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NORMAL ANATOMY

Ocular Melanocytes

I.Conjunctival and uveal melanocytes (Fig. 17.1; see also Fig.

17.29D, top) are derived from the neural crest; pigment epithelial cells (PE) are derived from neuroepithelium or

the layers of the optic cup.

II. Dermal and conjunctival melanocytes are solitary dendritic cells.

III.Uveal melanocytes are also solitary and dendritic, and their cytoplasm contains fine, dustlike, ovoid melanin granules of a size bordering on the limits of resolution of the light microscope.

Cultured human melanocytes from different-colored eyes can produce melanin in vivo. The color of the iris is determined by the density of melanocytes in the most anterior portion of the iris.

IV. Pigment epithelium is neither solitary nor dendritic, but is epithelial, and exists as a sheet of cuboidal cells containing large, easily visualized pigment granules.

The cytoplasm of PE cells contains two basic types of pigment granules: melanin granules, which are either ovoid or spherical, and lipofuscin granules, which are usually somewhat spherical.

V.Dermal, conjunctival, and uveal melanocytes tend to vary in size, number, and melanin content among the races.

VI. Normal PE tends to vary little, if at all, among the races, and always appears heavily pigmented.

VII. Dermal, conjunctival, and uveal melanocytes almost never undergo reactive (nonneoplastic) proliferation under

normal circumstances. Neoplastic proliferation, however, does occur.

VIII. The PE readily undergoes reactive proliferation, but rarely becomes neoplastic.

IX. Dysplastic nevus syndrome is associated with an increased prevalence of conjunctival nevi, iris nevi, iris freckles, and choroidal nevi. It has been postulated that such individuals may have overstimulation of the melanocytic system not only in the skin, but also in ocular tissues, possibly increasing the risk for melanocytic malignancies.

MELANOTIC TUMORS OF EYELIDS

Ephelis (Freckle)

I.An ephelis (freckle) is a brown, circumscribed macule normally only found on areas of skin exposed to sunlight.

II.The color is due to increased pigmentation in the basal cell layer of the epidermis. The pigment (melanin) is derived

from hyperactive melanocytes that “secrete” their pigment into epidermal basal cells.

III.The melanocytes are fewer in number, but larger and more functionally active than those in adjacent, surrounding, paler epidermis.

Lentigo

I.Lentigo

A.Lentigo is similar clinically to an ephelis but is somewhat larger.

B.In addition to hyperpigmentation of the basal cell layer of epithelium, increased numbers of melanocytes are

present. It may also be found on nonexposed skin in older people.

C.Multiple lentigines syndrome

1.Multiple lentigines syndrome also goes by the acronym LEOPARD (lentigines, multiple; electrocardiographic conduction defects; ocular hypertelorism; pulmonary stenosis; abnormal genitalia;

retardation of growth; and deafness, sensorineural).

2. In addition to ocular hypertelorism (occurring in 40% of patients), other ocular findings include ptosis; microcornea; cortical punctate lenticular opacities and anterior subcapsular and zonular cataracts; patches of myelinated nerve fibers; flat pigmented spots of the iris; and glaucoma.

Multiple lentigines also occur in Carney’s syndrome (complex; see p. 244 in Chapter 7). Carney’s syndrome has

an autosomal-dominant inheritance pattern and consists of bilateral, primary, pigmented, nodular adrenocortical hyperplasia; multiple lentigines, especially of the head and neck, and blue nevi; cutaneous myxomata; large cell, calcifying Sertoli’s cell tumor of testes; cardiac myxoma; myxoid fibroadenomas of breast; pituitary tumors (which may lead to Cushing’s syndrome); and melanotic schwannomas.

D.Lentigo maligna (melanotic freckle of Hutchinson; circumscribed precancerous melanosis of Dubreuilh; Fig. 17.2)

1.Lentigo maligna occurs as an acquired pigmented lesion, mostly in adults older than 50 years of age.

2.It appears as a brown or black flat lesion, usually on the face, sometimes with involvement of the eyelids and conjunctiva (see subsection Primary Acquired

Melanosis in section Melanotic Tumors of Conjunc-

tiva, later), enlarging slowly in an irregular manner.

3.Approximately one-third of all lentigo maligna eventuates in malignant melanoma, noted clinically by a thickening or infiltration that elevates into a papule or nodule.

Lentigo maligna melanoma is the most common type of melanoma of the eyelid.

4.Histologically, lentigo maligna is indistinguishable from a junctional nevus. An underlying, chronic, nongranulomatous inflammatory infiltrate is common.

Nevus*

I.General information

A.A nevus is a congenital, hamartomatous tumor, a flat or elevated, usually well-circumscribed lesion.

