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Damato BE. Can the MOLES acronym and scoring system improve the management of patients with melanocytic choroidal tumours? Eye (Lond) 2022; 37:830-836. [PMID: 35764877 PMCID: PMC9244298 DOI: 10.1038/s41433-022-02143-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/05/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
It can be difficult for practitioners to determine the likelihood of malignancy in melanocytic choroidal tumours. This author has therefore devised the MOLES acronym to highlight the most informative clinical features, which comprise mushroom shape, orange pigment, large size, enlargement, and subretinal fluid. Each of these is scored 0 if absent, 1 if subtle or uncertain, and 2 if present. Tumours are categorised as ‘common naevus’, ‘low-risk naevus’, ‘high-risk naevus’ and ‘probable melanoma’ according to whether the sum of these five scores is 0, 1, 2 or 3 or more, respectively. Tentative recommendations, subject to future studies, include: review of ‘common naevi’ by a community optometrist whenever the patient attends for another reason, such as a two-yearly ‘check-up’ (i.e., ‘self-care’); non-urgent referral of patients with ‘low-risk naevi’ or ‘high-risk naevi’ to an ophthalmologist to plan long-term surveillance (i.e., determining the frequency of assessments and whether these should be undertaken by an ophthalmologist or a community optometrist); and urgent referral of patients with a MOLES score >2 (i.e., ‘probable melanoma’) to an ophthalmologist for immediate referral to an ocular oncologist if a suspicion of malignancy is confirmed. The MOLES system does not require assessment of internal acoustic reflectivity by ultrasonography. MOLES scores correlate well with diagnosis of choroidal naevi and melanomas by ocular oncologists; however, further evaluation of this aid in routine optometric practice and other situations is needed. MOLES should prevent unnecessary referral of patients with naevi for second opinion and non-essential monitoring of these patients at hospital eye services.
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Affiliation(s)
- Bertil E Damato
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, and Ocular Oncology Service, Moorfields Eye Hospital, London, UK.
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2
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Bolling JP, Dagan R, Rutenberg M, Mamalui-Hunter M, Buskirk SJ, Heckman MG, Hochwald AP, Slopsema R. Treatment of Uveal Melanoma With Radioactive Iodine 125 Implant Compared With Proton Beam Radiotherapy. Mayo Clin Proc Innov Qual Outcomes 2022; 6:27-36. [PMID: 35005435 PMCID: PMC8715138 DOI: 10.1016/j.mayocpiqo.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective To review the current state of radiation therapy for uveal melanoma and compare particle radiation and brachytherapy. Patients and Methods The medical records of 156 patients treated for uveal melanoma between May 30, 2012, and March 16, 2020, were retrospectively reviewed. Treatments consisted of either radioactive iodine 125 implant (RAI) or fractionated proton radiation (proton beam therapy [PBT]). Baseline characteristics were compared using a Wilcoxon rank sum test or χ2 test. Outcomes were compared using Cox proportional hazards regression models or logistic regression models. Results The median length of follow-up after treatment was 2.7 years (range, 0.5 to 9.0 years). Patients who underwent treatment with RAI were older (median age, 67 vs 59 years; P<.001) and had a lower tumor classification (American Joint Commission on Cancer; P=.001) compared with those who underwent PBT. There was no significant difference between RAI and PBT in the outcomes of liver metastases, death, enucleation, tearing, vision loss, retinal detachment, tumor thickness, conjunctivitis, optic neuropathy, iris neovascularization, or neovascular glaucoma (all P>.05). Patients who underwent RAI treatment had significantly higher risk of diplopia (P<.001), cataract progression (P<.001), and maculopathy (P=.03) compared with those who received PBT. Patients who underwent RAI were at higher risk of eyelash loss (P=.006) compared with the PBT group. Conclusion Treatment with PBT and RAI has similar efficacy; however, there are differences in the adverse outcomes associated with these 2 modalities.
