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Kim BZ, Lim JZ, McGhee CNJ. Cysts and tumours of the iris: Diagnostic tools and key management considerations-A review. Clin Exp Ophthalmol 2024. [PMID: 38577954 DOI: 10.1111/ceo.14380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 03/24/2024] [Accepted: 03/24/2024] [Indexed: 04/06/2024]
Abstract
The iris is a unique structure, with exquisite variations in colour and form. Pathological changes, specifically including iris cysts and tumours are relatively uncommon, difficult to diagnose, and yet potentially blinding or life-threatening. Based on a comprehensive literature review, with highly illustrated key case examples, this report aims to guide the clinician in filtering the differential diagnoses of iris cysts and tumours. Evaluation is in the context of key diagnostic clinical tools and management considerations. Diagnostic imaging techniques include serial anterior segment photography, ultrasound, anterior segment optical coherence tomography, and iris fluorescein angiography, however, the roles of computerised topography and magnetic resonance imaging are also considered in this review. Management includes categorisation in terms of solid iris tumours (melanocytic vs. non-melanocytic), or iris cysts (primary vs. secondary) that may be usefully differentiated by clinical assessment, avoiding more invasive interventions. Cystic lesions are generally benign, although implantation cysts in particular cause significant complications and surgical challenges. Most solid tumours are melanocytic and also typically benign. However, in larger lesions, rapid growth, symptoms and complications more likely indicate malignancy, requiring further investigation.
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Affiliation(s)
- Bia Z Kim
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Ophthalmology, Greenlane Eye Clinic, Health New Zealand (Te Whatu Ora) Auckland, Auckland, New Zealand
| | - Joevy Z Lim
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Ophthalmology, Greenlane Eye Clinic, Health New Zealand (Te Whatu Ora) Auckland, Auckland, New Zealand
| | - Charles N J McGhee
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Ophthalmology, Greenlane Eye Clinic, Health New Zealand (Te Whatu Ora) Auckland, Auckland, New Zealand
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Lau WC, Huang L, Zheng X, Ming WK, Leong NC, Tak Wong Y, Yin Z, Yu H, Lyu J, Deng L. Prognostic nomograms for predicting long-term overall survival in spindle cell melanoma: a population-based study. Front Endocrinol (Lausanne) 2024; 15:1260966. [PMID: 38572477 PMCID: PMC10988970 DOI: 10.3389/fendo.2024.1260966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 03/06/2024] [Indexed: 04/05/2024] Open
Abstract
Background There are few research findings on the survival prognosis of spindle cell melanoma (SCM), which is an unusual kind of melanoma. The purpose of this study was to develop a thorough nomogram for predicting the overall survival (OS) of patients with SCM and to assess its validity by comparing it with the conventional American Joint Committee on Cancer (AJCC) staging system. Methods The Surveillance, Epidemiology, and End Results database was searched, and 2,015 patients with SCM were selected for the analysis. The patients were randomly divided into training (n = 1,410) and validation (n = 605) cohorts by using R software. Multivariate Cox regression was performed to identify predictive factors. A nomogram was established based on these characteristics to predict OS in SCM. The calibration curve, concordance index (C-index), area under the receiver operating characteristic curve, and decision-curve analysis were utilized to assess the accuracy and reliability of the model. The net reclassification improvement and integrated discrimination improvement were also applied in this model to evaluate its differences with the AJCC model. Results The developed nomogram suggests that race, AJCC stage, chemotherapy status, regional node examination status, marital status, and sex have the greatest effects on OS in SCM. The nomogram had a higher C-index than the AJCC staging system (0.751 versus 0.633 in the training cohort and 0.747 versus 0.650 in the validation cohort). Calibration plots illustrated that the model was capable of being calibrated. These criteria demonstrated that the nomogram outperforms the AJCC staging system alone. Conclusion The nomogram developed in this study is sufficiently reliable for forecasting the risk and prognosis of SCM, which may facilitate personalized treatment recommendations in upcoming clinical trials.
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Affiliation(s)
- Wai Chi Lau
- Department of Dermatology, The First Affiliated Hospital of Jinan University & Jinan University Institute of Dermatology, Guangzhou, China
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Liying Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xinkai Zheng
- Department of Dermatology, The First Affiliated Hospital of Jinan University & Jinan University Institute of Dermatology, Guangzhou, China
| | - Wai-kit Ming
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Nga Cheng Leong
- Department of Dermatology, The First Affiliated Hospital of Jinan University & Jinan University Institute of Dermatology, Guangzhou, China
- Department of Dermatology, Kiang Wu Hospital, Macau, China
| | - Yu Tak Wong
- Department of Dermatology, The First Affiliated Hospital of Jinan University & Jinan University Institute of Dermatology, Guangzhou, China
- SHENZHEN BeauCare Clinic, Shenzhen, China
| | - Zhinan Yin
- Guangdong Provincial Key Laboratory of Tumor Interventional Diagnosis and Treatment, Zhuhai Institute of Translational Medicine Zhuhai People’s Hospital Affiliated with Jinan University, Zhuhai, China
- The Biomedical Translational Research Institute, Health Science Center (School of Medicine), Jinan University, Guangzhou, China
| | - Hai Yu
- Department of Dermatology, The First Affiliated Hospital of Jinan University & Jinan University Institute of Dermatology, Guangzhou, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
| | - Liehua Deng
- Department of Dermatology, The First Affiliated Hospital of Jinan University & Jinan University Institute of Dermatology, Guangzhou, China
- Department of Dermatology, The Fifth Affiliated Hospital of Jinan University, Heyuan, China
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Cherkas E, Kalafatis NE, Marous MR, Shields CL. Iris melanoma: Review of clinical features, risks, management, and outcomes. Clin Dermatol 2024; 42:62-70. [PMID: 37865279 DOI: 10.1016/j.clindermatol.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Primary uveal melanoma is rare and affects approximately 8,000 persons per year worldwide. This malignancy can involve the iris, ciliary body, and choroid. Of these three structures, the iris is the least commonly affected site, representing only 4% of all uveal melanomas. Iris melanoma can arise from iris melanocytic nevus, iris melanocytosis, or de novo. In a longitudinal study of 1,611 patients with iris nevus, transformation into melanoma, using Kaplan-Meier estimates, was found in 2.6% by five years and in 4.1% by 10 years. The factors that predicted growth of iris melanocytic nevus into melanoma are denoted by a letter (ABCDEF) guide: A for age ≤40 years old at presentation (hazard ratio [HR] = 3, P = .01), B for blood (hyphema) (HR = 9, P < .0004), C for clock hour of tumor inferiorly (tumor location) (HR = 9, P = .03), D for diffuse flat tumor configuration (HR = 14, P = .02), E for ectropion uveae (HR = 4, P = .002), and F for feathery ill-defined margins (HR = 3, P = .02). At diagnosis, iris melanoma has a mean cross-sectional diameter of 5.5 mm and thickness of 2.1 mm, often with tumor seeding (28%) and secondary glaucoma (35%). We provide a comprehensive review of iris nevus and melanoma to explore relevant demographic and clinical data, risk factors for tumor growth, management, and prognosis, with the hope that clinicians will be more comfortable in understanding this rare malignant condition.
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Affiliation(s)
- Elliot Cherkas
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas E Kalafatis
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Molly R Marous
- Department of Dermatology, University of Rochester Medical Center, Rochester, New York, USA
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Gollrad J, Böker A, Vitzthum S, Besserer A, Heufelder J, Gauger U, Böhmer D, Budach V, Zeitz O, Joussen AM. Proton Therapy for 166 Patients with Iris Melanoma: Side Effects and Oncologic Outcomes. Ophthalmol Retina 2023; 7:266-274. [PMID: 36087876 DOI: 10.1016/j.oret.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the oncologic and functional outcomes of a large cohort of patients with a favorable stage of circumscribed and diffuse iris melanoma who underwent primary proton treatment and the risk factors related to initial tumor characteristics and the treatment field architecture. DESIGN Retrospective, single-center, case study. PARTICIPANTS We reviewed 225 patients with iris melanoma who were consecutively treated with proton beam therapy at our institution between 1998 and 2020. METHODS We performed Kaplan-Meier time-to-event analyses and multivariate Cox proportional hazard analyses to identify the impacts of tumor characteristics and target volumes on oncologic and functional outcomes. MAIN OUTCOME MEASURES We measured local tumor control, eye preservation rates, metastasis-free survival, cataract and glaucoma-directed surgery, intraocular pressure, and changes in visual acuity. RESULTS Of the 192 patients with tumors confined to the iris (T1a-c) who underwent proton therapy as primary treatment, a total of 166 patients (mean age, 58.4 years; 88 women) with a minimum follow-up of 6 months were included. Multifocal or diffuse tumor spread was present in 77 (46.4%) patients. The median follow-up time was 54.0 (interquartile range, 27.4-91.8 months) months. Local recurrence occurred in 2 patients (1.2%) with circumscribed iris melanoma. Enucleation was a rare event (n = 5, 3%) and no patient developed metastatic disease. A large-treatment field (full aperture, involving > 10 clock hours) was identified as a risk factor for the development of secondary glaucoma (hazard ratio [HR], 6.3; P < 0.001) and subsequent surgical interventions (HR, 10.85; P < 0.001). The large-treatment field group showed a significant decline in visual acuity (logarithm of the minimum angle of resolution > 0.3; log-rank P < 0.0001), which was associated with secondary glaucoma (HR, 3.40; P = 0.002). CONCLUSIONS Proton therapy provides an effective, noninvasive treatment option for patients with a favorable stage of iris melanoma. Irradiation of the anterior segment for up to 10 clock hours is associated with a low risk of the development of secondary glaucoma and vision loss. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Johannes Gollrad
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Germany
| | - Alexander Böker
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Germany; Department of Ophthalmology, Charité-Universitätsmedizin Berlin, Germany.
