Uveal malignant melanoma associated with ocular and oculodermal melanocytosis

Oculodermal melanocytosis in Asian Indian patients: Prevalence, clinical presentation, and association with choroidal melanoma

OBJECTIVE

To study the prevalence, clinical presentation, treatment, and follow-up of ocular (dermal) melanocytosis (ODM) and its association with choroidal melanoma (CM) in Asian Indian patients.

METHODS

This was a retrospective case series of patients with ODM conducted in a quaternary eye care center.

RESULTS

Of the total 1.48 million patients during the study period, we identified 213 patients with ODM with a prevalence rate of 0.014%. Median age at presentation was 13 years (range 0-76 years). Unilateral presentation of ODM was noted in 87% cases. ODM involved the sclera in 100% cases, the iris in 23%, the choroid in 20%, the eyelid in 29%, and V1 and V2 dermatomes in 53% cases. Nineteen patients (9%) were found to have CM, with 1.3 times increased risk of CM compared to the Caucasian population. The most common tumor location was in the inferior quadrant (n = 8, 44%). The mean tumor thickness was 8.3 ± 2.8 mm with a mean basal diameter of 14.0 ± 4.3 mm. Primary treatment of CM included plaque brachytherapy (n = 6), enucleation (n = 9), and few patients refused for treatment (n = 3). During a mean follow-up period of 21 months, one patient died because of lung metastasis.

CONCLUSION

Although rare, choroidal melanoma does occur in the presence of ODM with an increased risk in Asian Indians compared to the Caucasian population. Patients with ODM should be examined periodically for early detection of CM.

A case of choroidal melanocytosis observed by multimodal imaging with laser speckle flowgraphy

BACKGROUND

Choroidal melanocytosis is characterized by congenital diffuse melanin pigmentation with extensive parenchymal infiltration of spindle cells in the choroid; however, little is known about the choroidal circulation and morphological changes. We herein report a case of choroidal melanocytosis observed by multimodal imaging with laser speckle flowgraphy (LSFG).

CASE PRESENTATION

A 56-year-old woman was referred to our hospital because of serous retinal detachment (SRD) in her left eye. At the initial examination, her best-corrected visual acuity (BCVA) was 1.5 oculus dexter (OD) and 0.8 oculus sinister (OS). An irregular, flat, brownish lesion was noted around the macula OS. Optical coherence tomography showed a choroidal structure with marked hyporeflectivity and SRD where the retinal thickness was preserved. Indocyanine green angiography demonstrated fluorescence blockade throughout. Fundus autofluorescence revealed enlarged macular hypofluorescence, suggesting chronic retinal pigment epithelium damage associated with prolonged SRD. B-mode echography showed no choroidal elevation. Based on the clinical findings, the left eye was diagnosed with choroidal melanocytosis. Four years and 10 months after the initial visit, her BCVA was 0.5 and SRD remained. During the entire period of observation, the mean blur rate (MBR) (mean ± standard deviation) of choroidal blood flow velocity on LSFG was 10.15 ± 0.72 arbitrary units (AU) OD and 1.31 ± 0.06 AU OS.

CONCLUSION

Choroidal melanocytosis presented with chronic minor circulatory disturbances due to melanocyte proliferation in the choroid, but the markedly low MBR values by LSFG were dissociated from her retinal thickness and visual function. The proliferation of melanocytes may be a cause of overestimating the cold-color signal of LSFG due to their pigmentation.

An update on ophthalmological perspectives in oculodermal melanocytosis (Nevus of Ota)

PURPOSE

To provide a review of the literature on oculodermal melanocytosis (ODM) with a focus on the diagnostic and therapeutic implications of multimodal imaging techniques in the management of ophthalmic complications.

METHODS

The authors carried out a literature search on PubMed, Medline, and Scopus of English language articles published on ODM through August 2021. This review presents traditional and novel diagnostic methods in the diagnosis and follow-up of patients with particular emphasis on addressing the role of imaging in the management of the ophthalmic complications of the condition towards improving current practice patterns.

RESULTS

ODM is a rare, prevalently unilateral, congenital condition that presents with brown or blue/gray flat asymptomatic lesions of the skin, mucosae, episclera/sclera, and uvea localized within the territory of distribution of the ophthalmic and mandibular branches of the trigeminal nerve. Glaucoma and predisposition to uveal melanoma are the main ophthalmic complications. Diagnosis and management are through comprehensive opthalmological examination and traditional imaging methods such as ultrasonography and fluorescein/indocyanine green angiography as pigmentation of the fundus can conceal subtle retinal and choroidal alterations. Anterior segment optical coherence tomography and ultrasound biomicroscopy are used to evaluate the anterior segment and the ciliary body in the presence of glaucoma or melanoma of the anterior uveal tract. Fundus autofluorescence and retinal pigment epithelium (RPE) alterations are of aid in the differential diagnosis between choroidal nevi and melanoma. Enhanced depth imaging spectral domain optical coherence tomography offers outstanding in vivo evaluation of the dimensions and details of tumors or nevi and surrounding choroidal tissues and small choroidal melanomas may show distortions of the retinal and sub-retinal profile, presence of intra and sub-retinal fluid, abnormalities of the RPE, and compression of the choriocapillaris.

