Mixed-cell Melanoma Research Articles

Secondary endoresection for previously treated choroidal melanomas with a non-responsive course and persistent exudative retinal detachment

To evaluate the results and complications of secondary endoresection via pars plana vitrectomy for choroidal melanoma and review the previously reported endoresection studies on the treatment of choroidal melanoma. The medical records of 6 patients with choroidal melanoma who underwent secondary endoresection between March 2012 and March 2020 were retrospectively reviewed. The indications for secondary endoresection were progressive or recurrent tumor and severe exudative retinal detachment after previous treatment with plaque radiotherapy/Cyberknife radiosurgery/transpupillary thermotherapy (TTT). Before endoresection, 2 eyes had Iodine-125 plaque radiotherapy and TTT, 1 eye had Ruthenium-106 plaque radiotherapy and TTT, 1 eye had Cyberknife radiosurgery and TTT, 1 eye had Cyberknife radiosurgery, and 1 eye had TTT only. Preoperative visual acuity ranged from 20/63 to 20/1600 (Snellen) and from 0.5 to 1.9 (mean: 1.1) on the logMAR scale. The mean tumor base diameters were 9.5×8.7 mm and the mean tumor thickness was 5.4 mm. After secondary endoresection, transient vitreous hemorrhage developed in 2 (33.3%) eyes and retinal detachment in 1 (16.7%) eye. Cytopathological examination revealed epithelioid cell melanoma in 4 (66.7%) eyes and mixed cell melanoma in 1 (16.7%). Melanoma cell type was not specified in 1 (16.7%) eye. At a mean follow-up of 49.6mo (range: 16-90mo), mean visual acuity did not improve and 1 eye was enucleated due to tumor recurrence. Final visual acuity ranged from 20/63 to 20/1600 (Snellen) and from 0.5 to 1.9 (mean: 1.2) on the logMAR scale. Two patients with choroidal melanoma developed metastasis and eventually expired. Secondary endoresection seems to be an effective treatment option for globe salvage in choroidal melanoma not responsive to conventional treatment and displaying persistent exudative retinal detachment. There was no visual acuity increase among the treated eyes but globe salvage was possible in most cases in this study.

Plaque radiotherapy for anterior uveal melanomas

To determine the effectiveness of plaque radiation therapy for anterior uveal melanomas and to evaluate the risk and frequency of complications at different time intervals after the treatment. During 2010-2013 a total of 30 patients (10 male, 20 female) aged 11-73 (50 years on the average) with iris or iridociliary melanomas were treated with Ru-106 and Sr-90 ophthalmic plaques. In 8 patients the brachytherapy was preceded by local tumor excision. Morphological diagnosis was verified in 10 patients (8 iridectomies, 2 enucleations), of them 8 cases turned out to be spindle cell melanomas and the other 2--mixed cell melanomas. Follow-up period ranged from 1 to 54 months with the median of 13,5 months. Tumor regression was achieved in all cases. Enucleation had to be performed in 2 patients due to cornea and sclera necrosis. In the early post-brachytherapy period (up to 1 month) the most frequent radiation-related complications were keratopathy and uveitis (8 and 6 patients correspondingly). In patients observed for up to 3 months (28 patients) these were keratopathy and cataract (8 and 5 patients correspondingly). In the long-term (over 6 months) cataract predominated (17 patients). At the end of the study all patients were alive. Metastatic disease was diagnosed in one patient 30 months after the treatment. The results of the present clinical study confirm the effectiveness of brachytherapy for iris and iridociliary melanomas, which implies that tumor is well locally controlled and radiation-related complications are moderate and curable. This method of local tumor destruction can be another alternative to enucleation in cases when local tumor excision cannot be performed.

