Long-term progression in a case of transvitreal endoresection of a posterior choroidal malignant melanoma

BACKGROUND: In Japan, there are few reports of the prognosis of the endoresection of malignant choroidal melanoma. We previously reported this case of transvitreal endoresection of a posterior choroidal malignant melanoma. The tumor recurred and enucleation was carried out. Here we report the subsequent long-term clinical course. CASE: A choroidal tumor temporal to the macula was noted in the right eye of a 47-year-old male patient. The tumor size increased within the 1 year of observation and was suspected to be a malignant choroidal melanoma. Since the patient strongly wished to preserve his eyeball, he underwent infrared diode laser photocoagulation, resulting in further progress of the tumor. Three months later a transvitreal piecemeal endoresection was carried out. Four years after endoresection, the tumor recurred, and then the eyeball was enucleated. A pathological examination identified a spindle-cell type malignant melanoma located in the posterior part of the eyeball. No invasion was observed within the sclera or optic nerve. Neither local recurrence nor metastasis has been observed for 5 years after the enucleation. CONCLUSION: In this case, in spite of our utmost efforts, the eyeball could not be preserved. This case can provide useful information for considering endoresection as a management tool for choroidal melanoma.     

Secondary endoresection for previously treated choroidal melanomas with a non-responsive course and persistent exudative retinal detachment

AIM:To evaluate the results and complications of secondary endoresection via pars plana vitrectomy for choroidal melanoma and review the previously reported endoresection studies on the treatment of choroidal melanoma.METHODS:The medical records of 6 patients with choroidal melanoma who underwent secondary endoresection between March 2012 and March 2020 were retrospectively reviewed.The indications for secondary endoresection were progressive or recurrent tumor and severe exudative retinal detachment after previous treatment with plaque radiotherapy/Cyberknife radiosurgery/transpupillary thermotherapy(TTT).RESULTS:Before endoresection,2 eyes had Iodine-125 plaque radiotherapy and TTT,1 eye had Ruthenium-106 plaque radiotherapy and TTT,1 eye had Cyberknife radiosurgery and TTT,1 eye had Cyberknife radiosurgery,and 1 eye had TTT only.Preoperative visual acuity ranged from 20/63 to 20/1600(Snellen) and from 0.5 to 1.9(mean:1.1) on the log MAR scale.The mean tumor base diameters were 9.5×8.7 mm and the mean tumor thickness was 5.4 mm.After secondary endoresection,transient vitreous hemorrhage developed in 2(33.3%) eyes and retinal detachment in 1(16.7%) eye.Cytopathological examination revealed epithelioid cell melanoma in 4(66.7%) eyes and mixed cell melanoma in 1(16.7%).Melanoma cell type was not specified in 1(16.7%) eye.At a mean follow-up of 49.6 mo(range:16-90 mo),mean visual acuity did not improve and 1 eye was enucleated due to tumor recurrence.Final visual acuity ranged from 20/63 to 20/1600(Snellen) and from 0.5 to 1.9(mean:1.2) on the log MAR scale.Two patients with choroidal melanoma developed metastasis and eventually expired.CONCLUSION:Secondary endoresection seems to be an effective treatment option for globe salvage in choroidal melanoma not responsive to conventional treatment and displaying persistent exudative retinal detachment.There was no visual acuity increase among the treated eyes but globe salvage was possible in most cases in this study.     

Clinical and genetic characteristics of nevus of Ota with choroidal melanoma in Chinese

ABSTRACT

Purpose: The aim of the present study is to report the clinical and genetic characteristics of nevus of Ota with choroidal melanoma in Chinese patients.

Patients and Methods: Patients with nevus of Ota with choroidal melanoma were identified by searching the computerized database and patient medical records of Beijing Shijitan Hospital and Shaanxi Yulin Tradition Chinese Medicine Hospital. The patients (2 men and 1 woman; mean age, 52 years; age range, 52?57 years) were all treated by enucleation or local endoresection, and choroidal melanoma was confirmed by pathologic examination.

