Metastatic cutaneous malignant melanoma of the vitreous and retina

Local Excision of Retinal Metastasis from Cutaneous Melanoma

The incidence of cutaneous melanoma is constantly rising. Ocular involvement is rare and the choroid is the most accessible structure to metastatic emboli.

The case described is noteworthy on account of several particular features:

1) the missed diagnosis of the primary malignancy. This might be because either cutaneous melanoma or cutaneous nevi show several common features;

2) the rarity of the retinal metastatic site. Unlike the choroid, the retina is an unusual metastatic site but, regardless of organ blood flow, the metastatic efficiency may be related to interactions between tumour cells and host tissue;

3) the treatment of the retinal metastasis, excised conservatively. As far as we know, this is the first report of a retinal metastasis being treated by local resection.

Intraocular Metastases--A Review

Intraocular metastases almost invariably arise in the uveal tract, mostly in the posterior choroid. They are the most common type of intraocular malignancy and often the first sign of tumor dissemination. Choroidal metastases generally appear as a creamy white or pale yellow mass associated with subretinal fluid and may be multifocal and bilateral. The most common primary sites are breast and lung. Diagnosis is aided by a variety of tests, particularly ultrasonography and optical coherence tomography. Intraocular biopsy is useful in patients with clinical suspicion of uveal metastasis but no evidence of primary malignancy despite systemic evaluation. If systemic treatment fails to control the ocular tumor, a good response is usually achieved with local therapies such as external beam radiation therapy, photodynamic therapy, and transpupillary thermotherapy. The life expectancy of patients with choroidal metastases is generally poor but has been improving thanks to the therapeutic advances taking place.

A case of cutaneous melanoma metastatic to the vitreous cavity: possible pathomechanism and review of the literature

BACKGROUND

Isolated vitreous metastases are extremely rare and the pathogenesis of metastasis is still unclear. Here we present the detailed description of the disease progression in a 68-year-old patient with vitreous seeding of a metastatic cutaneous melanoma beginning at a very early stage.

METHODS

Interventional case report and review of the literature.

RESULTS

The initial retrohyaloidal metastatic lesion was identified adjacent to a small epiretinal hemorrhage. As the disease progressed golden brown spherules appeared in the posterior vitreous emanating from the area of the lesion. Further progression led to a dense metastatic infiltration of the entire vitreous cavity and a decline of the visual acuity to 20/1200. Diagnostic and therapeutic pars plana vitrectomy was performed to confirm the diagnosis and preserve the eye and useful vision.

CONCLUSIONS

For the first time the formation of vitreous metastases derived from cutaneous melanoma was carefully studied beginning at a very early stage. This made it possible to analyze the rare mechanism of vitreous metastasis, which has not been conclusively known till now. The features of metastatic cutaneous melanoma to the vitreous are discussed in context of a review of the literature that resulted from the study of 17 patients with 22 affected eyes.

Systemic melanoma metastatic to the retina and vitreous

PURPOSE

Report of a case of retinal and vitreous metastases of a systemic melanoma, possibly arising in the lung, that responded favourably to radiotherapy.

CASE REPORT

Retinal and vitreous metastases were demonstrated in a 57-year-old woman during routine follow-up after surgical resection of a melanoma presumed to be a primary pulmonary melanoma. After a 7-week observation period, which confirmed the progressive nature of the intra-ocular lesions, the patient was treated by external beam radiotherapy at a dose of 35 Gy delivered in 14 fractions of 2.5 Gy. Complete disappearance of the vitreous invasion and progressive elimination of the retinal invasion were observed over a period of 9 months. Final visual function was 20/25. REVIEW OF PUBLISHED CASES: A review of the literature identified 28 cases of melanoma with metastases to the retina and vitreous. In almost all of these cases, the primary tumour was a cutaneous melanoma and the mean patient survival following the diagnosis of intra-ocular metastases was 22 months. Retinal metastases, as in the case reported here, present a vascular tropism and tend to develop around veins. These metastases are generally unilateral and may be either solitary or multiple. Tumour invasion of the vitreous occurred by means of isolated cells forming a suspension of aggregates or spherules. Vitreous haemorrhage and irreducible neovascular glaucoma leading to functional impairment, which requires enucleation, were both the most frequent and the most serious complications of these metastases. Treatment is always palliative and is effective in cases with limited retinal and vitreous invasion, as in the case reported here.

CONCLUSIONS

Metastatic melanoma in the retina and vitreous is a rare entity and can lead to functional impairment and enucleation because of neovascular glaucoma. As treatment is only effective in cases with limited invasion, systematic screening is recommended in all patients with a metastatic cutaneous melanoma presenting with suggestive ocular symptoms.

Cutaneous melanoma metastatic to the vitreous cavity

OBJECTIVE

The authors report their experience with cutaneous melanoma metastatic to the vitreous and elaborate on the features of this entity.

DESIGN

The study design was a retrospective review.

PARTICIPANTS

Three patients with four affected eyes from cutaneous melanoma metastatic to the vitreous participated.

INTERVENTION

All three patients were white men, and their mean age was 58 years. The previously excised cutaneous melanomas were all Clark level IV. The mean interval from diagnosis of the primary cutaneous melanoma to vitreous metastasis was 25 months. Ocular findings included clumps of cells arranged in sheets or linear strands on the vitreous framework. The vitreous cells were nonpigmented in two cases and pigmented in one case. Neovascular glaucoma was found in all three cases. After the diagnosis of vitreous melanoma was made by cytopathologic examination, external beam irradiation (5000 cGy) was given in all patients.

MAIN OUTCOME MEASURES

Local tumor control and survival were measured.

RESULTS

At a mean follow-up of 14 months from diagnosis of vitreous melanoma, tumor control was achieved in only one of the four affected eyes. One eye was enucleated because of painful neovascular glaucoma, and the other two eyes had progressive vitreous disease. After a mean follow-up of 14 months (from ocular diagnosis), all three patients had died.

CONCLUSION

Cutaneous melanoma metastatic to the vitreous can present with nonpigmented or pigmented cells. Neovascular glaucoma frequently is found. External beam radiation therapy often is unsuccessful in local tumor control, and systemic prognosis is poor.