| | - Sebastian Vitzthum
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Germany
| | - Angela Besserer
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Germany
| | - Jens Heufelder
- Department of Ophthalmology, Charité-Universitätsmedizin Berlin, Germany
| | - Ulrich Gauger
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Germany
| | - Dirk Böhmer
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Germany
| | - Oliver Zeitz
- Department of Ophthalmology, Charité-Universitätsmedizin Berlin, Germany
| | - Antonia M Joussen
- Department of Ophthalmology, Charité-Universitätsmedizin Berlin, Germany
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Iris melanocytic tumours in New Zealand/Aotearoa: presentation, management and outcome in a high UV exposure environment. Eye (Lond) 2023; 37:692-699. [PMID: 35338357 PMCID: PMC9998588 DOI: 10.1038/s41433-022-02017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 02/09/2022] [Accepted: 03/04/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND/OBJECTIVES Iris melanoma, a rare intraocular malignancy, represents the smallest subgroup of uveal melanoma. This first, comprehensive study of iris melanocytic lesions in the high ultraviolet environment in New Zealand/ Aotearoa (NZ) examines diagnosis, management and outcomes. SUBJECTS/METHODS Retrospective study of iris melanocytic tumours referred to tertiary referral centres in Auckland, NZ, over 20 years (1999-2018). Data analysed include demographics, tumour characteristics, histology, genetic analyses, treatment modalities, recurrence, metastasis, 5-year and overall survival. RESULTS Cohort (N = 51) was predominantly NZ European (98.0%) with no indigenous Māori, or Pasifika. Median age at presentation was 58 years. Tumours involved a median of two clock hours of iris. The posterior tumour margin extended to the anterior chamber angle in 22 patients (45.8%). Management included initial observation 54.9%, iridectomy/excision biopsy 29.4%, irido-cyclectomy 7.8%, plaque radiotherapy 7.8%, proton beam radiotherapy 7.8%, and ultimately enucleation 17.6%. Histology was performed in 19 cases (37%) with 16 confirmed melanomas (84%). Mean follow-up 4.2 years with median visual acuity of 6/7.5 two years post intervention. Melanoma-related metastasis and mortality occurred in two cases with five-year melanoma-related mortality of 2.0%. CONCLUSION In a climate with high ultraviolet exposure iris melanocytic tumours occurred almost exclusively in NZ Europeans, however, the majority of cases were category T1, possibly reflecting early diagnosis in the NZ health system. Nonetheless, >50% underwent surgery or radiotherapy, often utilising more than one modality. A high index of suspicion and early referral of iris melanocytic lesions should be considered in regions with high UV exposure.
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Plaque brachytherapy in iris and iridociliary melanoma: a systematic review of efficacy and complications. J Contemp Brachytherapy 2021; 13:46-50. [PMID: 34025736 PMCID: PMC8117704 DOI: 10.5114/jcb.2021.103586] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/06/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose To evaluate the efficacy and vision-threatening complication rate of plaque brachytherapy with iodine-125 (125I), palladium-103 (103Pd), and ruthenium-106 (106Ru) for treatment of iris and iridociliary melanoma. Material and methods A literature review was done based on results yielded from searching PubMed, Embase, and Cochrane database, using following key words: iris melanoma, iridociliary melanoma, brachytherapy, iodine-125 brachytherapy, palladium-103 brachytherapy, and ruthenium-106 brachytherapy. Initially, relationships between mean radiation dose to apex and local recurrence and complication rate were analyzed, and then, a comparison was performed between 125I, 103Pd, and 106Ru studies. Results Twelve retrospective and prospective studies were selected, with 491 patients treated primarily with plaque brachytherapy. The range of radiation dose to tumor apex were from 84 to 151.5 Gy. Ranges of mean and median of follow-up time were from 27 to 96 months. Local recurrence rate following brachytherapy ranged from 0 to 8%. A decrease in the average study dose was not associated with an increased local recurrence or metastasis rate (p = 0.373 and 0.195, respectively); however, an increase in radiation dose was associated with higher radiation-related cataract and glaucoma (p < 0.05). The rate of post-treatment glaucoma was higher in studies with 125I plaque brachytherapy (p = 0.004). Conclusions For brachytherapy of iris and iridociliary melanoma, in a range of 84 to 150 Gy, an increase in radiation dose may increase the risk of complications, while the tumor control rate does not change.
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van Poppelen NM, de Bruyn DP, Bicer T, Verdijk R, Naus N, Mensink H, Paridaens D, de Klein A, Brosens E, Kiliҫ E. Genetics of Ocular Melanoma: Insights into Genetics, Inheritance and Testing. Int J Mol Sci 2020; 22:E336. [PMID: 33396957 PMCID: PMC7795687 DOI: 10.3390/ijms22010336] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/04/2020] [Accepted: 12/24/2020] [Indexed: 12/18/2022] Open
Abstract
Ocular melanoma consists of posterior uveal melanoma, iris melanoma and conjunctival melanoma. These malignancies derive from melanocytes in the uveal tract or conjunctiva. The genetic profiles of these different entities differ from each other. In uveal melanoma, GNAQ and GNA11 gene mutations are frequently found and prognosis is based on mutation status of BAP1, SF3B1 and EIF1AX genes. Iris melanoma, also originating from the uvea, has similarities to the genetic makeups of both posterior uveal melanoma (UM) and conjunctival melanoma since mutations in GNAQ and GNA11 are less common and genes involved in conjunctival melanoma such as BRAF have been described. The genetic spectrum of conjunctival melanoma, however, includes frequent mutations in the BRAF, NRAS and TERT promoter genes, which are found in cutaneous melanoma as well. The BRAF status of the tumor is not correlated to prognosis, whereas the TERT promoter gene mutations are. Clinical presentation, histopathological characteristics and copy number alterations are associated with survival in ocular melanoma. Tissue material is needed to classify ocular melanoma in the different subgroups, which creates a need for the use of noninvasive techniques to prognosticate patients who underwent eye preserving treatment.
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Affiliation(s)
- Natasha M. van Poppelen
- Department of Ophthalmology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (N.M.v.P.); (D.P.d.B.); (T.B.); (N.N.); (D.P.)
- Department of Clinical Genetics, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (A.d.K.); (E.B.)
| | - Daniël P. de Bruyn
- Department of Ophthalmology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (N.M.v.P.); (D.P.d.B.); (T.B.); (N.N.); (D.P.)
- Department of Clinical Genetics, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (A.d.K.); (E.B.)
| | - Tolga Bicer
- Department of Ophthalmology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (N.M.v.P.); (D.P.d.B.); (T.B.); (N.N.); (D.P.)
- Department of Ophthalmology, University of Health Sciences Diskapi Training and Research Hospital, Ankara 06330, Turkey
| | - Rob Verdijk
- Department of Pathology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands;
- Department of Pathology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Nicole Naus
- Department of Ophthalmology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (N.M.v.P.); (D.P.d.B.); (T.B.); (N.N.); (D.P.)
| | - Hanneke Mensink
- Department of Ophthalmic Oncology, The Rotterdam Eye Hospital, 3011 BH Rotterdam, The Netherlands;
| | - Dion Paridaens
- Department of Ophthalmology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (N.M.v.P.); (D.P.d.B.); (T.B.); (N.N.); (D.P.)
- Department of Ophthalmic Oncology, The Rotterdam Eye Hospital, 3011 BH Rotterdam, The Netherlands;
| | - Annelies de Klein
- Department of Clinical Genetics, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (A.d.K.); (E.B.)
| | - Erwin Brosens
- Department of Clinical Genetics, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (A.d.K.); (E.B.)
| | - Emine Kiliҫ
- Department of Ophthalmology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (N.M.v.P.); (D.P.d.B.); (T.B.); (N.N.); (D.P.)
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Abstract
Iris melanomas represent 2–5% of uveal melanomas. Iris melanomas vary in their size, shape, degree of pigmentation and clinical behavior. The main local clinical complications of iris melanomas are tumor vascularization, ectropion uvea, pupillary distortion, pigment dispersion, sector cataract, chronic uveitis, hyphema and glaucoma with irreversible optic nerve damage. The most effective treatment for iris nevus and melanoma remains debatable; treatment modalities have been proposed depending on the local status as well as the age and general condition of the patient. A melanocytic iris nevus is usually observed until documented progression is identified. In this case, radiotherapy or surgical resection is generally performed. Cataract, glaucoma and limbal stem cell deficiency are usually secondary to radiotherapy, while incomplete tumor excisions, which could lead to recurrence, hemorrhage, vitreous loss, dislocated lens, iridocyclitis, macular edema, retinal detachment, glaucoma and cataract, are related to surgical resection. In some cases, a combination of radiotherapy and surgery is used. Conservative treatment is an efficient alternative to enucleation and allows good local tumor control.
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Liu W, Kim JM, Young BK, Nath R, Chen Z, Decker RH, Astrahan MA, Pointdujour-Lim R. Novel Eye Plaque Designs for Brachytherapy of Iris and Ciliary Body Melanoma and the First Clinical Application. Ocul Oncol Pathol 2018; 5:220-227. [PMID: 31049331 DOI: 10.1159/000493269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/17/2018] [Indexed: 12/20/2022] Open
Abstract
Background While traditional eye plaque brachytherapy can be used for the treatment of iris melanoma, it faces challenges of poor patient tolerability due to cornea-plaque touch caused by radius of curvature mismatch and potential dosimetric inaccuracy from incomplete coverage. We present novel plaque designs and the first clinical application of the plaques for iris melanoma. Methods Two dome-shaped plaques (EP2132 and EP1930) were designed to vault above the cornea to treat tumors of the iris and ciliary body. Image-based treatment planning of the first 2 clinical cases using the EP2132 plaque covered the tumor base plus a 2 mm margin and the involved ciliary body with at least 75 Gy to the tumor apex. Results The tumors decreased in size following treatment. The patients tolerated the treatment well. There was no adverse event associated with the traditional iris plaques, such as decreased vision, pain, corneal edema, glaucoma, or cataract. Conclusion The novel dome-shaped plaques for the treatment of iris melanoma provide effective dose distribution, improved surgical maneuverability, and increased tolerability for the patient. This plaque model can be used to treat iris melanoma of various sizes, configurations, and locations, including the ciliary body. The need for a customized plaque platform for each patient is minimized.
