Ciliary body melanoma: a special challenge

Delayed recurrence of an iridociliary malignant melanoma 180° from the primary tumor

Purpose

We report the case of a 66-year-old female who returned with a rare recurrence of iridociliary melanoma 180° from the original lesion.

Observations

Upon initial presentation eleven years prior, a pigmented iris lesion suspicious for primary uveal melanoma was noted in the right eye at 9 o'clock. After one year of observation, inferior growth of the iris lesion prompted treatment via primary iridectomy with excisional biopsy and pupilloplasty. Postoperative biopsy confirmed spindle B type melanoma with epithelial foci, and adjuvant brachytherapy was performed to treat the reported positive anterior ciliary body involvement. Ten years after initial plaque brachytherapy treatment, the patient returned with a pigmented iris lesion in the right eye at 3:30–5 o'clock, which was treated with enucleation. On pathology, the new melanoma was predominantly epithelioid, consistent with a transformed recurrent iridociliary melanoma. The patient remains metastasis free 13 years after initial diagnosis.

Conclusions and importance

This case describes a rare, late recurrence of an iridociliary melanoma 180° away eleven years after initial presentation, emphasizing the importance of lifelong follow-up for patients with iridociliary melanoma. This rare form of recurrence has not been previously reported in the literature. We hypothesize the original lesion contained radiotherapy resistant epithelioid cells which grew superficially on the posterior iris and anterior ciliary body, ultimately breaking back through the anterior iris 180° away.

Proton beam irradiation of uveal melanoma involving the iris, ciliary body and anterior choroid without surgical localisation (light field)

AIMS

To assess treatment outcomes after proton beam irradiation (PBI) without surgical localisation of uveal melanomas involving the iris, ciliary body and anterior choroid.

METHODS

Retrospective chart review of 125 patients evaluated at Massachusetts Eye and Ear and treated with PBI using a light field set-up without localisation surgery between November 1975 and April 2017. The tumours were characterised as follows: iris (n=18, 14.4%), ciliary body (n=12, 9.6%), iridociliary (n=58, 46.4%), ciliochoroidal (n=24, 19.2%) and iridociliochoroidal (n=13, 10.4%). The tumours were measured by transillumination and ultrasonography before treatment. Tumours with posterior margin located less than two disc diameters from the ora serrata were treated using the light field technique. Patient outcomes after PBI were evaluated.

RESULTS

Most patients had good vision at the time of tumour diagnosis (69.6% had baseline visual acuity (VA) of ≥20/40). Median VA at last follow-up (median follow-up: 72.1 months) was 20/63. Recurrences occurred in 12 patients (9.6%) at a median time of 4.0 years post-treatment. Recurrences were treated by repeat PBI (n=5) or enucleation (n=7). Secondary enucleation was performed in 18 patients (14.4%), and 61.1% of these were due to complications. Neovascular glaucoma (NVG) developed in 21 patients (16.8%). Of seven patients who developed NVG after anti-vascular endothelial growth factor (anti-VEGF) therapies became available, five were treated with intravitreal Avastin injections (23.8% of patients with NVG). Of 69 patients diagnosed with cataract after treatment, 51 (73.9%) were characterised as radiation-related. Death from metastatic uveal melanoma occurred in 20.8% of the cohort, with a median follow-up of 10.1 years.

CONCLUSIONS

Patients treated with PBI using a light field set-up technique experience good outcomes after irradiation. Eye preservation and retention of good VA are seen in the majority of cases, and tumour recurrence is low.

Diagnosis and long-term monitoring of adenomas of the ciliary body epithelium by ultrasound biomicroscopy

INTRODUCTION

The natural course of adenomas of the ciliary-body epithelium (ACE) is uncertain, due to their low incidence and their frequent initial surgical management.Their differential diagnosis with amelanotic melanoma or metastasis is challenging and diagnostic biopsies require sufficient tissue and highly specialized pathologists. Ultrasound biomicroscopy offers high resolution images and clear sonographic signs suggestive of ACE allowing a more precise differential diagnosis and therefore, a more conservative initial attitude.

METHODS

Descriptive, retrospective, non-comparative study of consecutive cases of ACE observed between October 2003 and December 2019 in a reference unit in ocular oncology of a tertiary hospital. Patients were studied on a quarterly basis the first year and, subsequently, every 6 months with a complete ophthalmological exam and ultrasound biomicroscopy with the platform Aviso linear scanning 50 MHz probe (Quantel Medical, Clermont-Ferrand, France).

