What are the diagnosis and treatment options for a conjunctival mass?

Diagnosis and Management of Conjunctival Masses

Any conjunctival mass requires excisional or incisional biopsy to establish a definitive diagnosis, as clinical appearance alone cannot reliably distinguish benign from malignant lesions, and early identification of malignancies such as melanoma, squamous cell carcinoma, sebaceous carcinoma, and lymphoma is critical for preventing metastasis and mortality. 1, 2

Differential Diagnosis by Clinical Appearance

Pigmented Lesions (Brown/Dark)

• Conjunctival melanoma: Painless, flat or nodular brown or fleshy-pink lesion on bulbar/palpebral conjunctiva or caruncle; may have intrinsic blood vessels 1, 3
• Benign nevus: Can present as cystic masses, particularly along the limbus 4
• Primary acquired melanosis: Flat pigmentation that may progress to melanoma 1

Non-Pigmented/Fleshy Lesions

• Ocular surface squamous neoplasia (OSSN): Papillomatous or sessile nodules, may be leukoplakic or gelatinous, often at limbus with sentinel vessel 1
• Conjunctival lymphoma: Painless, pink "salmon patch" appearance with indolent fleshy swelling, most commonly on superior or inferior conjunctiva; mobile and non-lobulated 1, 5
• Sebaceous carcinoma: Subconjunctival multilobulated yellow mass or yellowish discoloration of tarsal plate; may mimic chronic chalazion 1, 2

Cystic Lesions

• Conjunctival myxoma: Slow-growing, well-circumscribed mass (though rapid growth can occur); typically bulbar conjunctiva 6, 7
• Metastatic disease: Deep conjunctival masses, particularly in patients with systemic malignancy history 8

Critical Warning Signs Requiring Urgent Evaluation

The following features mandate immediate biopsy: 1, 2, 3

• Enlargement of any conjunctival lesion
• Development of new blood vessels within the lesion
• Thickening or elevation of previously flat lesions
• Recurrence in the same location after previous excision
• History of multiple chalazion excisions (suggests sebaceous carcinoma)
• Unilateral chronic conjunctivitis unresponsive to treatment

Diagnostic Approach

Initial Clinical Assessment

Perform slit-lamp biomicroscopy on all conjunctival masses to document: 2

• Exact anatomic location (bulbar by quadrant, palpebral, fornix, limbus by clock hour, or caruncle) 1
• Lesion dimensions (length, width, thickness/elevation) 1
• Depth of involvement (superficial conjunctiva vs. episcleral/scleral invasion) 1
• Presence of ulceration 1
• Color characteristics (pigmented, amelanotic, yellow, pink, salmon-colored) 1
• Vascular pattern (intrinsic vessels, sentinel vessels) 1
• Laterality (unilateral vs. bilateral) 1

Biopsy Indications

Proceed with excisional or incisional biopsy for: 2

• Any atypical features on examination
• Lesions in elderly patients (fifth to ninth decades have higher malignancy risk) 1
• Recurrent lesions in the same location
• History of multiple excisions
• Any lesion with warning signs listed above

Pathologic Evaluation Requirements

For malignant lesions, the pathology report must include: 1

Conjunctival Squamous Cell Carcinoma

• Presence/absence of invasion into episclera or corneal stroma 1
• Tumor status at all resection margins (deep and lateral) 1
• Degree of differentiation (well, moderately, or poorly differentiated) 1
• Presence/absence of vascular, lymphatic, perineural invasion 1

Conjunctival Melanoma

• Presence/absence of invasion into episclera or corneal stroma 1
• Tumor status at all resection margins 1
• Tumor thickness in millimeters (Jakobiec measurement) 1
• Minimum clearance distance from surgical margins 1

Sebaceous Carcinoma

• Extent of invasion (tarsal plate, conjunctiva, corneal epithelium) 1
• Margin status 1
• Presence of pagetoid spread 1

Treatment Approach by Diagnosis

Malignant Lesions

Conjunctival melanoma: Complete surgical excision with wide margins; consider adjuvant topical chemotherapy or cryotherapy for positive margins; systemic staging required as melanoma can metastasize to regional lymph nodes and distant sites 1, 3

Ocular surface squamous neoplasia: Excisional biopsy with clear margins; adjuvant topical chemotherapy (mitomycin C or interferon alfa-2b) for extensive disease or positive margins 1

Sebaceous carcinoma: Wide local excision with frozen section margin control; may require exenteration for orbital invasion; high risk of regional and distant metastases 1

Conjunctival lymphoma: Systemic workup mandatory (up to 20% develop systemic disease); treatment options include external beam radiation, chemotherapy, immunotherapy, or combination regimens depending on subtype and systemic involvement 1, 5

Benign Lesions

Conjunctival myxoma: Complete excisional biopsy; cardiac evaluation mandatory to exclude Carney Complex (autosomal dominant syndrome with cardiac myxomas that can cause embolic events) 7

Benign nevi: Observation if stable; excision if growth documented or cosmetically bothersome 4

Common Pitfalls to Avoid

• Do not treat chronic unilateral conjunctivitis empirically without biopsy—sebaceous carcinoma and lymphoma commonly masquerade as chronic blepharoconjunctivitis 1
• Do not assume yellowish lesions are benign chalazia—sebaceous carcinoma frequently mimics chalazion, especially with history of multiple recurrences 1, 2
• Do not rely on clinical appearance alone—pigmented lesions can be amelanotic melanoma, and non-pigmented lesions can be melanoma variants 1
• Do not perform simple excision without documenting margins—inadequate margin assessment leads to recurrence and worse prognosis 1
• Do not forget systemic evaluation—conjunctival lymphoma requires full staging, conjunctival myxoma requires cardiac workup, and metastatic lesions indicate systemic malignancy 1, 8, 5, 7