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Yelta YS, Singh N, Oakey Z, Wrenn J, Singh AD. Choroidal Nevi in Children: Size, Growth, and Topographic Distribution. Am J Ophthalmol 2024; 266:102-109. [PMID: 38762092 DOI: 10.1016/j.ajo.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE To explore size, growth, and topographic distribution of choroidal nevi in children to gain insights into choroidal nevogenesis. DESIGN Retrospective consecutive case series using pediatric clinic - and population-study data, comparing to adult data. METHODS Clinical data from Cole Eye Institute (CEI) database (December 2005-January 2023) was derived from a retrospective consecutive case series of 20 children (< 20 years) with choroidal nevi. For population data, 48 children from previously reported pooled data of the participants of the Sydney Pediatric Eye Disease Study, Sydney Myopia Study, Sydney Childhood Eye Study, and Sydney Adolescent Vascular and Eye Disease Study were included. Fundus photographs were reviewed and the locations of 18 choroidal nevi seen at CEI with widefield imaging were mapped on a radial scatter plot. For comparison, 100 consecutive adults with choroidal nevi were identified from CEI database. Main outcomes were size, growth, and topographic distribution of choroidal nevi. RESULTS The median largest basal diameter was 1.6 mm (range 0.4-4.2) in children. Most choroidal nevi (75%) remained stable, and 16% demonstrated growth at follow-up. The mean growth rate was calculated as 0.12 mm/year (range 0.10-0.15). Malignant transformation was not noted during childhood. All secondary changes (drusen, orange pigment, and subretinal fluid) associated with choroidal nevi in children were less common than those in adults (p < .05). Choroidal nevi in children were located significantly more posterior than in adults. The median distance to fovea was 2.1 mm (range 0.5-8.5) in children and 5.1 mm (range 0.4-16) in adults (p < .0001). CONCLUSIONS The onset and growth of choroidal nevi in children suggest active choroidal nevogenesis in childhood. A posterior topographic distribution may support the developmental framework for migration and maturation of choroidal melanoblasts.
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Affiliation(s)
- Yağmur Seda Yelta
- From the Department of Ophthalmic Oncology (Y.S.Y., Z.O., J.W., A.D.S.), Cole Eye Institute, Cleveland, Ohio, USA
| | - Nakul Singh
- Wilmer Eye Institute (N.S.), Johns Hopkins University, Baltimore, Maryland, USA
| | - Zackery Oakey
- From the Department of Ophthalmic Oncology (Y.S.Y., Z.O., J.W., A.D.S.), Cole Eye Institute, Cleveland, Ohio, USA
| | - Jacquelyn Wrenn
- From the Department of Ophthalmic Oncology (Y.S.Y., Z.O., J.W., A.D.S.), Cole Eye Institute, Cleveland, Ohio, USA
| | - Arun D Singh
- From the Department of Ophthalmic Oncology (Y.S.Y., Z.O., J.W., A.D.S.), Cole Eye Institute, Cleveland, Ohio, USA.
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Damato B, Eleuteri A, Taktak A, Hussain R, Fili M, Stålhammar G, Heimann H, Coupland SE. Deferral of Treatment for Small Choroidal Melanoma and the Risk of Metastasis: An Investigation Using the Liverpool Uveal Melanoma Prognosticator Online (LUMPO). Cancers (Basel) 2024; 16:1607. [PMID: 38672688 PMCID: PMC11048814 DOI: 10.3390/cancers16081607] [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: 03/25/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND We estimated metastatic-death risk when the treatment of small choroidal melanomas is deferred until growth is observed. METHODS In 24 patients with choroidal melanoma (median diameter 5.85 mm), the exponential growth rate estimated by a mixed-effects model was 4.3% per year. Using the Liverpool Uveal Melanoma Prognosticator Online v.3 (LUMPO3), we measured changes in 15-year metastatic and non-metastatic death risks according to whether the tumor is treated immediately or after observing growth 4 or 12 months later, considering age, sex, and metastasis predictors. RESULTS In 40-year-old females with 10 mm, disomy 3 and monosomy 3 choroidal melanomas (prevalence 16%), the 15-year absolute risks of metastatic death are 4.2% and 76.6%, respectively, increasing after a 4-month delay by 0.0% and 0.2% and by 3.0% and 2.3% with tumor growth rates of 5.0% and 20.0%, respectively. With 12-month delays, these risks increase by 0.0% and 0.5% and by 1.0% and 7.1%, respectively. Increases in metastatic-death risk are less with smaller tumors and with a higher risk of non-metastatic death. CONCLUSIONS Deferring treatment of choroidal melanomas until documentation of growth may delay iatrogenic visual loss by months or years and is associated with minimal increase in metastatic mortality, at least with small tumors with usual growth rates of up to 40% per year.
