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ZusammenfassungIn dieser Übersichtsarbeit werden die diagnostischen und therapeutischen Möglichkeiten bei den häufigsten malignen oberflächlichen Tumoren abgehandelt, hierzu gehören Basalzellkarzinome, konjunktivale Lymphome, Plattenepithelkarzinome und maligne Melanome und deren Vorstufen. Entscheidend für die richtige Diagnostik und Therapie ist eine ausführliche Anamnese, Spaltlampenuntersuchung und Fotodokumentation des Tumorbefunds. Aber auch regelmäßige Kontrollen nach erfolgter Therapie sind unabdingbar.Das Basalzellkarzinom ist der häufigste Tumor der periokulären Haut. Histologisch werden 3 Subtypen (nodulär, superfiziell, Morpheatyp) unterschieden. Eine vollständige Exzision mit entsprechendem Sicherheitsabstand ist immer anzustreben.Das Lymphom ist der häufigste maligne primäre Tumor der Augenhöhle und der okulären Adnexe. Es kann sowohl primär als auch sekundär, im Rahmen einer lymphatischen Systemerkrankung, als auch ein- oder beidseitig auftreten. Das MALT-Lymphom (MALT: Mucosa associated lymphoid tissue) betrifft am häufigsten die Konjunktiven mit 20–33 %. Therapeutisch wird standardmäßig eine perkutane Bestrahlung des Tumors angewandt.Die Plattenepithelkarzinome der Bindehaut und deren Vorstufen (CIN I-III) stellen ebenfalls eine der häufigsten Tumorentitäten am Auge dar. Eine vollständige Tumorexzision ist immer anzustreben, jedoch aufgrund der häufig großflächigen Ausbreitung nicht möglich. Für eine gute Tumorkontrolle sind nach R1-Resektion daher adjuvante Therapien mit Mitomycin C (MMC) oder eine Radiotherapie mit Rutheniumapplikator oder Protonenbestrahlung notwendig.Das Bindehautmelanom ist selten, es kann jedoch lebensbedrohlich sein. Die primär erworbene Melanose (PEM) mit Atypien (PEM I-III) hat je nach Schweregrad ein erhöhtes Entartungsrisiko, dies macht eine Therapie mit Mitomycin-C-Augentropfen notwendig. Bei Verdacht auf einen malignen Prozess ist immer eine Exzision mittels Non-Touch-Technik anzustreben, damit das Streuungsrisiko von Tumorzellen gering bleibt. Zusätzlich ist, abhängig von Lokalisation und Ausbreitung eines Melanoms, immer eine adjuvante Therapie mittels Rutheniumapplikator oder Protonentherapie notwendig.

Background Conjunctival melanoma is a potentially deadly eye tumour. Despite effective local therapies, tumour recurrence and metastasis remain frequent. The genetics of conjunctival melanomas remain incompletely understood. Methods A large cohort of 63 conjunctival melanomas was screened for gene mutations known to be important in other melanoma subtypes by targeted next-generation sequencing. Mutation status was correlated with patient prognosis. Results Frequent mutations in genes activating the MAP kinase pathway were identified. NF1 mutations were most frequent (n = 21, 33%). Recurrent activating mutations were also identified in BRAF (n = 16, 25%) and RAS genes (n = 12, 19%; 11 NRAS and 1 KRAS). Conclusions Similar to cutaneous melanomas, conjunctival melanomas can be grouped genetically into four groups: BRAF-mutated, RAS-mutated, NF1-mutated and triple wild-type melanomas. This genetic classification may be useful for assessment of therapeutic options for patients with metastatic conjunctival melanoma