Langzeitergebnisse nach Iridozyklektomie bei Iristumoren

The aim of this study was to evaluate the long-term survival rate and functional results after iridocyclectomy. Between 1980 and 2002 39 patients (26 female and 13 male) ranging in age from 20 to 79 years (median m = 58 years) underwent iridocyclectomy for a tumour of periphery iris by means of a lamellar technique or by trepanating. Follow-up time ranged from 3 months to 24 years (m = 11.2 years). In 21 cases (54 %) there was a malignant tumour including 20 melanomas (mostly spindle-cell and mixed-cell melanomas) and one filiae of a bronchial carcinoma. There was a variety of histopathological entities in the 18 benign lesions (46 %). Naevi were the most frequent. The outcome was satisfactory: 57 % of the patients kept a visual acuity of > 0.5. Three eyes had to be enucleated. The rate of recurrence was 10 % (4 cases). The Kaplan-Meyer estimate for the 10-year-survival of the patients with a malignant iris tumour was 77 %. Two patients died of metastic melanoma following spindle-cell and mixed-cell melanoma. The long-term functional results after Iridocyclectomy are good, whereas complications and recurrences are rare. The 10-year-survival is high. Over a long period iridocyclectomy is a recommendable surgical procedure for removal of progredient tumours of the anterior uvea.

Progressive Enlargement of Cavity Within Melanoma Masquerading as Iris Cyst

To describe progressive enlargement of intralesional cavities within a mass that masqueraded clinically as an iris pigment epithelial cyst for 2 years but later proved to be a melanoma. An 81-year-old woman developed asymptomatic focal elevation of the iris, and ultrasound biomicroscopy showed a fluid-filled mass that was interpreted as an iris pigment epithelial cyst. Over a 2-year period of observation, the cavity enlarged from 0.7 to 10 mm, and the solid component enlarged from approximately 6 to 16 mm basal dimension. On referral, visual acuity was 20/400 in the right eye and 20/25 in the left eye. The affected right eye displayed a pigmented mushroom-shaped ciliary body mass with anterior chamber invasion, distorting the pupil and occupying 40% of the anterior chamber. Ultrasound biomicroscopy and B-scan ultrasonography revealed many cavities within the 14-mm-thick mass, suggestive of ciliary body melanoma. After enucleation, histopathology disclosed multiple cavities, some with granular eosinophilic material, within a mushroom-shaped mixed-cell melanoma. Cavitation can occur in ciliary body melanoma and can lead to misinterpretation as a cyst. Cavitary melanoma should be considered in the differential diagnosis of cystic lesions of the anterior segment.

Estudo de melanoma de coróide na Universidade Federal de Uberlândia

Purpose: To show the results of evaluation, management and evolution in a population of patients with choroidal melanoma that were examined between January 1st, 1994, and January 1st, 2000 at the Retina and Vitreous Service of the Federal University of Uberlândia - MG. Methods: This series was based on a retrospective chart review of 7 patients with a diagnosis of choroidal melanoma, analyzing: age, sex, race, symptoms and duration, diagnostic methods, treatment, tumor size and type, and evolution. Results: There was no difference regarding sex, and the patients' average age at diagnosis was 58.5 years. The tumor was more frequent in whites (66.5%) and visual loss was the most frequent symptom (66.5%). Indirect ophthalmoscopy was responsible for 66.5% of the diagnosis. All the patients were submitted to ultrasonography (USG) and underwent surgical treatment because they presented with large tumors (basal diameter larger than 12 mm). Mixed cell melanoma was the most frequent type (50%), and the average size of the tumors was 20.50 mm basal diameter and 15.16 mm thickness. The follow-up varied from 8 months to 5 years. Two patients had systemic metastases and died. Conclusion: All patients were diagnosed with the tumor at an advanced stage, needing surgical treatment. Two deaths were observed. Indirect ophthalmoscopy is very important in adults based on the malignancy of the tumor and the possibility of early detection, enlarging the treatment options and improving its results.

