Melanoma of the Eyelid

Cutaneous melanoma of the eyelid is uncommon (less than 1 percent of eyelid malignancies) but carries serious prognostic risk.

• Subtypes: lentigo maligna (most common on sun damaged lids of older adults), superficial spreading, nodular (the most aggressive), and desmoplastic.
• Risk factors: fair skin, sun exposure and sunburns, numerous naevi, dysplastic naevus syndrome, family history, CDKN2A mutation, and xeroderma pigmentosum.
• Prognosis depends on Breslow thickness, ulceration, mitotic rate, and nodal status. Lid lesions often present late because of the lesion being mistaken for benign pigmentation.

• A pigmented lesion with ABCDE features: Asymmetry, irregular Border, Colour variegation, Diameter above 6 mm, Evolution (change).
• Lentigo maligna: slowly enlarging flat brown to black patch.
• Nodular melanoma: dark raised nodule that may ulcerate or bleed; amelanotic variants appear pink.
• Lid margin lesions may disrupt lashes. Lesions may extend into the conjunctiva.
• Satellite lesions, in transit metastases and regional lymphadenopathy in advanced disease.

• Dermoscopy, then full thickness excisional biopsy with 1 to 2 mm margins to preserve the full depth for Breslow measurement. Avoid shave biopsy. Incisional biopsy if the lesion is large and diffuse (lentigo maligna).
• Histology: Breslow thickness, Clark level, ulceration, mitoses per mm2, margin status. Molecular testing for BRAF V600, NRAS and KIT.
• Staging: examine regional nodes (preauricular, parotid, submandibular, cervical); ultrasound of nodes; sentinel lymph node biopsy for tumours over 0.8 mm thickness or with ulceration. Cross sectional imaging (CT chest, abdomen, pelvis, MRI brain) for stage III disease or higher; PET-CT as appropriate.
• Serum lactate dehydrogenase for prognosis.

• Wide local excision with margin by Breslow thickness: in situ 5 mm; up to 1 mm thickness 1 cm; 1 to 2 mm thickness 1 to 2 cm; over 2 mm thickness 2 cm. On the eyelid, the margins are modified to preserve function (Mohs or staged excision with permanent section assessment) while still obtaining clear margins.
• Reconstruct after clear histology confirmed (usually delayed), with grafts and flaps as needed.
• Sentinel lymph node biopsy and completion dissection or surveillance for positive nodes.
• Adjuvant systemic therapy for stage III disease: nivolumab 480 mg every 4 weeks for up to 12 months, or pembrolizumab 200 mg every 3 weeks; or dabrafenib 150 mg twice daily with trametinib 2 mg daily for BRAF V600 mutated tumours, for 12 months.
• Advanced or metastatic: ipilimumab 3 mg/kg with nivolumab 1 mg/kg every 3 weeks for 4 doses then nivolumab maintenance; BRAF and MEK inhibitors for mutated tumours.
• Radiotherapy for lentigo maligna in patients unsuitable for surgery, and adjuvant for desmoplastic melanoma with close margins.
• Imiquimod 5 percent for in situ lentigo maligna is an off label alternative if surgery is impossible.
• Surveillance: dermatology and nodal examination every 3 to 6 months for 5 years.