Blue nevi are melanocytic tumors originating in the cutaneous dermis. Malignant tumors may arise in association with or resembling blue nevi, so called ‘blue nevus-like melanoma’, which can metastasize and result in patient death. Identifying which tumors will behave in a clinically aggressive manner can be challenging. Identifying genetic alterations in such tumors may assist in their diagnosis and prognostication. Blue nevi are known to be genetically related to uveal melanomas (eg, both harboring GNAQ and GNA11 mutations). In this study, we analyzed a large cohort (n=301) of various morphologic variants of blue nevi and related tumors including tumors diagnosed as atypical blue nevi (n=21), and blue nevus-like melanoma (n=12), screening for all gene mutations known to occur in uveal melanoma. Similar to published reports, we found the majority of blue nevi harbored activating mutations in GNAQ (53%) or GNA11 (15%). In addition, rare CYSLTR2 (1%) and PLCB4 (1%) mutations were identified. EIF1AX, SF3B1, and BAP1 mutations were also detected, with BAP1 and SF3B1 R625 mutations being present only in clearly malignant tumors (17% (n=2) and 25% (n =3) of blue nevus-like melanoma, respectively). In sequencing data from a larger cohort of cutaneous melanomas, this genetic profile was also identified in tumors not originally diagnosed as blue nevus-like melanoma. Our findings suggest that the genetic profile of coexistent GNAQ or GNA11 mutations with BAP1 or SF3B1 mutations can aid the histopathological diagnosis of blue nevus-like melanoma and distinguish blue nevus-like melanoma from conventional epidermal-derived melanomas. Future studies will need to further elucidate the prognostic implications and appropriate clinical management for patients with tumors harboring these mutation profiles.

The management of conjunctival melanoma is challenging and frequently ends in exenteration. The aim of this retrospective study was to evaluate the long-term results of proton beam radiation with regard to various clinical parameters. Eighty-nine patients with extended conjunctival melanoma (≥T2) and multifocal bulbar located tumors (T1c/d) were treated consecutively with proton radiotherapy (dose 45 Gy). The following parameters were assessed: TNM stage, tumor origin, local recurrence, performance of exenteration, occurrence of metastases, overall survival, and potential complications. A time-to-event analysis was preformed to the primary endpoints: relapse, metastasis, exenteration, and death by use of Kaplan-Meier cumulative survival estimates and Cox proportional hazards regression that provides hazard ratios and 95% confidence intervals. The median follow-up time was 4.2 years (max. 21.7 years). Local recurrence and metastatic disease occurred in 33% and 16% of patients, respectively. Exenteration-free survival and overall survival tended to be worse in T3 melanoma. No association between tumor origin and local recurrence, metastatic disease, or overall survival was observed. Main complications after proton radiotherapy were sicca-syndrome (30%), secondary glaucoma (11%), and limbal stem cell deficiency (8%). In summary, proton radiotherapy in conjunctival melanoma is an effective alternative to exenteration, with a 5-year cumulative probability of eye preservation of 69%.

Angiosarcomas are rare malignant mesenchymal tumors of endothelial differentiation. The clinical behavior is usually aggressive and the prognosis for patients with advanced disease is poor with no effective therapies. The genetic bases of these tumors have been partially revealed in recent studies reporting genetic alterations such as amplifications of MYC (primarily in radiation-associated angiosarcomas), inactivating mutations in PTPRB and R707Q hotspot mutations of PLCG1. Here, we performed a comprehensive genomic analysis of 34 angiosarcomas using a clinically-approved, hybridization-based targeted next-generation sequencing assay for 341 well-established oncogenes and tumor suppressor genes. Over half of the angiosarcomas (n = 18, 53%) harbored genetic alterations affecting the MAPK pathway, involving mutations in KRAS, HRAS, NRAS, BRAF, MAPK1 and NF1, or amplifications in MAPK1/CRKL, CRAF or BRAF. The most frequently detected genetic aberrations were mutations in TP53 in 12 tumors (35%) and losses of CDKN2A in 9 tumors (26%). MYC amplifications were generally mutually exclusive of TP53 alterations and CDKN2A loss and were identified in 8 tumors (24%), most of which (n = 7, 88%) arose post-irradiation. Previously reported mutations in PTPRB (n = 10, 29%) and one (3%) PLCG1 R707Q mutation were also identified. Our results demonstrate that angiosarcomas are a genetically heterogeneous group of tumors, harboring a wide range of genetic alterations. The high frequency of genetic events affecting the MAPK pathway suggests that targeted therapies inhibiting MAPK signaling may be promising therapeutic avenues in patients with advanced angiosarcomas. OA gold

