Treatment response and recurrence of conjunctival melanoma with orbital invasion treated with immune checkpoint inhibitors: case report and literature review

INTRODUCTION

Conjunctival melanoma (CM) has genetic characteristics that are similar to primary cutaneous melanoma (PCM). The management of advanced CM with orbital metastasis was limited until the adoption of novel immunotherapy agents that significantly improved the survival of metastatic PCM.

PURPOSE

To review and compare the immune checkpoint inhibitor (ICI) treatment response in cases reported in the English literature with orbital involvement secondary to CM versus PCM. In addition, we report a case of local recurrence of CM in a young female after successful treatment with ICI.

METHODS

In addition to reviewing the chart of one patient who presented to our clinic, we conducted a comprehensive literature review to identify CM cases and cases with orbital metastasis secondary to advanced CM and PCM. Outcomes included patient demographics, response to ICI, and associated adverse effects.

RESULTS

There were ten cases with orbital involvement, four were secondary to CM, and six were metastasis from PCM. Orbital metastasis from PCM regressed following treatment with ICI agents, whereas those secondary to CM resolved completely. There were 19 cases of CM without orbital invasion. Of the 29 cases identified, complete resolution of ocular melanoma was achieved in 15 patients, representing 52% of the cases collectively, and none of them reported recurrence except in our case.

CONCLUSION

CM with orbital invasion responds well to ICIs, with manageable toxic effects. Despite the complete resolution, close observation is needed as the recurrence risk remains.

Primary Testicular Lymphoma Mimicking Germ-Cell Tumor: A Case Report

There are 1% to 2% of lymphoma cases that include the testis as primary testicular non-Hodgkin lymphoma (NHL). In 35% of cases, it involves both testes and is usually seen as a painless testicular mass. Therefore, in most cases, the management option is radical orchiectomy. The overall prognosis in these cases is poor, as most cases are associated with systemic disease. We report a case of a 42-year-old male who presented with painless right scrotal swelling for three months. The only serologic marker of solid tumors that was elevated was βHCG; others were unremarkable. Ultrasonography was initially ordered as well and showed a heterogeneous intra-testicular lesion of relatively low echogenicity. According to the given age, epidemiology, and clinical presentation, the suspicion of a germ cell tumor was highly likely. Therefore, a right radical inguinal orchiectomy was done, and the specimen was sent for histopathology, which came back as B-cell non-Hodgkin lymphoma. The clinical presentation and the overall picture of the investigations made in this case mimicked a germ cell tumor presentation.

Periocular subcutaneous granuloma annulare in a child: A case report

Purpose

We describe a rare case of annular granuloma involving the eyelid of a child, a 6-year-old male, who presented with multiple subcutaneous nodular lesions involving the upper eyelid of the right eye.

Observations

The slit-lamp examination of the eye was normal. Extra-ocular examination showed a lesion on the dorsal aspect of the right foot, which was resistant to treatment with topical corticosteroids. He underwent surgical excision of the eyelid nodules under general anesthesia. Histopathology with immunohistochemical staining of the excisional biopsy confirmed the diagnosis of annular granuloma, with positive Vimentin and CD68 stains in many palisading histiocytic cells, while Factor VIIIa, S100, and CD1a were negative. Tuberculosis was ruled out by negative Ziehl-Neelsen staining for acid-fast bacilli.

Conclusions and importance

This idiopathic granulomatous condition proved to be a benign, self-limiting cutaneous disease that can regress spontaneously. It affects the skin of the foot in more than 70% of all patients; however, involvement of the eyelid is extremely rare. We report this case to highlight such a rare entity and increase awareness regarding this dermatological condition among ophthalmologists.

Biomarkers in fish as a measure of the state of marine environment of Kuwait

The health of a marine ecosystem can effectively be monitored by studying the levels of biomarkers in a representative species. A change in background level of a biomarker indicates exposure to a specific type of pollutants. It also identifies bioavailability and the organism response to the causative agent among the compounds present in the surrounding water body. Yellowfin seabream (Acanthopagrus latus), a local variety of fish, was examined for parent PAHs in the liver, its metabolites in bile by the GC-MS method as exposure biomarkers and cytochrome P4501A1 by assay of ethoxyresorufin-o-deethylase (EROD) in the liver as an effect biomarker. A comparison was made between fish collected in 2015 with the fish collected in 2005-2006 and stored at - 80 °C in the fish bank. The objective was to examine the extent of changes in the environmental quality of the Kuwait marine area and the status of fish health concerning oil-related pollutants since Arabian Gulf is surrounded by oil-producing countries. Interestingly, insignificant differences between the liver PAH content and EROD activity were observed in fish over the sampling periods. The fish efficiently metabolized PAHs and excreted hydroxy-metabolites in bile. The study suggested that environmental quality of the Kuwait marine area was not deteriorated to any serious extent in the last decade and biomarkers can be used effectively in assessing the thrust of sub-optimal levels of various contaminants present in the marine area on the resident biota.

