case_images: PMC11699862_01
case_images: Dynamic-enhanced computed tomography scans with enhancement at the initial visit, showing early-phase enhancement (arrow, a) and late-phase washout (arrow, b). Needle liver biopsy, showing hepatocellular carcinoma (c in low magnification, d in high magnification). Computed tomography during hepatic arteriography with marked staining (arrow, e), in contrast with computed tomography during arterial portography with no staining (arrow, f), consistent with hepatocellular carcinoma. Note foamy cells with degeneration (h) and necrotic cell debris spaces (arrow, g) after transcatheter arterial chemoembolization, compared with viable tumor cells (d). Scale bar = 500 microm in c and g, 50 microm in d and h.
case_images: jmc-16-028-g001.jpg
case_images: PMC11699862_01_jmc-16-028-g001.jpg
case_images: F1
case_images: Dynamic-enhanced computed tomography showed a spherical mass in hepatic segment VII (S7) in the diameter of 26 mm with early-phase staining (Fig. 1a) and late-phase washout (Fig. 1b), consistent with HBV-related hepatocellular carcinoma. A week later, needle liver biopsy revealed well-differentiated hepatocellular carcinoma (Fig. 1c, d) which were positive for hepatocyte-specific antigen (anti-Hep-Par1, hepatocyte paraffin 1), and negative for melanoma triple cocktail-mix (anti-melanosome, HMB45; anti-MART1/melan A, A103; anti-tyrosinase, T311) antibodies. She showed early-phase filling (Fig. 1e) and no filling (Fig. 1f) in computed tomography during hepatic arteriography and arterial portography, respectively, indicative of hepatocellular carcinoma, and then, underwent transcatheter arterial chemoembolization using epirubicin-lipiodol mixture and gelatin sponge for presurgical treatment. The pathology showed a 24 mm-diameter mass of moderately differentiated hepatocellular carcinoma (Fig. 1g, h) at stage II (T2N0M0).
case_images: Pigmented lesions mainly along the lower conjunctival fornix (arrow, a) in the right eye just before excisional biopsy at the initial visit and reduced pigmented lesions in the fornix (arrow, b) one month later. Excisional biopsy showing conjunctival malignant melanoma in situ (c in low magnification, d in high magnification). Three months after the initial visit, the lower bulbar conjunctiva excised as wide as possible (presurgical photo in e, postsurgical photo in f). The excised tissue diagnosed as conjunctival malignant melanoma in situ (g in low magnification, h in high magnification). Scale bar = 200 microm in c and g, 50 microm in d and h.
case_images: jmc-16-028-g002.jpg
case_images: PMC11699862_01_jmc-16-028-g002.jpg
case_images: F2
case_images: Excisional biopsy of the lower conjunctival fornical lesion (Fig. 2a, b) in the right eye showed malignant melanoma in situ (Fig. 2c, d). Two weeks later, she underwent a second surgery to extirpate the lower bulbar conjunctival pigmented lesions as wide as possible (Fig. 2e, f) in the right eye, leading again to pathological diagnosis of malignant melanoma in situ (Fig. 2g, h).
case_images: Clear lower bulbar conjunctiva (a) in the right eye one month after the resection but pigmented lesions along the corneal limbus (b) relapsing in half a year. The excision of relapsed lesion showing conjunctival malignant melanoma in situ (c in low magnification, d in high magnification). Relatively clear lower bulbar conjunctiva just after the excision (e) and one month later (f), 1 year from the initial visit. The pigmented lesions gradually increase half a year after the excision (g) and 1 year later (h), 2 years from the initial visit. Scale bar = 200 microm in c, 50 microm in d.
