Trans-scleral Local Resection Research Articles

Intraocular schwannoma: A case series of 3 patients.

Schwannoma is a proliferation of neoplastic Schwann cells. Schwannomas comprise 8-10% of all primary intracranial tumors. Primary intraorbital schwannoma arising from the ciliary nerves in the uvea, which accounts for 1-2% of all intracranial tumors, is a rare intraocular neoplasm. Intraocular schwannoma frequently masquerades as melanoma, reflecting the difficulty in clinically distinguishing it from malignant melanoma and the requirement for a histopathological diagnosis. The aim of the present study was to report a case series of 3 patients diagnosed with intraocular schwannoma at the Department of Ophthalmology, Peking University People's Hospital (Beijing, China). Patients with intraocular schwannoma were identified by searching the computerized database and patient medical records of the Department of Ophthalmology of Peking University People's Hospital. The patients (2 men and 1 woman; mean age, 34 years; age range, 25-48 years) were all treated by trans-scleral local resection, and schwannoma was confirmed by biopsy. The study found that choroidal schwannoma has a variety of clinical manifestations, with iridodialysis, subluxation of the lens and exudative detachment of the retina observed. The present study indicates that a pathological biopsy is required for diagnosis and that the optimal therapy is local resection.

Choroidal schwannoma: a case series of five patients

AimTo report a case series of five patients diagnosed with choroidal schwannoma at the Liverpool Ocular Oncology Centre.MethodsPatients with choroidal schwannoma were identified by searching the computerised database of the...

Trans-scleral local resection of toxic choroidal melanoma after proton beam radiotherapy

AimTo report on trans-scleral local resection of choroidal melanoma for exudative retinal detachment and neovascular glaucoma (toxic tumour syndrome) after proton beam radiotherapy (PBR).MethodsA non-randomised, prospective study of secondary trans-scleral...

Clinical observation of extraocular extension of choroidal melanoma

To evaluate the clinical features, diagnostic methods and treatment of extraocular extension of choroidal melanoma. It was a retrospective case series study. The records of 12 consecutive cases with extraocular extension of choroidal melanoma confirmed by pathologic examination were analyzed with special attention to the case histories, clinical manifestations, imaging findings, treatment and follow up results. Four patients were misdiagnosed as glaucoma. Another 4 patients were confirmed the diagnosis of melanoma and 3 of them received the operations of transscleral local resection. The common clinical manifestations included: impaired vision, exophthalmos, blepharoptosis, limited ocular motility, conjunctival hyperemia, and increased ocular or orbital pressure, etc. Characteristic sign was raised mass on the surface of sclera. All cases underwent orbital MRI preoperatively, 6 underwent ocular B-scan echography, and 6 underwent orbital CT scanning to evaluate for extraocular extension of tumor. Typical ultrasonography revealed the discontinued ocular wall and an intraocular mass with a continuous hypoechoic extraocular mass. In some cases the extraocular mass showed hypoechoic with medium echo area. CT scan showed a well-defined homogeneous intraconal mass connecting with intraocular lesion in 6 cases, which could infiltrate eye or optic nerve. The MR signal features of intraocular tumors with extraocular extension showed 4 patterns in all patients. The typical pattern was the tumor showed hyperintensity on T(1) and hypointensity on T(2)-weighted image. The maximum diameter of extraocular tumor was measured over 4 mm in 9 cases. MRI was useful for demonstrating multiple extraocular lesions, remote metastatic lesion or micro extraocular tumor, of which minimal diameter was 3 mm in our cases. Orbital exenteration was performed in 11 cases and ocular enucleation with excision of extraocular tumor was in 1 cases. Microscopic examination showed the epithelioid-cell-type tumors were the most common. The tumor extended out of the eye by three types of way in our cases. Follow-up ranged from 1 to 5 years in 8 cases, who underwent chemotherapy, radiotherapy or interferon. Six cases had no recurrences and general health. Death and metastasis was respectively recorded in one case. Delayed treatment could induce the growth of choroidal melanoma to the stage of extraocular extension, which has few specific clinical manifestations. The combination of multiple imaging examinations was helpful for the correct diagnosis. Surgical operation with adjunctive therapies could partly reduce recurrence and metastasis of melanoma.

