Histopathologic Analysis of Transvitreal Fine Needle Aspiration Biopsy Needle Tracts for Uveal Melanoma

INFUSION PORT SITE TUMOR SEEDING AFTER PARS PLANA VITRECTOMY-ASSISTED BIOPSY OF CHOROIDAL MELANOMA

PURPOSE

To report a rare case of infusion port site tumor seeding of choroidal melanoma after pars plana vitrectomy-assisted biopsy and successful treatment with second plaque brachytherapy.

METHODS

Observational case report with clinical data and diagnostic images.

RESULTS

A 55-year-old White woman diagnosed with choroidal melanoma of the left eye was found to have a second intraocular tumor 30 months after plaque brachytherapy and pars plana vitrectomy-assisted tumor biopsy. The second melanoma developed at the 5 o'clock vitrectomy infusion port site. The tumor regressed after plaque brachytherapy, and the patient has not developed systemic metastasis 5 years after diagnosis of intraocular seeding.

CONCLUSION

Intraocular seeding into the infusion port site, although rare, may be encountered after pars plana vitrectomy-assisted biopsy of choroidal melanoma.

Choroidal biopsies; a review and optimised approach

The majority of choroidal tumours are diagnosed accurately with clinical examination and the additional data obtained from non-invasive imaging techniques. Choroidal biopsies may be undertaken for diagnostic clarity in cases such as small melanocytic or indeterminate lesions, identifying the primary tumour in the case of choroidal metastases or the subclassification of rarer conditions such as uveal lymphoma. There is however an increasing use of biopsy techniques for prognostication in uveal melanoma. This review explores the main indications and surgical techniques for tumour acquisition, and the optimised approach utilised by the current authors to improve successful yield for histological and genetic analysis.

Intraocular metastases of lung origin: Case reports and cytology correlates

Intraocular metastases from the lung are a common occurrence and an important differential for cytopathologists reading fine needle aspiration biopsies (FNAB). It is a particularly challenging diagnosis when the patient has had no previous diagnosis of lung cancer. We present two cases of intraocular metastases from lung primaries, and we discuss the clinical, radiological, and cytopathological features that help differentiate intraocular metastases of lung primary from other intraocular tumours, in the setting of FNAB. We also discuss the importance of recognising the spectrum of FNAB cases that can be seen specific to an institution, which may vary according to different patient populations. A thorough metastatic workup and ancillary testing, such as IHC or molecular genetics, ensures an accurate diagnosis.

Multiple Uveal Melanoma

Introduction

Multiple uveal melanoma is a rare occurrence and includes bilateral melanoma, unilateral multiple/multifocal melanoma, or melanoma with metastasis to the ipsilateral or contralateral eye.

Methods

A chart review of patients diagnosed with uveal melanoma between January 2013 and January 2019 at the Duke University Eye Center Ophthalmic Oncology Service was performed.

Results

Three patients with multiple, sequential melanoma were identified; patient 1 had bilateral choroidal melanoma and patients 2 and 3 had 2 choroidal melanomas occurring in the same eye. In all 3 patients, both the first and sequential choroidal melanomas were treated with I-125 radioactive plaque brachytherapy (PBT). Two patients were found to have developed secondary metastatic uveal melanoma as a presenting sign of systemic metastases. Patient 4, initially treated with PBT, was diagnosed with ipsilateral metastatic choroidal melanoma, also treated with PBT. Patient 5 had right eye enucleation for choroidal melanoma and developed vision-threatening metastasis in the left eye, which was treated with PBRT. None of the patients had history of cancer prior to their first diagnosis. Patients 1 and 5 were tested with a systemic melanoma panel; both were negative for BAP1, but patient 1 had a variant of unknown significance in BRCA2. Patient 3 had oculodermal melanocytosis, an established risk factor of uveal melanoma.

Conclusion

Although rare, the possibility of multiple uveal melanoma does exist. Examination of the treated and contralateral eye on a regular basis is crucial, not only to identify local failure but also new metastases from the primary tumor and additional primary tumors.

Identification of differentially expressed metastatic genes and their signatures to predict the overall survival of uveal melanoma patients by bioinformatics analysis

AIM

To identify metastatic genes and miRNAs and to investigate the metastatic mechanism of uveal melanoma (UVM).

METHODS

GSE27831, GSE39717, and GSE73652 gene expression profiles were downloaded from the Gene Expression Omnibus (GEO) database, and the limma R package was used to identify differentially expressed genes (DEGs). Gene Ontology (GO) term enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were performed using the DAVID online tool. A comprehensive list of interacting DEGs was constructed using the Search Tool for the Retrieval of Interacting Genes (STRING) database and Cytoscape software. The Cytoscape MCODE plug-in was used to identify clustered sub-networks and modules of hub genes from the protein-protein interaction network. GEPIA online software was used for survival analysis of UVM patients (n=80) from the The Cancer Genome Atlas (TCGA) cohort. OncomiR online software was used to find that the miRNAs were associated with UVM prognosis from the TCGA cohort. TargetScan Human 7.2 software was then used to identify the miRNAs targeting the genes.