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Affiliation(s)
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
| | - Michael Rutenberg
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
| | - Maria Mamalui-Hunter
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville
| | | | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Alexander P Hochwald
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Roelf Slopsema
- Department of Radiation Oncology, Emory University Proton Therapy Center, Winship Cancer Institute, Atlanta, GA
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Negretti GS, Harley U, Arora AK, Hay G, Sagoo MS, Damato BE. Detecting Progression of Treated Choroidal Melanomas: Is Ultrasonography Necessary? Cancers (Basel) 2021; 13:cancers13225832. [PMID: 34830987 PMCID: PMC8616414 DOI: 10.3390/cancers13225832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Long-term surveillance following radiotherapy for choroidal melanoma is important for detecting recurrence. There is a perceived notion that regular ultrasonography is required to detect recurrence. The skills required to perform ocular ultrasound are not widely available, which can prevent patients being seen close to home. We aimed to determine whether local treatment failure can reliably be detected with colour fundus photography alone. We found that in 74 out of 75 patients (98.7%), with a clear view of their fundus, recurrence could be detected using colour photography alone. One patient with a clear fundal view developed extraocular extension which was detected on ultrasound without visible change in the intraocular part of the tumour. We conclude that most treated choroidal melanomas can be monitored without ultrasonography if they can be adequately imaged with colour photography. Abstract Prompt detection and treatment of local treatment failure after radiotherapy for choroidal melanoma optimises any opportunities for conserving vision and the eye, possibly reducing an increased risk of metastatic disease. Long-term surveillance is therefore required but is hampered by the perceived need to perform ultrasonography, which may not be available at a patient’s local hospital. The aim of this study was to determine whether local treatment failure can reliably be detected with colour fundus photography alone, and, if so, in which patients. Patients were included in the study if diagnosed with local treatment failure between April 2016 and February 2021 after eye-conserving therapy for choroidal melanoma. Wide-field colour and fundal autofluorescence (FAF) images, optical coherence tomography (OCT), and ultrasonography (US) were analysed by two of the authors (GN and UH). The cohort included 87 patients with local treatment failure. In 75 patients with clear media, tumour progression was detected by colour photography alone in 74 (98.7%) patients. Sensitivity was not increased by the addition of either OCT or AF. One patient with clear media developed extraocular extension detected with US without visible change in the intraocular part of the tumour. In the other 12 patients, US was required because of opaque media and a consequently poor fundal view. Local treatment failure after radiotherapy for choroidal melanoma is detected in 98.7% of cases with colour photography when the media are clear. Ultrasonography is useful when photography is prevented by opaque media or tumours having locations in the far periphery.
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Affiliation(s)
- Guy S. Negretti
- Ocular Oncology Service, Moorfields Eye Hospital, London EC1V 2PD, UK; (U.H.); (A.K.A.); (G.H.); (M.S.S.); (B.E.D.)
- Correspondence: ; Tel.: +44-2075662251
| | - Umiya Harley
- Ocular Oncology Service, Moorfields Eye Hospital, London EC1V 2PD, UK; (U.H.); (A.K.A.); (G.H.); (M.S.S.); (B.E.D.)
- Ocular Oncology Service, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
| | - Amit K. Arora
- Ocular Oncology Service, Moorfields Eye Hospital, London EC1V 2PD, UK; (U.H.); (A.K.A.); (G.H.); (M.S.S.); (B.E.D.)
| | - Gordon Hay
- Ocular Oncology Service, Moorfields Eye Hospital, London EC1V 2PD, UK; (U.H.); (A.K.A.); (G.H.); (M.S.S.); (B.E.D.)
- Department of Ophthalmology, St. Bartholomew’s Hospital, London EC1A 7BE, UK
- UCL Institute of Ophthalmology, 11-43 Bath Street, London EC1V 9EL, UK
| | - Mandeep S. Sagoo
- Ocular Oncology Service, Moorfields Eye Hospital, London EC1V 2PD, UK; (U.H.); (A.K.A.); (G.H.); (M.S.S.); (B.E.D.)