Results: The patients (2 men and 1 woman; mean age, 52 years; age range, 52?57 years) were all treated by enucleation or local endoresection, and choroidal melanoma was confirmed by pathologic examination. The study found that patients with nevus of Ota had higher risk for malignant melanoma. Furthermore, we found two suspicious gene mutations involving FAM111B and DSC2, that might contribute to the etiology of the disease.

Conclusions: The results indicate that patients with nevus of Ota should undergo regular ophthalmological observation and be aware of the potential for malignancy.     

Histopathology of eyes enucleated after endoresection of choroidal melanoma

PURPOSE: To demonstrate the histopathologic features of eyes enucleated after endoresection for choroidal melanoma to assess the complications of this treatment and to determine indications for further treatment after endoresection in the setting of possible tumor recurrence. DESIGN: Retrospective, observational case series. PARTICIPANTS: Sixty-one consecutive patients who had undergone endoresection for uveal melanoma. METHODS: Eyes that had undergone enucleation after endoresection were identified, and their charts and histologic characteristics were reviewed. Pertinent features were described. One patient was excluded because enucleation was performed as a primary treatment when endoresection was abandoned at the time of his initial treatment. MAIN OUTCOME MEASURES: The outcome measures included: reasons for enucleation; tumor recurrence; and location, clinical, and histologic characteristics of each recurrence. RESULTS: Twelve eyes were identified that had undergone enucleation after endoresection. The reasons for enucleation were: (1) local tumor recurrence detected by ophthalmoscopy (2 patients) or echography (1 patient); (2) opaque media preventing adequate ophthalmoscopy (4 patients); (3) blind and painful eye of uncertain cause (1 patient); and (4) a combination of blind eye and limited fundus view (4 patients), which was the result of untreatable retinal detachment (3 patients) and endophthalmitis (1 patient). Eight of 12 patients had recurrent choroidal melanoma. Recurrences were all located adjacent to the resection site, although in 1 patient there was extensive diffuse recurrence throughout the eye. The recurrence was visible clinically in 3 patients and obscured because of opaque media (2 patients), a combination of inadequate echography and retinal detachment (1 patient), retinal detachment (1 patient), and endophthalmitis (1 patient). CONCLUSIONS: Recurrent disease occurred at the site of the primary tumor with no seeding except in 1 patient, whose marginal recurrence was not immediately detected and treated because of opaque media. As with other treatments conserving the eye, enucleation should be performed if adequate ocular examination is not possible, and follow-up should be lifelong.     

Post-brachytherapy tumor endoresection for treatment of toxic maculopathy in choroidal melanoma

Purpose

Toxic tumor syndrome may occur when the irradiated choroidal melanoma releases cytokines, by exudation from irradiated ischemic tissue. We report our experience and outcomes in a series of post-brachytherapy tumor endoresection to mediate radiation complications.

Methods

Patients who underwent endoresection of a choroidal melanoma treated with iodine-125 plaque brachytherapy were evaluated. Baseline patient and tumor parameters were tabulated.

Results

Five patients underwent post-brachytherapy tumor endoresection with intraocular gas or silicone oil tamponade. Three of the five patients underwent concomitant phacoemulsification with intraocular lens placement. Initial tumor height ranged from 2.03–8.91 mm (mean 5.81 mm). Time between brachytherapy and endoresection ranged from 13–62 months (mean 26.8 months), and total follow-up time from brachytherapy ranged from 2.5–9.75 years (mean 5.2 years). Vision post-brachytherapy and pre-endoresection ranged from 20/30 to 20/400. Final visual acuity ranged from 20/70 to no light perception. One patient developed neovascular glaucoma. Radiation maculopathy increased in all patients. One patient developed metastasis at last follow-up. No patient developed exudative retinal detachment, none had local treatment failure, and none required enucleation.

Conclusion

Although tumor endoresection post-brachytherapy is a technically feasible procedure, all patients in our series experienced progressive radiation maculopathy with gradual visual decline.     

