Vitreoretinal Surgery for Complications of Choroidal Tumor Biopsy

Coexistence of choroidal melanoma and rhegmatogenous retinal detachment: a case report and literature review

Introduction and importance

The simultaneous occurrence of rhegmatogenous retinal detachment (RRD) and choroidal melanoma is extremely rare, and diagnosis of choroidal melanoma in RRD patients is challenging. As a result, choroidal masses in RRD patients tend to be overlooked, resulting in delayed treatment. The authors report a rare case presenting with simultaneous choroidal melanoma and RRD, and the authors review the related literature.

Case presentation

A 45-year-old Thai man who presented with inferior RRD and choroidal elevation in the left eye was examined using fundoscopy and ultrasonography. The presumptive diagnosis was simultaneous RRD and haemorrhagic choroidal detachment (CD). Vitrectomy and external drainage were attempted but were unsuccessful in draining fluid from the presumed haemorrhagic CD. Although the retina was reattached, the choroidal elevation remained unchanged. After being lost to follow-up, the patient returned later with severe proptosis in the left eye. MRI findings suggested a presumptive diagnosis including choroidal melanoma and choroidal metastasis, which choroidal melanoma was later confirmed through histopathological examination after exenteration.

Clinical discussion

Important clinical clues were provided for distinguishing between choroidal melanoma and haemorrhagic CD in cases of coexisting RRD.

Conclusions

In the differential diagnosis of RRD with suspicious choroidal elevation, the possibility of the presence of choroidal melanoma should be considered. In particular, in cases where haemorrhagic CD fails to drain during surgery, the possibility of underlying choroidal melanoma should be investigated.

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.

Evaluation of optical coherence tomography (OCT) changes following transretinal tumour biopsy for choroidal melanoma

AIM

This study uses OCT imaging to examine morphological changes at the chorioretinal interface of the choroidal melanoma biopsy site over time.

SETTING

Liverpool Ocular Oncology Centre (LOOC), St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.

METHODOLOGY

Retrospective analysis of all patients who underwent 25G vitrector-assisted transretinal biopsy for choroidal melanoma between 1st Jan 2017 and 31st Dec 2019. The biopsy procedure does not involve full vitrectomy, treatment of the retinal hole or tamponade. Patients routinely undergo OCT imaging over the tumour site at each follow up. Cases required a minimum of a baseline OCT and two consecutive post-operative OCT scans of adequate quality, overlying the biopsy site. All images were reviewed and graded by an ophthalmic specialist.

RESULTS

Fifty-one patients met the criteria for inclusion. OCT analysis identified 2 characteristic morphologies following transretinal biopsy -a choroidal plugging of biopsy site (47.0%), or a flat retinal hole (53.0%). Choroidal plugging morphologies tend to remain unchanged over time, whereas flat holes demonstrate greater variability and would more commonly seal over with atrophic retina (Fisher Exact Value = <0.01). 60.8% demonstrated vitreous plugging of the biopsy site.

CONCLUSION

OCT analysis has identified key morphological changes following transretinal choroidal melanoma biopsy. The morphologies identified may provide dynamic protective effects against vitreous flow into the subretinal space, accounting for low rates of retinal detachment despite the presence of an untreated iatrogenic retinal hole following transretinal biopsy.

Surgical Technique, Indications, and Outcomes of BIOM-Assisted Transvitreal Biopsy for Uveal Melanoma

PURPOSE

Controversy exists regarding the best method for biopsy of uveal melanoma. We describe our transvitreal technique and evaluate the safety of this technique as well as the efficacy for obtaining sample for prognostic genetic profiling.

METHODS

Description of surgical technique and retrospective case series. Medical records for uveal melanoma patients who underwent transvitreal biopsy using our described technique were analyzed for tumor size, location, primary treatment, method of biopsy, and any complications thereof. Characteristics of tumors that underwent transvitreal biopsy were noted including tumor size, location, or presence of subretinal fluid, to see whether these affected surgeon preference for biopsy modality. A cohort of contemporaneous uveal melanoma patients who underwent biopsy through a transscleral technique served as a comparator group for these patient, tumor, and complication factors.