Eye-wall resection

In this retrospective study, the authors reviewed the ocular retention rates, visual results, and metastases in uveal tumors managed with eye-wall resection techniques performed by a single surgeon. A total of 132 eyes were scheduled for eye-wall resection surgery. Mean patient age was 52 years (range, 11 to 86 years). Tumors involved the iris alone in 17 cases, the iris-ciliary body in 53, the ciliary body alone in 16, and the choroid (ciliochoroidal, iris-ciliary body-choroid, or choroid) in 46 cases). A total of 114 eyes harbored melanomas; tumors located more posteriorly were more likely to have epithelioid cells (P < .05). Mean follow-up was 6 years. Mean number of clock hours in iris and iris-ciliary body tumors was 3.5. In tumors that involved the choroid, the mean largest diameter was 12.6 mm and the mean thickness was 8.2 mm. Ninety-three of 132 eyes were retained. Histologic assessment of surgical margins did not correlate with either evidence of tumor in enucleated eyes or metastatic disease. Surgical margins of tumors located more anteriorly were more likely to be clear on histologic evaluation (P < .05). Approximately 56% of retained eyes had a final visual acuity of 20/40 or better; visual results were significantly better in tumors located more anteriorly (P < .05). All retained eyes with iris tumors had a final visual acuity of 20/40 or better. In tumors that involved the choroid, 8 of 25 retained eyes kept visual acuity of 20/40 or better. Metastases developed in 8 patients; all metastatic events developed in patients with tumors that involved the choroid, and 7 of 8 were mixed cell melanomas. Seventy percent of eyes were retained, and 56% of these had a final visual acuity of 20/40 or better. Only 7% of patients with uveal melanoma developed metastatic disease (mean follow-up, 6 years). The authors conclude that survival did not appear to be compromised with eye-wall resection and in very thick melanomas located more posteriorly, ocular retention and visual results appeared to be better than that attained with radiation alone.—Thomas J. Liesegang

Ultrasound Biomicroscopic Imaging of the Anterior Aspect of Peripheral Choroidal Melanomas

To correlate ultrasound biomicroscopic features of the anterior aspect of peripheral choroidal melanoma with respect to histopathology. We examined 17 eyes of 17 patients who had clinically diagnosed peripheral choroidal melanomas that approached the ora serrata or extended into the ciliary body and who had been assessed with ultrasound biomicroscopy before enucleation. Comparisons were made between anterior tumor margins imaged by ultrasound biomicroscopy and histopathologic specimens. Anatomic features noted on ultrasound biomicroscopy before enucleation were correlated with enucleation specimens, including supraciliary effusion, rotation of the ciliary body, angle involvement, and internal reflectivity patterns. Anterior tumor margin position was determined with reference to the scleral spur. Mean distances from the anterior tumor margin to the scleral spur were 1.47 mm on ultrasound biomicroscopy and 1.65 mm on pathologic examination. This difference was not statistically significant (P = .325). Tumor features evident on ultrasound biomicroscopy were also seen on pathologic examination: supraciliary choroidal effusions in seven of seven, ciliary body rotation in seven of eight, and angle involvement in seven of eight. All tumors were mixed-cell melanomas, and 12 of 17 (70%) demonstrated homogeneous ultrasound biomicroscopic internal reflectivity. Irregular internal reflectivity was seen in five of 17 tumors (29%) and was related to prominent internal vascularity on pathology in three of five. Ultrasound biomicroscopy is an accurate imaging technique for the in vivo assessment of anterior tumor margins of peripheral choroidal melanomas and can provide detailed imaging of the tumor's interface with the ciliary body.

Iris Melanomas: Diagnostic Problems

To illustrate some management problems with pigmented iris tumors. This is a retrospective analysis of 234 iris tumors managed by one of the authors. Five patients were selected whose clinical course and pathologic data illustrate diagnostic problems that can occur with these tumors. In the patients described, diagnostic problems were noted. In two patients, glaucoma specialists were unable to correctly diagnose an iris melanoma before filtration. One patient had a 3-clock-hour iris biopsy that was not diagnostic for malignancy, yet the enucleated eye showed melanoma. One patient with a clinically stable iris tumor had a mixed-cell melanoma. Most iris-pigmented tumors have a benign disease course. In some case, despite little clinical evidence of disease activity or progression, a melanoma, often with epithelioid cells, may be present and neither a fine-needle nor an open biopsy is always diagnostic.

The Value of Nucleolar Organizer Regions in Uveal Melanoma

Silver staining of nucleolar organizer regions is an objective method for evaluating the malignancy of a variety of tumors. We studied 126 ciliochoroidal melanomas, three coincidental nevi that occurred in eyes with melanomas, and one magnocellular nevus collected from the Collaborative Ocular Melanoma Study to determine the effectiveness of the silver-stained nucleolar organizer region technique in assessing the malignant potential of these tumors. Malignant lesions demonstrated higher mean silver-stained nucleolar organizer region counts (4.347) than benign nevi (1.855) (P less than or equal to .0001). Among malignant melanomas, mixed-cell melanomas had slightly higher counts than spindle-cell melanomas (P less than or equal to .0001), but this difference was not important clinically. Results were also compared to other histopathologic variables, which disclosed correlation of silver-stained nucleolar organizer regions with mitoses and tumor size. Comparison with computerized cytomorphometric analyses of prognosis also disclosed significant correlation. This technique may prove to be a useful adjunct in the assessment of malignancy and treatment response of uveal melanomas.