Bilateral uveal melanoma: a series of four cases

AIM: To describe the occurrence of bilateral primary choroidal melanoma in four patients. METHODS: All patients attending the Liverpool Ocular Oncology Centre with uveal melanoma between January 1993 and February 2002 were identified, and those with bilateral primary choroidal melanoma were reviewed. Their presentation and management are described. RESULTS: Four patients, all female, were identified. Patient 1 presented with a right juxtapapillary melanoma at the age of 64, which was treated with krypton laser and endoresection, and then when aged 73 required proton beam radiotherapy for a melanoma in her left eye. Patient 2 presented at the age of 82 with bilateral choroidal melanomas and underwent simultaneous bilateral plaque radiotherapy. Patient 3 presented with bilateral choroidal melanomas at the age of 75 and was treated initially with bilateral proton beam radiotherapy. Patient 4 was treated at the age of 54 with right plaque radiotherapy for a choroidal melanoma, and 3 years later needed plaque radiotherapy for a melanoma in her other eye. CONCLUSION: Bilateral choroidal melanoma is possible and should be a consideration in the continuing management of patients with choroidal melanoma.     

Endoresection of choroidal melanoma

AIMS—The results of 52 endoresections for choroidal melanoma are reported.
METHODS—The current technique involves vitrectomy, retinal incision over or peripheral to the tumour, haemostasis by raising intraocular pressure and by moderate hypotensive anaesthesia, choroidal incision around tumour, endoresection with vitrector, endodiathermy to bleeding points and residual tumour, fluid-air exchange to reattach retina, endolaser to achieve retinal adhesion around the coloboma and destroy residual tumour in the sclera, silicone oil injection with removal after 12 weeks, cryotherapy to the sclerotomies, and adjunctive ruthenium plaque radiotherapy in selected cases.
RESULTS—Patients receiving primary endoresection had a mean age of 53 years, a mean largest basal tumour diameter of 8.2 mm, and a mean tumour thickness of 3.9 mm. 40 tumours extended to within 2 disc diameters of the optic disc, with 17 involving disc. Follow up ranged from 40 days to 7 years (median 20 months). At the last visit, 90% of eyes were retained, with vision of 6/6-6/12 (two), 6/18-6/36 (three), 6/60 to counting fingers (18), hand movements (nine), and light perception (four). The main complications were retinal detachment in 16 and cataract in 25. Secondary endoresection (11) was performed after plaque radiotherapy (four), photocoagulation (four), trans-scleral local resection (two), and proton beam radiotherapy (one), with retention of the eye in nine cases. By the close of the study, no patients developed definite local tumour recurrence but one died of metastatic disease 41 months postoperatively.
CONCLUSION—Depending on tumour location, endoresection may conserve central vision or temporal field when radiotherapy would be expected to cause optic neuropathy. Longer follow up is necessary to establish the efficacy of tumour control.

Keywords: uveal melanoma; choroidal melanoma; ocular neoplasms; vitrectomy; endoresection; photocoagulation     

Therapy of radiation resistant malignant uveal melanoma with endoresection by pars plana vitrectomy in two patients]

BACKGROUND: Since introduction of brachytherapy using (106)ruthenium plaque therapy for treating malignant choroidal melanomas a number of comparative studies have shown that survival rates are equal between patients who underwent radiation or enucleation. When radiation treatment fails, the patient might be determined to choose removal of the tumor by pars plana vitrectomy. PATIENTS AND METHODS: Between 1995 and 1998 a total number of 48 patients underwent (106)ruthenium plaque irradiation. In 9 patients tumor regression was not sufficient. Two of these nine patients decided explicitly against enucleation and choose to have the tumor removed from within the eye employing pars plana vitrectomy. RESULTS: Intraoperatively, the previously radiated melanoma was easily removed with the vitrectomy cutter without significant bleeding. Postoperative recovery was without complications. Silicone oil removal was carried out in one patient after one year. Vision 9 months and 2.5 years after surgery was 0.2 and 0.02, respectively. The cosmetic results with parallel axis of the globes were very good and one patient gained binocular vision. No recurrent tumor growth was seen so far. Histologically, no mitotic figures were found. CONCLUSION: Malignant choroidal melanomas can be safely removed by pars plana vitrectomy with stable intraocular pressure. Previous radiation therapy alters the tumor, inducing fibrous tissue growth and necrosis of tumor cells. These tissue types are not prone to bleed when they are resected by the vitrectomy cutter. Long time studies have to elucidate the difference in survival rates between patients undergoing enucleation of the eye and patients who chose endoresection of the melanoma by pars plana vitrectomy.     