RESULTS

A total of 27 patients aged 27.2 to 88.6 years (mean 64.8) underwent transvitreal biopsy using our described technique between 2013 and 2016. There were 15 small, 10 medium, and 2 large tumors at diagnosis with the majority (n = 17) posterior to the equator. Intraoperative complications included a clot or small trickle of blood at the biopsy site in 20 (74.1%) of patients, small localized subretinal hemorrhage in 8 (29.6%), small vitreous hemorrhage in 4 (14.8%), and small transient choroidal detachments in 1 patient (3.6%). When subretinal hemorrhage occurred, it was almost always into a pre-existing pocket of subretinal fluid ( P = 0.0093). However, the presence of subretinal fluid was not associated with the decision to proceed with any biopsy ( P = 0.36) or transvitreal biopsy specifically ( P = 1.00). By 3 months, subretinal and/or vitreous hemorrhage resolved in essentially all cases. There were no cases of iatrogenic retinal detachment or extraocular tumor spread over a mean follow-up of 41.7 (range: 20-62.1) months. Adequate tissue for gene expression profiling was obtained from each biopsy. The comparator group of patients undergoing transscleral biopsy including 21 uveal melanomas in 20 patients (one eye had two melanomas). Transvitreal biopsies were more common in patients with small (n = 15; P < 0.0001), posterior (n = 17; P < 0.0001) tumors, compared with patients who underwent transscleral biopsy during the same period.

CONCLUSION

This technique can be used for small or posterior tumors or for small anterior tumors where a transscleral approach would risk tumor perforation. Complications were minor, transient, and self-limited. Biopsy yields for molecular prognosis were adequate in all cases. The presence of subretinal fluid may be considered a relative contraindication because it may lead to subretinal hemorrhage in the fluid pocket but did not dissuade us from using this transvitreal technique for patients who would benefit from it.

Biopsy for molecular risk stratification in uveal melanoma: Yields and molecular characteristics in 119 patients

BACKGROUND

Prognostic cytological and molecular features of uveal melanoma have been well researched and are essential in management. Samples can be obtained in vivo through fine needle aspirate biopsy, vitrector cutter, forceps or post-enucleation for off-site testing. This study aims to examine cytological and chromosome microarray yields of these samples.

METHODS

A retrospective cohort analysis of 119 uveal melanoma biopsies submitted to our laboratory. Samples included those taken in vivo (n = 57) and post-enucleation (n = 62). Patient and tumour features were collected including age, sex, primary tumour location, basal diameter and tumour height. Prognostic outcomes measured include cell morphology, chromosomal status and immunohistochemistry.

RESULTS

Post-enucleation biopsies accounted for just over half of our samples (52%). Post-enucleation samples had a more successful genetic yield than in vivo biopsies (77% vs. 50%, p = 0.04) though there was no difference for cytological yields. There was no difference in cytological or microarray yields between instruments. The vitrector biopsy group had the smallest tumour thickness (5 mm vs. 10 mm [fine-needle aspirate biopsy], p = 0.003). There was a strong correlation between monosomy 3, BAP1 aberrancy and epithelioid cell type in post-enucleation samples (Tb  = 0.742, p = 0.005). However, epithelioid morphology was not associated with either monosomy 3 (p = 0.07) or BAP1 aberrancy (p = 0.24) for in vivo biopsies.

CONCLUSIONS

All three biopsy instruments provide similar cytological yields as post-enucleation sampling, although post-enucleation samples had a more successful chromosome microarray yield. Epithelioid cytomorphology alone is insufficient for prognostication in in vivo biopsies, immunohistochemistry would be a useful surrogate test.

Small High-Risk Uveal Melanomas Have a Lower Mortality Rate

Simple Summary

The current paradigm concerning metastatic spread in uveal melanoma is that the critical point for dissemination occurs prior to presentation and that treatment of the primary tumor does not change outcome. However, we show that patients with small uveal melanomas with genetic characteristics typical for high risk for metastatic disease have a lower mortality rate from metastatic disease, if treated earlier. Our data demonstrate that such small melanomas are potentially lethal (like larger tumors), but that there is a window of opportunity to prevent life-threatening metastatic spread if actively treated, rather than being monitored, as is often done currently.