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Affiliation(s)
- Wu Liu
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Smilow Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jenna May Kim
- Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin K Young
- Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ravinder Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Smilow Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zhe Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Smilow Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Smilow Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Renelle Pointdujour-Lim
- Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Smilow Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
This study examined malignant melanoma of the iris in Denmark over a 25-year period on the basis of the files of the Eye Pathology Institute. From 1961 to 1985 a total of 80 cases were found (41 males, 39 females; median age 53 years, range 8 - 83). This means an average of 3.2 cases/year with an average population of 4.9 million. In contrast to malignant melanoma of the choroid, an increase was observed. The reason is not known, although exposure to actinic rays may be a factor. More than a third of cases were close to the pupil, a little less than a third invaded the chamber angle/ciliary body. Ten cases were ring melanomas. Half of the tumours were spindle-celled, a quarter mixed and a few epithelioid or naevoid in cell morphology. Iridectomy was performed in 28 cases, primary enucleation in 27 and secondary enucleation in ten. Iridocyclectomy was performed in 15 cases. All patients could be traced. At the date of follow-up (Dec. 1, 1991) eight had died with metastases; four of these were patients with ring melanoma and four with tumours invading the ciliary body. After iridocyclectomy, only one metastatic death was recorded –- a case of incomplete resection. The grave prognosis of a ring melanoma is highlighted.
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Affiliation(s)
- O A Jensen
- Eye Pathology Institute, University of Copenhagen, Denmark
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11
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Secondary Glaucoma due to Iridescent Crystalline Particles Masquerading as Refractory Hypertensive Uveitis in an Eye With Irradiated Iris Melanoma. J Glaucoma 2018; 27:385-388. [PMID: 29394206 DOI: 10.1097/ijg.0000000000000891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We report a previously unrecognized mechanism of secondary glaucoma due to iridescent crystalline particles released from an irradiated iris melanoma. It masqueraded as refractory hypertensive uveitis following uncomplicated phacoemulsification. MATERIALS AND METHODS A 58-year-old gentleman had an iris melanoma that underwent successful regression following irradiation with proton beam radiotherapy. Three years later an uncomplicated phacoemulsification with intraocular lens implant was performed and subsequently the patient presented with apparently "refractory hypertensive uveitis." Closer examination identified unique iridescent crystalline particles originating from a disintegrating tumor and dispersing within the anterior chamber and drainage angle. The patient developed a unilateral secondary open-angle glaucoma attributable to these particles. Ultrasound biomicroscopy of the anterior segment confirmed absence of tumor recurrence or intrascleral spread and systemic investigations ruled out distant metastases. RESULTS The intraocular pressure was refractory to maximal medical treatment, but was eventually controlled with trans-scleral diode laser cyclo-photocoagulation. CONCLUSIONS This is the first report of a secondary glaucoma attributable to trabecular blockage with iridescent crystalline particulate material released from a disintegrating, previously irradiated, iris melanoma. Proton beam radiotherapy and possibly phacoemulsification may have played a role in triggering the release of these previously undescribed particles from the atrophied tumor surface. This unique mechanism of secondary glaucoma needs to be kept in mind in such rare cases. Trans-scleral cyclodiode laser may be used as a good initial option in such cases to minimize potential risk of tumor seeding with incisional glaucoma surgery.
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Riechardt AI, Karle B, Cordini D, Heufelder J, Budach V, Joussen AM, Gollrad J. Proton therapy of iris melanoma with 50 CGE : Influence of target volume on clinical outcome. Strahlenther Onkol 2017. [PMID: 28631017 DOI: 10.1007/s00066-017-1166-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study was to evaluate local tumour control, incidence of radiation-induced glaucoma and associated interventions of sector-based and whole anterior segment proton beam therapy (PBT) for the treatment of iris melanoma. PATIENTS AND METHODS We retrospectively analysed the data of 77 patients with iris melanoma who underwent PBT applied as 50 CGE in four daily fractions. Of the patients, 47 received PBT with a circular-shaped collimator and 30 with a conformal sector-shaped target volume. Local control, eye preservation and secondary glaucoma were evaluated. RESULTS Median follow-up time was 54.9 months. Local tumour control was 100% in patients receiving whole anterior segment irradiation. Two patients developed pigment dispersion in the non-irradiated area after sector-based PBT and received whole anterior segment salvage PBT. The mean volume of ciliary body irradiated was 89.0% and 34.9% for whole anterior segment and lesion-based irradiation, respectively. At the end of follow-up, secondary glaucoma was found in 74.3% of the patients with whole anterior segment irradiation and in 19.2% with sector-based irradiation. Patients with sector-based PBT had a stable visual acuity of logMAR 0.1, while it declined from logMAR 0.1 to 0.4 after whole anterior segment irradiation. CONCLUSION We found a significant reduction in radiation-induced secondary glaucoma and glaucoma-associated surgical interventions and stable visual acuity after sector-based irradiation compared with whole anterior segment irradiation. Sector-based irradiation revealed a higher risk for local recurrence, but selected patients with well-circumscribed iris melanoma benefit from applying a lesion-based target volume when treated with sector-based PBT.
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Affiliation(s)
- Aline I Riechardt
- Department of Ophthalmology, Charité University of Medicine, Berlin, Germany
| | - Bettina Karle
- Department of Radiation Oncology, Helios Klinikum Emil-von-Behring, Berlin, Germany
| | - Dino Cordini
- Department of Ophthalmology, Charité University of Medicine, Berlin, Germany.,Berlin-Protonen, Helmholtz-Zentrum Berlin, Lise-Meitner-Campus, Berlin, Germany
| | - Jens Heufelder
- Department of Ophthalmology, Charité University of Medicine, Berlin, Germany.,Berlin-Protonen, Helmholtz-Zentrum Berlin, Lise-Meitner-Campus, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité University of Medicine, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Antonia M Joussen
- Department of Ophthalmology, Charité University of Medicine, Berlin, Germany
| | - Johannes Gollrad
- Berlin-Protonen, Helmholtz-Zentrum Berlin, Lise-Meitner-Campus, Berlin, Germany. .,Department of Radiation Oncology, Charité University of Medicine, Hindenburgdamm 30, 12200, Berlin, Germany.
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Popovic M, Ahmed IIK, DiGiovanni J, Shields CL. Radiotherapeutic and surgical management of iris melanoma: A review. Surv Ophthalmol 2017; 62:302-311. [DOI: 10.1016/j.survophthal.2016.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 12/16/2016] [Accepted: 12/23/2016] [Indexed: 10/20/2022]
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Song JSA, Dmytriw AA, Lakosha H. Brachytherapy and anterior segment imaging in iris melanoma. Ecancermedicalscience 2017; 11:734. [PMID: 28487752 PMCID: PMC5406218 DOI: 10.3332/ecancer.2017.734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Indexed: 11/23/2022] Open
Abstract
A 40-year-old male presented to the ophthalmology clinic with a darkly pigmented infratemporal lesion in his right eye. The corrected visual acuity in both eyes was 6/6 and both pupils were equal and reactive. Slit lamp biomicroscopy showed a well-demarcated and heavily pigmented lesion in the peripheral iris between 6 and 8 o’clock. Ultrasound biomicroscopy (UBM) revealed a solid mass deriving from the iris stroma without ciliary body involvement, helping to classify the uveal melanoma and establishing the diagnosis of iris melanoma. Fine needle aspiration (FNA) confirmed melanoma with inactivation of the BAP1 gene. The patient was treated with brachytherapy using an I-125 plaque. Follow-up UBM, three years later, demonstrated significantly reduced dimensions of the tumour. UBM has become crucial to the differentiation of uveal melanomas from benign growths, and lesions <3 mm cannot be reliably visualised by other imaging modalities or localised to the correct uveal structure. Brachytherapy represents a safe and effective treatment option even in lesions that are BAP1 positive.
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Affiliation(s)
- Jin Soo Andy Song
- Department of Ophthalmology and Vision Sciences, Dalhousie Medical School, 6299 South St, Halifax, NS B3H 4R2, Canada
| | - Adam A Dmytriw
- Department of Medical Imaging, University of Toronto, 263 McCaul St, Toronto, ON M5T 1W7, Canada
| | - Hesham Lakosha
- Department of Ophthalmology and Vision Sciences, Dalhousie Medical School, 6299 South St, Halifax, NS B3H 4R2, Canada
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Chaugule SS, Finger PT. Regression Patterns of Iris Melanoma after Palladium-103 ( 103Pd) Plaque Brachytherapy. Ophthalmology 2017; 124:1023-1030. [PMID: 28377036 DOI: 10.1016/j.ophtha.2017.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the patterns of regression of iris melanoma after treatment with palladium-103 (103Pd) plaque brachytherapy. DESIGN Retrospective, nonrandomized, interventional case series. PARTICIPANTS Fifty patients with primary malignant melanoma of the iris. METHODS Palladium-103 plaque brachytherapy. MAIN OUTCOME MEASURES Changes in tumor size, pigmentation, and vascularity; incidence of iris neovascularization; and radiation-related complications. RESULTS The mean age in the case series was 61.2±14.9 years. The mean tumor thickness was 1.4±0.6 mm. According to the American Joint Committee on Cancer, eighth edition, staging criteria for iris melanoma, 21 tumors (42%) were T1a, 5 tumors (10%) were T1b, and 24 tumors (48%) were T2a. The tumor was melanotic in 37 cases (74%) and amelanotic in 13 cases (26%); of these, 13 tumors (26%) showed variable pigmentation. After brachytherapy, mean tumor thickness decreased to 0.9±0.2 mm. Pigmentation increased in 32 tumors (64%), decreased in 11 tumors (22%), and was unchanged in 6 tumors (12%). For intrinsic vascularity (n = 19), 12 tumors (63%) showed decrease and 7 tumors (37%) showed complete resolution. Appearance of ectropion uveae showed diminution in 15 tumors (43%); newly present corectopia was observed in 6 patients (12%). On high-frequency ultrasound imaging, of the 42 tumors (84%) with low to moderate internal reflectivity, 30 tumors (60%) showed an increase in internal reflectivity on regression. Iris stromal atrophy was noted in 26 patients (52%), progression or new-onset cataract was noted in 22 patients (44%), neovascular glaucoma was noted in 1 patient (2%), and there were no cases of corneal opacity. There was no clinical evidence (0%) of radiation-induced retinopathy, maculopathy, or optic neuropathy. Mean follow-up in this series was 5.2 years (range, 0.5-17 years). CONCLUSIONS The most common findings related to iris melanoma regression after 103Pd plaque brachytherapy included decreased intrinsic tumor vascularity, increased tumor pigmentation, and decreased tumor thickness with synchronous increase in internal ultrasonographic reflectivity. No irreversible sight-limiting complications were noted.