标准化A超联合B超诊断脉络膜血管瘤和脉络膜黑色素瘤

目的：探讨标准化A超和B超联合诊断脉络膜血管瘤和脉络膜黑色素瘤的价值。方法：使用标准化A超联合B超诊断5例脉络膜血管瘤和4例脉络膜黑色素瘤。结果：脉络膜血管瘤标准化A超表现为病变内反射波较高，结构规则，声衰减不明显，B超示眼后极部孤立性占位病变，内回声强而均匀。脉络膜黑色素瘤标准化A超表现为病变内反射较低，声衰减明显，B起示眼内半圆形或蘑菇形实性隆起，可见脉络膜凹陷现象。结论：标准化A超对脉络膜血管瘤和脉络膜黑色素瘤可提供如病变内部结构、内反射、声衰减等诊断信息，B超对病变的形状、定位更有价值。标准化A超鉴别肿瘤的性质要优于B超，并具有可重复性和可比较性的优点。标准化A超联合B超可对脉络膜血管瘤和脉络膜黑色素瘤的诊断起到较好效果。     

Posterior choroidal leiomyoma: new findings from a case and literature review

Posterior choroidal leiomyoma is a sporadic, rare benign tumor that is always confused with anaplastic melanoma. Here we report a case and provide a review. Most of the preoperative findings in our case were suggestive of malignant choroidal melanoma. However, the contrast enhanced ultrasound (CEUS) suggested a benign hemangioma. In summary, the posterior choroidal leiomyomas were yellowish-white in color and most commonly located in the temporal quadrant of the fundus (11/15). They were more frequent in Asians (13/16), the prevalence was almost equal in males and females (9:7), with a mean age of 35y. Microscopically, the tumor typically showed spindle cell bundles and nonmitotic ovoid nuclei arranged in intersecting fascicles. Vitrectomy is now a popular treatment option and definitive diagnosis can be made after immunohistochemistry. Finally, some summarized features of this tumor differ from those previously described. These may help in the diagnosis of posterior choroidal leiomyoma and differentiation from malignant melanoma.     

Long-term surgical outcome of posterior choroidal melanoma treated by endoresection

PURPOSE: To report the visual acuity, enucleation rates, and initial mortality after transvitreal endoresection of posterior uveal melanoma. METHODS: Twenty consecutive patients with medium-sized posterior choroidal melanomas were treated. Vitrectomy was performed, followed by posterior hyaloid dissection, retinotomy, melanoma removal with a vitrectomy probe, retinal reattachment with perfluorocarbon liquid, and silicone oil or gas exchange. RESULTS: Twenty patients (13 men [65%] and 7 women [35%]) were included in the study. The mean patient age +/- SD was 47.1 +/- 16 years (range, 22-70 years). Tumor thickness and tumor diameter ranged from 5.5 mm to 11 mm and 8.0 mm to 15.7 mm, respectively. Preoperative visual acuity ranged from hand motion to 20/40, and postoperative visual acuity ranged from no light perception to 20/30. Two eyes (10%) were enucleated during tumor resection due to severe bleeding. Enucleation was performed on 3 eyes (15%) during follow-up due to tumor recurrence at the edge of surgical coloboma in 1 patient, new focus of tumor in another sector distant from surgical coloboma in 1 patient, and painful blind eye in 1 patient. Fifteen eyes (75%) were saved. One patient (5%) died of metastasis to the liver. The mean follow-up period +/- SD was 89.55 +/- 38.4 months (range, 24-132 months. CONCLUSION: These data suggest that transvitreal endoresection of posterior uveal melanoma is an acceptable management option to conserve the globe and functional vision in selected patients. Distant metastasis is an infrequent event in this modality of treatment.     

