THE CONJUNCTIVA

1. THE CONJUNCTIVA

2. Case 1

3. History • 75 year-old male. • Bilateral vascular, wedge shaped lesions, encroaching on the medial cornea. • Lived in Australia for 30 years.

4. BIOPSY…….

5. Bluish curly fibres of degenerate elastin in substantia propria

6. DIAGNOSIS ?

7. PTERYGIUM WATCH FOR OCULAR SURFACE SQUAMOUS NEOPLASIA. Always send pterygia for histology because of chance of squamous neoplasia. Response to chronic dryness and uv exposure Some association with HPV ??-controversial… Stocker’s line at preceding edge. Pingeculum looks the same histologically

8. CASE 2

10. DIAGNOSIS ? WHAT WOULD YOU EXPECT TO FIND ON THE BIOPSY ?

11. Skin type tissue Located on limbus

12. cartilage Lacrimal gland tissue

13. Dermoids Choristoma-congenital overgrowth of normal tissue at an abnormal location. Associations: Goldenhaar, Treacher-Collins and Naevus Sebaceous Syndrome

15. Dermolipoma Adult Outer canthus Mature adipose tissue and collagen.

16. CASE 3

17. HISTORY • 25 year-old male • ‘Growth’ on conjunctiva • Has had them before…………..

19. BIOPSY

22. DIAGNOSIS ?

23. Squamous papilloma Fibrovascular cores making up finger like projections Covered inconjunctival type epithelium (can be non goblet cell epithelium) HPV 6 and 11 INFECTION (THERFORE-SO CALLED INFECTIOUS PAPILLOMAS)

24. CASE 4

27. BIOPSY

28. EPITHELIUM ?

31. Cystic benign naevus Bland naevus cells in nests, arranged around INCLUSION cysts No mitoses IN NAEVUS COMPONENT. Preservation of cysts means architecture is being respected. Can TRANSFORM TO MALIGNANT MELANOMA. BEWARE OF FORNICEAL OR TARSAL CONJUNCTIVAL PIGMENTED LESIONS-USUALLY MALIGNANT.

32. CASE 5

37. Atypical melanosis / in-situ melanoma (C-MIN) Intraepithelial proliferation of atypical melanocytes . Cytological Atypia =nucleus larger tha basal keratinocyte nucleus, increase in cytoplasmic volume and nucleolus. Architectural atypia=pagetoid, nested, nests, confluent nests… MULTIFOCAL PAM IS A CLINICAL DIAGNOSIS MUST GIVE FULL INFORMATION ON HISTOLOGY FORM ie., age, how long present for….. IF LEFT 75-90% GIVE RISE TO INVASIVE MALIGNANT MELANOMA. The pathologists role is to day whether melanocytic atypia present or not.

38. CASE 6

41. NODULE IN SUBSTANTIA PROPRIA

44. mitosis

45. Brown melanin pigment

46. DIAGNOSIS ?

47. Invasive malignant melanoma

48. MACROSCOPIC PROGNOSTIC FACTORS a. Location • Primary conjunctival melanoma located at unfavourable sites, such as the fornix, palpebral conjunctiva, caruncle, plica seminlunaris and corneal stroma is associated with a higher recurrence rate and a higher rate of metastatic death, compared to favourable sites, such as the bulbar and limbal conjunctiva b. Size of melanoma • Melanomas larger than 10 mm in greatest width6 and those that are pathological stage pT3 and above have a greater local recurrence rate and higher death rate from metastatic tumour. c. Multifocality • Multifocal primary conjunctival melanomas are associated with a higher rate of recurrence and metastatic death, than unifocal tumours, principally at favourable site locations.

49. MICROSCOPIC PROGNOSTIC FEATURES Thickness of invasive melanoma • The thickness of invasive melanoma has prognostic significance. More than 0.8 mm thick-worse prognosis. Cell types within the invasive melanoma • Tumours with an epithelioid cell component exhibit a higher recurrence rate and a higher tumour-related mortality compared to those composed of pure spindle cells. Lymphatic/blood vessel invasion • Tumours exhibiting lymphatic invasion, at favourable and unfavourable sites are associated with a higher tumour metastatic death Anatomical structures infiltrated • The higher the TNM grade, the greater the cumulative probability of recurrence and the greater the tumour related mortality from metastatic disease Status of excision margins • Excision margins involved by melanoma are correlated with local tumour recurrence, higher risk of metastasis and greater magnitude of tumour related mortality.

50. CASE 7