RESULTS

Three ACE were analysed for a median of 3 years (interquartile range: 2.5-5.5 years). Clinical features include a whitish-to-brown spherical mass, with engorged superficial vessels. Ultrasound biomicroscopy shows an oval-spherical shape, medium-to-high echogenicity, low acoustic attenuation, regular internal structure, and respect for the neighboring structures. By their clinical-ultrasonographic characteristics, one was considered an adenoma of the pigmented ciliary-body epithelium (browner and hyperechogenic) and two were classified as adenomas of the non-pigmented ciliary epithelium (whitish appearance and medium-echogenicity).

CONCLUSION

Ultrasound biomicroscopy allows a reasonable clinicalsonographic suspicion of ACE. An initial conservative management is proposed as a safer option for stable, mildly symptomatic patients, avoiding aggressive sight threatening treatments.

Diagnostic and Management Challenges of Ciliary Body Tumor in an African-American Patient

<b><i>Purpose:</i></b> To discuss the diagnostic and management challenges of a ciliary body tumor in an African-American patient. <b><i>Procedures:</i></b> Our 52-year-old African-American female patient, referred with a nasal ciliary body tumor in the right eye, underwent investigations including A- and B-scan ultrasonography, Optos fundus photography and fundus fluorescein angiography at clinical consultation. A diagnostic fine-needle aspiration cytology and open flap biopsy were undertaken. <b><i>Results:</i></b> Histopathology and cytology confirmed a malignant melanoma, which is extremely rare in the African-American population. The patient was treated with brachytherapy with an iodine-131 plaque ensuring adequate coverage of the tumor site but, at the same time, taking special precaution not to disturb the biopsy site. <b><i>Conclusions:</i></b> The diagnosis of a ciliary body tumor, especially in an African-American patient, can be challenging despite advances in imaging systems, given the multitude of differential diagnoses. Uveal melanomas are extremely rare in African-Americans. On detailed questioning, our patient reported having mixed ancestry, with Caucasian ancestors on the mother's side and native Indian ancestors on the father's side. Information on true ethnicity should be specifically asked for as it alters the incidence rate. Biopsy provides the only option for a correct diagnosis and for developing a management plan. Fine-needle aspiration biopsy can be diagnostic, though an open flap biopsy is superior as it provides information on tissue architecture and the possibility of immunohistochemistry. Also, with plaque brachytherapy treatment, special care needs to be taken not to disturb the biopsy site to reduce the risk of seeding, and an innovative approach may need to be taken to ensure adequate radiation coverage of these anterior tumors.

Explaining The Current Role Of High Frequency Ultrasound In Ophthalmic Diagnosis (Ophthalmic Ultrasound)

Ultrasound has become as indispensable as indirect ophthalmoscopy or slit lamp in evaluation of the eye. It is an important adjuvant for the clinical assessment of a variety of ocular and orbital diseases. Advances in instrumentation, higher frequencies and more sensitivity and resolution have resulted in continuous improvement in image quality.Very high frequency ultrasound uses frequencies in the range of 35 to 100 MHz to show greater detail of the anterior segment. Penetration is limited for these higher frequencies to only a few millimeters and thus only the anterior vitreous behind the ciliary body and lens can be imaged. High frequency ultrasound in the range of 20 to 30 MHz has a penetration of about 10 mm and can be used for posterior pole evaluation of the retina and choroid.

Uveal melanoma: Ocular and systemic disease

Although rare, uveal melanoma is the most common intraocular tumor in adults. Most cases arise from the choroidal layer of the uvea, displaying a discoid, collar-button, or mushroom shaped growth. Histopathologically, neoplasms are classified by the dominant cell type: spindle, epithelioid or mixed spindle cell type. The most important prognostic factors are cell type, nucleolar size, largest tumor dimension, and mitotic figures. Patient prognosis is poor when metastases occur in the liver, one of the main reasons that despite advances in the diagnosis and treatment of uveal melanoma, the mortality rate has not change significantly since 1973.

Ultrasound biomicroscopy of the ciliary body in ocular/oculodermal melanocytosis

PURPOSE

To describe the ultrasound biomicroscopy (UBM) findings of the ciliary body in patients with ocular/oculodermal melanocytosis.

DESIGN

Retrospective observational case series study.

