Conjunctival Melanocytic Lesions: A Practical Sequential Treatment Approach

To evaluate the outcomes of a stepwise multimodal treatment approach for conjunctival melanocytic lesions ranging from low-grade conjunctival melanocytic intraepithelial lesion (LG-CMIL) through high-grade CMIL (HG-CMIL) to invasive conjunctival melanoma (iCoM) and to propose a practical management framework.

Retrospective, single-center cohort study.

Patients diagnosed with LG-CMIL, HG-CMIL, or iCoM and managed at the Liverpool Ocular Oncology Centre between January 2015 and April 2025 were included.

A sequential stepwise strategy was employed, comprising surgical excision or incisional biopsy, topical chemotherapy (mitomycin C, 5-fluorouracil, or interferon alfa 2b), and adjuvant Ruthenium-106 plaque brachytherapy or proton beam radiotherapy when indicated, selected according to histopathological grade and clinical growth pattern (focal vs. diffuse). Kaplan-Meier survival analysis and Cox proportional hazards regression identified prognostic factors for recurrence and metastasis.

Local recurrence was the primary endpoint; metastatic disease and residual pigmentation after primary therapy were the secondary endpoints.

Among 165 eyes, including 39 LG-CMIL, 39 HG-CMIL, and 87 iCoM cases, HG-CMIL demonstrated the highest recurrence rate (24.3%; 9 eyes) and the earliest recurrence events (median 8.2 months), whereas LG-CMIL showed the lowest recurrence risk (11.1%; 4 eyes). Metastatic disease occurred exclusively in iCoM (11.4%; 8 eyes), accounting for 16.7% of deaths in the cohort. Nonbulbar involvement (hazard ratio [HR] 2.76, P = 0.014) and residual pigmentation (HR 2.77, P = 0.024) independently predicted local recurrence, whereas ulcerative features (HR 15.08, P = 0.001), nonbulbar involvement (HR 7.28, P = 0.015), and increased tumor thickness (HR 2.15, P = 0.030) were associated with metastatic spread.

A tailored sequential multimodal approach achieved satisfactory local disease control, with local recurrence being primarily driven by nonbulbar involvement and residual pigmentation after primary therapy, whereas metastatic spread was strongly associated with ulcerative features, followed by nonbulbar involvement and tumor thickness.

The author has no/the authors have no proprietary or commercial interest in any materials discussed in this article.