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Skalet AH, Li Y, Lu CD, Jia Y, Lee B, Husvogt L, Maier A, Fujimoto JG, Thomas CR, Huang D. Optical Coherence Tomography Angiography Characteristics of Iris Melanocytic Tumors. Ophthalmology 2016; 124:197-204. [PMID: 27856029 DOI: 10.1016/j.ophtha.2016.10.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 01/27/2023] Open
Abstract
PURPOSE To evaluate tumor vasculature with optical coherence tomography angiography (OCTA) in malignant iris melanomas and benign iris lesions. DESIGN Cross-sectional observational clinical study. PARTICIPANTS Patients with iris lesions and healthy volunteers. METHODS Eyes were imaged using OCTA systems operating at 1050- and 840-nm wavelengths. Three-dimensional OCTA scans were acquired. Iris melanoma patients treated with radiation therapy were imaged again after I-125 plaque brachytherapy at 6 and 18 months. MAIN OUTCOME MEASURES OCT and OCTA images, qualitative evaluation of iris and tumor vasculature, and quantitative vessel density. RESULTS One eye each of 8 normal volunteers and 9 patients with iris melanomas or benign iris lesions, including freckles, nevi, and an iris pigment epithelial (IPE) cyst, were imaged. The normal iris has radially oriented vessels within the stroma on OCTA. Penetration of flow signal in normal iris depended on iris color, with best penetration seen in light to moderately pigmented irides. Iris melanomas demonstrated tortuous and disorganized intratumoral vasculature. In 2 eyes with nevi there was no increased vascularity; in another, fine vascular loops were noted near an area of ectropion uveae. Iris freckles and the IPE cyst did not have intrinsic vascularity. The vessel density was significantly higher within iris melanomas (34.5%±9.8%, P < 0.05) than in benign iris nevi (8.0%±1.4%) or normal irides (8.0%±1.2%). Tumor regression after radiation therapy for melanomas was associated with decreased vessel density. OCTA at 1050 nm provided better visualization of tumor vasculature and penetration through thicker tumors than at 840 nm. But in very thick tumors and highly pigmented lesions even 1050-nm OCTA could not visualize their full thickness. Interpretable OCTA images were obtained in 82% of participants in whom imaging was attempted. CONCLUSIONS This is the first demonstration of OCTA in iris tumors. OCTA may provide a dye-free, no-injection, cost-effective method for monitoring a variety of tumors, including iris melanocytic lesions, for growth and vascularity. This could be helpful in evaluating tumors for malignant transformation and response to treatment. Penetration of the OCT beam remains a limitation for highly pigmented tumors, as does the inability to image the entire iris in a single field.
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Affiliation(s)
- Alison H Skalet
- Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
| | - Yan Li
- Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
| | - Chen D Lu
- Electrical Engineering & Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Yali Jia
- Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
| | - ByungKun Lee
- Electrical Engineering & Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Lennart Husvogt
- Electrical Engineering & Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts; Pattern Recognition Lab and SAOT, University Erlangen Nuremberg, Erlangen, Germany
| | - Andreas Maier
- Pattern Recognition Lab and SAOT, University Erlangen Nuremberg, Erlangen, Germany
| | - James G Fujimoto
- Electrical Engineering & Computer Science and Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon
| | - David Huang
- Casey Eye Institute, Oregon Health and Science University, Portland, Oregon.
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[Role of surgery in the management of pigmented iris tumors: Case report]. J Fr Ophtalmol 2015; 38:e231-4. [PMID: 26542678 DOI: 10.1016/j.jfo.2015.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 03/17/2015] [Indexed: 11/24/2022]
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Kottschade LA, Grotz TE, Dronca RS, Salomao DR, Pulido JS, Wasif N, Jakub JW, Bagaria SP, Kumar R, Kaur JS, Morita SY, Moran SL, Nguyen JT, Nguyen EC, Hand JL, Erickson LA, Brewer JD, Baum CL, Miller RC, Swanson DL, Lowe V, Markovic SN. Rare presentations of primary melanoma and special populations: a systematic review. Am J Clin Oncol 2014; 37:635-41. [PMID: 23563206 PMCID: PMC4349521 DOI: 10.1097/coc.0b013e3182868e82] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A subset of patients with melanoma present in rare and unique clinical circumstances requiring specific considerations with respect to diagnostic and therapeutic interventions. Herein, we present our review of patients with: (1) primary mucosal melanoma of the head and neck, gastrointestinal, and genitourinary tracts; (2) primary melanoma of the eye; (3) desmoplastic melanoma; (4) subungual melanoma; (5) melanoma in special populations: children, nonwhites, as well as a discussion of familial melanoma.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Riten Kumar
- Department of Pediatric Hematology/Oncology-Hospital for Sick Children, Toronto
| | | | - Shane Y. Morita
- The Queen’s Medical Center/Queen’s Cancer Center-University of Hawaii/John A Burns School of Medicine
| | | | | | | | - Jennifer L. Hand
- Department of Dermatology-Mayo Clinic
- Department of Pediatrics-Mayo Clinic
- Department of Medical Genetics-Mayo Clinic
| | | | | | | | | | | | - Val Lowe
- Department of Radiology-Mayo Clinic
| | - Svetomir N. Markovic
- Department of Oncology- Mayo Clinic
- Department of Hematology-Mayo Clinic
- Department of Immunology-Mayo Clinic
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Proton beam therapy for presumed and confirmed iris melanomas: a review of 36 cases. Graefes Arch Clin Exp Ophthalmol 2014; 252:1515-21. [PMID: 25038910 DOI: 10.1007/s00417-014-2735-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/23/2014] [Accepted: 07/02/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND To report the clinical features and outcomes of iris melanomas treated by proton beam therapy. MATERIALS AND METHODS A retrospective study was conducted at the Croix-Rousse University Hospital of Lyon, Department of Ophthalmology, in 36 patients treated by proton beam therapy for presumed (n = 29) and confirmed (n = 7) iris melanomas between July 1997 and October 2010. Ciliary body melanomas with iris involvement were excluded. The patients' mean age was 54.4 years (range, 22-82 years). The average tumor diameter was 3.8 mm (range, 2.5-8.0). The iridocorneal angle was invaded by the tumor in 47% of cases (n = 17), the ciliary body in 17% of cases (n = 6), and the sclera in 3% (n = 1). Raised intraocular pressure was present before treatment in 11.1 % of cases (n = 4). Tumor biopsy was performed in 19% of cases (n = 7). Four patients had undergone an initial incomplete surgical excision of tumor before radiotherapy. Surgical preparation of the eye with tantalum ring positioning had been performed in all cases 3-4 weeks before irradiation. The prescribed dose was 60 Cobalt Gray Equivalent (CGE) of proton beam radiotherapy delivered in four fractions on four consecutive days. RESULTS The median follow-up was 50 months (mean 60.5, range 15-136). One patient (2.7%) was lost to follow-up. None of the patients showed tumor progression, local recurrence, or metastasis. None of the patients required secondary enucleation. Cataract was developed in 62% of patients, glaucoma in two cases (6%) after irradiation, and hyphema with the aggravation of pre-existing glaucoma in one patient. No patients developed neovascular glaucoma. CONCLUSIONS Proton beam therapy appears to be the treatment of choice for the conservative treatment of iris melanomas with excellent tumor control and an acceptable rate of complications. Longer follow-up studies on a larger series is necessary to consolidate these results.
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Chong CF, Patel DV, Hadden PW, McGhee CN. Conservative biopsy excision and management of a large iris melanoma. Clin Exp Optom 2013; 97:278-9. [PMID: 24117749 DOI: 10.1111/cxo.12111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/17/2013] [Accepted: 08/18/2013] [Indexed: 11/29/2022] Open
Affiliation(s)
- Chee Foong Chong
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Iris melanoma management with iodine-125 plaque radiotherapy in 144 patients: impact of melanoma-related glaucoma on outcomes. Ophthalmology 2012; 120:55-61. [PMID: 22980742 DOI: 10.1016/j.ophtha.2012.06.053] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 06/26/2012] [Accepted: 06/28/2012] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To evaluate the outcomes of iris melanoma managed with plaque radiotherapy on the basis of the initial presence or absence of glaucoma. DESIGN Retrospective, comparative case series. PARTICIPANTS A total of 144 patients. INTERVENTION Custom-designed iodine-125 plaque radiotherapy delivering planned 8000 cGy to melanoma apex using transcorneal application. MAIN OUTCOME MEASURES Tumor control and treatment-related complications. RESULTS Of 144 patients with iris melanoma, glaucoma was present at the initial visit in 58 (40%). Causes of elevated intraocular pressure included angle infiltration by melanoma in 50 patients (86%), angle neovascularization in 4 patients (7%), and hyphema in 4 patients (7%). At presentation, the eyes displaying iris melanoma with glaucoma (vs. without glaucoma) were statistically more likely to display angle tumor (66% vs. 43%), with minimal thickness (1.9 vs. 2.9 mm), and melanoma seeding in iris stroma (7 vs. 3 clock hours) and angle (5 vs. 2 clock hours). Plaque radiotherapy was performed in all cases. Kaplan-Meier estimates at 7 years post-treatment revealed no statistical differences in outcomes of local recurrence (14% vs. 15%), enucleation (14% vs. 11%), or metastasis (2% vs. 0%) comparing eyes with and without glaucoma. Of the entire group, multivariate analysis for factors predictive of recurrence included partial (vs. complete) anterior segment irradiation and postradiotherapy glaucoma. Factors related to enucleation included diabetes mellitus, poor initial visual acuity, higher radiation dose to tumor apex, and tumor recurrence. There were no factors predictive of metastasis. CONCLUSIONS Iodine-125 plaque radiotherapy provides adequate tumor control for iris melanoma with a low metastatic potential of 1% at 7 years. Iris melanoma with secondary glaucoma showed a statistically significant greater likelihood of flat tumor with iris and angle seeding and no difference in outcomes compared with eyes without glaucoma. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Lack of Radiation Maculopathy After Palladium-103 Plaque Radiotherapy for Iris Melanoma. Int J Radiat Oncol Biol Phys 2012; 83:1107-12. [DOI: 10.1016/j.ijrobp.2011.09.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 08/30/2011] [Accepted: 09/12/2011] [Indexed: 11/18/2022]
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Razzaq L, Keunen JEE, Schalij-Delfos NE, Creutzberg CL, Ketelaars M, de Keizer RJW. Ruthenium plaque radiation therapy for iris and iridociliary melanomas. Acta Ophthalmol 2012; 90:291-6. [PMID: 20670343 DOI: 10.1111/j.1755-3768.2010.01967.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the long-term effects of ruthenium-106 plaque radiation therapy for iris and iridociliary melanomas in terms of tumour regression and complications. METHODS Between 1 November 1997 and 31 December 2007, 36 patients with an iris or iridociliary melanoma were treated with Ruthenium-106 (Ru-106) ophthalmic plaque radiation therapy. The median follow-up was 6.5 years with a range of 2-11 years. The mean tumour apex dose was 151.5 Gy. Main outcome measures were local tumour control and radiation-related ocular complications. RESULTS The mean age of the patients at the time of treatment was 54 years (range 14-82). The tumours had a median largest basal dimension of 4.8 mm (range 3-11) and a prominence of 2.3 mm (range 0.8-5), with a median involvement of three clock hours (range 1-6). The tumours were confined to the iris in 14 patients (39%), extended into the anterior ciliary body in 12 (33%), while the anterior ciliary body tumour extended into the iris in ten patients (28%). Tumours regressed in all patients (100%) with a mean regression of 80% of the original tumour size at 7 years of follow-up. Radiation-related complications included corneal erosions on the first postoperative day in nine patients (25%), cataract in four of 11 patients free of cataract before treatment (36%) and postradiation glaucoma in one patient (3%). Visual acuity of 20/200 or worse was present in one of 20 patients (5%) at 6 years of follow-up. Local recurrences occurred in two patients (5%), 2 and 5 years after the radiation therapy respectively, and both underwent enucleation. Distant metastases occurred in one of these enucleated patients (3%) 2 years after treatment. CONCLUSION Ru-106 plaque radiation therapy for iris and iridociliary melanoma resulted in good local tumour control and preservation of visual acuity with few and treatable side-effects.