In dieser Studie sollen die Langzeitergebnisse der Ex-vivo-Expansion von autologem Limbusepithel zur Oberflachenrekonstruktion bei limbaler Stammzellinsuffizienz (LSZI) untersucht werden. Bei 61 Augen von 57 Patienten (m:w 46:11) mit einer LSZI erfolgte eine autologe Transplantation von kultiviertem Limbusepithel. Folgende Atiologien einer LSZI wurden behandelt: Veratzungen (n = 32), Verbrennungen (n = 2), Mitomycin C (MMC)/INF-α-induziert bei Zustand nach Tumorexzision (n = 9), rezidivierende, bzw. primare, grose Pterygien (n = 12), schwere infektiose Keratitiden (n = 3), Zustand nach Perforationstrauma, Epidermolysis bullosa, kontaktlinsenassoziierte Keratopathie (jeweils n = 1). Nur Augen mit einem Nachbeobachtungszeitraum von mindestens 12 Monaten wurden in die Studie eingeschlossen. Der Nachbeobachtungszeitraum betrug im Mittel 50,8 ± 32,7 Monate (Intervall: 12,5 bis 142 Monate). Ein stabiles okulares Oberflachenepithel wurde bei 46 Augen (75,4 %) erzielt. Die Sehscharfe stieg bei 40 Augen (65,6 %) an, war stabil bei 12 Augen (19,7 %) und verschlechterte sich bei 9 Augen (14,8 %). Der durchschnittliche logMAR-Visus verbesserte sich signifikant (p

Blue nevi are common melanocytic tumors arising in the dermal layer of the skin. Similar to uveal melanomas, blue nevi frequently harbor GNAQ and GNA11 mutations. Recently, recurrent CYSLTR2 and PLCB4 mutations were identified in uveal melanomas not harboring GNAQ or GNA11 mutations. All four genes (GNAQ, GNA11, CYSLTR2, and PLCB4) code for proteins involved in the same signaling pathway, which is activated by mutations in these genes. Given the related functional consequences of these mutations and the known genetic similarities between uveal melanoma and blue nevi, we analyzed a cohort of blue nevi to investigate whether CYSLTR2 and PLCB4 mutations occur in tumors lacking GNAQ or GNA11 mutations (as in uveal melanoma). A targeted next-generation sequencing assay covering known activating mutations in GNAQ, GNA11, CYSLTR2, PLCB4, KIT, NRAS, and BRAF was applied to 103 blue nevi. As previously reported, most blue nevi were found to harbor activating mutations in GNAQ (59%, n = 61), followed by less frequent mutations in GNA11 (16%, n = 17). Additionally, one BRAF (1%) and three NRAS (3%) mutations were detected. In three tumors (3%) harboring none of the aforementioned gene alterations, CYSLTR2 mutations were identified. All three CYSLTR2 mutations were the same c.386T > A, L129Q mutation previously identified in uveal melanoma that has been shown to lead to increased receptor activation and signaling. In summary, our study identifies CYSLTR2 L129Q alterations as a previously unrecognized activating mutation in blue nevi, occuring in a mutually exclusive fashion with known GNAQ and GNA11 mutations. Similar to GNAQ and GNA11 mutations, CYSLTR2 mutations, when present, are likely defining pathogenetic events in blue nevi.