Iris Melanomas

Most iris tumors behave benignly, reflecting their small size and the high proportion of nevi and spindle A melanomas. Of 1,043 reported iris melanomas, 31 metastasized (3%). Metastasis from a spindle A melanoma is not known to occur despite documented growth and local recurrence after excision. If known spindle A melanomas are excluded from all reported spindle cell tumors of the iris, the rate of metastasis for spindle cell tumors is 2.6%. Mixed-cell melanomas have a metastasis rate of 10.5% and epithelioid melanomas a rate of 6.9%. The interval between the histologic diagnosis and death from metastases ranged from three months to 12 years, with an average of 6.5 years. Five- and ten-year mortality rates for different cell types cannot be ascertained. Iris angiography may be useful in defining the limits of tumor involvement but is of uncertain value in differentiating benignancy from malignancy. Of the 31 cases with metastases, 21 included information on the type of surgical procedure used to obtain the histologic diagnosis. In 13 of the 21 cases (62%), the tumors were initially involved with either incomplete excision or inadvertent transection before enucleation.

Growth Rates and Doubling Times of Posterior Uveal Melanomas

AbstractSeventeen patients having a posterior uveal melanoma underwent enucleation following documentation of tumor growth. Duration of follow-up from diagnosis to enucleation ranged from 3 weeks to 30 months. The mean rate of enlargement in cubic tumor volume was 56.3 mm3/mo for eight spindle cell melanomas and 270.3 mm3/mo for nine mixed cell melanoma. The mean tumor doubling time calculated according to the exponential growth equation was 291.6 days for the eight spindle cell melanomas and 128.2 days for the nine mixed cell melanomas. The mean mitotic activity was 3.5 mf/40 hpf for the eight spindle cell melanomas and 5.4 mf/40 hpf for the nine mixed cell melanomas. These results suggest that mixed cell posterior uveal melanomas generally grow faster and have shorter doubling times than do spindle cell melanomas.

Reappraisal of Callender'S Spindle a Type of Malignant Melanoma of Choroid and Ciliary Body

A follow-up study and histologic reevaluation were made of 105 melanomas of the choroid and ciliary body that had originally been classified as Callender's spindle A type. There were 18 deaths attributable to tumor, with metastatic disease confirmed by autopsy or biopsy in eight cases. We were able to separate the 105 melanomas histopathologically into three groups. The first group consisted of 15 cases in which the spindle-shaped tumor cells were cytologically benign; no deaths were observed for this group. The 75 tumors in the second group were composed of spindle cells, but differed from those in the first group by their malignant features, namely, more atypicality of cells, mitotic activity, necrosis, invasion into sclera or through Bruch's membrane, larger size of the tumor, or any combination of the above. The prognosis for this group was good, comparable to that of spindle B melanomas. The 15 tumors in the third group contained epithelioid cells and had a poor prognosis, comparable to that of mixed-cell melanomas.

Correlation between Degree of Malignancy and the Radioactive Phosphorus Uptake Test in Ocular Melanomas

Twenty-nine patients who had undergone enucleation for ocular malignant melanoma were studied. The results of the radioactive phosphorus uptake (32P) tests were correlated with histopathologic observations. There was a positive correlation between the 32P test results and the histologic degree of malignancy. Mixed cell melanomas were more frequent in the patients ranked with higher 32P test results. Spindle cell melanomas occurred more frequently in patients with lower 32P test results. Mitoses per field and degree of malignancy correlated positively with 32P test results when ranked in a masked manner by two ocular pathologists. Tumor volume and clinical factors did not correlate with the 32P test results. While patients with mixed cell melanomas had higher mean 32P test results than those with spindle cell melanomas, a large variance was noted. Because of this the 32P test is unreliable in predicting the histopathology of a tumor in individual cases.