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Affiliation(s)
- Lubna Razzaq
- Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands
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Shields CL, Kaliki S, Shah SU, Luo W, Furuta M, Shields JA. Iris melanoma: features and prognosis in 317 children and adults. J AAPOS 2012; 16:10-6. [PMID: 22370659 DOI: 10.1016/j.jaapos.2011.10.012] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 10/19/2011] [Accepted: 10/21/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate iris melanoma in children versus adults. METHODS Retrospective, nonrandomized clinical case series including all patients with a clinical diagnosis of iris melanoma managed at the Ocular Oncology Service at Wills Eye Institute over 40 years. Patients were divided into three age categories based on age at presentation: children (≤ 20 years), mid-adults (21-60 years), and older adults (>60 years). The clinical features, treatments, and outcomes were statistically analyzed based on patient age at presentation. The main outcome measures were melanoma features and related metastasis and death. RESULTS Of 8,101 eyes with uveal melanoma, there were 317 (4%) with iris melanoma, including 24 (8%) children (≤ 20 years), 187 (59%) mid-adults (21-60 years), and 106 (33%) older adults (>60 years). There was no age-related difference in race, sex, tumor quadrant, thickness, pigmentation, associated corectopia, ectropion uveae, hyphema, or extraocular extension. Significant age-related differences were found with mean tumor basal diameter, tapioca appearance, mean intraocular pressure, secondary glaucoma, tumor seeding in angle, and mean number of clock hours of angle seeding. Multivariate analysis of factors predictive of metastasis included extraocular extension and high intraocular pressure. Factors predictive of death included increased tumor thickness and high intraocular pressure. There was no difference in metastasis or death by age group. CONCLUSIONS Iris melanoma shows significant clinical differences in children versus adults, with smaller tumor size, less tumor seeding in angle, and lower incidence of secondary glaucoma. There was no significant difference in metastasis or death by age group.
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Affiliation(s)
- Carol L Shields
- Ocular Oncology Service, Wills Eye Institute, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
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Shields CL, Kancherla S, Patel J, Vijayvargiya P, Suriano MM, Kolbus E, Badami A, Sharma P, Jacobs E, Voluck M, Zhang Z, Kansal R, Shields PW, Bianciotto CG, Shields JA. Clinical survey of 3680 iris tumors based on patient age at presentation. Ophthalmology 2011; 119:407-14. [PMID: 22035581 DOI: 10.1016/j.ophtha.2011.07.059] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 07/29/2011] [Accepted: 07/29/2011] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To report the spectrum of iris lesions based on patient age at presentation. DESIGN Retrospective, nonrandomized, single-center case series. PARTICIPANTS We included 3680 iris tumors in 3451 patients. METHODS Chart review. MAIN OUTCOME MEASURES Diagnostic category based on age. RESULTS The mean age at presentation was 48 years and there were 449 (12%) tumors in children (≤20 years), 788 (21%) in young adults (21-40 years), 1308 (36%) in mid adults (41-60 years), and 1135 (31%) in senior adults (>60 years). Of 3680 tumors, the diagnostic category was cystic (n = 768; 21%) or solid (n = 2912; 79%). The cystic tumors originated from iris pigment epithelium (IPE; n = 672; 18%) or iris stroma (n = 96; 3%). The solid tumors included melanocytic (n = 2510; 68%) and nonmelanocytic (n = 402; 11%). The melanocytic tumors comprised nevus (n = 1503; 60%), melanocytoma (n = 68; 3%), melanoma (n = 645; 26%), and melanocytosis (n = 64; 3%). Of 2510 melanocytic tumors, the first and second most common diagnoses by age (children, young adult, mid adult, senior adult) were nevus (53%, 57%, 63%, and 63%, respectively) and melanoma (17%, 27%, 26%, and 27%, respectively). The nonmelanocytic tumors included categories of choristomatous (n = 4; <1%), vascular (n = 57; 2%), fibrous (n = 2; <1%), neural (n = 3; <1%), myogenic (n = 2;, <1%), epithelial (n = 35; 1%), xanthomatous (n = 8; <1%), metastasis (n = 67; 2%), lymphoid (n = 12; <1%), leukemic (n = 2; <1%), secondary (n = 12; <1%), and nonneoplastic simulators (n = 198; 5%). The median age (in years) at diagnosis included cystic (39), melanocytic (52), choristomatous (0.7), vascular (56), fibrous (53), neural (8), myogenic (42), epithelial (63), xanthomatous (1.9), metastasis (60), lymphoid (57), leukemic (25.5), secondary (59), and nonneoplastic simulators (49). Overall, the 3 most common specific diagnoses (children, young adult, mid adult, senior adult) were nevus (25%, 36%, 47%, and 47%, respectively), IPE cyst (28%, 30%, 15%, and 14%, respectively), and melanoma (8%, 16%, 20%, and 19%, respectively). CONCLUSIONS In an ocular oncology practice, the spectrum of iris tumors includes cystic (21%) and solid (79%) tumors. The solid tumors were melanocytic (68%) or nonmelanocytic (11%). At all ages, the most common specific diagnoses were nevus (42%), IPE cyst (19%), and melanoma (17%).
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Affiliation(s)
- Carol L Shields
- Ocular Oncology Service, Suite 1440, Wills Eye Institute, 840 Walnut Street, Philadelphia, PA 19107, USA.
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Giuliari GP, McGowan HD, Pavlin CJ, Heathcote JG, Simpson ER. Ultrasound biomicroscopic imaging of iris melanoma: a clinicopathologic study. Am J Ophthalmol 2011; 151:579-585.e1. [PMID: 21238949 DOI: 10.1016/j.ajo.2010.09.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 09/19/2010] [Accepted: 09/21/2010] [Indexed: 11/17/2022]
Abstract
PURPOSE To demonstrate the correlation of ultrasound biomicroscopy (UBM) features of iris melanoma with histopathology. DESIGN Retrospective analysis of medical records. METHODS The medical records of patients that underwent surgery for iris melanoma at the Princess Margaret Hospital, University of Toronto, from June 1990 to October 1998 were reviewed. The clinical features, as well as the UBM findings prior to surgical intervention, were evaluated. The anatomic features noted on UBM were correlated with histopathologic features seen in the surgical specimens. RESULTS Fourteen cases met the inclusion criteria and were included in the final analysis. The ultrasound acoustic characteristics showed a broad spectrum of findings among iris melanomas. Tumor acoustic parameters correlated well with histologic features, including tumor vascularity, surface plaque, extrascleral extension, ciliary body involvement, and integrity of iris pigment epithelium. CONCLUSIONS UBM is a useful imaging technique for the in vivo assessment of primary iris melanoma and can provide detailed imaging of the tumor's interface with the angle structures. The preoperative assessment of these tumors by UBM may aid the surgeon in choosing the most appropriate technique to ensure total removal.
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Affiliation(s)
- G Paolo Giuliari
- Princess Margaret Hospital, Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada.
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Management of iris melanomas with 125Iodine plaque radiotherapy. Am J Ophthalmol 2010; 149:70-6. [PMID: 19892312 DOI: 10.1016/j.ajo.2009.08.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 08/05/2009] [Accepted: 08/06/2009] [Indexed: 11/22/2022]
Abstract
PURPOSE To report the experience of the Princess Margaret Hospital/University Health Network with the treatment of iris melanoma (IM) with (125)Iodine plaque brachytherapy. DESIGN Retrospective noncomparative case series. METHODS All cases of IM submitted to (125)Iodine plaque radiotherapy were included. Patients' demographic, clinical, management, and follow-up data were reviewed. Outcome measures included rates of tumor control, eye preservation, systemic metastases, and brachytherapy-related complications. RESULTS Fourteen IMs were included in the study. All patients had blue/green irises. Mean largest basal dimension and thickness were 7.1 +/- 2.1 mm (range, 4.0 to 11.5 mm) and 2.2 +/- 0.8 mm (range, 1.0 to 3.5 mm), respectively. Ten patients (71%) had seeding and 2 (14%) had glaucoma at presentation. Median follow-up was 26.6 +/- 19.5 months (range, 6 to 72 months). Tumor control was achieved in 100% of the cases and no eye was enucleated because of radiation-induced complications. At last visit, all patients were alive and free of metastasis. Final visual acuity was the same as or better than before treatment in 9 patients (75%). Cataract was the most common complication (8; 75%), followed by persistent glaucoma (2; 17%) and anterior uveitis (1; 8%). No other significant complication was seen during the follow-up period. CONCLUSIONS Plaque radiotherapy is a safe and effective conservative treatment option for IM, although cataract is a common, yet treatable, complication. This treatment scheme circumvents an intraocular procedure and may avoid the dissemination of malignant cells, and provides a margin of safety in the treatment of clinically undetectable disease.