Immunohistochemical assessment of mitotic count in uveal melanoma

The mitotic count of uveal melanomas correlates with the risk of metastatic death, but with haematoxylin and eosin (H&E)-stained sections, it can be difficult to identify mitotic figures (MF) reliably. We investigated whether this measurement could be enhanced by immunohistochemistry, using the mitosis-specific marker Phospho-Histone H3 Ser10 (PHH3). Formalin-fixed, paraffin-embedded choroidal melanomas from patients treated by enucleation or trans-scleral local resection between 2006 and 2008 were used in this study. Sections from 132 tumours were stained with H&E and PHH3. Mitotic count was defined as the sum of MF counted in 40 high-power fields (HPF). In both H&E and PHH3-stained sections, mitotic count was determined independently by an experienced pathologist (SEC) and by a trainee ophthalmologist (MA). Data were assessed using the Kolmogorov-Smirnov (KS) statistical test and the Bland-Altman (BA) analysis. The mitotic count determined by SEC in H&E and PHH3-stained sections had median values of 4/40 HPF and 8/40 HPF, respectively (KS, Z = 2.585 p < 0.001; BA, mean difference -5.95 [CI -22.15-10.22]), indicating poor reproducibility between these two methods. Similarly, the mean difference between the H&E and the PHH3 methods for calculating the mitotic count by MA was -7.03 (BA) [CI -23.38-9.31]. In contrast, the median mitotic counts determined by SEC & MA using PHH3 were 8/40 HPF and 9/40 HPF, respectively (KS, Z = 0.308 p = 1; BA, mean difference -0.29 [CI -2.65-2.06]), indicating good reproducibility between examiners. MF were more easily identified following immunohistochemical staining with anti-PHH3. This resulted in higher mitotic counts than obtained with H&E sections. For PHH3, the mitotic count determined by a MA was virtually the same as those obtained by an experienced pathologist. PHH3 is now routinely used in our centre, and new prognostic thresholds for uveal melanoma will be defined in further studies.

Choroidal melanoma in a 7-year-old child treated by trans-scleral local resection

To report a choroidal melanoma in a 7-year-old child treated by trans-scleral local resection and adjuvant brachytherapy with a family history of neurofibromatosis type I (NF1) and cutaneous melanoma. A 7-year-old child was referred for treatment of a choroidal tumor in her left eye with a differential diagnosis of melanoma, neurilemmoma, leiomyoma, and neurofibroma. Trans-scleral local resection and, subsequently, adjuvant brachytherapy were performed. Histopathology and immunohistochemistry of the specimen diagnosed an amelanotic melanoma of spindle cell type, with a moderately high number of mitoses (7/40 HPF). Multiplex ligation-dependent probe amplification (MLPA) analysis showed two copies of chromosome 3, three copies of the short arm of chromosome 6, and two copies of chromosome 8, strongly suggesting a good prognosis. Postoperative ophthalmic evaluation at 6 months showed no visible tumor and flat retina with visual acuity (VA) of 6/60. Trans-scleral local resection with adjuvant brachytherapy in children is possible using the same techniques as for adults. Although the follow-up is short, our patient retained the eye with good vision and our cytogenetic studies allowed us to reassure the mother.

Recurrent choroidal melanoma after transscleral local resection with diffuse vitreous seeding

Choroidal melanoma usually spreads systemically via the vascular system or extraocularly through channels in the sclera. Intraocular spread through vitreous seeding is uncommon. We present two patients in whom melanoma recurred following transscleral local resection and widespread fine patchy pigmentation of the retina was identified grossly. The eyes were submitted for histological examination. In one case there was recurrent melanoma in the surgical coloboma with diffuse vitreous seeding and a pre-retinal membrane composed of tumour cells. Tumour cells were also identified in the anterior chamber. In the second case there was no tumour in the coloboma although two small satellite choroidal nodules were identified. Tumour cells were also present in the vitreous and covering the surface of the retina. We described two cases of recurrent choroidal melanoma following transscleral local resection with vitreous seeding. Intraocular seeding following local resection is uncommon. There are several potential mechanisms for this although it seems likely that in these cases loss of the retinal barrier assisted in the intraocular spread of these tumours.