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Affiliation(s)
- Bertil Damato
- Ocular Oncology Service, St. Erik Eye Hospital, 17164 Stockholm, Sweden; (M.F.); (G.S.)
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, 17177 Solna, Sweden
- Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool L7 8XT, UK
- Ocular Oncology Service, Moorfields Eye Hospital, London EC1V 2PD, UK
| | - Antonio Eleuteri
- NHS Digital Services, Liverpool University Hospitals NHS Foundation Trust, Kilby House, Liverpool Innovation Park, Liverpool L7 9NJ, UK;
| | - Azzam Taktak
- Clinical Engineering, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS2 8HW, UK;
| | - Rumana Hussain
- Ocular Oncology Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (R.H.); (H.H.)
| | - Maria Fili
- Ocular Oncology Service, St. Erik Eye Hospital, 17164 Stockholm, Sweden; (M.F.); (G.S.)
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, 17177 Solna, Sweden
| | - Gustav Stålhammar
- Ocular Oncology Service, St. Erik Eye Hospital, 17164 Stockholm, Sweden; (M.F.); (G.S.)
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, 17177 Solna, Sweden
| | - Heinrich Heimann
- Ocular Oncology Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; (R.H.); (H.H.)
| | - Sarah E. Coupland
- Department of Eye and Vision Science, University of Liverpool, Liverpool L7 8XT, UK;
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Incidence and Risk Factors for Secondary Glaucoma in Eyes with Uveal Melanoma. Ophthalmol Glaucoma 2023; 6:29-41. [PMID: 35964940 DOI: 10.1016/j.ogla.2022.08.002] [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: 04/25/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To estimate incidence of and analyze risk factors for developing secondary glaucoma in eyes with uveal melanoma before and after diagnosis. DESIGN A cross-sectional, population-based cohort study. PARTICIPANTS Seven hundred eighty-one patients (median age, 64 years; range, 14-93) consecutively diagnosed with uveal melanoma from 1997 to 2012 in a national ocular oncology service, 708 (91%) of whom received ruthenium (50%) or iodine (50%) brachytherapy. METHODS Patient, tumor, treatment, and follow-up data were collected prospectively. Frequency and associations of melanoma-related glaucoma at tumor diagnosis were assessed. Incidence of developing secondary glaucoma after diagnosis was estimated by Kaplan-Meier analysis. Independent risk factors were modeled using Cox regression. MAIN OUTCOME MEASURES Melanoma-related glaucoma and related risk factors. RESULTS Forty-five patients (5.8%; 95% confidence interval [CI], 4.2-7.6) had tumor-related secondary glaucoma at diagnosis, 34 (76%) from a narrow-to-closed angle (25 had direct angle invasion) and 10 (22%) from anterior neovascularization. Synchronous metastases were common in patients with initial secondary glaucoma (11% vs. 1.2% with incident glaucoma, P = 0.005). Patients with secondary glaucoma were often male (58% vs. 48% without glaucoma; P = 0.010) and had larger tumors (median thickness, 9.1 vs. 4.0 mm; P < 0.001) involving the ciliary body (43% vs. 21%; P < 0.001) with retinal detachment (53% vs. 30%; P < 0.001). One hundred and sixty-eight patients 165 of which were treated with brachytherapy developed incident tumor- or treatment-related secondary glaucoma a median of 1.7 years (range, 0.1-13.6) after tumor diagnosis. Cumulative proportion of developing secondary glaucoma was 23% (95% CI, 20-27) at 5 years. The most common mechanism was neovascularization in 119 patients (71%; 95% CI, 63-78). By multivariable regression, initial retinal detachment 3 to 4 quadrants (hazard ratio [HR], 2.18; P < 0.001), initial intraocular pressure 17 mmHg or higher (HR, 1.64; P = 0.01), and tumor thickness predicted incident secondary glaucoma. CONCLUSIONS Secondary glaucoma at initial uveal melanoma diagnosis predicts high risk of synchronous metastases. Although anterior neovascularization is the most common mechanism for secondary glaucoma after diagnosis, other mechanisms such as angle narrowing and anterior chamber hemorrhage are not infrequent. Initial retinal detachment and intraocular pressure with tumor thickness could inform interim assessments of intraocular pressure and neovascularization.
