Wald2 | P | Hazard Ratio (95% CI) |
Univariate analysis | | | | |
Age at diagnosis* | 0.018 (0.010) | 3.425 | 0.064 | 1.018 (0.999–1.037) |
Nonepibulbar location | 1.286 (0.294) | 19.113 | <0.001 | 3.617 (2.033–6.438) |
Uni/multilocular | 0.439 (0.196) | 5.210 | 0.025 | 1.551 (1.056–2.278) |
Origin† (referenced to melanoma)¶ | | 1.417 | 0.702 | |
Nevus | −12.293 (354.707) | 0.001 | 0.973 | 0.000 (0.000–8.948) |
Nevus + PAM | 0.192 (0.644) | 0.089 | 0.765 | 1.212 (0.343–4.279) |
PAM | −0.333 (0.341) | 0.954 | 0.329 | 0.716 (0.367–1.399) |
Thickness‡ | 0.678 (0.200) | 11.465 | 0.001 | 1.969 (1.330–2.916) |
Basal diameter§ | 0.320 (0.176) | 3.299 | 0.069 | 1.378 (0.975–1.946) |
Therapy∥ (referenced to excision + brachytherapy)¶ | | 2.788 | 0.426 | |
Excision | 0.649 (0.728) | 0.795 | 0.372 | 1.914 (0.460–7.972) |
Excision + cryotherapy | −0.819 (1.226) | 0.446 | 0.504 | 0.441 (0.040–4.873) |
Irradiation | 0.544 (0.918) | 0.351 | 0.553 | 1.723 (0.285–10.417) |
Multivariate analysis | | | | |
Model 1 (−2 log likelihood 319.991) | | | | |
Nonepibulbar location | 1.148 (0.337) | 11.595 | 0.001 | 3.152 (1.628–6.103) |
Thickness‡ | 0.491 (0.202) | 5.914 | 0.015 | 1.634 (1.100–2.426) |
The authors thank participating universities and ophthalmologists, especially Leo E. Blank (Radiotherapy, Academic Medical Center, Amsterdam, The Netherlands) and Amy S. Keegan, members of the National Committee on Ocular and Orbital Tumors; Nico Bleichrodt of the Cancer Registration Leiden for help with the survival data; Paul H. C. Eilers (Department of Biomedical Statistics, Leiden University Medical Center) for statistical advice; and, especially, the reviewers and editorial board member for many suggestions and statistical advice that improved the manuscript substantially.
FolbergR, McLeanIW, ZimmermanLE. Malignant melanoma of the conjunctiva. Hum Pathol. 1985;16:136–143.
[CrossRef] [PubMed]ShieldsJA, ShieldsCL. Tumors of the conjunctiva and cornea.SmolinG TholftRA eds. The Cornea: Scientific Foundations and Clinical Practice. 1993; 3rd ed. 579–595.Little, Brown & Co. Boston.
ShieldsJA, ShieldsCL. Tumors of the conjunctiva.StephensonCM eds. Ophthalmic Plastic, Reconstructive and Orbital Surgery. 1997;253–271.Butterworth-Heinemann Stoneham, MA.
LommatzschP, LommatzschR, KirschI, FuhrmannP. Therapeutic outcome of patients suffering from malignant melanomas of the conjunctiva. Br J Ophthalmol. 1990;74:615–619.
[CrossRef] [PubMed]SeregardS. Conjunctival melanoma: major review. Surv Ophthalmol. 1998;42:321–350.
[CrossRef] [PubMed]TuomaalaS, EskelinS, TarkkanenA, KivelaT. Population-based assessment of clinical characteristics predicting outcome of conjunctival melanoma in whites. Invest Ophthalmol Vis Sci. 2002;43:3399–3408.
[PubMed]de VriesE, SchoutenLJ, VisserO, EggermontAM, CoeberghJW. Rising trends in the incidence of and mortality from cutaneous melanoma in The Netherlands: a Northwest to Southeast gradient?. Eur J Cancer. 2003;39:1439–1446.
[CrossRef] [PubMed]YuG-P, HuD-N, McCormickS, FingerP. Conjunctival melanoma: is it increasing in the United States?. Am J Ophthalmol. 2003;135:800–806.
[CrossRef] [PubMed]BergmanL, SeregardS, NilssonB, et al. Incidence of uveal melanoma in Sweden from 1960–1998. Invest Ophthalmol Vis Sci. 2002;43:2579–2583.
[PubMed]de Wolff-RouendaalD, OosterhuisJA. Conjunctival melanoma in the Netherlands: a follow-up study. Doc Ophthalmol. 1983;56:49–54.
[CrossRef] [PubMed]FuchsU, KiveläT, LiestoK, TarkkanenA. Prognosis of conjunctival melanomas in relation to histopathological features. Br J Cancer. 1989;59:261–267.
[CrossRef] [PubMed]de Wolff-RouendaalD. Conjunctival melanoma in the Netherlands: a clinicopathological and follow-up study. Thesis. 1990;University of Leiden Leiden, The Netherlands.
SeregardS, KockE. Conjunctival malignant melanoma in Sweden 1969–1991. Acta Ophthalmol. 1992;70:289–296.