Choroidal neovascular membrane in a series of cases of malignant melanoma of the choroid

PURPOSE: To examine a series of choroidal melanoma specimens to determine the frequency of overlying choroidal neovascularization (CNV) and to ascertain whether CNV over choroidal malignant melanoma is associated with any particular histological tumour characteristics. METHODS: We carried out a retrospective histological analysis of globes containing choroidal melanomas for evidence of choroidal neovascular membranes. RESULTS: Microscopic evidence of choroidal neovascular membranes was evident in 6% of cases. Choroidal neovascularization was not associated with any particular histological tumour characteristic. CONCLUSION: Choroidal neovascularization over choroidal malignant melanoma is not an infrequent occurrence and possibly appears as frequently as CNV over choroidal naevi. The presence of a choroidal neovascular membrane over a pigmented fundal lesion should not be taken as reassurance that the lesion is benign.     

Fundus autofluorescence of choroidal nevus and melanoma

BACKGROUND: To describe autofluorescence patterns of choroidal melanocytic lesions using the Heidelberg Retinal Angiograph 2 system (HRA2). METHODS: 20 patients with choroidal melanocytic lesions in the ocular fundus underwent ophthalmologic examination, fundus photography, autofluorescence and optical coherence tomography (OCT). Pathologic examination was performed on one enucleated eye with a large choroidal melanoma. RESULTS: 15 patients had choroidal nevi and 5 had malignant choroidal melanoma (1 small, 1 medium and 3 large tumours). Choroidal nevi did not show any characteristic autofluorescence pattern, although secondary retinal pigment epithelium (RPE) changes, such as drusen and pigment epithelium detachment, appeared faintly hyperautofluorescent in 2 patients. Only the small malignant choroidal melanomas had prominent orange pigmentation, although all melanomas had an intense confluent hyperautofluorescent signal over the lesions. Pathology of one large malignant melanoma revealed lipofuscin underlying RPE. CONCLUSION: Most nevi did not have characteristic hyperautofluorescent features, but choroidal melanomas seemed to have a pattern of confluent hyperautofluorescence. Therefore, autofluorescence may be a useful non-invasive tool to assess lipofuscin in pigmented choroidal lesions, which may contribute to the diagnosis of malignancy. This hypothesis, however, remains to be confirmed in large prospective studies.     

Zweiphotonenfluoreszenz okulärer Melanome

Choroidal melanoma is the most frequent form of primary neoplasia among malignant ocular tumors. Since it is presumed that metastasis often occurs before the primary tumor is first diagnosed, early detection is exigent.The aim of the studies described in this report was to develop an objective, noninvasive method for the diagnosis of choroidal melanoma. The underlying new principle of fluorescence excitation is presented. This is based on the observation that melanin, due to its unique absorption characteristics, is selectively excited into fluorescence via stepwise absorption of two photons of a femtosecond laser emitting at 800 nm. In the experiment described, the fluorescence of excised tissue from healthy choroidal pigment epithelium was compared to that of excised choroidal melanoma.The fluorescence of choroidal melanomas exhibited a more reddish appearance and less intensity than that of healthy tissue. This implies that the configuration of melanin apparently changes during the process of malignant degeneration.The method described here could thus serve as an evidentiary objective diagnostic technique before initiating treatment for choroidal melanomas.     

Treatment options for choroidal malignant melanoma: a case report featuring transpupillary thermotherapy.

BACKGROUND: Choroidal melanoma is the most common primary ocular tumor in adults. These tumors are almost always unilateral and develop spontaneously or arise from pre-existing nevi. Historically, treatment for choroidal melanoma was enucleation. New therapies have been developed to treat choroidal melanoma and to preserve the eye. Currently, these treatment options include brachytherapy and transpupillary thermotherapy. CASE REPORT: A 51-year-old man came to the eye clinic with symptoms of mildly decreased fluctuating vision and floaters with no flashes in the temporal visual field of the right eye. Best-corrected visual acuities were 20/30 O.D. and 20/20 O.S. A small-to-medium choroidal lesion was found in the right eye. Ultrasonography and A-scan showed this lesion to be a choroidal malignant melanoma. The patient's surgical options included enucleation, brachytherapy, and transpupillary thermotherapy. The patient opted to have transpupillary thermotherapy to preserve the eye, and subsequently underwent two procedures that eventually obliterated the melanoma, resulting in best-corrected visual acuity of 20/40. CONCLUSION: Transpupillary thermotherapy is an excellent option for treatment of small-to-medium choroidal melanomas. Brachytherapy is also an option for treatment, but with increased ocular side effects and complications. Enucleation is still commonly performed on medium and/or large choroidal melanomas.     