Die okulare GvHD („graft versus host disease“; Transplantat-gegen-Wirt-Reaktion) nach allogener Blutstammzelltransplantation beinhaltet immunologisch getriggerte Gewebsveranderungen in vielen Bereichen des Auges und insbesondere der Augenoberflache. Im Rahmen des Leitthemas wird hier besonders auf die Hornhautkomplikationen im Rahmen einer chronischen okularen GvHD eingegangen. Diese Arbeit soll einen Beitrag zum verbesserten Verstandnis der Einflussfaktoren, Diagnostik und Therapiemoglichkeiten bei einer Hornhautbeteiligung im Rahmen einer okularen GvHD leisten. Dabei soll auch die Frage der Pravention erortert werden. Die Auswertung basiert auf der aktuellen Literatur sowie Daten aus der Klinik fur Augenheilkunde am Universitatsklinikum Essen. Hornhautkomplikationen treten im Rahmen einer okularen GvHD haufig sekundar als Folge schwerer entzundlicher Bindehaut- und Lidveranderungen auf. Seltener sind spontane und symptomarme Hornhautperforationen im Verlauf der Erkrankung. Die Diagnostik orientiert sich an Vorschlagen von Konsensuskonferenzen. Wichtig ist aus ophthalmologischer Sicht die Berucksichtigung der inflammatorischen Aktivitat in den verschiedenen okularen Geweben. Die Therapie kann einem Stufenschema folgen und beinhaltet Substitution, Immunsuppression und chirurgische Rehabilitation. Die systematische Diagnostik einer okularen GvHD hilft, Hornhautkomplikationen zu verhindern oder fruhzeitig richtig einzuschatzen. Sowohl bei der Diagnostik als auch in der Planung der Therapie ist eine interdisziplinare Abstimmung erforderlich, um die lokale und systemische immunsuppressive Therapie richtig und moglichst zielgerichtet einzusetzen.

Background:Recently, activating mutations in the TERT promoter were identified in cutaneous melanoma. We tested a cohort of ocular melanoma samples for similar mutations.Methods:The TERT promoter region was analysed by Sanger sequencing in 47 uveal (ciliary body or choroidal) melanomas and 38 conjunctival melanomas.Results:Mutations of the TERT promoter were not identified in uveal melanomas, but were detected in 12 (32%) conjunctival melanomas. Mutations had a UV signature and were identical to those found in cutaneous melanoma.Conclusion:Mutations of TERT promoter with UV signatures are frequent in conjunctival melanomas and favour a pathogenetic kinship with cutaneous melanomas. Absence of these mutations in uveal melanomas emphasises their genetic distinction from cutaneous and conjunctival melanomas. © 2013 Cancer Research UK. All rights reserved.

The majority of human tumours can be easily and correctly diagnosed based on clinical information and pathological assessment. In some cases however, correct diagnosis can prove difficult. In such cases, molecular approaches can be of significant diagnostic value. In recent years, the understanding of genetic alterations has greatly increased. In cutaneous melanoma, it is now well recognised, that 70-80% of tumours harbour BRAF and NRAS mutations. These mutations never occur in uveal melanoma. On the other hand activating GNAQ and GNA11 mutations are found in ∼90% of uveal melanomas, and are exceptionally rare in other melanomas (

Melanocytic tumors originating in the central nervous system (MT-CNS) are rare tumors that generally have a favorable prognosis, however malignant tumors do occur. Pathogenetically MT-CNS are not well characterized. Similar to uveal melanoma and blue nevi, they frequently harbor activating GNAQ or GNA11 mutations. Rare NRAS mutations have also been reported. Other mutations have not yet been described. We analyzed 19 MT-CNS, 7 uveal melanomas and 19 cutaneous melanomas using a targeted next generation sequencing approach analyzing 29 genes known to be frequently mutated in other melanocytic tumors (in particular uveal and cutaneous melanomas). In concordance with previous studies, cutaneous melanoma samples showed frequent NRAS or BRAF mutations, as well as mutations in other genes (e.g. NF1, RAC1, PIK3CA, ARID1A). Metastasized uveal melanomas exhibited mutations in GNAQ, GNA11 and BAP1. In contrast, MT-CNS almost exclusively demonstrated mutations in GNAQ (71 %) or GNA11 (12 %). Interestingly both GNA11 mutations identified were detected in MT-CNS diagnosed as intermediate grade melanocytomas which also recurred. One of these recurrent cases also harbored an inactivating BAP1 mutation and was found to have lost one copy of chromosome 3. Our findings show that while MT-CNS do have GNAQ or GNA11 mutations, they rarely harbor other recurrent mutations found in uveal or cutaneous melanomas. Considering chromosome 3 and BAP1 loss are robust markers of poor prognosis in uveal melanoma, it will prove interesting to determine whether these genomic alterations are also of prognostic significance in MT-CNS.