CONCLUSIONS

Novel multimodal imaging techniques are significant in the diagnosis and management of the ophthalmic complications of ODM. Fundus autofluorescence and enhanced depth spectral domain optical coherence tomography have adjunctive value in the detection of early-stage melanoma and differential diagnosis between nevi and melanoma. Awareness of current and emerging imaging techniques can propagate improved standardized definition and assessment of the complications of ODM.

Clinical Characteristics of UM and Association of Metastasis of Uveal Melanoma with Congenital Oculocutaneous Melanosis in Asian Patients: Analysis of 1151 Consecutive Eyes

PURPOSE

To analyze the clinical characteristics of uveal melanoma (UM) and evaluate the relationship of congenital oculocutaneous melanosis (OCM) to the prognosis of Asian patients with UM.

DESIGN

Retrospective cohort study.

PARTICIPANTS

We included a total of 1151 Asian patients with UM who were managed at the Beijing Tongren Hospital from June 26, 2005, to July 27, 2020.

METHODS

I-125 plaque brachytherapy, local resection, thermotherapy, or enucleation.

MAIN OUTCOME MEASURES

Melanoma-related metastasis and death.

RESULTS

Of 1151 Asian patients with UM, congenital OCM was present in 23 (0.20%). The melanocytosis involved the conjunctiva (78%), sclera (74%), eyelid (70%), face (26%), forehead (2.2%), iris (0.87%), choroid (0.87%), and auricle (0.4%). Univariate analysis of Cox proportional hazards regression model showed that age, tumor thickness, largest tumor basal diameter, and ciliary body involvement were the risk factors for the poor prognosis of Asian patients with UM. By multivariable analysis, the only factor predictive of melanoma-related metastasis and death was the largest tumor basal diameter (hazard ratio [HR], 1.21 [1.11-1.33], P < .001; 1.17 [1.01-1.35], P = 0.033). Probability-of-censoring weighted (IPW) estimation was used to mitigate selection bias due to loss to follow-up. Probability-of-censoring weighted estimation revealed the largest tumor basal diameter and ciliary body involvement were associated with metastasis (HR, 1.29 [1.15-1.45], P < 0.001; HR, 2.64 [1.01-6.90], P < 0.048). During the median follow-up period of 53 (33-67) months, 2 patients with OCM (8.7%) developed melanoma-related metastasis. By using nested case-control design and matched with the factors of age, largest tumor basal diameter, tumor thickness, and ciliary body involvement, Kaplan-Meier survival analysis showed that UM combined with OCM did not increase the risk of melanoma-related metastasis and death (P = 0.68, log-rank test).

CONCLUSIONS

The prominent risk for metastasis from UM was the largest tumor basal diameter in Asian patients. Estimation of IPW revealed that the largest tumor basal diameter and ciliary body involvement were the risk factors for UM metastasis. Patients with UM combined with OCM had a similar risk for metastasis compared with those with no OCM.

Isolated choroidal melanocytosis: clinical update on 37 cases

PURPOSE

Isolated choroidal melanocytosis is a congenital melanocytic hyperpigmentation involving the choroid that is not associated with iridic or scleral features of ocular melanocytosis. The purpose of this work was to describe the clinical features and course of a relatively large series of patients with this disorder.

METHODS

A retrospective clinical study of 37 patients with isolated choroidal melanocytosis encountered in a single practice 1986-2018 was done. All lesions were 5 mm or larger in the largest basal diameter, homogeneously melanotic, and completely flat by conventional ocular ultrasonography.

RESULTS

The 37 patients ranged in age from 2 weeks to 87 years (mean 31.5 years, median 18 years) at initial diagnosis of the melanotic choroidal lesion. Arc length largest basal diameter of the melanotic choroidal lesion ranged from 5.5 to 37 mm (mean 14.6 mm, median 13 mm). The lesion extended beneath the fovea in 18 eyes and to the optic disc margin in 6 eyes. Ten of the lesions straddled the ocular equator, but the center point of all of the lesions was posterior to the equator. The retina was fully attached and appeared normal over the melanotic choroidal lesion in each of these eyes. None of the melanotic choroidal lesions exhibited clumps of orange pigment or drusen on its surface. The lesion was unilateral and unifocal in 36 of the 37 patients. One patient had bilateral choroidal melanocytosis that was isolated in one eye but associated with partial iris melanocytosis in the fellow eye. Three adult patients had a choroidal melanoma localized to the patch of choroidal melanocytosis at baseline. One other adult patient had a choroidal melanoma in the fellow eye at baseline. One pediatric patient had viable unilateral non-familial retinoblastoma in the fellow eye and two adult patients had a classic choroidal nevus in the fellow eye. None of the flat patches of choroidal melanocytosis that were monitored periodically after initial diagnosis expanded appreciably during follow-up ranging from 4.9 months to 15.2 years (mean 5.0 years, median 2.3 years).