Abstract

Our aim was to determine whether size impacts on the difference in metastatic mortality of genetically high-risk (monosomy 3) uveal melanomas (UM). We undertook a retrospective analysis of data from a patient cohort with genetically characterized UM. All patients treated for UM in the Liverpool Ocular Oncology Centre between 2007 and 2014, who had a prognostic genetic tumor analysis. Patients were subdivided into those with small (≤2.5 mm thickness) and large (>2.5 mm thickness) tumors. Survival analyses were performed using Gray rank statistics to calculate absolute probabilities of dying as a result of metastatic UM. The 5-year absolute risk of metastatic mortality of those with small monosomy 3 UM was significantly lower (23%) compared to the larger tumor group (50%) (p = 0.003). Small disomy 3 UM also had a lower absolute risk of metastatic mortality (0.8%) than large disomy 3 UM (6.4%) (p = 0.007). Hazard rates showed similar differences even with lead time bias correction estimates. We therefore conclude that earlier treatment of all small UM, particularly monosomy 3 UM, reduces the risk of metastatic disease and death. Our results would support molecular studies of even small UM, rather than ‘watch-and-wait strategies’.

Instrument Gauge and Type in Uveal Melanoma Fine Needle Biopsy: Implications for Diagnostic Yield and Molecular Prognostication

PURPOSE

To systematically evaluate and compare the effects of using small-gauge needles and vitrectors on the ability to obtain adequate diagnostic and prognostic uveal melanoma biopsy specimens.

DESIGN

Comparative evaluation of biopsy instruments.

METHODS

Survival of uveal melanoma cells was evaluated in vitro following needle aspiration. Five therapeutically enucleated eyes were sampled in triplicate for ex vivo diagnostic biopsy experiments with 25 gauge (25 G) needle, 27 gauge (27 G) needle, and 27 G vitrector. During surgery in 8 patients, paired diagnostic transscleral fine needle aspiration biopsies were performed using both 25 G and 27 G needles. A review of cytologic specimens was performed by a panel of 3 expert cytopathologists. A retrospective chart review was performed to evaluate 100 consecutive tumors undergoing prognostic biopsy for gene expression profiling to assess the relationship between needle gauge and prognostic adequacy.

RESULTS

No significant cell shearing of uveal melanoma cells occurred in vitro with 25 G, 27 G, or 30 G needles. For ex vivo biopsy samples, diagnostic yield was 100% using 25 G needle (5/5) or 27 G vitrector (5/5) but 60% using a 27 G needle (3/5). For in vivo samples, no difference in diagnostic yield was found between 25 G (75%, 6/8) or 27 G (75%, 6/8) needle sizes. Of 100 molecular prognostic biopsy samples evaluated, 65 were obtained using 27 G needles; for these biopsies, the prognostic yield was 65/65 (100%).

CONCLUSIONS

For diagnostic biopsy of uveal melanoma, a larger-gauge needle or a 27 G vitrector may have better overall cellularity and diagnostic yield when compared to a 27 G needle. However, for much more common molecular prognostic testing, a 27 G needle provided adequate sample in 100% (65/65) of cases, and a larger needle provided no additional benefit.

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.

New concepts in the diagnosis and management of choroidal metastases

The most frequent site of ocular metastasis is the choroid. The occurrence of choroidal metastases has increased steadily due to the longer survival of metastatic patients and the improvement of diagnostic tools. Fundoscopy, ultrasonography, and fluorescein angiography are now complemented by indocyanine green angiography and optical coherence tomography. Choroidal tumor biopsy may also confirm the metastatic nature of the tumor and help to determine the site of the primary malignancy. There is currently no consensus on the treatment strategy. Most patients have a limited life expectancy and for these complex treatments are generally not recommended. However, recent advances in systemic therapy have significantly improved survival of certain patients who may benefit from an aggressive ocular approach that could preserve vision. Although external beam radiation therapy is the most widely used treatment, more advanced forms of radiotherapy that are associated with fewer side effects can be proposed in select cases. In patients with a shorter life expectancy, systemic therapies such as those targeting oncogenic drivers, or immunotherapy can induce a regression of the choroidal metastases, and may be sufficient to temporarily decrease visual symptoms. However, they often acquire resistance to systemic treatment and ocular relapse usually requires radiotherapy for durable control. Less invasive office-based treatments, such as photodynamic therapy and intravitreal injection of anti-VEGF, may also help to preserve vision while reducing time spent in medical settings for patients in palliative care. The aim of this review is to summarize the current knowledge on choroidal metastases, with emphasis on the most recent findings in epidemiology, pathogenesis, diagnosis and treatment.