PURPOSE Ocular surface squamous neoplasia, including intraepithelial neoplasia (CIN) and invasive squamous cell carcinoma (SCC), are one of the most common malignant tumors of the conjunctiva. Little is known of the genetic alterations involved in their pathogenesis. Promoter mutations in telomerase reverse transcriptase (TERT) have been identified in various cancers, including many associated with ultraviolet (UV) exposure. Our study analyzes the mutation rate and clinicopathological associations of TERT promoter mutations in ocular surface squamous neoplasia. METHODS DNA was isolated and the region of the TERT promoter where hotspot mutations can occur analyzed by Sanger-sequencing in 48 ocular surface squamous neoplasia tumor samples (6 CIN and 42 SCC). An analysis of associations between TERT promoter mutation status and various clinicopathological parameters was performed. RESULTS We identified TERT promoter mutations in 21 of 48 ocular surface squamous neoplasia samples (43.8%), including 4 in CIN and 17 in SCC. The mutations consisted of 8 Chr.5:1295228C>T, 1 Chr.5:1295228_1295229CC>TT, 5 Chr.5:1295242_1295243CC>TT, and 12 Chr.5:1295250C>T mutations. All mutations were C>T or CC>TT alterations, demonstrating a UV-signature. TERT promoter mutations showed no statistically significant associations with clinicopathological parameters. CONCLUSIONS Telomerase reverse transcriptase promoter mutations are found in almost half of ocular surface squamous neoplasias and have a mutation profile supporting UV induction as the major source of mutagenesis. We conclude that UV induced TERT promoter mutations leading to aberrant overexpression of telomerase is a major pathogenetic factor in ocular surface squamous neoplasia.

// Simone L. Scholz 1 , Susanne Horn 2 , Rajmohan Murali 6, 7 , Inga Moller 2 , Antje Sucker 2 , Wiebke Sondermann 2 , Mathias Stiller 2, 5 , Bastian Schilling 2 , Elisabeth Livingstone 2 , Lisa Zimmer 2 , Henning Reis 3 , Claudia H. Metz 1 , Michael Zeschnigk 4 , Annette Paschen 2 , Klaus-Peter Steuhl 1 , Dirk Schadendorf 2 , Henrike Westekemper 1 , Klaus G. Griewank 2 1 Department of Ophthalmology, University Hospital Essen, University Duisburg-Essen, West German Cancer Center and the German Cancer Consortium (DKTK), Essen Germany 2 Department of Dermatology, University Hospital Essen, University Duisburg-Essen, West German Cancer Center and the German Cancer Consortium (DKTK), Essen Germany 3 Institute of Pathology, University Hospital Essen, University Duisburg-Essen, West German Cancer Center and the German Cancer Consortium (DKTK), Essen Germany 4 Department of Human Genetics, University Hospital Essen, University Duisburg-Essen, West German Cancer Center and the German Cancer Consortium (DKTK), Essen Germany 5 University Duisburg-Essen and the German Cancer Consortium (DKTK), Essen Germany 6 Department of Pathology, Memorial Sloan Kettering Cancer Center, New York NY, USA 7 Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York NY, USA Correspondence to: Klaus Griewank, e-mail: klaus.griewank@uk-essen.de Keywords: melanoma, SDHD, promoter mutations Abbreviations: NGS = next generation sequencing; ETS = E26 transformation-specific; SDHD = Succinate dehydrogenase complex subunit D Received: May 09, 2015 Accepted: July 15, 2015 Published: July 27, 2015 ABSTRACT Objectives: Recently, recurrent mutations in regulatory DNA regions, such as promoter mutations in the TERT gene were identified in melanoma. Subsequently, Weinhold et al. reported SDHD promoter mutations occurring in 10% of melanomas and being associated with a lower overall survival rate. Our study analyzes the mutation rate and clinico-pathologic associations of SDHD promoter mutations in a large cohort of different melanoma subtypes. Methods: 451 melanoma samples (incl. 223 non-acral cutaneous, 38 acral, 33 mucosal, 43 occult, 43 conjunctival and 51 uveal melanoma) were analyzed for the presence of SDHD promoter mutations by Sanger-sequencing. Statistical analysis was performed to screen for potential correlations of SDHD promoter mutation status with various clinico-pathologic criteria. Results: The SDHD promoter was successfully sequenced in 451 tumor samples. ETS binding site changing SDHD promoter mutations were identified in 16 (4%) samples, of which 5 mutations had not been described previously. Additionally, 5 point mutations not located in ETS binding elements were identified. Mutations in UV-exposed tumors were frequently C>T. One germline C>A SDHD promoter mutation was identified. No statistically significant associations between SDHD promoter mutation status and various clinico-pathologic variables or overall patient survival were observed. Conclusions: Melanomas harbor recurrent SDHD promoter mutations, which occur primarily as C>T alterations in UV-exposed melanomas. In contrast to the initial report and promoter mutations in the TERT gene, our analysis suggests that SDHD promoter mutations are a relatively rare event in melanoma (4% of tumors) of unclear clinical and prognostic relevance.