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Zhou X, Ishikawa H, Gomi F. Macular hole and vitreous hemorrhage subsequent to stereotactic hypofractionated radiotherapy for choroidal melanoma: A case report and review of the literature. Front Oncol 2022; 12:1060307. [PMID: 36483031 PMCID: PMC9723233 DOI: 10.3389/fonc.2022.1060307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
Choroidal melanoma is the leading primary intraocular tumor with potentially fatal outcomes in adults. The coexistence of choroidal melanoma and a macular hole is extremely rare, and treatment strategies and information on the prognosis of associated complications are currently lacking. We report the first case of choroidal melanoma complicated with a macular hole and vitreous hemorrhage after stereotactic hypofractionated radiotherapy in Japan, and review the relevant literature in relation to the possible mechanisms, treatment strategies, and outcomes. An 83-year-old male with choroidal melanoma was treated with stereotactic hypofractionated radiotherapy in January 2021. Five months later, a full-thickness macular hole developed, followed by an acute massive vitreous hemorrhage about 2 weeks later. Following confirmation of tumor regression, the patient underwent a pars plana vitrectomy and internal limiting membrane peeling. The macular hole was closed postoperatively and the patient’s best-corrected visual acuity improved to 20/125. There was no evidence of intraocular tumor dissemination or distant metastases during follow-up. A systematic literature search only identified 10 previous cases of choroidal melanoma with a macular hole in eight reports worldwide, mainly in females. Macular edema may be the primary cause of macular hole formation in these cases. Most patients who underwent vitrectomy for complications after tumor regression achieved a good prognosis. The development of a macular hole is a rare complication associated with choroidal melanoma. Anterior-posterior traction of posterior vitreous detachment and secondary macular edema may have contributed to the formation of the macular hole in the current case.
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Affiliation(s)
- Xiaoyin Zhou
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroto Ishikawa
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
- Department of Ophthalmology, Mirai Eye & Skin Clinic, Osaka, Japan
- *Correspondence: Hiroto Ishikawa,
| | - Fumi Gomi
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
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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: 0] [Impact Index Per Article: 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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Rantala ES, Hernberg MM, Piperno-Neumann S, Grossniklaus HE, Kivelä TT. Metastatic uveal melanoma: The final frontier. Prog Retin Eye Res 2022; 90:101041. [PMID: 34999237 DOI: 10.1016/j.preteyeres.2022.101041] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022]
Abstract
Treatment of primary intraocular uveal melanoma has developed considerably, its driver genes are largely unraveled, and the ways to assess its risk for metastases are very precise, being based on an international staging system and genetic data. Unfortunately, the risk of distant metastases, which emerge in approximately one half of all patients, is unaltered. Metastases are the leading single cause of death after uveal melanoma is diagnosed, yet no consensus exists regarding surveillance, staging, and treatment of disseminated disease, and survival has not improved until recently. The final frontier in conquering uveal melanoma lies in solving these issues to cure metastatic disease. Most studies on metastatic uveal melanoma are small, uncontrolled, retrospective, and do not report staging. Meta-analyses confirm a median overall survival of 10-13 months, and a cure rate that approaches nil, although survival exceeding 5 years is possible, estimated 2% either with first-line treatment or with best supportive care. Hepatic ultrasonography and magnetic resonance imaging as surveillance methods have a sensitivity of 95-100% and 83-100%, respectively, to detect metastases without radiation hazard according to prevailing evidence, but computed tomography is necessary for staging. No blood-based tests additional to liver function tests are generally accepted. Three validated staging systems predict, each in defined situations, overall survival after metastasis. Their essential components include measures of tumor burden, liver function, and performance status or metastasis free interval. Age and gender may additionally influence survival. Exceptional mutational events in metastases may make them susceptible to checkpoint inhibitors. In a large meta-analysis, surgical treatment was associated with 6 months longer median overall survival as compared to conventional chemotherapy and, recently, tebentafusp as first-line treatment at the first interim analysis of a randomized phase III trial likewise provided a 6 months longer median overall survival compared to investigator's choice, mostly pembrolizumab; these treatments currently apply to selected patients. Promoting dormancy of micrometastases, harmonizing surveillance protocols, promoting staging, identifying predictive factors, initiating controlled clinical trials, and standardizing reporting will be critical steppingstones in reaching the final frontier of curing metastatic uveal melanoma.
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Affiliation(s)
- Elina S Rantala
- Ocular Oncology Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4 C, PL 220, FI-00029, HUS, Helsinki, Finland.
| | - Micaela M Hernberg
- Comprehensive Cancer Center, Department of Oncology, Helsinki University Hospital and University of Helsinki, Paciuksenkatu 3, PL 180, FI-00029, HUS, Helsinki, Finland.
| | | | - Hans E Grossniklaus
- Section of Ocular Oncology, Emory Eye Center, 1365 Clifton Road B, Atlanta, GA, 30322, USA.
| | - Tero T Kivelä
- Ocular Oncology Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4 C, PL 220, FI-00029, HUS, Helsinki, Finland.
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