MICROSURGERY OF CHOROIDAL MELANOMA—SURGICAL TECHNIQUES OF LOCAL EXCISION

Six cases of malignant choroidal melanoma were treated by microsurgical excision under hypotensive anaesthesia with follow-up periods varying from four months to four years. This paper presents the case for local excision of malignant choroidal melanoma in the light of the current controversy surrounding the management and natural history of choroidal melanoma. The indications for surgery, techniques, and results are described. Vision was preserved best in tumours with diameters of less than 10mm. No deaths and no evidence of extraocular recurrence occurred.     

Antibodies to skeletal muscle actin and their reactivity with malignant melanoma of the choroid.

Imprints of choroidal malignant melanoma cells were treated with serum containing antibodies to a purified preparation of actin derived from skeletal muscle. Evidence of a positive reaction, as shown by indirect immunofluorescence, substantiated an impression based on morphological criteria that choroidal melanoma cells contain actin protein. The significance of this protein in tumour biology is discussed, and a possible interference by antiactin antibodies in the immunodiagnosis of choroidal melanoma is highlighted.     

Choroidal neovascularization associated with malignant melanoma: a case report

Subretinal neovascularization observed over an elevated, pigmented choroidal lesion is usually considered evidence in favour of the benign nature of that lesion, a nevus. Histologic verification of malignant melanoma with choroidal neovascularization has never appeared in the literature. In this report, we present a case of subretinal neovascularization documented by fundus photography, fluorescein angiography, and histology in an eye containing a malignant choroidal melanoma.     

绿色荧光蛋白标记的脉络膜恶性黑色素瘤原位移植瘤模型

目的 建立新型裸鼠脉络膜恶性黑色素 瘤原位移植瘤模型。 方法 利用脂质体将绿色荧光蛋白（GFP）真核表达 质粒pEGFP-N₁转入人脉络膜恶性黑色素瘤细胞（OC-1），新霉素、荧光显微镜及流式细胞仪筛选稳定表达GFP的细胞克隆。将2 μl细胞浓度为4.5×10⁷~5.5×10⁷个/ml的细胞悬液注射到麻醉后的40只裸鼠右眼视网膜下间隙，左眼不注射作为对照眼。手术后利用带荧光的体视显微镜连续观察肿瘤生长情况，分别于肿瘤生长的眼内期、眼外期及衰竭期处死动物，荧光显微镜观察裸鼠视神经、颅底、肺、肝、肾的肿瘤转移情况，并行肿瘤组织的GFP免疫组织化学染色。 结果 手术后10~12 d肿瘤开始生长，血管扩张、扭曲，新生血管形成；手术后20~22 d肿瘤占满玻璃体腔；手术后24~26 d肿瘤生长至眼外；眼外期后，迅速进入衰竭期，衰竭期嗅球、肾、肺、肝脏有转移灶。移植瘤病理组织学表现类似于人脉络膜恶性黑色素瘤；免疫组织化学染色肿瘤细胞GFP染色阳性。 结论 以GFP基因标记的OCM-1经裸鼠视网膜下间隙移植建立的脉络膜恶性黑色素瘤原位移植瘤模型，为研究自然状态下肿瘤的生长和转移提供了一个新的方法。 （中华眼底病杂志，2004，20：245-248）     

Choroidal melanoma. An anatomic-clinical case report

A 78-year-old-male-patient had his left eye affected by a 10 mm thick choroidal malignant melanoma. The size of the tumor did not allowed to keep the eye, and no conservative treatment was used for therapy. Enucleation was performed and histopathological study of the eye showed a mushroom-shaped and mixed-cell choroidal melanoma, devoid of transcleral extension, but harboring intrascleral infiltration. A period of 2 year-follow-up without metastasis was observed since the removal of the tumoral eye.