OcuLearning › Oncology

Conjunctival Tumors

URGENT — Oncology

Symptoms

Visible growth or mass on the conjunctiva.

Foreign-body sensation or irritation.

Changes in pigmentation, size, or vascularity.

Vision changes (rare; usually from corneal encroachment or induced astigmatism).

Clinical Findings

Conjunctival nevus (benign)

  • Pigmented bulbar lesion near the limbus.
  • Hallmark: intralesional cysts (clear, fluid-filled microcysts).
  • Note: lesions in the palpebral conjunctiva or fornix are atypical and suspicious.

OSSN / squamous cell carcinoma

  • Gelatinous pink-gray or leukoplakic (white) lesion at the interpalpebral limbus.
  • Signature finding: prominent "corkscrew" feeder vessels.
  • Stains with Rose Bengal due to defective surface glycoproteins.

Primary acquired melanosis (PAM)

  • Flat, unilateral, patchy golden-brown pigmentation in fair-skinned adults.
  • Requires biopsy to distinguish PAM without atypia (benign) from PAM with atypia (high malignant potential).

Conjunctival melanoma

  • Raised, nodular, pigmented or pink (amelanotic) mass with intrinsic vascularity.
  • Often arises from PAM with atypia; exhibits rapid growth and feeder vessels.

Conjunctival lymphoma

  • Salmon-pink patch, typically in the fornix.
  • Often bilateral (25%); most are MALT (extranodal marginal zone) lymphomas.

Other lesions

  • Pyogenic granuloma: friable red vascular nodule; bleeds easily.
  • Papilloma: cauliflower-like lesion; HPV-related (pedunculated in children, sessile/dysplastic in adults).
  • Dermoid/Dermolipoma: congenital limbal dome-shaped lesion; may have hair follicles.
  • Kaposi sarcoma: violaceous lesion mimicking chronic hemorrhage; associated with HIV.

Etiology

Risk factors

  • UV light exposure: primary driver for OSSN and melanoma.
  • Immunosuppression: HIV or transplant status markedly increases OSSN risk.
  • Viral: HPV 16/18 implicated in papillomas and some OSSN.

Precursors

  • PAM with atypia: main precursor for conjunctival melanoma.
  • Systemic disease: lymphoma may be a local manifestation of systemic disease.

Red Flags

Rapid enlargement or new elevation of a pigmented lesion.

Prominent "corkscrew" feeder or sentinel vessels.

Lesion crossing from the limbus onto the cornea.

Ulceration, symblepharon, or fixation to deep tissue (suggests invasion).

Investigations

Clinical assessment

  • Slit-lamp photography to document size, pigment, and vascular patterns.
  • AS-OCT or UBM to assess depth of invasion.

Biopsy

  • Excisional or incisional biopsy (with map biopsies) for histopathology.
  • Lymphoma biopsy must be sent fresh/non-fixed for flow cytometry.

Systemic workup

  • Melanoma: full-body skin exam and liver imaging.
  • Lymphoma: CT chest/abdomen/pelvis and bone marrow biopsy.
  • OSSN in young patients: HIV testing.

Treatment

Benign nevus

  • Observation with serial photography every 6–12 months.
  • Excision only if growth occurs or for cosmesis.

OSSN / CIN

  • Complete "no-touch" excision with cryotherapy to margins.
  • Adjuvant topical chemotherapy: Interferon alpha-2b, 5-FU, or Mitomycin C.

Conjunctival melanoma

  • Wide excisional biopsy; avoid tumor seeding.
  • Supplemental cryotherapy to margins and absolute alcohol for corneal involvement.
  • Adjuvant topical chemotherapy (MMC or Interferon).

Lymphoid tumors

  • Excision for localized MALT lymphoma.
  • Low-dose radiation or chemotherapy/Rituximab for systemic or incomplete excision cases.

Miscellaneous

  • Kaposi Sarcoma: highly active antiretroviral therapy (HAART); excision or irradiation if needed.
  • Pyogenic Granuloma: excision with cautery.
  • Papilloma: observation in children; excision/cryotherapy for adults.

Clinical Pearl

Pigmented lesions with feeder vessels or rapid growth are melanoma until proven otherwise. Benign nevi are usually static, flat at the limbus, and contain clear epithelial inclusion cysts.

Differential Diagnosis

  • Pterygium
  • Pinguecula
  • Pyogenic granuloma
  • Conjunctival lymphoma
  • Squamous cell carcinoma

Related Oncology Conditions