Die Strahlentherapie des Bindehautmelanoms hat in den vergangenen Jahren gegenuber weniger invasiven therapeutischen Ansatzen an Bedeutung gewonnen. Das liegt an den erheblichen Rezidivraten, die bei fehlender adjuvanter Therapie erzielt werden, und an der zunehmenden Verfugbarkeit adaquater strahlentherapeutischer Methoden. Damit konnen auch Tumore bestrahlt werden, die zuvor nicht organerhaltend therapiert werden konnten. Die Arbeit beschreibt die aktuellen Bestrahlungstechniken fur die Therapie von Bindehautmelanomen. Ziel der Arbeit ist es, die diagnostischen und therapeutischen Strategien und Ablaufe bei der Behandlung von malignen Bindehautmelanomen darzustellen. Es ist den Autoren wichtig, die Notwendigkeit einer adjuvanten Behandlung zu begrunden und die interdisziplinare Zusammenarbeit im Verlauf der Tumortherapie aufzuzeigen. Die Arbeit basiert auf Ergebnissen aus der Literatur ebenso wie auf eigenen Erfahrungen und Daten des Zentrums.

Recent advances in tissue engineering have facilitated the development of new strategies in ocular surface reconstruction. Limitations and possibilities of ex vivo cultivation and limbal epithelium cell culture techniques as well as the short and long-term complications after transplantation of ex vivo expansion of cultivated limbal epithelium for the treatment of limbal stem cell deficiency are summarized in this review.

PURPOSE. The most common malignant intraocular tumors with a high mortality in adults are uveal melanomas. Uveal melanomas arise most frequently in the choroid or ciliary body (97%) and rarely in the iris (3%). Whereas conjunctival and posterior uveal (ciliary body and choroidal) melanomas have been studied in more detail genetically, little data exist regarding iris melanomas. METHODS. In our study, we genetically analyzed 19 iris melanomas, 8 ciliary body melanomas, 3 ring melanomas, and 4 iris nevi. A targeted next-generation sequencing approach was applied, covering the mutational hotspot regions of nine genes known to be mutated in conjunctival and uveal melanoma (BRAF, NRAS, KIT, GNAQ, GNA11, CYSLTR2, SF3B1, EIF1AX, and BAP1). RESULTS. Activating GNAQ or GNA11 hotspot mutations were detected in a mutually exclusive fashion in 84% (16/19) of iris melanomas. EIF1AX gene mutations also were frequent, detected in 42% (8/19) of iris melanomas. In 4 iris nevi, one GNAQ mutation was identified. GNAQ, GNA11, EIF1AX, and BAP1 mutations were identified at varying frequencies in ciliary body and ring melanomas. CONCLUSIONS. In this most comprehensive genetic analysis of iris melanomas published to date, we find iris melanomas to be related genetically to choroidal and ciliary body melanomas, frequently harboring GNAQ, GNA11, and EIF1AX mutations. Future studies will need to assess if screening mutation profiles in iris melanomas may be of diagnostic or prognostic value. CA Griewank und Scholz