CONCLUSIONS

Isolated choroidal melanocytosis is a distinct clinical entity that must be distinguished from broad-based choroidal nevus, choroidal melanocytoma, small choroidal malignant melanoma, acquired bilateral patchy-streaky choroidal melanocytic fundopathy associated with disorders such as cutaneous vitiligo and Waardenburg syndrome, acquired bilateral zonal choroidal melanocytic fundopathy, and diffuse uveal melanocytic proliferation associated with systemic cancer. This disorder appears to predispose affected eyes to development of choroidal melanoma arising from the hypermelanotic patch.

Congenital choroidal melanocytoma in a child with ocular melanocytosis

A 1-day-old child was brought to the clinic for evaluation of enlarged right eye (OD). On examination, OD showed buphthalmos with diffuse scleral melanocytosis, fleshy blackish-brown extrascleral mass with corneal extension, and secondary glaucoma. Anterior segment evaluation revealed darkly pigmented iris and fundus evaluation OD revealed a darkly pigmented choroidal lesion. The left eye was within normal limits. A clinical diagnosis of choroidal melanocytoma with ocular melanocytosis was made. Enucleation OD followed by orbital implant was performed. Histopathology showed features of diffuse ocular melanocytosis involving limbus, iris, ciliary body, choroid, sclera, optic nerve head, optic nerve sheath, along with choroidal melanocytoma with extrascleral tumour extension. We presume that choroidal melanocytoma may have arisen from ocular melanocytosis.

Primary Episcleral Melanoma Consistent with Uveal Melanoma Mutations Treated by Excision and Gamma Knife Stereotactic Radiosurgery

Ocular melanocytosis has traditionally been associated with increased risk of developing uveal melanoma; however, rarely primary episcleral melanoma has been reported in the literature. Herein, we present the third case of primary episcleral melanoma treated by complete excision and cryotherapy. In contrast to previous cases, we obtained molecular genetic testing which revealed a GNA-11 mutation, and gene expression profiling resulted in a Class 2 PRAME positive tumor diagnosis. These two tests which have never been performed on previous cases, support lineage similar to uveal melanoma. In addition, we are the first case to report treatment of the surgical bed and surrounding orbital tissue with Gamma Knife stereotactic radiotherapy to both treat residual tissue and decrease risk of recurrence.

Clinical and histopathological features of choroidal melanoma-related enucleated eyes in a Spanish tertiary hospital

OBJECTIVE

To study clinical and pathological variables leading to a poor prognosis in a sample of uveal malignant melanoma patients who required eyeball enucleation as final treatment approach. All patients were seen and treated in the same public tertiary hospital in Madrid (Spain) within a 6-year time-period.

MATERIALS AND METHODS

Longitudinal observational retrospective study. The presence of clinical and pathologic factors known to be linked to poor prognosis, as well as other features, was assessed in 30 malignant melanoma: 20 de novo-enucleated malignant melanoma eyes (group A), and 10 in eyes that received radiotherapy prior to enucleation (group B). The diagnostic reliability of magnetic resonance imaging was assessed by comparing it with the histology results (gold standard) as a means to detect scleral and extra-scleral extension.

RESULTS

Tumour size, Bruch's membrane rupture, scleral infiltration, and distance to the optic nerve were the most decisive factors for a poor prognosis in the study sample. In 93% of cases the condition was under control, with a 6% incidence rate of metastatic spread and a 100% rate of overall survival for a mean follow-up period of 3±1.5 (range 1.2-6) years. In the study population, the sensitivity of the magnetic resonance imaging to detect scleral infiltration was 27%, which increased to 100% for identifying extra-scleral involvement.

CONCLUSIONS

The analyses of the clinical and pathological data collected within the framework of this study justify enucleation as the treatment of choice for the patients of this study. Magnetic resonance imaging was not found to be an optimum screening method to detect scleral infiltration in this study sample.

Multifocal Primary Uveal Melanoma: Clinical and Molecular Characteristics

We report two patients who developed a second distinct choroidal melanoma in the same eye following successful regression of their first choroidal melanoma after iodine-125 plaque brachytherapy. Neither patient demonstrated ocular melanocytosis, local tumor recurrence, or vitreous seeding. One patient had the second tumor arising from a previously documented choroidal nevus, and after undergoing enucleation, there was no detectable connection between the tumors on histopathologic examination. Germline BAP1 mutation was absent in both cases. Multifocal primary uveal melanoma is a rare entity in which the second tumor may occur either de novo or from a malignant transformation of a choroidal nevus. Known risk factors include ocular melanocytosis or germline BAP1 mutation. Additional underlying mechanisms have yet to be elucidated.

