Clinicopathological correlation of choroidal melanoma in Indian population: A study of 113 cases

Experiences of two different modalities in the management of choroidal melanoma in the Asian Indian population

BACKGROUND

Choroidal malignant melanoma is a rare intraocular cancer in Asian Indian population. There is a paucity of data from our population comparing iodine 125 (I-125) brachytherapy and enucleation.

AIM

This study aims to compare two groups of choroidal melanoma patients treated with either I-125 brachytherapy or enucleation in the Asian Indian population.

OBJECTIVES

To evaluate the long-term morbidity and mortality rates in choroidal melanoma patients treated with either I-125 brachytherapy or enucleation.

METHODS

It is a retrospective study involving forty four eyes, diagnosed with choroidal melanoma from May 2008 to February 2015. All were evaluated preoperatively for metastasis. Twenty-two underwent globe salvaging I-125 brachytherapy surgery whereas remaining 22 underwent globe destructive primary enucleation procedure.

RESULTS

At a mean follow-up 39 months, 2 of 22 cases (9%) died in the brachytherapy group. One was secondary to metastasis in the liver while the other case died of a natural cause. In the enucleation group also, there were two deaths (9%) secondary to metastasis. The metastasis free survival was 95% in the brachytherapy group and 91% in the enucleation group, which was not statistically significant (P = 0.3577). Kaplan-Meier survival at 3 years and 5 years was 95% and 89% for brachytherapy group and 94% and 89% for enucleation group.

CONCLUSION

This study found no difference in the long-term survival of choroidal melanoma patients treated with either brachytherapy or enucleation in the Asian Indian eyes.

Posterior uveal melanoma in 321 Asian Indian patients: analysis based on the 8th edition of American Joint Committee Cancer classification

PURPOSE

To evaluate the presenting features, treatment, and outcomes of posterior uveal melanoma (PUM) in Asian Indians based on the 8th edition of American Joint Committee on Cancer (AJCC) classification.

METHODS

Retrospective interventional case series of 321 Asian Indian patients with PUM.

RESULTS

Based on AJCC, PUM was classified into categories T1 (n = 36; 11%), T2 (n = 74; 23%), T3 (n = 126; 39%), and T4 (n = 85; 27%). Regarding tumor features, T4 was more likely to have pre-equatorial epicenter (vs T1 and T2; p ≤ 0.011), iris abnormalities (vs T2 and T3; p ≤ 0.002), and extraocular tumor extension (vs T3; p = 0.001), whereas T1 was more likely to have macular epicenter (vs T2, T3, T4; p ≤ 0.013), lipofuscin deposits (vs T3 and T4; p ≤ 0.008), and amelanotic tumors (vs. T4; p = 0.003). On multivariate analysis, factors predictive of systemic metastasis were increasing tumor thickness (p = 0.002) and extraocular tumor extension (p = 0.009). The 5-, 10-, and 15-year melanoma-related metastases rates were 0%, 0%, and 0% in T1, 0%, 60%, and 60% in T2, 7%, 40%, and 70% in T3 and 13%, 36%, and 76% in T4, respectively. Risk for metastasis was 1.23 times more for every 1-mm increase in tumor thickness and 9 times more with extraocular tumor extension.

CONCLUSION

The AJCC 8th edition provides prognostic classification for PUM in Asian Indian patients. The significant risk factors for metastasis were increasing tumor thickness and extraocular tumor extension.

Choroidal Nevus and Melanoma in Patients with Oculocutaneous Albinism

Background

There are limited reports of uveal "melanocytic" lesions in patients with oculocutaneous albinism, with no reports from Asia.

Objectives

In this study, we report 3 eyes with uveal "melanocytic" lesions in Asian patients with oculocutaneous albinism.

Methods

Retrospective small case series. Three eyes of 2 Asian patients with oculocutaneous albinism were included. Case 1 was a 54-year-old female who presented with juxtapapillary choroidal melanoma and underwent enucleation. Case 2 was a 39-year-old male with pigmented choroidal nevus in the right eye and suspicious nevus/choroidal variegation in the left eye.

Results

For case 1, metastatic workup including ultrasound of the abdomen, liver function test, and chest X-ray was unremarkable. Magnetic resonance imaging of the cranium ruled out extraocular extension. The left eye was enucleated due to the large tumor size and poor visual potential, and histopathological examination confirmed the diagnosis of choroidal melanoma with mixed cell type. At the last follow-up 6 months after enucleation, there was no evidence of metastasis. Case 2 was observed.

