Conjunctival Melanoma With Lymph Node Involvement

Purpose: To present a clinical case of recurrent conjunctival melanoma with nodal metastasis. Observations: A 27-year-old male presented with a new pigmented conjunctival lesion. On initial clinical exam, there were signs of local spread to the regional lymph nodes that were confirmed by fine-needle aspiration biopsy. The patient underwent combined surgery for wide local excision of the conjunctival lesion with ipsilateral parotidectomy and neck dissection. Pathology results revealed conjunctival melanoma with nodal spread and high-risk histological features. The patient was subsequently treated with adjuvant interferon for 1 year; this was prior to the availability of immune checkpoint inhibitors. Over the next 4 years of follow-up, the patient was diagnosed with local recurrence and treated with a second local excision, followed by unilateral and later bilateral neck lymph nodes metastases treated with systemic immunotherapy and neck dissection. He did not have distant metastases at last follow-up. Conclusions: The patient presented only 2 months after his initial lesion appeared, but he already had a very large bulbar conjunctival melanoma with regional nodal metastasis. After surgical resection and pathological analysis, the high-risk histological features, including tumor thickness greater than 2 mm and presence of ulceration, were confirmed. Despite adjuvant treatment with systemic therapy (first interferon), he experienced recurrence and progression and was later treated with immune checkpoint inhibitors. This case highlights the importance of careful evaluation of the regional lymph nodes at the time of initial treatment of patients with conjunctival melanoma. Immune checkpoint inhibitors show promise in treatment of metastatic conjunctival melanoma.