Disparities in Uveal Melanoma: Patient Characteristics

Uveal melanoma is the most common intraocular malignancy in adults. Despite excellent rates of local control, half of all patients with uveal melanoma ultimately go on to develop fatal metastatic disease. This review focuses on disparities and differences in the underlying characteristics of the patients, and how these patient characteristics impact the development of metastasis and subsequent patient survival. Specifically, we detail disparities in epidemiology and risk factors as they relate to the development of primary uveal melanoma, to the development of metastasis, and to patient survival following metastasis.

SUBMILLIMETER CHOROIDAL MELANOMA DETECTION BY ENHANCED DEPTH IMAGING OPTICAL COHERENCE TOMOGRAPHY IN A PATIENT WITH OCULODERMAL MELANOCYTOSIS

PURPOSE

To describe a tiny subclinical choroidal melanoma visualized only with enhanced depth imaging optical coherence tomography in a newly symptomatic patient with known oculodermal melanocytosis.

METHODS

Case report.

RESULTS

A 52-year-old white man with heterochromia and known oculodermal melanocytosis of the right eye, followed for 2 years without change, developed blurred vision and was referred for possible central serous chorioretinopathy. On examination, visual acuity was 20/20 in each eye. There was oculodermal melanocytosis in the right eye involving the periocular skin, episclera, iris, and choroid. On ophthalmoscopy and ocular ultrasonography, there was no appreciable mass, but subtle subfoveal fluid and perifoveal orange pigment were detected, as well as equatorial drusen. Enhanced depth imaging optical coherence tomography demonstrated a subtle optically dense focal choroidal mass measuring 4.5 mm in basal dimension and 0.7 mm in enhanced depth imaging optical coherence tomography thickness. There was choroidal vascular compression, obliteration of choroidal details, and related overlying subretinal fluid with shaggy photoreceptors, consistent with early choroidal melanoma in an eye with oculodermal melanocytosis. The patient elected early treatment considering the risk factors for growth and the risk for metastasis associated with melanoma in the setting of oculodermal melanocytosis. Plaque radiotherapy was performed with complete tumor regression clinically and by enhanced depth imaging optical coherence tomography. At 2-year follow-up, visual acuity remains 20/20, with regressed tumor and no systemic metastasis.

CONCLUSION

Enhanced depth imaging optical coherence tomography is a useful tool in the evaluation of eyes with oculodermal melanocytosis, permitting high-resolution visualization of the choroid and detection of submillimeter early melanoma that might not be apparent with indirect ophthalmoscopy or ultrasonography.

The occurrence and proposed significance of Schnabel cavernous degeneration in uveal melanoma

IMPORTANCE

Schnabel cavernous degeneration (SCD) has been observed in eyes with uveal melanoma (UM), but, to our knowledge, a definitive study establishing the association between SCD and UM has not been conducted.

OBJECTIVE

To explore an association between SCD and UM.

DESIGN, SETTING, AND PARTICIPANTS

A historical cohort analysis was performed using histologic slides and related clinical records of cases from the Collaborative Ocular Melanoma Study and Eye Pathology Laboratory at the University of Wisconsin, including 1985 UM eyes, 517 eye bank eyes, and 155 enucleated glaucomatous eyes.

MAIN OUTCOMES AND MEASURES

The prevalence of SCD was calculated and compared between each group; subgroup analysis was also conducted of eyes with and without SCD for the prevalence of glaucoma.

RESULTS

Schnabel cavernous degeneration was seen in 17 (0.9%) UM eyes, 9 (1.7%) eye bank eyes, and 2 (1.3%) enucleated glaucomatous eyes. No difference was detected between the prevalence of SCD in UM eyes and eye bank eyes (odds ratio [OR], 0.49; 95% CI, 0.22-1.10) or enucleated glaucomatous eyes (OR, 0.66; 95% CI, 0.15-2.89). Subgroup analysis, performed on 421 UM eyes, provided sufficient clinical information to definitively establish the presence or absence of glaucoma. Of the 95 (22.6%) eyes with glaucoma, 11 (11.6%) revealed histopathologic evidence of SCD. Compared with enucleated end-stage glaucoma eyes, this represents a 10-fold increase in SCD in UM eyes with glaucoma (OR, 10.10; 95% CI, 2.17-46.26). The prevalence of glaucoma in UM eyes with SCD, however, was respectively 7- and 15-fold higher than the prevalence of glaucoma in SCD-negative UM eyes (OR, 6.98; 95% CI, 2.51-19.43) and SCD-positive eye bank eyes (OR, 14.67; 95% CI, 1.46-146.97).

CONCLUSIONS AND RELEVANCE

Although an association between SCD and UM was not confirmed, subgroup analysis did reveal an increased incidence of SCD in eyes with both UM and glaucoma. This suggests that the occurrence of glaucoma may increase the risk of SCD in eyes with UM.