- UCL Institute of Ophthalmology, 11-43 Bath Street, London EC1V 9EL, UK
- NIHR Biomedical Research Centre, at Moorfields Eye Hospital and University College London Institute of Ophthalmology, 11-43 Bath Street, London EC1V 9EL, UK
| | - Bertil E. Damato
- Ocular Oncology Service, Moorfields Eye Hospital, London EC1V 2PD, UK; (U.H.); (A.K.A.); (G.H.); (M.S.S.); (B.E.D.)
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Al Harby L, Sagoo MS, O'Day R, Hay G, Arora AK, Keane PA, Cohen VML, Damato B. Distinguishing Choroidal Nevi from Melanomas Using the MOLES Algorithm: Evaluation in an Ocular Nevus Clinic. Ocul Oncol Pathol 2021; 7:294-302. [PMID: 34604203 PMCID: PMC8443944 DOI: 10.1159/000511363] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/02/2020] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine the sensitivity and specificity of the MOLES scoring system in differentiating choroidal melanomas from nevi according to Mushroom shape, Orange pigment, Large tumor size, Enlarging tumor, and Subretinal fluid (SRF). METHODS Color photographs, fundus-autofluorescence images, and optical coherence tomography of 222 melanocytic choroidal tumors were reviewed. Each MOLES feature was retrospectively scored between 0 and 2 and tumors categorized as "common nevus," "low-risk nevus," "high-risk nevus," and "probable melanoma" according to the total score. MOLES scores were compared with the experts' diagnosis of melanoma. RESULTS The MOLES scoring system indicated melanoma in all 81 tumors diagnosed as such by ocular oncologists (100% sensitivity) and nevus in 135 of 141 tumors given this diagnosis by these experts (95.7% specificity). Of the 6 tumors with discordant diagnoses, 4 had basal diameters exceeding 6 mm, all with SRF and/or orange pigment, and 2 small tumors showed either significant SRF with traces of orange pigment, or vice versa. CONCLUSIONS The MOLES system for diagnosing melanocytic choroidal tumors compares well with expert diagnosis but needs to be evaluated when deployed by ophthalmologists and community optometrists in a wide variety of working environments.
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Affiliation(s)
- Lamis Al Harby
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- University College London Institute of Ophthalmology, London, United Kingdom
| | - Mandeep S. Sagoo
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- University College London Institute of Ophthalmology, London, United Kingdom
| | - Roderick O'Day
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
| | - Gordon Hay
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- University College London Institute of Ophthalmology, London, United Kingdom
| | - Amit K. Arora
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
| | - Pearse A. Keane
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- University College London Institute of Ophthalmology, London, United Kingdom
| | - Victoria M.-L. Cohen
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
| | - Bertil Damato
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Soleimani M, Mehrpour M, Mohammad-Rabei H. Ophthalmic practice during COVID-19 pandemic. Int J Ophthalmol 2021; 14:639-642. [PMID: 34012876 DOI: 10.18240/ijo.2021.05.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/11/2021] [Indexed: 11/23/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) pandemic has caused significant changes in ophthalmic practice. The initial strategy of strict restriction of elective activities has been replaced with various guidelines to revitalize ophthalmic procedures considering the new safety concerns. In this manuscript, we reviewed recent recommendations for ophthalmic practice in different fields of ophthalmology during the COVID-19 pandemic.