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Abstract
The presence of melanin pigment within the iris is responsible for the visual impression of human eye colouration with complex patterns also evident in this tissue, including Fuchs' crypts, nevi, Wolfflin nodules and contraction furrows. The genetic basis underlying the determination and inheritance of these traits has been the subject of debate and research from the very beginning of quantitative trait studies in humans. Although segregation of blue-brown eye colour has been described using a simple Mendelian dominant-recessive gene model this is too simplistic, and a new molecular genetic perspective is needed to fully understand the biological complexities of this process as a polygenic trait. Nevertheless, it has been estimated that 74% of the variance in human eye colour can be explained by one interval on chromosome 15 that contains the OCA2 gene. Fine mapping of this region has identified a single base change rs12913832 T/C within intron 86 of the upstream HERC2 locus that explains almost all of this association with blue-brown eye colour. A model is presented whereby this SNP, serving as a target site for the SWI/SNF family member HLTF, acts as part of a highly evolutionary conserved regulatory element required for OCA2 gene activation through chromatin remodelling. Major candidate genes possibly effecting iris patterns are also discussed, including MITF and PAX6.
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Affiliation(s)
- Richard A Sturm
- Melanogenix Group, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Qld, Australia.
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Isager P, Engholm G, Overgaard J, Storm H. Uveal and Conjunctival Malignant Melanoma in Denmark 1943–97: Observed and Relative Survival of Patients Followed Through 2002. Ophthalmic Epidemiol 2009; 13:85-96. [PMID: 16581612 DOI: 10.1080/09286580600553330] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the observed and relative survival of patients diagnosed with a malignant melanoma in the ocular region in Denmark during the period 1943-97. METHODS The study included 2,504 patients (1,292 men and 1,212 women) diagnosed with a melanoma in the ocular region, of which 2,434 cases could be topographically subclassified into 2,178 in the choroid/ciliary body, 141 in the iris, and 115 in the conjunctiva. The patients were followed through 2002 and the observed survival proportions and relative survival ratios were estimated. RESULTS For the total ocular region and the choroid/ciliary body, the observed survival did not vary statistically significantly with the year of diagnosis. A statistically insignificant higher observed survival for women than men was found for tumors in the ocular region and the subgroups choroid/ciliary body, iris, and conjunctiva. During the 55-year study period, the 5- and 10-year relative survival remained stable for the ocular region for men at 67% and 57% and for women at 71% and 60%, respectively, and stable for the choroid/ciliary body for men at 66% and 55% and for women at 69% and 57%, respectively. The 5- and 10-year relative survival for the iris was for men 90% and 85% and for women 99% and 101%, respectively, and for the conjunctiva for men 83% and 70% and for women 93% and 82%, respectively. CONCLUSION The observed and relative survival of patients diagnosed with a melanoma in the ocular region and choroid/ciliary body in Denmark during the period 1943-97 and followed through 2002 has remained stable. The highest observed and relative survival was found for iris melanomas, the lowest for choroid/ciliary body melanomas, and intermediate for conjunctival melanomas.
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Affiliation(s)
- P Isager
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark.
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Abstract
The iris is the least common site of primary uveal melanoma. The prognosis of iris melanoma is better than that of melanoma of the ciliary body and choroid, but the reason for this difference is unclear. One possible explanation is that iris melanoma is smaller than its posterior segment counterparts at the time of diagnosis. Most iris melanomas are spindle cell types, according to a modified Callender classification system. There is evidence that the proliferation of melanocytes of the anterior iris surface (iris plaque) and diffuse stromal invasion may be risk factors for local recurrence and metastasis, respectively.
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Affiliation(s)
- Evita Henderson
- Department of Pathology, Veterans Administration Hospital, Tampa, USA
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Markovic SN, Erickson LA, Rao RD, Weenig RH, Pockaj BA, Bardia A, Vachon CM, Schild SE, McWilliams RR, Hand JL, Laman SD, Kottschade LA, Maples WJ, Pittelkow MR, Pulido JS, Cameron JD, Creagan ET. Malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment. Mayo Clin Proc 2007; 82:490-513. [PMID: 17418079 DOI: 10.4065/82.4.490] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Critical to the clinical management of a patient with malignant melanoma is an understanding of its natural history. As with most malignant disorders, prognosis is highly dependent on the clinical stage (extent of tumor burden) at the time of diagnosis. The patient's clinical stage at diagnosis dictates selection of therapy. We review the state of the art in melanoma staging, prognosis, and therapy. Substantial progress has been made in this regard during the past 2 decades. This progress is primarily reflected in the development of sentinel lymph node biopsies as a means of reducing the morbidity associated with regional lymph node dissection, increased understanding of the role of neoangiogenesis in the natural history of melanoma and its potential as a treatment target, and emergence of innovative multimodal therapeutic strategies, resulting in significant objective response rates in a disease commonly believed to be drug resistant. Although much work remains to be done to improve the survival of patients with melanoma, clinically meaningful results seem within reach.
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Affiliation(s)
- Svetomir N Markovic
- Division of Hematology, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Sahin A, Kiratli H, Tezel GG, Soylemezoglu F, Bilgic S. Expression of vascular endothelial growth factor a, matrix metalloproteinase 9 and extravascular matrix patterns in iris and ciliary body melanomas. Ophthalmic Res 2006; 39:40-4. [PMID: 17164576 DOI: 10.1159/000097905] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2005] [Accepted: 07/08/2006] [Indexed: 12/17/2022]
Abstract
PURPOSE It was the aim of this study to assess the expression of vascular endothelial growth factor (VEGF)-A, matrix metalloproteinase (MMP)-9 and extravascular matrix patterns (EMPs) in iris and ciliary body melanomas and their correlations with histopathologic parameters. METHODS The study was conducted on 3 iris and 15 ciliary body melanomas. All tumors were subjected to immunohistochemical techniques for VEGF-A and MMP-9 expressions, the presence of EMPs was assessed, and routine paraffin sections were stained with hematoxylin-eosin. Cell type, tumor localization, degree of pigmentation, necrosis, mitotic index, lymphocytic infiltration and sclera invasion were analyzed using light microscopy. RESULTS The mean patient age at the time of treatment was 43 years (range 19-69, median 39.5); 10 (55.6%) patients were males and 8 (44.4%) females. Histopathological cell types were spindle cells in 55.6%, mixed cells in 16.7%, and epithelioid cell types in 27.8% of tumors. Positive reaction for VEGF-A and MMP-9 was present in 66.7 and 72.3% of the tumors, respectively. Microvascular loops and/or networks were seen in 33.4% of the tumors, with the remaining 66.7% of tumors displaying one or more of the other patterns. Metastatic disease developed in only 1 patient during follow-up. Tumor cell type, tumor size, mitotic rate, degree of pigmentation and EMPs were not correlated with metastasis. CONCLUSIONS This study suggests that VEGF-A and MMP-9 were positive in the majority of iris and ciliary body melanomas. No correlation was found between VEGF-A and MMP-9 immunoreactivity and EMPs and occurrence of metastases in cases of anterior uveal melanoma.
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Affiliation(s)
- Afsun Sahin
- Department of Ophthalmology, Ocular Oncology Service, Hacettepe University School of Medicine, Ankara, Turkey
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Abstract
AIM To report results of proton beam therapy for iris melanoma. METHODS A retrospective case series of 15 patients with nonresectable iris melanomas treated with proton beam therapy between August 1998 and August 2004. The main outcome measures were (1) local tumour control, (2) complications, and (3) eye retention. RESULTS Of the 15 cases, 11 patients showed documented growth (including two cases of local recurrence following iridocyclectomy) while a further three cases were biopsy-proven melanoma. One patient presented with a newly acquired vascular nodule of the iris associated with angle seeding and glaucoma. Tumour control at mean follow-up of 34 months was 93% (14 of 15 eyes). Common complications included glaucoma in 53% (five patients had glaucoma prior to irradiation), dry eye (27%) and cataract in three patients (20%). Eye retention was possible in 80% (12 cases). CONCLUSION Proton beam therapy is an effective treatment for cases of nonresectable iris melanoma. The major complications are cataract and glaucoma.
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Affiliation(s)
- P Rundle
- Ocular Oncology Clinic, Royal Hallamshire Hospital, Sheffield, UK.
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Abstract
Iris melanoma is a rare ocular tumour, which can be detected early in its development. This tumour is almost always unilateral and arises usually from a pre-existing naevus. Failure to detect it may be associated with morbid ocular and systemic complications, yet there are successful therapies to treat this condition, if detected early. The patient presented to the eye clinic with symptoms of occasional, brief loss of vision in his left eye for a few weeks prior to his visit. Slit-lamp examination revealed a mass on the inferior part of the iris of the left eye. Intra-ocular pressure measurements were RE 15 mmHg and LE 38 mmHg. It was found that a tumour had spread throughout the iris stroma and invaded the anterior chamber angle. Although enucleation would have been the treatment of choice in the past, the trend today in the treatment of a growing, large circumscribed iris tumour is to excise it. It was successfully excised by irido-cyclo-trabeculectomy.
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Affiliation(s)
- Michel Millodot
- Department of Optometry, Hadassah College of Technology, Jerusalem, Israel.