Epidemiology and management of uveal melanoma

Uveal melanoma is the most common primary intraocular malignancy in adults. The disease overwhelmingly affects white populations. Other risk factors include fair skin, light iris color, ancestry from northern latitudes, and ocular/oculodermal melanocytosis. Historically, enucleation was the definitive treatment of uveal melanoma, but brachytherapy and proton beam irradiation are now the most commonly used treatment methods. However, there are still no effective therapies against metastatic uveal melanoma, which is almost always fatal. Continued advances in understanding of the molecular mechanisms of uveal melanoma will facilitate the identification of prognostic markers and therapeutic targets.

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.

Don't it make my blue eyes brown: heterochromia and other abnormalities of the iris

Eye colour is one of the most important characteristics in determining facial appearance. In this paper I shall discuss the anatomy and genetics of normal eye colour, together with a wide and diverse range of conditions that may produce an alteration in normal iris pigmentation or form.

Sector (partial) oculo(dermal) melanocytosis in 89 eyes

PURPOSE

To describe sector (partial) involvement of the uvea with melanocytosis.

DESIGN

Noninterventional, retrospective case series.

PARTICIPANTS

A total of 89 eyes of 86 patients.

METHODS

Review of medical records, color photographs, and ultrasound images.

MAIN OUTCOME MEASURES

Clinical features and relationship with uveal melanoma.

RESULTS

Approximately all patients were Caucasian (n = 83, 97%), and sector melanocytosis involved the right (n = 41, 46%) or left (n = 48, 54%) eye. The involved tissue included iris (n = 58, 65%), choroid (n = 48, 54%), and both iris and choroid (n = 17, 19%). The melanocytosis affected a mean of 6 clock hours of iris and 5 clock hours of choroid. Related melanocytosis involved the sclera (n = 39, 44%), eyelid (n = 4, 4%), temple (n = 4, 4%), scalp (n = 1, 1%), and palate (n = 1, 1%). Uveal melanoma was found at presentation in 7 patients (8%) and was multifocal in 2 of these patients. A comparison of eyes with versus without melanoma revealed clinically significant factors (odds ratio [OR] > 2) of male gender (71% vs. 43% [OR 3.36]); cutaneous/palate melanocytosis (14% vs. 7% [OR 2.11]); scleral melanocytosis heaviest in superior, temporal, or nasal quadrants (57% vs. 29% [OR 2.41, confidence interval, 2.24-3.92]); and any degree of choroidal melanocytosis (86% vs. 70% [OR 2.63]), particularly diffuse choroidal melanocytosis (29% vs. 16% [OR 3.85]). None of these factors reached statistical significance in this small cohort. Over a mean follow-up of 6 years, there was no metastatic event.

CONCLUSIONS

Ocular melanocytosis can be sectoral (partial), affecting only a mean of 5 to 6 clock hours of the uvea and can manifest melanoma within the melanocytosis region. There were no specific features of melanocytosis statistically related to the presence of melanoma.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Prevalence of ocular and oculodermal melanocytosis in Spanish population with uveal melanoma

PURPOSE

The aim of this study was to determine the prevalence of ocular and oculodermal melanocytosis (ODM) among patients with uveal melanoma (UM) in a Spanish population.

METHODS

Retrospective review of the medical records of patients with ODM among patients with UM.

RESULTS

Ten (11 eyes) of 400 patients (2.7%) with UM associated had ODM. The mean age at diagnosis of UM among patients with ODM was 62 years. One patient had bilateral tumours. UM was diagnosed during a routine-examination in two cases. All tumours were medium (7/11) or large (4/11) in size, with a mean maximum base of 13 mm and height of 7 mm. No patient had extraocular extension or metastatic disease at diagnosis. Enucleation was done in five cases and I-125-brachytherapy in six. The mean follow-up was 43 months. One patient died because of metastasis 2 years after enucleation; one patient is currently on treatment of systemic metastasis 11 years after.

CONCLUSIONS

ODM is more frequent in spanish population with UM than in American population. Despite the risk of UM in ODM, it is often diagnosed late when a conservative treatment is not indicated.

Malignant melanoma of the choroid in the eye with oculodermal melanocytosis of a Chinese woman

In this study, we report a rare case of choroidal melanoma in an eye with oculodermal melanocytosis (Nevus of Ota). A 56-year-old Taiwanese woman with oculodermal melanocytosis in the right eye was found to have an ipsilateral uveal melanoma. Histopathology of the enucleated eye confirmed the diagnosis of malignant choroidal melanoma of mixed cell type. A search of the literature revealed strong evidence that oculodermal melanocytosis can predispose to the development of uveal melanoma in Caucasians. Only seven such cases have been reported in the East Asian population. This is believed to be the first such reported case in a patient of Chinese descent.