RESULTS

There were 1600 up-regulated genes and 1399 down-regulated genes. The up-regulated genes were mainly involved in protein translation in the cytosol, whereas the down-regulated genes were correlated with extracellular matrix organization and cell adhesion in the extracellular space. Among the 2999 DEGs, five genes, Znf391, Mrps11, Htra3, Sulf2, and Smarcd3 were potential predictors of UVM prognosis. Otherwise, three miRNAs, hsa-miR-509-3-5p, hsa-miR-513a-5p, and hsa-miR-1269a were associated with UVM prognosis.

CONCLUSION

After analyzing the metastasis-related enriched terms and signaling pathways, the up-regulated DEGs are mainly involved in protein synthesis and cell proliferation by ribosome and mitogen-activated protein kinase (MAPK) pathways. However, the down-regulated DEGs are mainly involved in processes that reduced cell-cell adhesion and promoted cell migration in the extracellular matrix through PI3K-Akt signaling pathway, focal adhesion, and extracellular matrix-receptor interactions. Bioinformatics and interaction analysis may provide new insights on the events leading up to the development and progression of UVM.

Uveal Melanoma Biopsy: A Review

Intraocular tumor diagnosis is based on clinical findings supported by additional imaging tools, such as ultrasound, optical coherence tomography and angiographic techniques, usually without the need for invasive procedures or tissue sampling. Despite improvements in the local treatment of uveal melanoma (UM), the prevention and treatment of the metastatic disease remain unsolved, and nearly 50% of patients develop liver metastasis. The current model suggests that tumor cells have already spread by the time of diagnosis, remaining dormant until there are favorable conditions. Tumor sampling procedures at the time of primary tumor diagnosis/treatment are therefore now commonly performed, usually not to confirm the diagnosis of UM, but to obtain a tissue sample for prognostication, to assess patient's specific metastatic risk. Moreover, several studies are ongoing to identify genes specific to UM tumorigenesis, leading to several potential targeted therapeutic strategies. Genetic information can also influence the surveillance timing and metastatic screening type of patients affected by UM. In spite of the widespread use of biopsies in general surgical practice, in ophthalmic oncology the indications and contraindications for tumor biopsy continue to be under debate. The purpose of this review paper is to critically evaluate the role of uveal melanoma biopsy in ophthalmic oncology.

Fine-Needle Aspiration Biopsy for Molecular Genomic Classification: Evaluation of Transscleral vs Transvitreal Biopsy

Purpose:

To evaluate the transvitreal and transscleral fine-needle aspiration biopsy (FNAB) approach for molecular classification with gene-expression profiling (GEP) of uveal melanoma.

Methods:

Institutional review board–approved single-surgeon retrospective analysis of a consecutive case series of all patients undergoing FNAB using a 25-gauge-needle multipass approach for GEP analysis of uveal melanoma between 2012 and 2016. All FNAB specimens were processed for uveal melanoma diagnostic testing using a standard processing approach, and all testing was completed at a single laboratory (Castle Biosciences, Inc.).

Results:

Three hundred fifty-three eyes (353 patients) were included. Transvitreal biopsies were performed in 216 eyes (216/353, 61.2%), whereas transscleral biopsies were performed in 137 eyes (137/353, 38.8%). Twenty biopsies exhibited multiple gene failure (20/353, 5.6%). Excessive fluid biopsy volume was the primary association with reported multiple gene failure, occurring in 10 of 20 eyes (50%). FNAB performed via the transvitreal approach was significantly more likely to have an excessive volume report compared with transscleral biopsy (18/216, 8.3% vs 1/137, 0.7%; P < .001).

Conclusions:

FNAB performed via a transscleral or transvitreal multipass approach utilizing a 25-gauge needle achieves molecular classification in 95% of all patients undergoing treatment for presumed uveal melanoma independent of tumor size. Complications related to FNAB using these techniques are rare and may be associated with the presentation of the uveal melanoma.