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Damato B, Kacperek A, Chopra M, Sheen MA, Campbell IR, Errington RD. Proton beam radiotherapy of iris melanoma. Int J Radiat Oncol Biol Phys 2005; 63:109-15. [PMID: 16111578 DOI: 10.1016/j.ijrobp.2005.01.050] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2004] [Revised: 01/10/2005] [Accepted: 01/11/2005] [Indexed: 11/18/2022]
Abstract
PURPOSE To report on outcomes after proton beam radiotherapy of iris melanoma. METHODS AND MATERIALS Between 1993 and 2004, 88 patients with iris melanoma received proton beam radiotherapy, with 53.1 Gy in 4 fractions. RESULTS The patients had a mean age of 52 years and a median follow-up of 2.7 years. The tumors had a median diameter of 4.3 mm, involving more than 2 clock hours of iris in 32% of patients and more than 2 hours of angle in 27%. The ciliary body was involved in 20%. Cataract was present in 13 patients before treatment and subsequently developed in another 18. Cataract had a 4-year rate of 63% and by Cox analysis was related to age (p = 0.05), initial visual loss (p < 0.0001), iris involvement (p < 0.0001), and tumor thickness (p < 0.0001). Glaucoma was present before treatment in 13 patients and developed after treatment in another 3. Three eyes were enucleated, all because of recurrence, which had an actuarial 4-year rate of 3.3% (95% CI 0-8.0%). CONCLUSIONS Proton beam radiotherapy of iris melanoma is well tolerated, the main problems being radiation-cataract, which was treatable, and preexisting glaucoma, which in several patients was difficult to control.
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Affiliation(s)
- Bertil Damato
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.
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Torres VLL, Allemann N, Erwenne CM. Ultrasound Biomicroscopy Features of Iris and Ciliary Body Melanomas Before and After Brachytherapy. Ophthalmic Surg Lasers Imaging Retina 2005. [DOI: 10.3928/1542-8877-20050301-09] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Spandau UHM, Dithmar S, Grossniklaus HE, Völcker HE, Jonas JB. Recurrent spontaneous hyphaema secondary to a melanocytic iris lesion. ACTA OPHTHALMOLOGICA SCANDINAVICA 2004; 82:494-5. [PMID: 15291954 DOI: 10.1111/j.1395-3907.2004.00274.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Starr OD, Patel DV, Allen JP, McGhee CNJ. Iris melanoma: pathology, prognosis and surgical intervention. Clin Exp Ophthalmol 2004; 32:294-6. [PMID: 15180843 DOI: 10.1111/j.1442-9071.2004.00821.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A case of an iris melanoma in a 58-year-old woman is described. The clinical and pathological findings are discussed, highlighting the correlations between histopathology and prognosis for iris melanoma, which differ markedly from choroidal melanoma. The mixed cellular pathology of this iris melanoma (containing both spindle B cells and epithelioid cells) carries a higher metastatic rate than tumours composed exclusively of either. This contrasts with choroidal melanoma, where the presence of epithelioid cells is the strongest pathological marker for a poor prognosis. The ocular outcome that can be achieved with local surgical excision of a well-delineated iris melanoma that does not involve the angle is discussed.
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Affiliation(s)
- Oliver D Starr
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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Abstract
The most common anterior segment tumors are primary neuroepithelial cysts, uveal melanomas, metastatic tumors, and benign tumors. In the majority of cases, the diagnosis can be made utilizing a careful clinical history and ocular examination. Ultrasound examination (low and high frequency) has become an indispensable tool used to determine tumor extension and involvement of the surrounding structures. In particular, high-frequency ultrasound has been used to uncover iris pigment epithelial cysts, to allow for the diagnosis of small ciliary body melanomas, and to measure tumors for plaque radiation planning. Whereas fluorescein angiography and computerized tomography have come to play a limited role, fine-needle aspiration biopsy has been found to be quite helpful in selected cases. Once the diagnosis is established, treatment decisions depend on the tumors' location, size, local extension, patterns of growth, and secondary complications. Most anterior segment tumors can be observed for growth prior to treatment. Other options include local resection (iridectomy, lamellar sclerouvectomy, or eye-wall resection) and radiation (ophthalmic plaque or external beam). Enucleation is typically employed if these eye- and vision-sparing treatments are not possible and for uncontrollable secondary glaucoma. This review examines the unique role of high-frequency ultrasonography for the diagnosis and treatment of anterior segment tumors as well as an overview of clinical practice.
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Affiliation(s)
- Flavio A Marigo
- The New York Eye Cancer Center; The Federal University of Minas Gerais and Instituto da Visão, Belo Horizonte, Brazil
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Shields CL, Naseripour M, Shields JA, Freire J, Cater J. Custom-designed plaque radiotherapy for nonresectable iris melanoma in 38 patients: tumor control and ocular complications. Am J Ophthalmol 2003; 135:648-56. [PMID: 12719072 DOI: 10.1016/s0002-9394(02)02241-9] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate plaque radiotherapy for iris melanoma. DESIGN Prospective noncomparative interventional case series. METHODS For 38 patients, custom-designed plaque radiotherapy using iodine 125 isotope was applied overlying the cornea with a tumor apex dose of 80 Gy. The main outcome measures were tumor control and ocular complications using Kaplan-Meier estimates and Cox proportional hazards regression analysis. RESULTS In all cases, the melanoma was nonresectable owing to large or discohesive tumor. The tumor configuration was nodular in 24 cases (63%) and flat (diffuse) in 14 (37%). The mean tumor basal diameter was 9 mm (range 4 to 13 mm). Solid tumor extended into the anterior chamber angle in 36 eyes (95%). Tumor seeds were noted on the iris stroma for a mean of 7 clock hours and in the anterior chamber angle for a mean of 4 clock hours. Five-year follow up revealed tumor metastasis in 0% and tumor recurrence in 8% of patients. Visual acuity of 20/200 or worse was found in 16% at 5 years. Radiation-related complications at 5 years included corneal epitheliopathy (9%), cataract (70%), and neovascular glaucoma (8%). No patients developed corneal necrosis, scleral necrosis, retinopathy, or papillopathy. After treatment, the combined incidence of tumor-related and radiation-related elevated intraocular pressure at 5 years was 33%. Enucleation was necessary in 13% at 5 years, for tumor recurrence (n = 3) and patient preference (n = 1). CONCLUSIONS Plaque radiotherapy is a useful alternative to enucleation for eyes with nonresectable iris melanoma. Tumor control is 92% at 5 years, but related complications, especially cataract and elevated intraocular pressure, should be anticipated.
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Affiliation(s)
- Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Abstract
PURPOSE To report on plaque radiation therapy for malignant melanomas involving the iris and ciliary body. METHODS Twenty-two eyes (22 patients) with anterior uveal melanomas were treated with (103)Pd ophthalmic plaque radiation therapy. Transillumination and ultrasonography were used to evaluate ciliary body involvement and posterior iris extension. Plaques were placed onto the cornea to treat the anterior tumor margins. The targeted-zone included the tumor and a 2 to 3 mm tumor-free margin. After plaque removal, patients were examined at 1 day, 7 days, 4 weeks, and then every 3 to 6 months thereafter. Systemic evaluations for possible metastatic disease were performed every 6 months. RESULTS After plaque radiation therapy, the melanomas decreased in thickness (mean 47%) in all 22 eyes, and no secondary enucleation was performed. One patient died of metastatic melanoma 5 years after radiation therapy. Despite anterior plaque placement that covered portions of the cornea, no epiphora, eyelash loss, or visually significant corneal opacities were noted. Whereas 15 of 21 phakic eyes (71%) developed secondary cataract, no eyes developed ischemic or neovascular radiation maculopathy. Four eyes were noted to have glaucoma before treatment, and two developed it after irradiation. Twenty of 22 eyes (91%) were within 2 lines of their pretreatment visual acuity. After radiation, the mean +/- SD follow-up was 56 +/- 34.4 months (range, 9 to 117 months). CONCLUSIONS Plaque radiotherapy of melanomas involving the iris and ciliary body resulted in excellent local control with preservation of vision. Although there was high incidence of secondary cataracts, (103)Pd plaque radiation therapy resulted in no visually significant corneal opacity or radiation retinopathy.
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Affiliation(s)
- P T Finger
- The New York Eye Cancer Center, 115 East 61st Street, New York, NY 10021, USA.
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Shields CL, Materin MA, Shields JA, Gershenbaum E, Singh AD, Smith A. Factors associated with elevated intraocular pressure in eyes with iris melanoma. Br J Ophthalmol 2001; 85:666-9. [PMID: 11371484 PMCID: PMC1724017 DOI: 10.1136/bjo.85.6.666] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To identify clinical factors associated with secondary elevated intraocular pressure (IOP) in eyes with iris malignant melanoma METHODS A retrospective case series of 169 consecutive patients with microscopically confirmed iris malignant melanoma. The main outcome measure was the presence of tumour induced secondary elevated IOP. Cox proportional regression models were used to calculate the relation of clinical features to elevated IOP. RESULTS Of 169 patients with microscopically proved iris melanoma, 50 (30%) presented with tumour induced secondary elevated IOP. The mean pressure in those eyes with elevated IOP at diagnosis was 33 mm Hg (median 31 mm Hg, range 23-65 mm Hg). The tumour configuration was nodular in 23 (46%) and diffuse in 27 (54%) with a mean base dimension of 7.4 mm and thickness of 2.0 mm. Invasion of the angle structures by melanoma seeds was visible for a mean of 7 clock hours (median 7, range 0-12 clock hours). The mechanism of elevated IOP was judged to be outflow obstruction from tumour invasion into the trabecular meshwork. There were no cases of neovascular glaucoma. The tumour was ultimately managed with enucleation in 30 patients (60%), local resection (iridectomy, iridocyclectomy, or iridocyclogoniectomy) in 11 (22%), and plaque radiotherapy in five (10%). In four cases (8%), observation of cytologically low grade tumour was the patient's preference. Using multivariate analysis, the clinical factors at initial evaluation associated with tumour induced secondary elevated IOP from iris melanoma included increasing extent of tumour seeding in the anterior chamber angle (p=0.01) and poor visual acuity at presentation (p=0.02). CONCLUSIONS Microscopically confirmed iris melanoma demonstrates tumour related elevated IOP in 30% cases at the time of presentation, usually secondary to tumour involvement of the trabecular meshwork obstructing aqueous outflow. Enucleation is necessary in the majority of these patients (60%) as opposed to those cases without elevated intraocular pressure (18%).