Conclusion

Pigmented choroidal nevus and melanoma are rarely observed in patients with oculocutaneous albinism.

Clinical spectrum, treatment and outcomes of uveal melanoma in a tertiary centre

INTRODUCTION

We aimed to describe the clinical characteristics, diagnostic challenges, treatment patterns and outcomes of uveal melanoma (UM) in a tertiary care centre.

METHODS

This is a retrospective case series of 11 consecutive patients with UM who were managed in a tertiary referral centre between 2002 and 2017. Epidemiological, clinical, pathological and radiological characteristics were reviewed. Classification of choroidal melanoma as small, medium or large was based on the criteria established by the Collaborative Ocular Melanoma Study.

RESULTS

Mean age at presentation was 42.9 (range 27‒67) years. In 7 (64%) patients, a definitive diagnosis of UM was made after a mean follow-up period of 6.4 (range 1‒17) months. There were one, six and four patients with small-, medium- and large-sized choroidal melanomas, respectively. Treatment was enucleation in 5 (45.5%) patients, plaque brachytherapy in 4 (36.4%) patients, transpupillary thermotherapy in 1 (9.1%) patient, and observation in 1 (9.1%) patient. Median follow-up was 29 months. Metastatic disease developed in 5 (45.5%) patients at the mean age of 46.6 (range 38‒56) years, with median overall survival of 20 months. Genetic mutations in three patients were monosomy 3 (n = 2), and gain of 3q and 8q (n = 1).

CONCLUSION

Our study supports the finding that UM in Chinese and Asian Indian patients presents at a younger age than in Caucasians. Although it is rare, ophthalmologists should remain mindful of this life-threatening disease. We propose establishing a national and regional registry for ocular tumours with genetic information to characterise the disease spectrum in Southeast Asia.

Enucleation in Asian Indian patients: a histopathological review of 2009 cases

OBJECTIVE

To review the indications of enucleation in Asian Indian patients and study the trend over the 22-year period.

METHODS

Retrospective study of 2009 patients who underwent enucleation.

RESULTS

The mean age at presentation of patients who underwent enucleation was 155 months The histopathology diagnosis included a benign tumor (n = 22, 1%), malignant tumor (n = 1472, 73%), acute trauma (n = 93, 5%), retinal vascular disease (n = 50, 3%), inflammatory/infective pathology (n = 33, 2%), or other miscellaneous/non-specific diagnosis (n = 460, 23%). There was a good correlation between the clinical and histopathology diagnoses at 96%. The most common indication for enucleation in young patients ( ≤ 20 years) was retinoblastoma (n = 1257, 82%; p < 0.001), atrophic bulbi or phthisis bulbi (n = 163, 39%; p < 0.001) in middle-age adults, and uveal melanoma (n = 25, 42%; p < 0.001) in older adults. Over the years, there was a decreasing trend of enucleations for atrophic bulbi/phthisis bulbi/painful blind eye (33% from the years 1996 through 2000 to 7% from 2010 to 2018; p < 0.001) and acute trauma (3% from the years 1996 through 2000 to < 1% from 2010 to 2018; p < 0.001) and an increasing trend for intraocular tumors including retinoblastoma (56% from the years 1996 through 2000 to 73% from 2010 to 2018; p = 0.01) and uveal melanoma (3% from the years 1996 through 2000 to 11% from 2010 to 2018; p < 0.006).

CONCLUSION

In Asian Indian population, malignant tumors remain the most common indication for enucleation in young and older patients, while desire for better cosmesis with customized ocular prosthesis is the main indication for enucleation in middle-age adults.

Choroidal melanoma: A short review with an Indian perspective

Choroidal melanoma (CM), the most common intraocular tumor in adults, is still a rarity in Asia. Having a high propensity for metastasis with a poor survival, recognizing it early is essential. Although it has typical clinical features, there are instances of simulating lesions. Fine-needle aspiration biopsy can be a valuable tool not only to confirm our clinical suspicion but also aid in prognosticating it. From days of histopathological prognostic markers, we are moving on to genetic markers which are reliably providing insights, helping us in providing a better care for our patients. Eye preservation has taken an all new important meaning in CM with many centers opting for different modalities of radiation. Herein, we try to provide a short synopsis of CM looking into its epidemiology, clinical features, diagnosis, and management. We also look briefly into the role of fine-needle biopsy in managing CM. Being a tertiary referral ocular center in India, we do come across CM; we have shared the preliminary reports of our analysis of managing CM over a 9-year period.