Is systemic treatment warranted for a patient with local recurrence of conjunctival melanoma after surgical excision?

Systemic Treatment for Local Recurrence of Conjunctival Melanoma

Systemic treatment is NOT warranted for isolated local recurrence of conjunctival melanoma after surgical excision—surgical re-excision with adjuvant local therapy (brachytherapy or topical chemotherapy) is the standard of care. 1

Primary Treatment Approach for Local Recurrence

Surgical re-excision is the definitive standard treatment for local recurrence of conjunctival melanoma. 1 The management algorithm should proceed as follows:

Initial Workup Before Treatment

• Confirm the recurrence pathologically through biopsy (FNA or excision biopsy) whenever possible 1
• Perform baseline staging imaging (chest radiograph, CT, and/or PET/CT or MRI) to evaluate for extraregional disease before proceeding with local treatment 1
• Examine regional lymph nodes carefully, as conjunctival melanoma metastasizes via ipsilateral lymph nodes (unlike uveal melanoma) 2

Surgical Management

• Complete surgical excision with negative margins using "no-touch" technique to avoid tumor cell seeding 2, 3
• Avoid direct manipulation of the tumor during excision to prevent spreading malignant cells to new areas 2
• Excision alone has a high recurrence rate (up to 45-50%), so adjuvant local therapy is essential 4, 5

Adjuvant Local Therapy (Not Systemic)

Combine surgical excision with one of the following local adjuvant treatments:

• Ruthenium brachytherapy (preferred based on superior local control rates) 3
• Topical mitomycin C chemotherapy for residual intraepithelial disease 3
• Cryotherapy (though brachytherapy has largely replaced this due to better outcomes) 2, 3

The evidence shows that excision with adjunctive brachytherapy achieved high rates of local tumor control with minimal ocular morbidity 3. Treatment without radiotherapy significantly increases risk of further local recurrence (Log-rank, P=0.03) 3.

When Systemic Treatment Would Be Considered

Systemic therapy is only indicated if there is evidence of:

• Regional lymph node metastases confirmed by biopsy 1
• Distant metastatic disease detected on staging imaging 1
• Unresectable local disease that cannot be controlled with surgery and local therapies 1

For truly isolated local recurrence without these features, systemic treatment adds no survival benefit and is not recommended 1.

Critical Prognostic Factors to Assess

Location matters significantly for prognosis:

• Caruncular involvement carries significantly poorer prognosis with higher metastatic risk 3
• Extralimbal tumors (especially at fornix, plica, caruncle) have worse outcomes than limbal tumors 2
• Tumor thickness >2mm increases metastatic risk substantially 5

Inadequate initial surgical intervention increases both local recurrence and metastatic death risk 3. This emphasizes the importance of proper technique at re-excision.

Post-Treatment Surveillance

Indefinite lifelong follow-up is mandatory due to high recurrence rates 2:

• Clinical examination with photodocumentation every 3-6 months for first 2-5 years 1
• Palpation of regional lymph nodes at each visit 2
• Patient education for self-examination of conjunctiva and lymph nodes 1

Common Pitfalls to Avoid

• Do not use systemic chemotherapy for isolated local recurrence—there is no evidence it improves outcomes and it adds unnecessary toxicity 1
• Do not perform inadequate excision—incomplete surgery dramatically increases both recurrence and metastatic risk 3
• Do not omit adjuvant local therapy—excision alone has unacceptably high recurrence rates of 45-50% 4, 5
• Do not assume sentinel lymph node biopsy will change management—it does not appear to impact survival or subsequent treatment in conjunctival melanoma 5