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Affiliation(s)
- C L Shields
- Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
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Conway RM, Chua WC, Qureshi C, Billson FA. Primary iris melanoma: diagnostic features and outcome of conservative surgical treatment. Br J Ophthalmol 2001; 85:848-54. [PMID: 11423461 PMCID: PMC1724056 DOI: 10.1136/bjo.85.7.848] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To describe features influencing the management of primary iris melanoma and report the outcome of conservative surgical treatment of patients diagnosed with this condition in a tertiary referral academic setting over a 20 year period. METHODS Retrospective non-comparative case series of consecutive patients diagnosed with iris melanoma from 1980-2000 using medical records from the University of Sydney Department of Ophthalmology and NSW Cancer Registry RESULTS 51 cases were identified. The most common presentation was growth of a previously noted pigmented lesion. Initial management was either observation or local resection (two had enucleations) with iris reconstruction where possible (23.8%). The mean follow up was 8.7 years (range 1-17 years). Vision of 6/12 or better was maintained in the majority (78.6%) treated by local resection. Pupil reconstruction significantly reduced reported postoperative glare symptoms. Four patients had features suggestive of local recurrence and there was no documented metastatic disease or death from iris melanoma in this series. Histologically, the majority were spindle B cell melanomas. Clinical features including prominent tumour vascularity, rapid growth, and heterogeneous pigmentation were each significantly associated with an epithelioid cell component. Involvement of the iridocorneal angle was frequently associated with ciliary body invasion. CONCLUSIONS Management decisions for iris melanoma will depend on the clinical features. Mixed or epithelioid histology is more likely in the presence of two or more of the features of malignancy and may justify earlier intervention. When treatment is undertaken, local resection achieves long term tumour clearance with an acceptable morbidity. In resecting iris melanoma, careful assessment for iridocorneal angle involvement is important in treatment planning. Iris reconstruction has a useful role in reducing postoperative photophobia.
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Affiliation(s)
- R M Conway
- Save Sight Institute and Department of Clinical Ophthalmology, University of Sydney, Sydney, Australia.
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Shields CL, Shields JA, Materin M, Gershenbaum E, Singh AD, Smith A. Iris melanoma: risk factors for metastasis in 169 consecutive patients. Ophthalmology 2001; 108:172-8. [PMID: 11150284 DOI: 10.1016/s0161-6420(00)00449-8] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To identify risk factors that predict distant metastases of iris malignant melanoma. DESIGN Retrospective case series. PARTICIPANTS The participants included 169 consecutive patients with microscopically confirmed iris malignant melanoma managed on the Oncology Service at Wills Eye Hospital between 1974 and 1999. MAIN OUTCOME MEASURES The main outcome measure was the development of distant tumor metastasis. Cox proportional regression models were used to calculate the risk of eventual metastatic spread. RESULTS Of 1054 patients referred with suspicious iris melanocytic tumors (rule out malignant melanoma) over a 25-year period, 169 patients (16%) had microscopically proven iris melanoma, and the remainder (84%) had clinically diagnosed iris nevus. Of the patients with iris melanoma, the mean age at the time of diagnosis was 43 years (median, 45 years; range, 1-90 years). All patients were Caucasian. The mean tumor base was 6 mm (median, 5 mm; range, 1-17 mm), and mean tumor thickness was 2 mm (median, 2 mm; range, 1-4 mm). The mean number of clock hours of tumor involvement in the iris was four, tumor seeding on the iris was four, and tumor seeding into the anterior chamber angle was four. Extraocular extension was present in 10 eyes (6%). The tumor management consisted of local resection (iridectomy, iridocyclectomy, or iridocyclogoniectomy) in 102 patients (60%), enucleation in 51 (30%), plaque radiotherapy in 9 (5%), and observation in 7 patients (4%). Metastasis developed in nine patients (5%). Using Kaplan-Meier life table analysis, metastasis was found in 3% of patients at 5 years, 5% at 10 years, and 10% at 20 years. The clinical factors at initial evaluation predictive of eventual metastasis from iris melanoma included increasing age at diagnosis (P = 0.03), elevated intraocular pressure (P = 0.03), posterior tumor margin at angle or iris root (versus midzone) (P = 0.02), extraocular extension (P: = 0.02), and prior surgical treatment of the tumor elsewhere before referral (versus observation) (P = 0.006). The method of management (resection, radiotherapy, or enucleation) did not have an impact on metastasis. CONCLUSIONS Microscopically confirmed iris melanoma demonstrates distant metastasis in 5% of patients at 10 years follow-up. Metastases are more likely to develop in those patients who are older and show tumor features of iris root/angle location with elevated intraocular pressure and extraocular extension.
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Affiliation(s)
- C L Shields
- Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Abstract
BACKGROUND: Malignant melanoma of the uveal tract is a rare malignancy but a significant cause of mortality and visual loss. Approximately 50% of patients diagnosed with a melanoma of the choroid or ciliary body will die of the disease within 15 years of enucleation. METHODS: The author reviewed the current literature on the clinical findings, epidemiology, and treatment of uveal melanoma. RESULTS: Methods of diagnosis have improved substantially in the past several years, although clinical diagnosis by an experienced examiner remains the standard in eyes with clear media. Ultrasound is the most useful adjunctive technique. While enucleation has been the mainstay of therapeutic intervention, alternative therapies - especially different types of irradiation - offer hope for tumor control and vision preservation. The Collaborative Ocular Melanoma Study, a multicenter national trial, is designed to provide long-term data on the natural history as well as therapeutic intervention. CONCLUSIONS: Malignant melanoma of the uveal tract can be diagnosed clinically with more confidence than ever before. It is also possible in many cases to retain the eye and functional vision while controlling the tumor. However, unanswered questions remain about the natural history and optimal therapy of uveal melanoma.
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Affiliation(s)
- MC Kincaid
- Departments of Ophthalmology and Pathology, Saint Louis University Eye Institute, Saint Louis University School of Medicine, St. Louis, Missouri 63104, USA
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Ursea R, Coleman DJ, Silverman RH, Lizzi FL, Daly SM, Harrison W. Correlation of high-frequency ultrasound backscatter with tumor microstructure in iris melanoma. Ophthalmology 1998; 105:906-12. [PMID: 9593396 DOI: 10.1016/s0161-6420(98)95036-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE This study aimed to correlate histologic characteristics with high-frequency ultrasound backscatter spectra in malignant melanomas of the iris. DESIGN The study design was a cohort (case series) study of patients diagnosed with iris melanoma in the authors' clinic. PARTICIPANTS Sixteen patients with iris melanoma participated. INTERVENTION The patients were scanned with a 50-MHz ultrasound unit equipped for digitization of raw echo data. Spectral parameter images representing the spatial distribution of size and concentration of tissue inhomogeneities were produced. MAIN OUTCOME MEASURES The variation of spectral properties within and between tumors was determined. In the two tumors in this series for which histologic material was available, the authors compared scatterer concentration and size with histology and mathematically modeled the effect of melanocyte distribution on spectra. RESULTS Ultrasound scattering characteristics differed considerably among tumors. Where histology was available, acoustic parameters correlated with the size and number of melanocytes present. CONCLUSIONS Iris melanomas exhibited a wide range in acoustic backscatter properties. Whereas characteristics such as vascularity and necrosis might contribute to this, in the two cases examined here, backscatter characteristics could be largely accounted for by melanocyte distribution. A better understanding of the relationship of histology to noninvasive ultrasound data will enhance the diagnostic utility of this technique.
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Affiliation(s)
- R Ursea
- Department of Ophthalmology, Cornell University Medical College, New York, New York 10021, USA
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Abstract
PURPOSE To illustrate some management problems with pigmented iris tumors. METHODS This is a retrospective analysis of 234 iris tumors managed by one of the authors. Five patients were selected whose clinical course and pathologic data illustrate diagnostic problems that can occur with these tumors. RESULTS In the patients described, diagnostic problems were noted. In two patients, glaucoma specialists were unable to correctly diagnose an iris melanoma before filtration. One patient had a 3-clock-hour iris biopsy that was not diagnostic for malignancy, yet the enucleated eye showed melanoma. One patient with a clinically stable iris tumor had a mixed-cell melanoma. CONCLUSIONS Most iris-pigmented tumors have a benign disease course. In some case, despite little clinical evidence of disease activity or progression, a melanoma, often with epithelioid cells, may be present and neither a fine-needle nor an open biopsy is always diagnostic.
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Affiliation(s)
- D H Char
- Department of Ophthalmology, University of California, San Francisco, CA 94143, USA
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Harbour JW, Augsburger JJ, Eagle RC. Initial management and follow-up of melanocytic iris tumors. Ophthalmology 1995; 102:1987-93. [PMID: 9098306 DOI: 10.1016/s0161-6420(95)30765-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSES To identify clinical variables prognostic for prompt excision of melanocytic iris tumors and to determine the clinical factors predictive of enlargement of those tumors managed initially by observation. METHODS A retrospective study of 285 patients evaluated in a referral center over a 15-year interval (1972-1986). RESULTS Thirty-six lesions were excised promptly, whereas 249 were observed. Eighty-nine percent of the 36 promptly excised tumors were malignant melanomas on histopathologic examination. Five clinical variables were associated strongly with prompt excision: largest basal tumor diameter greater than 3 mm; presence of pigment dispersion; prominent tumor vascularity; elevated intraocular pressure; and tumor-related ocular symptoms. In the observed group, the actuarial 5-year rate of lesion enlargement was 6.5% (standard error = 2.1%). Of the ten lesions that enlarged, six were excised and evaluated histopathologically. Five of these six lesions were malignant melanomas on histopathologic study. Largest basal tumor diameter was the only clinical variable strongly predictive of lesion enlargement. Only two patients died of metastatic uveal melanoma, and both were in the promptly treated group. CONCLUSIONS Most melanocytic iris tumors are benign and do not enlarge appreciably when followed or lead to metastatic disease. However, even prompt locally effective treatment (excision) is insufficient to prevent metastasis in some patients. Clinical features of the iris lesion appear to enable clinicians to differentiate reasonably well between probable malignant melanomas, for which prompt treatment seems appropriate, and benign nevi, for which observation with periodic follow-up is likely to be the best management.
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Affiliation(s)
- J W Harbour
- Oncology Unit, Wills Eye Hospital, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107-5598, USA
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