A CASE OF RETINAL METASTASIS OF LARYNGEAL SQUAMOUS CELL CARCINOMA WITH HISTOPATHOLOGIC CONFIRMATION BY VITRECTOMY-ASSISTED EN BLOCK EXTRACTION

BACKGROUND/PURPOSE

To present a case report of retinal metastasis of laryngeal squamous cell carcinoma that was diagnosed by a histopathologic finding from the surgically extracted tumor tissue.

METHODS

A 66-year-old man, who was suffered from the treatment-resistant laryngeal carcinoma, was referred to our department because of visual field defect in his right eye. A fundus examination revealed a parafoveal white retinal lesion, which rapidly expanded to the central fovea and decreased the visual acuity. A tissue extraction by 27G pars plana vitrectomy was performed to confirm the diagnosis.

RESULTS

The abnormal retinal tissue was extracted en block through 10-mm sclerocorneal tunnel during pars plana vitrectomy. The histopathologic findings revealed that the retinal lesion was retinal metastasis of laryngeal carcinoma.

CONCLUSION

We must keep in mind that retinal metastasis can be one of the differential diagnoses for white retinal lesions of unknown cause.

Analysis of monosomy-3 in immunomagnetically isolated circulating melanoma cells in uveal melanoma patients

Monosomy-3 in primary uveal melanoma (UM) is associated with a high risk of metastasis and mortality. Although circulating melanoma cells (CMC) can be found in most UM patients, only approximately 50% of the patients develop metastases. We utilized a novel immuno-FISH assay to detect chromosome-3 in intact CMC isolated by dual immunomagnetic enrichment. Circulating melanoma cells were detected in 91% of the patients (n = 44) with primary non-metastatic UM, of which 58% were positive for monosomy-3. The monosomy-3 status of CMC corresponded to the monosomy-3 status of the primary tumor in 10 of the 11 patients where this could be tested. Monosomy-3 in the CMC was associated with an advanced tumor stage (P = 0.046) and was detected in all four patients who developed metastasis within the follow-up period of 4 yr. This non-invasive technique may enable the identification of UM patients at risk for metastasis particularly when a primary tumor specimen is unavailable.

Outcomes of 27-Gauge Vitrectomy-Assisted Choroidal and Subretinal Biopsy

BACKGROUND AND OBJECTIVE

To report the initial experience of 27-gauge vitrectomy-assisted choroidal and subretinal biopsy PATIENTS AND METHODS: Retrospective, interventional case series. Eighteen eyes of 18 patients undergoing 27-gauge vitrectomy-assisted choroidal (n = 16) or subretinal biopsy (n = 2). Clinical and lesion characteristics, cytopathology, histology, gene expression profiling (GEP), visual acuity (VA), complications including vitreous hemorrhage (VH), development of rhegmatogenous retinal detachment (RD), and need for additional surgeries were analyzed.

RESULTS

Indications were choroidal melanoma (n = 10), indeterminate choroidal (n = 5), and subretinal lesions (n = 3). Mean lesion height was 3.33 mm ± 1.55 mm (range: 0.80 mm to 6.75 mm) and largest diameter was 8.63 mm ± 4.14 mm (range: 3 mm to 15.5 mm). Mean number of intralesional biopsy passes required was 1.76 ± 0.83 (range: one to four). During a mean follow-up of 7.4 months ± 2.7 months (range: 4 months to 14 months), VA was unchanged (0.5 logMAR ± 0.6 logMAR vs. 0.7 logMAR ± 0.84 logMAR; P = .07). Pathologic diagnosis was obtained in 16 of 18 eyes (88.9%), and GEP data were collected for all 11 choroidal melanomas. Post-biopsy VH occurred in 13 of 18 eyes (72.2%) and was severe enough to require a concurrent limited vitrectomy in six eyes (33.3%). These eyes had a greater lesion height compared to eyes not requiring a vitrectomy (4.08 mm ± 1.68 mm vs. 2.76 mm ± 1.43 mm; P = .04). A rhegmatogenous RD requiring repeat surgery developed in two of 18 eyes (11.1%).

CONCLUSION

The authors concluded that 27-gauge vitrectomy-assisted choroidal and subretinal biopsy established a diagnosis in 88.9% of eyes in lesions 0.8 mm or larger. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:406-415.].