Cyclo-oxygenase-2 expression in photon-radiated and non-radiated uveal melanomas

PURPOSE

To determine and compare cyclo-oxygenase-2 (COX-2) expression in photon-radiated and non-radiated malignant uveal melanomas and to analyse the correlation between COX-2 expression and prognosis.

METHODS

Immunohistochemical staining for COX-2 was performed on 21 uveal melanomas that were endoresected after prior stereotactic radiotherapy with photons and on 22 tumours that were treated by endoresection without prior radiotherapy. COX-2 staining was further analysed in respect to cell type, maximal prominence, time interval between radiotherapy and surgery, apoptotic index (AI), proliferative index (PI) and the development of metastatic disease.

RESULTS

There was no difference in COX-2 expression between radiated and non-radiated melanomas (P>0.15). COX-2 staining correlated with neither the tumour prominence (P>0.40) nor the AI or the PI (both P>0.35). Tumours with high COX-2 expression were significantly more likely to develop metastasis (P=0.022).

CONCLUSION

Radiotherapy with photons does not induce COX-2 expression in malignant melanomas of the uvea. But high COX-2 expression may be a marker for poor prognosis.

Choroidal malignant melanoma in a 6-year-old girl without melanocytosis

PURPOSE

To describe a case of choroidal malignant melanoma in a child without ocular melanocytosis.

METHODS

A 6-year-old girl presented with misalignment of the right eye of a few weeks' duration. Visual acuity was counting fingers in the right eye and 20/20 in the left eye. Ophthalmoscopy of the right eye revealed a well defined choroidal mass in the macular region measuring 10 mm in diameter with overlying subretinal fluid. Ultrasonography revealed that the mass was 10.1 mm thick with choroidal excavation. On the basis of clinical and ultrasonographic findings, the diagnosis was choroidal melanoma without ocular melanocytosis. The eye was enucleated.

RESULTS

Histopathologic examination revealed malignant melanoma of the choroid. There was not extrascleral extension.

CONCLUSION

Choroidal malignant melanoma can occur in young patients, even in the absence of melanocytosis.

Iris melanoma arising in iris nevus in oculo(dermal) melanocytosis

A 50-year-old white man with oculo(dermal) melanocytosis and longstanding iris nevus was found to have growth of the iris mass. Excision and histopathologic examination revealed a mixed cell type malignant melanoma. Benign nevus cells were present at the periphery of the tumor surrounding the entire melanoma. White patients with oculo(dermal) melanocytosis have a predisposition to uveal melanoma, which is usually choroidal in origin. Literature review showed only three confirmed cases of iris melanoma in this setting. Two additional cases initially published as spindle A melanoma have been reclassified as iris nevi based on the modified Callender classification of uveal melanomas. It is recommended that patients with oculo(dermal) melanocytosis be followed for the occurrence of uveal melanoma.

Iridociliary melanoma associated with ocular melanocytosis in a 6-year-old boy

A previously healthy 6-year-old boy presented to the ophthalmologist and was found to have congenital ocular melanocytosis associated with uveal melanoma. He was treated with enucleation of the affected eye and has shown no evidence of tumor recurrence or metastasis through over 20 years of postenucleation follow-up. Ocular melanocytosis can be associated with uveal melanoma even in young children.

Malignant melanoma of the conjunctiva

BACKGROUND

Conjunctival melanoma is a relatively rare ocular malignancy with substantial associated morbidity and mortality.

METHODS

More than 100 articles on conjunctival melanoma were reviewed, including most of the relevant recent publications cited in a current MEDLINE search. The author's experience with conjunctival melanomas is also incorporated in this review.

RESULTS

Recognition of their precursor lesions at an early stage is important. Staging of the disease by sentinel lymph node biopsy is now advocated in some centers. Surgical excision with adjuvant cryotherapy and alcohol corneal epithelialectomy is usually effective in eradicating most of these lesions. Extensive cases of flat primary acquired melanosis with atypia may be managed with mitomycin C. Multifocal and advanced melanoma, especially in cases showing intraocular or orbital invasion, may require exenteration and/or radiotherapy to adequately extirpate the neoplasm locally. However, systemic metastases already may have occurred in these patients with advanced disease.

CONCLUSIONS

Conjunctival melanoma is a condition of concern because of its rarity and lethal potential. Advances in the understanding and management of this neoplasm have markedly reduced the mortality and possibly the morbidity associated with this malignancy.

Isolated choroidal melanocytosis: a distinct clinical entity?

PURPOSE

The objective was to describe a distinct, limited form of congenital ocular melanocytosis that involves the choroid only.

METHODS

A retrospective descriptive case series study of 11 patients with similar appearing broad-based but entirely flat melanotic choroidal lesions was carried out.

RESULTS

All 11 lesions were homogeneously dark brown in color with at least one striated margin. They were located in various regions of the fundus from the macula and juxtapapillary area to the periphery. They ranged in size from 6 to 23 mm in the largest basal diameter, but all 11 were completely flat. The youngest patient was only 2 months old when the lesion was first detected, but the oldest was 82 years old. None of the 7 lesions that were re-evaluated over a median follow-up of 4 years enlarged or changed appreciably otherwise.