case_images: jmc-16-028-g003.jpg
case_images: PMC11699862_01_jmc-16-028-g003.jpg
case_images: F3
case_images: She was well (Fig. 3a) until the age of 66 years, 10 months later from the initial visit, when she showed pigmented lesions along the lower corneal margin (Fig. 3b). She underwent the third resection of the bulbar conjunctiva in the right eye, showing malignant melanoma in situ (Fig. 3c, d). The bulbar conjunctival pigmented lesion in the right eye gradually relapsed and spread at a slow pace in a year (Fig. 3e-h).
case_images: Resection of lower eyelid-edge pigmented lesion in the right eye, 2.5 years after the initial visit, showing malignant melanoma in situ (a in low magnification, b in high magnification). Photos just before the resection (c) and 1 year later (d), 3.5 years from the initial visit. Pigmented lesions spreading to the lower palpebral conjunctiva (e) and upper bulbar conjunctiva (f) half a year later, 4 years from the initial visit. Scale bar = 200 microm in a, 50 microm in b.
case_images: jmc-16-028-g004.jpg
case_images: PMC11699862_01_jmc-16-028-g004.jpg
case_images: F4
case_images: At the age of 68 years, 2.5 years from the initial visit, she showed marked proliferation of the bulbar conjunctival pigmented lesion in the previous 1 year (Fig. 4c), and thus, underwent resection of the lower eyelid-edge lesion in the right eye for a genomic DNA-based test of BRAF mutations (V600E and V600K) which turned out to be absent. The pathological examination showed melanoma in situ (Fig. 4a, b). The conjunctival pigmented lesions were basically stable but were slow in progress (Fig. 4d-f) until 2 years later, 5 years from the initial visit, when a non-pigmented nodular lesion (Fig. 5e) developed on the temporal side of the bulbar conjunctiva along the corneal limbus in the right eye. [18F]-fluorodeoxyglucose positron emission tomography showed no abnormal uptake systemically, except for slightly higher uptake with maximum standardized uptake value (SUVmax) less than 2.0 (Fig. 5b) in the surface area of the right eye globe, compared with 5 years previously (Fig. 5a).
case_images: Positron emission tomography, showing no abnormal uptake in ocular surface of the right eye at the initial visit (arrow, a) and mildly increased uptake 5 years from the initial visit (arrow, b). Magnetic resonance imaging with enhancement, showing saucer-like ocular surface lesion on the right side (arrow, c) with marked enhancement in arterial phase (arrow, d), 5.5 years from the initial visit. Non-pigmented nodular lesion on the temporal bulbar conjunctiva along the corneal limbus (arrow, e), 5 years from the initial visit, and pigmented nodular lesions in the upper and lower eyelids (arrows, f). 3 months later. No pigmented lesion in the eyelids and ocular surface immediately after the completion of proton beam therapy (g), 1 month later (h), 3 months later (i), and 5 months later (j). Note clear cornea with slit-lamp examination (i, j).
case_images: jmc-16-028-g005.jpg
case_images: PMC11699862_01_jmc-16-028-g005.jpg
case_images: F5
case_images: The conjunctival pigmented lesions were basically stable but were slow in progress (Fig. 4d-f) until 2 years later, 5 years from the initial visit, when a non-pigmented nodular lesion (Fig. 5e) developed on the temporal side of the bulbar conjunctiva along the corneal limbus in the right eye. [18F]-fluorodeoxyglucose positron emission tomography showed no abnormal uptake systemically, except for slightly higher uptake with maximum standardized uptake value (SUVmax) less than 2.0 (Fig. 5b) in the surface area of the right eye globe, compared with 5 years previously (Fig. 5a). Further 3 months later, pigmented tumorous lesions developed near the edge of upper and lower eyelid (Fig. 5f). Magnetic resonance imaging showed the ocular surface saucer-like lesion without deep orbital infiltration on the right side which was enhanced in the arterial phase (Fig. 5c, d). She became free of pigmented lesions on the ocular surface, upper and lower eyelids (Fig. 5g, h) on the right side and maintained the transparent cornea in the right eye in half a year until the latest follow-up (Fig. 5i, j).