Extraskeletal Myxoid Chondrosarcoma of the Orbit

Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue tumor. Numerous cases of EMC have been reported in different anatomical locations. There is currently only a single case of EMC of the orbit and that was reported in 1985. We report a second case of orbital EMC in a 34-year-old healthy male.

Seasonal effect on biomarkers of exposure to petroleum hydrocarbons in fish from Kuwait's marine area

The aquatic biota of the Arabian Gulf deals with exposure to chronic oil pollution, several constituents of which cause induction of Cytochrome P450 1A that serves as a biomarker of AhR ligand exposure. In this study, fluorescent aromatic compounds (FACs) in bile and 7-ethoxyresorufin-o-deethylase (EROD) catalytic activity were determined as a measure of exposure biomarkers in two fish species, yellow fin seabream (Acanthopagrus latus) and tonguesole (Cynoglossus arel) captured from Kuwait Bay and outside the Bay area. FACs in fish bile determined by using fixed-wavelength fluorescence (FF) showed high fluorescence ratios between FF290/335 and FF380/430 indicating predominant exposure to low molecular weight, naphthalene-rich petroleum products (375±91.0 pg ml(-1)). Exposures to benzo(a)pyrene-type high-molecular weight polycyclic aromatic hydrocarbons (PAHs) originating from burnt fuel were also present in appreciable concentration in the bile. The ratio of petrogenic to pyrogenic hydrocarbon was twofold higher in winter compared to summer months in both species. Seasonal effect on EROD was significant in tonguesole in Auha site (P<0.05); whereas seabream resisted seasonal change. Tonguesole is considered to be a suitable bioindicator of oil pollution in Kuwait Bay area.

Metallothionein, oxidative stress and trace metals in gills and liver of demersal and pelagic fish species from Kuwaits' marine area

Two fish species yellowfin seabream (Acanthopagrus latus) and tonguesole (Cynoglossus arel) were collected from two locations in Kuwait's territorial waters in non-reproductive periods and used as bio-indicator organism for the assessment of metals in the marine environment. Species variation in fish was observed; seabream contained high metal content and metallothionein in liver and gill tissues compared to tonguesole, especially from Kuwait Bay area. Oxidative injury was registered in the gills of both species, but in tonguesole liver was also involved. Consequently, antioxidant enzyme catalase was elevated in tonguesole enabling bottom dwelling fish to combat oxidative assault. The study provided information about the current status of metals in marine sediment and levels of metals accumulated in representative species along with oxidative damage in exposed tissues and the range of biomarker protein metallothionein and enzymes of antioxidant defence mechanism enhancing our understanding about the biological response to the existing marine environment in Kuwait.

Comparison of three commercial RT-PCR systems for the detection of respiratory viruses

BACKGROUND

Due to the insensitivity of rapid tests for respiratory viruses, nucleic acid amplification tests are quickly becoming the standard of care.

OBJECTIVES AND STUDY DESIGN

The performance of the FilmArray Respiratory Panel (RP) and Verigene RV+ (RV+) were compared in a retrospective analysis of 89 clinical specimens previously determined to be positive for the following viruses by our test of record, Prodesse (Pro): influenza A (29, FluA), influenza B (13, FluB), respiratory syncytial virus (12, RSV), human metapneumovirus (10, hMPV), parainfluenza (14, PIV), and adenovirus (10, AdV). Samples positive for influenza A, B or RSV were tested by both methods, while the remainder were tested by RP only. True positives were defined as positive by two or more assays.

RESULTS

Limit of detection (LOD) analyses demonstrated Pro had the lowest LOD for all FluA strains tested, PIV1, PIV2 and AdV; RV+ had the lowest LOD for FluB; and RP had the lowest LOD for RSV, PIV3 and hMPV. Of the 55 samples tested by RV+, all 54 true positive samples were positive by RV+. Of the 89 samples tested by RP, 85 of the 88 true positive samples were positive by RP. From these results, the overall sensitivities for influenza A, B and RSV were 100% and 98% for RV+ and RP, respectively. The overall sensitivity of RP for all viruses was 97%.

CONCLUSIONS

In summary, these systems demonstrated excellent performance. Furthermore, each system has benefits which will ensure they will all have a niche in a clinical laboratory.

Seasonal effect on heat shock proteins in fish from Kuwait bay

Heat shock proteins (HSP70) play a significant role in adaptation to temperature and have been proposed as an indicator of cellular stress. Since the water temperature in Kuwait's marine area varies from 13 to 35 degrees C from winter to summer, HSP70 could be a valuable tool in aquaculture in Kuwait. HSP70 levels were quantified by Western blotting in liver, muscle and gill tissues of two varieties of native fish species captured during the winter and summer months from both inside and outside the highly stressed Kuwait Bay area. The HSP70 levels did not differ statistically between fish captured from the two sampling areas. The most common response in both species was higher median levels of HSP70 in winter months. This inverse relation between HSP70 levels in the fish and the water temperature may be due to either genetic adaptation in the fish to the hot climatic conditions of the region or other stressors, such as changes in pollutant levels in the surrounding water.