CONCLUSIONS

The choroidal lesions described in this report may be a distinct, limited form of congenital ocular melanocytosis. We refer to these lesions as "isolated choroidal melanocytosis." Lesions of this type may predispose affected patients to choroidal melanoma.

Les mélanocytes choroïdiens normaux et malins : de la cellule à la clinique

The molecular and cellular basis of human choroidal malignant melanoma progression has remained largely unknown. However, choroidal melanoma is the most important primary intraocular tumor in adults. Developmentally, choroidal melanocytes are of neural crest origin similar to cutaneous melanocytes. However, there are some significant differences between cutaneous and uveal melanocytes that have yet to be fully assessed. The purpose of this study is to describe choroidal melanocytes. We will describe the significant differences between cutaneous and uveal melanocytes as well as the congenital and acquired diseases of uveal melanocytes. We will then describe the cellular and molecular mechanisms involved in melanoma progression.

Primary choroidal melanoma in phakomatosis pigmentovascularis IIa

PURPOSE

To describe a previously unreported association between phakomatosis pigmentovascularis (PPV) IIa and primary choroidal melanoma.

DESIGN

Case series.

PARTICIPANTS

Three patients with PPV type IIa and choroidal melanoma.

RESULTS

Nevus flammeus was present unilaterally in each patient, involving the hemiface, the hemithorax, or both. Ocular melanocytosis also was present unilaterally in all patients involving the sclera, the iris, the choroid, the distribution of the trigeminal nerve, or a combination thereof. Renal cysts were noted in patient 1, and a nevus anemicus of the neck was noted in patient 3. A unilateral choroidal melanoma was detected in each of these 3 patients, in each patient involving the same eye in which melanocytosis had been seen. No metastases were found in any patient.

CONCLUSIONS

Clinicians should be aware of the possibility that PPV, and in particular that occurring in patients with ocular melanocytosis, can be associated with choroidal melanoma.

Mode of presentation and time to treatment of uveal melanoma in Finland

AIMS

To investigate the current referral pattern and delays in treatment of patients with primary uveal melanoma.

METHODS

184 consecutive Finnish patients with uveal melanoma diagnosed between July 1994 and June 1999 were eligible, and 159 were enrolled (inclusion rate, 86%). Their mean age was 60 years (range 14-87). The dates of visits to dispensing optician, physician, ophthalmologist and ocular oncologist, the presence of symptoms, and reason for consultation were determined by structured telephone interview. Time intervals to treatment planning and treatment were calculated.

RESULTS

139 patients (87%) had symptoms at presentation and 44 patients (28%) had been seen by an ophthalmologist less than 2 years previously. The median height of the tumour was 6 mm (range, 1.0-17.0) and its largest basal diameter 11 mm (range 2.5-22.0) at diagnosis. Melanoma developed from a previously detected presumed naevus in 13 patients (8%). When the first contact was a dispensing optician (15%) the median time to treatment planning was 22 days (range 1-1156). When a physician other than an ophthalmologist (19%) was contacted the delay was 68 days (range 0-1283) and when an ophthalmologist (65%) was seen it was 34 days (range 1-1426). These differences were not significant (p=0.32). The chance of being referred at first visit was 89%. Median time to treatment was not associated with symptoms (p=0.16) and tumour volume (p=0.29), but it was significantly different between patients who were and were not referred at first visit (140 days v 34 days; p<0.001) and between those treated by ruthenium and iodine brachytherapy (59 days v 33 days; p=0.009).

CONCLUSIONS

Analysis of delays in management indicates that earlier treatment could be achieved if dilated fundus examinations were performed without exceptions, all suspicious naevi were referred for a second opinion, and if the patients with melanoma were referred to the ocular oncology service concurrently with staging examinations done at the regional hospital.

Two discrete choroidal melanomas in an eye with ocular melanocytosis

We report a case of multifocal choroidal melanoma arising in an eye with ocular melanocytosis and review the pertinent literature. A 63-year-old Caucasian male with ocular melanocytosis in the left eye was found to have two discrete choroidal melanomas in the same eye. Histopathology of the enucleated eye confirmed the diagnosis of two discrete choroidal melanomas of mixed cell type within a region of choroidal melanocytosis. It is estimated that 1 in 160,000 patients with unilateral ocular melanocytosis may develop two uveal melanomas, based on the reported data. On the basis of random chance, patients with two melanomas in the same eye would be expected to have approximately 1000-fold greater likelihood of underlying ocular melanocytosis than the general Caucasian population. In conclusion, multifocal choroidal melanoma is rare and may be related to underlying ocular melanocytosis.