Genetic prognostication in uveal melanoma

Uveal melanoma (UM) is a rare tumour with a high propensity to metastasize. Although no effective treatment for metastases yet exists, prognostication in UM is relevant for patient counselling, planning of follow-up and stratification in clinical trials. Besides conventional clinicopathologic characteristics, genetic tumour features with prognostic significance have been identified. Non-random chromosome aberrations such as monosomy 3 and gain of chromosome 8q are strongly correlated with metastatic risk, while gain of chromosome 6p indicates a low risk. Recently, mutations in genes such as BAP1, SF3B1 and EIF1AX have been shown to be related to patient outcome. Genetics of UM is a rapidly advancing field, which not only contributes to the understanding of the pathogenesis of this cancer, but also results in further refinement of prognostication. Concomitantly, advances have been made in the use of genetic tests. New methods for genetic typing of UM have been developed. Despite the considerable progress made recently, many questions remain, such as those relating to the reliability of prognostic genetic tests, and the use of biopsied or previously irradiated tumour tissue for prognostication by genetic testing. In this article, we review genetic prognostic indicators in UM, also comparing available genetic tests, addressing the clinical application of genetic prognostication and discussing future perspectives for improving genetic prognostication in UM.

Brachytherapy for patients with uveal melanoma: historical perspectives and future treatment directions

Surgical management with enucleation was the primary treatment for uveal melanoma (UM) for over 100 years. The Collaborative Ocular Melanoma Study confirmed in 2001 that globe-preserving episcleral brachytherapy for UM was safe and effective, demonstrating no survival difference with enucleation. Today, brachytherapy is the most common form of radiotherapy for UM. We review the history of brachytherapy in the treatment of UM and the evolution of the procedure to incorporate fine-needle-aspiration biopsy techniques with DNA-and RNA-based genetic prognostic testing.

Yield, Techniques, and Complications of Transvitreal and Transscleral Biopsies in Small Uveal Melanoma

Importance

Intraoperative adequacy check of biopsy samples can lead to a higher biopsy yield rate, and subsequent genomic analysis can provide patients with valuable prognostic information.

Objectives

To examine the yield rates for transscleral and transvitreal fine-needle aspiration biopsies of small uveal melanoma less than 3.6 mm in apical height and to discuss techniques that would maximize yield rates and minimize complications.

Design, Setting, and Participants

A retrospective, consecutive observational case series was conducted from January 29, 2013, to May 23, 2017, at Retina Consultants of Houston and Houston Methodist Hospital among 44 patients with uveal melanoma of the ciliary body or choroid.

Interventions or Exposures

Fine-needle aspiration biopsy and intraoperative histopathologic analysis prior to iodine 125 brachytherapy.

Main Outcomes and Measures

Tumor locations and dimensions were identified by histopathologic analysis and B-scan ultrasonography. Either transscleral or transvitreal biopsy was performed for tumors anterior to the equator and posterior to the equator, respectively. Biopsy specimens were checked for adequacy intraoperatively. Specimens were examined using hematoxylin-eosin, double immunostain with human melanoma black 45 and Ki67, and gene expression profile.

Results

A total of 44 patients were included in the study, with a mean (SD) age of 63.3 (12.7) years (21 men [47.7%]; 23 women [52.3%]). Median tumor height was 2.7 mm (interquartile range, 2.3- 2.9 mm). Forty of 44 biopsy samples (90.9%; 95% CI, 82.4%-99.4%) yielded adequate cells for gene expression profile analysis. Transscleral and transvitreal yield rates were 11 of 11 (100%) and 29 of 33 (87.9%), respectively. Most localized vitreous hemorrhages were resolved by 3 months. There was a moderate association between localized vitreous hemorrhage and transvitreal biopsy method, for which the phi value was -0.526 (95% CI, -0.712 to -0.157; P < .001).

Conclusions and Relevance

These findings suggest intraoperative adequacy evaluation of fine-needle aspiration biopsy specimens leads to high yield and is more informative for patients.

Recent advancements in the management of retinoblastoma and uveal melanoma

Retinoblastoma and uveal melanoma are the most common intraocular malignancies observed in pediatric and adult populations, respectively. For retinoblastoma, intra-arterial chemotherapy has dramatically improved treatment outcomes and eye salvage rates compared with traditional salvage rates of systemic chemotherapy and external beam radiation therapy. Intravitreal injections of chemotherapy have also demonstrated excellent efficacy for vitreous seeds. Uveal melanoma, on the other hand, is treated predominantly with iodine-125 plaque brachytherapy or with proton beam therapy. Major strides in uveal melanoma genomics have been made since the early 2000s, allowing ocular oncologists to better understand the metastatic risks of the tumor on the basis of specific genetic signatures. Loss-of-function mutations of the BAP1 gene are associated with the highest metastatic risk, whereas gain-of-function mutations of SF3B1 and EIF1AX often confer a better prognosis. Expression of a cancer-testis antigen called PRAME (preferentially expressed antigen in melanoma) has been shown to increase metastatic risks in both low-risk and high-risk melanomas. New therapeutic approaches, including molecular therapies and nanoparticle phototherapy, are currently being investigated as alternative treatment modalities for uveal melanoma.