The treatment of uveal melanoma with iodine plaque brachytherapy

Abstract Purpose To provide an overview of managing uveal melanoma (UM) with iodine brachytherapy (IBT). Methods Personal experience of the author in using IBT since 1990. Results IBT is an effective option for managing a UM of any size, although it is mostly used for medium‐sized tumours, preference being given to ruthenium brachytherapy (RBT) when the tumour is &lt;5‐6 mm thick and to transscleral local resection when thickness is &gt;6 mm, especially when vision is good. IBT is also a safe alternative to enucleation of large UM &gt;10 mm in thickness if the patient is keen to preserve the eye and motivated to accept eventual complications. The plaque is positioned over the UM with a 1‐2 mm safety margin when using a collimated/rimmed plaque. Because of stray radiation, a safety margin is not mandatory when the plaque is non‐collimated/non‐rimmed. Otherwise, surgical technique does not differ from RBT. An advantage of IBT is that the radioactive seeds are separate from the plaque, allowing economical use of plaques of many different sizes and shapes and individual positioning of the seeds in a conformal way. A disadvantage is a short half‐life; the seeds need to be changed every 6 months. The dose the author uses is 80 Gy to tumour apex, which is reduced on an individual basis to 60‐70 Gy when the UM is very thick. Local tumour control rate is 90% and, paradoxically, not worse for large UM as compared to smaller ones. There are no unequivocal safety distances for avoiding radiation cataract, maculopathy and optic neuropathy, which are more or less frequent depending on the size and location of the UM. Conclusion IBT achieves good local tumour control of UM of all sizes, but preservation of vision is decidedly less frequent than after RBT, which is always given preference.

Introduction: Uveal melanoma

Introduction: Uveal melanoma

Bovine Pericardium for Scleral Closure in Transscleral Local Resection of Choroidal Melanoma

Bovine Pericardium for Scleral Closure in Transscleral Local Resection of Choroidal Melanoma

Transscleral local resection versus iodine brachytherapy for uveal melanomas that are large because of tumour height

To compare visual outcome and ocular complications of transscleral local resection (TSR) with those of iodine-125 plaque brachytherapy (IBT) for uveal melanomas categorised as large because of tumour height. Retrospective study of 87 patients with a uveal melanoma <or=16 mm by largest basal diameter (median, 12.6 vs 14.0 mm for TSR and IBT, respectively) and large by height (median, 11.0 vs 10.6 mm) by the Collaborative Ocular Melanoma Study (COMS) criteria. Thirty-three patients underwent TSR in the United Kingdom and 54 underwent IBT in Finland. Loss of 20/65 and 20/400 vision, local tumour recurrence, cataract, iris neovascularization, glaucoma, maculopathy, optic neuropathy, persistent retinal detachment, and vitreous haemorrhage were analysed using competing risks and logistic regression to control for confounders. All patients save one managed with TSR lost 20/70 vision within 3 years. The 2-year cumulative incidence of losing 20/400 vision was 60% (95% CI, 35-75) for TSR and 75% (95% CI, 59-86) for IBT. The 5-year incidence of local tumour recurrence was 41% (95% CI, 17-63) after TSR and 7% (95% CI, 2-17) after IBT. Glaucoma and optic neuropathy were rare after TSR. Cataract, maculopathy, retinal detachment, and vitreous haemorrhage were common after either treatment. The number of patients needed to treat with TSR instead of IBT was four for one additional patient to benefit by avoiding loss of visual acuity 20/400 for at least 2 years, and the corresponding number was three for one additional patient to experience a local recurrence from TSR. If TSR is further evaluated as an alternative to IBT in avoiding blindness of an eye with a ciliochoroidal melanoma categorised as large by COMS criteria because of its height, special emphasis must be given to increased risk of local tumour recurrence.

