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 were 10.3 ± 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.
Highlights
There is scope for improvement in the management of patients with melanocytic choroidal tumors
As choroidal melanomas are infrequently seen in non-subspecialty clinics, up to one third of patients referred to an ocular oncology center for uveal melanoma are found to have a simulating lesion, most commonly a choroidal nevus [1,2], which often has minimal risk of malignancy
We reviewed the electronic medical records of all 615 patients undergoing treatment for uveal melanoma between 1 January 2016 and 31 December 2019 with laser, plaque brachytherapy, proton beam radiotherapy or enucleation
Summary
There is scope for improvement in the management of patients with melanocytic choroidal tumors. As choroidal melanomas are infrequently seen in non-subspecialty clinics, up to one third of patients referred to an ocular oncology center for uveal melanoma are found to have a simulating lesion, most commonly a choroidal nevus [1,2], which often has minimal risk of malignancy. Patients with melanoma frequently experience long delays in referral and diagnosis because their tumor is incorrectly classified as a ‘suspicious nevus’, in many instances because the referring clinician is falsely reassured by its relatively small size. Some patients suffer greater ocular morbidity, visual loss, and perhaps and increased risk of metastasis that may have been prevented by timely referral and treatment.
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