The influence of aging and low zinc nutrition on the choroid in the pig: I. The melanocyte

The effects of low zinc nutrition and aging on central choroidal melanocytes were examined in the pig. Three populations of pigs (young, pregnant and aged), were maintained on either control (C) or low zinc (LZ) diets. Twenty-five weanling boars were sacrificed at 2, 4, 8, 10, and 12-month intervals, and nine pregnant sows and eight aged sows were sacrificed after a 6-month interval. Melanocytes of the central choroid were morphologically and morphometrically examined. The melanocyte was found to be conservative in its form, which was mostly elliptical longitudinal profile, throughout the different age populations that were fed the C diet. Morphometric observations revealed that this cell type increased in size in the oldest animals, having been 40% greater than that in the younger two populations. However, the overall percentage area occupied by melanocytes remained the same throughout all age groups. In the animals that were fed the LZ diets, a large subpopulation of choroidal melanocytes was oval to round in shape in the pregnant and aged groups. Many members of this subpopulation possessed less opaque pigment than the elliptically shaped cell. Measurements of the size and percentage area occupied in these oldest groups increased significantly. In addition to the change of size, shape and melanin opaqueness, unusually large melanosomes were consistently observed in the pregnant and aged LZ groups. Low zinc nutrition had a remarkable age-related impact on the usually quiescent melanocyte.

Pigmented lesions of the conjunctiva

A careful examination of the conjunctiva and ocular adnexa should be performed as part of a complete dermatologic examination. This article reviews the clinical presentation and classification of pigmented lesions of the conjunctiva. The histologic features of these conjunctival lesions are compared with those of pigmented lesions of the skin.

Ocular melanomas and melanocytic lesions of the eye

This article describes several melanocytic lesions of the eye. Benign and malignant lesions will be discussed as well as a review of the dysplastic nevus syndrome and its proposed association with ocular melanoma. Ocular melanomas arise from the same embryologically derived melanocytes as their cutaneous counterparts. However, ocular and cutaneous melanomas differ in many respects. The diagnosis and management of these ocular tumors rely heavily on the ophthalmologist. However, knowledge of melanocytic lesions will aid the dermatologist in detection and in proper referral of these patients.

Lifetime prevalence of uveal melanoma in white patients with oculo(dermal) melanocytosis

OBJECTIVE

In the white population, an association between oculo(dermal) melanocytosis (ODM) and uveal melanoma is well recognized. However, the lifetime prevalence of uveal melanoma in the ODM population is not known. This study was designed to determine the lifetime prevalence of uveal melanoma among patients with ocular melanocytosis.

DESIGN

Fifty-six white patients manifesting ODM with uveal melanoma formed the basis of the study.

MAIN OUTCOME MEASURES

Published prevalence rates of ODM and uveal melanoma were used for calculations using Bayes' theorem.

RESULTS

The lifetime prevalence of uveal melanoma in white patients with ODM is estimated to be 2.6 x 10(-3). The median age at diagnosis of uveal melanoma in the ODM population was similar to a randomly selected population (60.5 years and 62.5 years, respectively). In the vast majority of patients (90%) with ODM-associated uveal melanoma, the uveal melanoma was diagnosed between the ages of 31 years and 80 years.

CONCLUSIONS

One of about 400 patients with ODM followed for life is estimated to develop uveal melanoma. Excessive melanocytes in the uveal tract in ODM may provide the biologic basis for susceptibility to the development of uveal melanoma. Patients with ODM should be monitored ophthalmoscopically, especially during the susceptible period, for the development of uveal melanoma. The authors suggest that a national registry of ODM patients be created and prospective data collected to better assess the risk of developing uveal melanoma.

Posterior uveal melanoma. The Swedish perspective

Posterior uveal melanoma is the most common primary intraocular malignant tumour and in Sweden some 70-80 new cases present each year. While uveal melanoma is more prevalent in the setting of ocular melanocytosis and neurofibromatosis, there is little conclusive data on the aetiology. Most patients experience a progressive visual field defect and present with a grey or greyish-brown mass of the posterior choroid. Diagnostic procedures include fluorescein angiography, ultrasound and magnetic resonance imaging. In some cases, intraocular biopsy may be required to make a correct diagnosis. Posterior uveal melanomas can usually be managed by any of a number of eye-preserving options like plaque radiotherapy and charged particle irradiation, but eyes containing large tumours are often enucleated. Nearly half of patients with posterior uveal melanoma, and in particular those with large tumours, ultimately succumb to metastatic disease. While most patients with tumour dissemination are treated with systemic chemotherapy possibly combined with interferon, metastatic spread confined to the liver may potentially be managed by intraarterial perfusion chemotherapy or liver resection. However, outcome of patients with systemic disease remains extremely poor with a median survival following detectable tumour dissemination of only two to five months. There are still insufficient data on the impact of various treatments on survival, but a large prospective trial addressing this issue is in progress. The present review summarizes the state-of-the-art knowledge and current management of posterior uveal melanoma from a Swedish perspective.