1.It may be pigmented early in life, or not until puberty or even early adulthood.

2.The nevus is composed of nevus cells that are atypical but benign-appearing dermal melanocytes.

Congenital melanocytic nevus has occurred in association with ankyloblepharon. This lesion may be explained by a failure of eyelid separation, which should occur near the 20th week of gestation..

B.Five types:

1.Junctional

2.Intradermal

*A nevus is any congenital lesion composed of one of several types of cells found in the skin. A melanocytic nevus is composed of atypical but benign-appearing melanocytes (nevus cells). In this chapter (and elsewhere in the book), the term nevus always refers to the melanocytic nevus.

3.Compound (Fig. 17.3)

4.Blue (Fig. 17.5)

5.Congenital oculodermal melanocytosis (nevus of Ota) (Fig. 17.6)

C.The familial atypical mole and melanoma (FAM-M) syndrome (dysplastic nevus syndrome; B-K mole syndrome)

1.The FAM-M syndrome consists of multiple, large, typical and atypical cutaneous nevi of the upper part of the trunk, buttocks, and extremities.

2.The nevi appear at an early age (usually during adolescence) and increase in number throughout life.

3.Familial cases are inherited in an autosomal-domi- nant pattern; sporadic cases also occur.

4.Patients who have the syndrome definitely carry an increased risk for development of cutaneous melanomas; melanomas develop in them at an earlier age than in the general population.

Unlike cutaneous melanomas, ocular (conjunctival and uveal) melanocytic lesions rarely occur, and may be no more common in patients with FAM-M syndrome than in the general population.

II.Junctional nevus

A.A junctional nevus is flat, well circumscribed, and a uniform brown color.

B.The nevus cells are located at the “junction” of the epidermis and dermis (Fig. 17.3C).

C.The nevus has a low malignant potential.

III.Intradermal nevus (common mole; Fig. 17.4)

A.Intradermal nevus is usually elevated, frequently is papillomatous, and is the most common type of nevus.

B.It has a brown to black color when pigmented; often, however, it is almost flesh-colored.

C.The nevus cells are entirely in the dermis.

1.The nuclei of the nevus cells tend to become “mature” (i.e., smaller, thinner or spindle-shaped,

A

C

and darker) as they go deeper into the dermis. This orderly progression in structural change from superficial to deep layers is termed the normal polarity of the nevus.

2.No inflammatory cells are present unless the nevus is inflamed secondarily.

D.The nevus may be seen with proliferated Schwann elements (i.e., a neural nevus).

E.An unusual intradermal (or subepithelial) nevus is the peripunctal melanocytic nevus.

1.These involve the lower punctum, are dome-shaped and benign, and circumferentially surround the punctum, creating swollen punctal lips that result in a slitlike punctal orifice

2.The nevus cells are subepithelial and also infiltrate the orbicularis muscle fibers.

F.Intradermal nevus probably has no malignant potential.

IV. Compound nevus (see Fig. 17.3)

A.It combines junctional and dermal components, and is usually brown.

B.The dermal component shows a normal polarity (see

Fig. 17.4C; i.e., cells closest to the epidermis are larger, plumper, rounder, and paler than the deeper cells).

C.The spindle cell nevus (juvenile “melanoma,” Spitz nevus) is a special form of compound nevus that occurs predominantly in children, often as a solitary lesion on the face.

B

Fig. 17.3 Compound nevus. A, Moderately pigmented nevus at lid margin. B, Histologic section shows nevus cells at junction of epidermis and dermis as well as in dermis. C, Increased magnification demonstrates nevus cells in junctional and dermal locations.

1.Histologically, it superficially resembles a malignant melanoma, but biologically it is benign.

2.It may contain spindle cells, “epithelioid” cells, and single-nucleus and multinucleated giant cells that contain abundant basophilic cytoplasm.

D.The compound nevus has a low malignant potential.

The malignant melanoma arises from the junctional component.

V.Blue nevus

A.The blue nevus is usually flat and is almost always pigmented from birth; it appears blue to slate-gray.

Congenital pigmented (melanocytic) nevi are arbitrarily divided into small (<3 to 4 cm), large (up to 10 cm), and giant (>10 cm). The large and giant melanocytic nevi have an approximately 8.5% chance of undergoing malignant transformation during the first 15 years of life. Most primary orbital melanomas occur in white patients and are associated with blue nevi.

B.Nevus cells are present deep in the dermis in interlacing fasciculi.

1.The cells are located deeper than junctional, dermal, or compound nevus cells.

2.The nevus cells are more spindle-shaped, more elongated, and contain larger branching processes than other types of nevus cells. They more closely resemble uveal nevus cells than do other skin nevus cells.