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Affiliation(s)
- Mohammad Soleimani
- Ocular Trauma and Emergency Department, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran 1336616351, Iran
| | - Mohammad Mehrpour
- Ocular Trauma and Emergency Department, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran 1336616351, Iran
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Zubair T, Rajeshuni N, Mruthyunjaya P. Do Racial/Ethnic Disparities in Rates of Enucleation for Uveal Melanoma Indicate Poor Quality of Care or Financial Obstacles?-Reply. JAMA Ophthalmol 2021; 139:488-489. [PMID: 33570551 DOI: 10.1001/jamaophthalmol.2020.6831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Talhah Zubair
- Department of Ophthalmology, University of Minnesota, Minneapolis
| | - Nitya Rajeshuni
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Prithvi Mruthyunjaya
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
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Detecting Progression of Melanocytic Choroidal Tumors by Sequential Imaging: Is Ultrasonography Necessary? Cancers (Basel) 2020; 12:cancers12071856. [PMID: 32664236 PMCID: PMC7408899 DOI: 10.3390/cancers12071856] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/20/2020] [Accepted: 07/07/2020] [Indexed: 02/03/2023] Open
Abstract
Purpose: To determine if ultrasonography is necessary to detect progression of choroidal melanocytic tumors undergoing sequential multi-modal imaging with color photography, autofluorescence (AF) and optical coherence tomography (OCT). Methods: All patients with choroidal melanoma undergoing treatment at Moorfields Eye Hospital between January 2016 and March 2020 were reviewed to identify those with treatment deferred by ≥2 months. Tumors that showed progression prior to treatment, defined as an increase in (a) basal dimensions (b) thickness (c) orange pigment and/or (d) sub-retinal fluid, were included. Mushroom shape, Orange pigment, Large size, Enlargement and Sub-retinal fluid (MOLES) scores were assigned to all tumors at earliest date and date of treatment. Results: A total of 99 patients with a mean age of 66 years (range: 26-90) were included. The initial MOLES score was 1 in 2 cases, 2 in 23 cases, and ≥3 in 74 cases. Progression was detected with sequential color photography alone in 100% of MOLES 1/2 and 97% of lesions with a MOLES score of ≥3. When findings on AF and OCT were included, sensitivity for detecting subtle change without ultrasonography improved to 100% for MOLES 3 and 97% for MOLES 4/5. Only one patient included in this study had an isolated increase in thickness that may have been missed had sequential ultrasonography not been performed. Overall, the sensitivity for detecting progression with color photographs alone was 97% (95% CI 93-100%) and increased to 99% (95% CI 97-100%) by including autofluorescence and OCT. Conclusions: Monitoring of choroidal nevi, particularly those classified as MOLES 1 or 2 (i.e., low-risk or high-risk naevi), can be accomplished safely without the need for ultrasonography. The findings of this study may remove barriers to the implementation of tele-oncology clinics for the monitoring of choroidal melanocytic tumors.
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The MOLES System for Planning Management of Melanocytic Choroidal Tumors: Is It Safe? Cancers (Basel) 2020; 12:cancers12051311. [PMID: 32455720 PMCID: PMC7281649 DOI: 10.3390/cancers12051311] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To evaluate the MOLES system for identifying malignancy in melanocytic choroidal tumors in patients treated for choroidal melanoma. METHODS Records of 615 patients treated for choroidal melanoma between January 2017 and December 2019 were reviewed. Patients were excluded if iris and/or ciliary body involvement (106 patients), inadequate fundus photography (26 patients), no images available for review (21 patients) and/or treatment was not primary (11 patients). Demographic data and AJCC TNM Stage were collected. Color fundus and autofluorescence photographs (FAF), optical coherence tomography (OCT) and B-scan ultrasounds were prospectively reviewed. MOLES scores were assigned according to five criteria: mushroom shape, orange pigment, large size, enlarging tumor and subretinal fluid. RESULTS A total of 451 patients (mean age, 63.9 ± 13.9 years) were included. At treatment, mean largest basal tumor diameter (LBD) and thickness were10.3 ± 2.8 mm (range, 3.0-23.0) and 4.3 mm (range, 1.0-17.0). All but one (0.2%) had MOLES scores of ≥3. Eighty-two patients were treated after surveillance lasting a mean of 1.5 years. Initially, most (63/82; 76.8%) had a MOLES score ≥ 3. Importantly, none of the 451 tumors had a score of <2, and as such, the MOLES protocol would have indicated referral to an ocular oncologist for 100% of patients. CONCLUSION The MOLES scoring system is a sensitive (99.8%) tool for indicating malignancy in melanocytic choroidal tumors (MOLES ≥ 3). If the examining practitioner can recognize the five features suggestive of malignancy, MOLES is a safe tool to optimize referral of melanocytic choroidal tumors for specialist care.
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