METHODS

A retrospective chart and imaging database review was conducted for patients with unilateral ocular/oculodermal melanocytosis who underwent UBM examination at the Ocular Oncology Clinic of Princess Margaret Hospital. Radial images of the ciliary body at the 3-, 6-, 9-, and 12-o'clock positions were obtained in both eyes. UBM characteristics included ciliary body thickness and reflectivity. The eye with ocular/oculodermal melanocytosis was compared with the contralateral unaffected eye as a control. Statistical significance was analyzed with Student t test.

RESULTS

Twelve patients were included. All patients showed unilateral diffuse pigmentation involving episclera and anterior chamber angle. The iris showed diffuse pigmentation in 10 cases and sectorial in 2. Mean ciliary body thickness of the affected eyes was 0.581 ± 0.058 mm (range 0.489-0.744) compared with 0.475 ± 0.048 mm (range 0.406-0.622) in the contralateral eye, which was found to be a statistically significant difference (P < .001). The affected ciliary body showed hyperreflectivity when compared with the unaffected eye. All affected eyes were graded as medium to high reflectivity compared with the unaffected eyes that showed a medium to medium/low reflectivity.

CONCLUSION

Ciliary body involvement in ocular/oculodermal melanocytosis presents as increased thickness and higher ultrasound reflectivity on UBM when compared with the unaffected eye. UBM is helpful in imaging clinically undetectable areas of melanocytosis involving the ciliary body.

Semiautomatic extraction algorithm for images of the ciliary muscle

PURPOSE

To develop and evaluate a semiautomatic algorithm for segmentation and morphological assessment of the dimensions of the ciliary muscle in Visante Anterior Segment Optical Coherence Tomography images.

METHODS

Geometric distortions in Visante images analyzed as binary files were assessed by imaging an optical flat and human donor tissue. The appropriate pixel/mm conversion factor to use for air (n = 1) was estimated by imaging calibration spheres. A semiautomatic algorithm was developed to extract the dimensions of the ciliary muscle from Visante images. Measurements were also made manually using Visante software calipers. Interclass correlation coefficients and Bland-Altman analyses were used to compare the methods. A multilevel model was fitted to estimate the variance of algorithm measurements that was due to differences within- and between-examiners in scleral spur selection vs. biological variability.

RESULTS

The optical flat and the human donor tissue were imaged and appeared without geometric distortions in binary file format. Bland-Altman analyses revealed that caliper measurements tended to underestimate ciliary muscle thickness at 3 mm posterior to the scleral spur in subjects with the thickest ciliary muscles (t = 3.6, p < 0.001). The percent variance due to within- or between-examiner differences in scleral spur selection was found to be small (6%) when compared with the variance because of biological difference across subjects (80%). Using the mean of measurements from three images, achieved an estimated interclass correlation coefficient of 0.85.

CONCLUSIONS

The semiautomatic algorithm successfully segmented the ciliary muscle for further measurement. Using the algorithm to follow the scleral curvature to locate more posterior measurements is critical to avoid underestimating thickness measurements. This semiautomatic algorithm will allow for repeatable, efficient, and masked ciliary muscle measurements in large datasets.

Long-term follow-up of 42 patients with small ciliary body tumors with ultrasound biomicroscopy

PURPOSE

To establish the growth behavior of small ciliary body tumors in a relatively large cohort of patients over an extended period.

DESIGN

Retrospective, noncomparative case series.

METHODS

Ciliary body tumors less than 4 mm in size within the penetration power of ultrasound biomicroscopy (UBM) were included. Tumor height was assessed by ultrasound biomicroscopy. Tumor growth was defined as an increase in height of at least 20% from baseline, as measured on 2 consecutive UBM readings. The data were collected longitudinally, and a statistical analysis was performed.

RESULTS

Forty-two patients were included in the study with a median follow-up of 9.0 years (range, 1.0 to 17.2 years). The median age was 59 years (range, 17 to 82 years). Median initial tumor height was 2.05 mm (range, 1.11 to 3.80 mm). The overall average rate of growth was 0.0014 mm per year (P = .68). The 5- and 10-year accumulative tumor growth rates were 12% and 29%, respectively. In the first 3 years after diagnosis, the growth rate of ciliary body lesions with an initial tumor thickness less than or equal to 2 mm was 0.054 mm per year (P = 0.0001); thereafter, tumor size appeared to stabilize. Tumors with an initial thickness greater than 2 mm showed a small but significant rate of regression of 0.0125 mm per year (P = 0.04).

CONCLUSIONS

Most small tumors of the ciliary body show little growth over an extended period and can be managed conservatively without invasive diagnostic interventions. However, long-term follow-up is required. Indications for treatment include growth in height or lateral extension, extrascleral extension or the need for cataract surgery.