The Histopathological Finding of the Surgically Extracted Atypical Dome-Shaped Choroidal Osteoma

Purpose. To report a case of atypical dome-shaped choroidal osteoma, which was diagnosed by histopathological finding of surgically extracted tumor. Case Report. A 35-year-old woman presented with visual field abnormality in the left eye (OS). Her best-corrected visual acuity with Landolt ring chart was 1.0 OS. The funduscopic examination revealed a yellowish dome-shaped choroidal tumor located in the temporal side of the macula with exudative retinal detachment. 25-gauge pars plana vitrectomy and the extraction of the tumor were performed for the definitive diagnosis. Results. As a result of histopathological finding from the extracted tumor, she was diagnosed with choroidal osteoma. 10 months after the last surgery, the BCVA is 0.7 OS. The tumor is not relapsed. Conclusions. We must keep in mind that choroidal osteoma can be one of the differential diagnoses for the dome-shaped choroidal tumor.

Fine Needle Aspiration Biopsy in Uveal Melanoma: Technique, Complications, and Outcomes

PURPOSE

To report the technical aspects, complications, and outcomes concerning fine needle aspiration biopsy (FNAB) in uveal melanoma.

DESIGN

Retrospective cohort study.

METHODS

Patients with uveal melanoma who underwent transscleral or transvitreal FNAB at an ocular oncology center were retrospectively evaluated. FNAB was performed if the tumor was more than 5 mm in thickness. Array comparative genomic hybridization analysis was performed on biopsy samples with sufficient tissue. The main outcome measures were success (sample that gave a successful result for biomarker analysis) rate, complications, liver metastasis, and overall survival.

RESULTS

There were 217 (114 male, 52%) consecutive study patients with a mean age of 56.7 (16-84) years. The mean follow-up period was 31 (range 3.6-61.3) months. Mean tumor thickness was 8.4 (range 5-12) mm. The overall success rate of the procedure was 169 patients (77.9%). Thirty-one patients (14.3%) experienced intravitreal hemorrhage, of whom 9 (4.1%) required vitreal surgery. There was no case of endophthalmitis, orbital dissemination, local recurrence, or rhegmatogenous retinal detachment. Thirty-two patients (14.7%) developed metastasis during the study, of whom 20 (9.2%) died. Of the 169 successful samples, 53 patients (31%) were classified as low risk, 41 (24%) as intermediate risk, and 54 (32%) as high risk. Fifteen patients (9%) did not have any detectable chromosomal abnormality and 6 (4%) could not be classified.

CONCLUSION

FNAB is a relatively safe and successful technique that can be routinely used to obtain tissue for molecular genomic analysis; such analysis helps determine the diagnosis and prognosis in uveal melanoma.

Concordant chromosome 3 results in paired choroidal melanoma biopsies and subsequent tumour resection specimens

BACKGROUND/AIM

The study's aim was to compare chromosome 3 aberrations of choroidal melanoma (CM) as determined by multiplex ligation dependent probe amplification (MLPA) or microsatellite analysis (MSA) in intraocular tumour biopsies with those results obtained from subsequent endoresection/enucleation of the same CM.

METHODS

A retrospective cohort of 28 patients with CM seen between 2007 and 2014 at the Liverpool Ocular Oncology Centre was analysed. Prognostic genetic testing, for chromosome 3 status, was performed on all tumour specimens, either by MLPA or MSA, depending on DNA yield. In nine cases genetic testing was performed on a sample taken after radiotherapy; four of these had genetic information pre- and post-radiotherapy.

RESULTS

Fourteen biopsy specimens were analysed by MLPA and 14 by MSA. Twenty-seven endoresection or enucleation specimens were analysed by MLPA, and a single enucleation specimen by MSA. Chromosome 3 data showed prognostic concordance for the patient-matched samples in all 28 cases including 4 cases where samples were taken pre pre- and post radiotherapy. Thirteen cases were classified as monosomy 3 and 12 as disomy 3. Two cases had a loss of chromosome arm 3q in both samples and a single case showed loss of 3p in the biopsy sample with complete monosomy 3 in the subsequent enucleation sample taken 5 months later.

CONCLUSIONS

Intraocular biopsy of CM yields similar prognostic information to larger surgical specimens. Initial evidence, that genetic testing can be successfully conducted post radiotherapy, is also provided.

TRIAL REGISTRATION NUMBER

NITRO trial, ISRCTN35236442.