What are the molecular features of conjunctival melanoma?
In this case series of 8 patients with conjunctival melanoma examined, 1 had BRAF/V600E mutation, 3 had NRAS/Q61R mutation, 3 had NF1 mutations, and 1 had triple-wild type; mutation burden ranged from 1.1 to 15.6 mutations per megabase. A patient with an unresectable tumor and BRAF/V600E mutation was treated with combined systemic BRAF and MEK inhibitors, and after 3 months of therapy, conjunctival melanoma responded and the residual tumor was excised.
Conjunctival melanoma appears to show some distinctive molecular features and its mutational profile may be worth evaluating in patients with advanced disease where neoadjuvant/adjuvant therapy may be considered.
Greater understanding of molecular features of conjunctival melanoma (CM) may improve its clinical management.
To evaluate molecular features of CM and application of this information into clinical care.
Design, Setting, and Participants
In a prospective case series of CM with integrative exome and transcriptome analysis, 8 patients at an academic ocular oncology setting were evaluated. The study was conducted from November 2015 to March 2018.
Integrative exome and transcriptome analysis of CMs and clinical management of a patient’s care by using this information.
Main Outcomes and Measures
Molecular characterization of CM and its potential clinical application.
In the 8 patients (4 men) included in analysis, 4 subgroups of CM were observed, including the BRAF V600E mutation in 1 tumor, NRAS Q61R mutation in 3 tumors, NF1 mutations (Q1188X, R440X, or M1215K+ S15fs) in 3 tumors, and triple-wild type (triple-WT) in 1 tumor. The triple-WT case had CCND1 amplification and mutation in the CIC gene (Q1508X). Five tumors, including the triple-WT, also harbored mutations in MAPK genes. In addition to the genes linked to mitogen-activated protein kinase and phosphoinositol 3-kinase pathways, those involved in cell cycle and/or survival, ubiquitin-mediated protein degradation, and chromatin remodeling/epigenetic regulation (ATRX being the most frequently mutated: noted in 5 tumors) may play an important role. Other frequently mutated genes included PREX2 (n = 3), APOB (n = 4), and RYR1/2 (n = 4), although their relevance remains to be determined. The mutation burden ranged from 1.1 to 15.6 mutations per megabase (Mut/Mb) and was 3.3 Mut/Mb or less in 3 tumors and more than 10 Mut/Mb in 2 tumors. A patient with a large tumor and BRAF V600E mutation was treated with combined systemic BRAF (dabrafenib) and MEK (trametinib) inhibitors. After 3 months of therapy, her CM responded substantially and the residual tumor was removed by local surgical excision.
Conclusions and Relevance
The NRAS Q61R and NF1 mutations were more common than the BRAF V600E mutation in this series. Although small tumors (where incisional biopsy is not indicated) are treated with surgical excision regardless of mutational profile, in large tumors carrying the BRAF V600E mutation, neoadjuvant therapy with combined systemic BRAF and MEK inhibitors followed by local excision may be used as an alternative to exenteration. Integrative omics analysis of CM may be informative and guide clinical management and treatment in selected cases.
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Demirci H, Demirci FY, Ciftci S, et al. Integrative Exome and Transcriptome Analysis of Conjunctival Melanoma and Its Potential Application for Personalized Therapy. JAMA Ophthalmol. 2019;137(12):1444–1448. doi:10.1001/jamaophthalmol.2019.4237
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