De PotterP, ShieldsC, ShieldsJ, MendukeH. Clinical predictive factors for development of recurrence and metastasis in conjunctival melanoma: a review of 68 cases. Br J Ophthalmol. 1993;77:624–630.
[CrossRef] [PubMed]ParidaensAD, MinassianDC, McCartneyAC, HungerfordJL. Prognostic factors in primary malignant melanoma of the conjunctiva: a clinicopathological study of 256 cases. Br J Ophthalmol. 1994;78:252–259.
[CrossRef] [PubMed]NorregaardJC, GernerN, JensenOA, PrauseJU. Malignant melanoma of the conjunctiva: occurrence and survival following surgery and radiotherapy in a Danish population. Graefes Arch Clin Exp Ophthalmol. 1996;234:569–572.
[CrossRef] [PubMed]Bobic-RadovanovicA, LatkovicZ, MarinkovicJ, RadovanovicZ. Predictors of survival in malignant melanoma of the conjunctiva: a clinico-pathological and follow-up study. Eur J Ophthalmol. 1998;8:4–7.
[PubMed]DesjardinsL, PoncetP, LevyC, et al. Facteurs pronostiques du melanoma malin de la conjonctive: etude anatomo-clinique sur 56 patients. J Fr Ophtalmol. 1999;22:315–321.
[PubMed]ShieldsCL. Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients. Trans Am Ophthalmol Soc. 2000;98:471–492.
[PubMed]ShieldsC, ShieldsJ, GündüzK, et al. Conjunctival melanoma: risk factors for recurrence, exenteration, metastasis, and death in 150 consecutive patients. Arch Ophthalmol. 2000;118:497–1507.
WerschnikC, LommatzschPK. Long-term follow-up of patients with conjunctival melanoma. Am J Clin Oncol. 2002;25:248–255.
[CrossRef] [PubMed]LommatzschPK, WerschnikC. Das maligne Melanom der Bindehaut. Klinische Übersicht mit Empfehlungen zur Diagnose, Therapie und Nachsorge. Klin Monatsbl Augenheilkd. 2002;219:710–721.
[CrossRef] [PubMed]de Wolff-RouendaalD. Melanozytäre tumoren der bindehaut.LommatzschP eds. Ophthalmologische onkologie. 1990;81–95.Enke Stuttgart, Germany.
ShieldsCL, FasiuddenA, MashayekhiA, ShieldsJA. Conjunctival nevi: clinical features and natural course in 410 consecutive patients. Arch Ophthalmol. 2004;122:167–175.
[CrossRef] [PubMed]EsmaeliB, WangX, YoussefA, GershenwaldJE. Patterns of regional and distant metastasis in patients with conjunctival melanoma: experience at a cancer center over four decades. Ophthalmology. 2001;108:2101–2105.
[CrossRef] [PubMed]BreslowA. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg. 1970;172:902–908.
[CrossRef] [PubMed]LommatzschP, VollmarR. Ergebnisse der Beta-Therapie bei epibulbären tumoren. Klin Monatsbl Augenheilkd. 1964;144:856–871.
[PubMed]LommatzschP. Beta-ray treatment of malignant epithelial tumors of the conjunctiva. Am J Ophthalmol. 1976;81:198–206.
[CrossRef] [PubMed]LommatzschP. Beta-ray treatment of conjunctival melanomas. Trans Ophthalmol Soc UK. 1977;97:378–380.
[PubMed]AnastassiouG, HeiligenhausA, BechrakisN, et al. Prognostic value of clinical and histopathological parameters in conjunctival melanoma retrospective study. Br J Ophthalmol. 2002;86:163–167.
[CrossRef] [PubMed]PraysonR, SebekB. Parotid gland malignant melanomas. Arch Pathol Lab Med. 2000;124:1780–1784.
[PubMed]WilsonMW, FlemingJC, FlemingRM, HaikBG. Sentinel node biopsy for orbital and ocular adnexal tumors. Ophthalmic Plast Reconstr Surg. 2001;17:338–345.
[CrossRef] EsmaeliB, EicherS, PoppJ, et al. Sentinel lymph node biopsy for conjunctival melanoma. Ophthal Plast Reconstr Surg. 2001;17:436–442.
[CrossRef] [PubMed]EsmaeliB. Sentinel node biopsy in conjunctival lesions.HonavarSG eds. XIIIth International Congress Ocular Oncology. 2004;Hyderabad, India.Abstract 35
EsmaeliB, ReiflerD, PrietoVG, et al. Conjunctival melanoma with a positive sentinel lymph node. Arch Ophthalmol. 2003;121:1779–1783.
[CrossRef] [PubMed]TuomaalaS, KivelaT. Metastatic pattern and survival in disseminated conjunctival melanoma: implication for sentinel lymph node biopsy. Ophthalmology. 2004;111:816–821.
[CrossRef] [PubMed]ParidaensAD, MinassianDC, McCartneyAC, HungerfordJL. Orbital exenteration in 95 cases of primary conjunctival malignant melanoma. Br J Ophthalmol. 1994;78:520–528.
[CrossRef] [PubMed]ShieldsC, ShieldsJ. Tumors of the conjunctiva and cornea. Surv Ophthalmol. 2004;49:3–24.
[CrossRef] [PubMed]