Combined parathyroid adenoma and an occult papillary carcinoma

Although the pathological association of thyroid and parathyroid disease is common, the association of both parathyroid adenoma and thyroid cancer is rare. We report here a case of a 45-year-old Saudi woman who was diagnosed to have primary hyperparathyroidism due to a single parathyroid adenoma as confirmed biochemically and radiologically. At operation, the adenoma was found to be an intrathyroid and therefore a thyroid lobectomy was performed. Histology of the excised lobe revealed in addition to the intrathyroid parathyroid adenoma a concurrent occult thyroid papillary carcinoma. This interesting association is discussed based on a literature review.

Reliability of commercially available immunocytochemical markers for identification of neuroendocrine differentiation in bronchoscopic biopsies of bronchial carcinoma

BACKGROUND

Although neuroendocrine differentiation occurs quite commonly in non-small cell bronchial malignancies, its biological significance and implications for management remain uncertain. Determining these facts requires its recognition early, ideally at diagnosis, which is usually made on tissue from bronchoscopy, but the best means of its detection in such material is unclear. A prospective comparative study was performed of 10 commercially available antisera to a series of markers of neuroendocrine differentiation, to test their efficacy when applied to fibreoptic bronchoscopy biopsy specimens.

METHODS

Expression of chromogranin A, synaptophysin, neurone-specific enolase, protein gene product 9.5, the BB isoenzyme of creatine kinase, gastrin releasing peptide, adrenocorticotrophic hormone, calcitonin, calcitonin gene related peptide, and leucine enkephalin was sought by immunolabelling of bronchoscopic biopsy tissue from 83 primary bronchial carcinomas, 22 of them of small cell type.

RESULTS

Only synaptophysin and chromogranin were sensitive and specific enough for neuroendocrine differentiation to discriminate between small cell and non-small cell lesions, whereas protein gene product 9.5 and creatine kinase were neither particularly sensitive nor specific and neurone-specific enolase actually labelled more non-small cell tumours than small cell lesions. Of the five secretory products sought, only gastrin releasing peptide was detectable in just one tumour. Three squamous and two morphologically undifferentiated tumours immunolabelled for synaptophysin and chromogranin, almost certainly indicating neuroendocrine differentiation in the absence of small cell morphology.

CONCLUSIONS

Of the markers studied, only synaptophysin and chromogranin were sufficiently specific and sensitive for neuroendocrine differentiation to justify their inclusion in any panel of antibodies used in its detection in tissue obtained at fibreoptic brochoscopy.

Exposure to cigarette smoke and expression of the protein encoded by the p53 gene in bronchial carcinoma

Mutation of the onco-suppressor gene encoding the protein known as p53 may cause synthesis of a mutant p53 protein which can bind to and inactivate its wild-type equivalent. This protein is detectable in many malignant neoplasms, including bronchial carcinoma, and has been associated with cigarette smoking. Of 59 tissue biopsy specimens of primary bronchial malignancies immunolabeled for p53 by the avidin-biotin technique using the antibodies PAb 1801, CM1, and D07, 13 (22%) expressed the protein. Of these 13 patients, 10 (77%) smoked more than 20 cigarettes a day and their mean total exposure was 53 pack-years. Corresponding figures for those with p53-negative tumors were 21 (46%) smoking more than 20 cigarettes a day with a mean total exposure of 36 pack-years. There was, however, no difference between the groups in total duration of exposure (46 vs. 47 years). Although p53 was expressed more commonly in adenocarcinoma (30% of 10) and squamous carcinoma (28% of 29) than in small cell tumors (10% of 20), this could be accounted for by the smoking history. This study supports a relationship between mutations of the p53-encoding gene associated with overexpression of its protein product and intensity of exposure to cigarette smoke.

c-myc oncoprotein in bronchial carcinoma: expression in all major morphological types

We have studied the prevalence of a 62 kd protein product of the c-myc oncogene in tissue biopsies from 79 primary bronchial carcinomata using the monoclonal antibody Myc 1-9E10 and the avidin-biotin complex (ABC) technique. This oncoprotein was strongly expressed in 43% of 37 squamous lesions, 29% of 14 adenocarcinomata, 42% of 7 non-small cell lesions not further classifiable and 19% of 21 small cell neoplasms, all of classical morphology. There was no statistical difference between groups in the prevalence of its expression, nor was it related to survival. This oncoprotein is commonly expressed in non-small cell as well as small cell bronchial carcinomata and, in the latter, is not confined to those variant tumours which possess a "large cell" morphology and carry a poor prognosis.