Delayed Treatment of Choroidal Melanoma Due to Pregnancy

The authors report a 27-year-old woman who presented with a large, choroidal melanoma when she was 28 weeks pregnant. Following detailed discussion with the patient, the decision was made to postpone any surgical treatment until after the birth of her child. Case report. The patient had successful transscleral local resection of the tumor with 6/12 vision 6 months later. Cytogenetic studies showed a low risk of subsequent metastases. This case illustrates that deferring the treatment of a choroidal melanoma presenting during pregnancy can be a reasonable treatment plan, if the patient is highly motivated to keep the eye.

Treatment of primary intraocular melanoma

The treatment of intraocular melanoma has evolved recently. Enucleation has been superseded largely by brachytherapy, proton beam radiotherapy, stereotactic irradiation, trans-scleral local resection, transretinal resection and diode laser phototherapy. Many patients develop metastatic disease, which usually involves the liver and occurs hematogenously. Disseminated disease rarely responds to therapy, and is usually fatal within 1 year of the onset of symptoms. Uveal melanomas develop characteristic chromosomal abnormalities, such as loss of chromosome 3. This is associated with a reduction in the 5-year survival from approximately 95% to less than 50%.

Developments in the management of uveal melanoma

Uveal melanomas threaten visual loss, enucleation, and death from metastatic disease. Most patients present because of symptoms, but failures of detection and diagnosis still occur commonly. Treatments aimed at avoiding enucleation include: plaque, proton beam or stereotactic radiotherapy; trans-scleral or trans-retinal local resection; and transpupillary thermotherapy. Increasingly, different modalities are being used in combination. The ocular outcomes are related to tumour size, location, spread and cell type. Metastatic disease occurs in many patients and is related to factors such as tumour dimensions, ciliary body involvement, cell type, extravascular matrix patterns and cytogenetics. Abnormalities related to chromosomes 3, 6 and 8 are strongly related to tumour behaviour, for the first time enabling survival probability to be estimated with a high degree of reliability in an individual patient. This enables high-risk individuals to be targeted for screening while providing reassurance to those with a minimal chance of developing metastatic disease. Such targeting would allow selection of patients for adjuvant systemic therapy, should a suitable treatment become available, and would also facilitate the evaluation of such treatment by increasing the statistical power of any randomized prospective study. The high mortality in patients with monosomy 3 melanoma suggests that in these patients ocular treatment is only palliative. Cytogenetic studies suggest that some melanomas may never develop any metastatic potential and if these impressions are confirmed by further studies, then in these patients the main priority of treatment would be to conserve vision.

Conservation of eyes with choroidal melanoma by a multimodality approach to treatment: An audit of 1632 patients

Objective To report on conservation of eyes with choroidal melanoma with a multimodality approach to treatment. Design Prospective, noncomparative, interventional case series. Participants All 1632 patients with choroidal melanoma treated at a single center between 1993 and 2002. Intervention Primary enucleation (35%), brachytherapy (31.3%), proton beam radiotherapy (16.7%), transscleral local resection (11.0%), endoresection (3.7%), transpupillary thermotherapy (2.5%), and photocoagulation (0.1%). Main outcome measures Primary and secondary enucleation. Results Logistic regression showed the main predictive factors for primary enucleation to be: age more than 60 years (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.8%–3.2%); reduced visual acuity (OR, 2.5; 95% CI, 1.9%–3.2%); posterior extension close to or involving the optic disc and fovea (OR, 1.7; 95% CI, 1.2%–2.4%); circumferential spread around the ciliary body, iris, or angle (OR, 3.1; 95% CI, 1.8%–5.5%); basal tumor diameter (OR, 3.5; 95% CI, 2.4%–5.0%); and tumor height (OR, 6.3; 95% CI, 4.5%–8.9%). After conservative treatment, the actuarial rate of secondary enucleation was 11.1% at 5 years (95% CI, 8.6%–13.6%). Cox multivariate analysis indicated the factors independently predicting secondary enucleation as: nasal/midline tumor location (risk ratio [RR], 2.6; 95% CI, 1.6%–4.4%); disc involvement (RR, 2.2; 95% CI, 1.2%–4.1%); tumor diameter (RR, 1.2; 95% CI, 1.0%–1.5%); and tumor thickness (RR, 1.8; 95% CI, 1.5%–2.1%). Conclusions With a multimodality approach to treatment, 65% of patients underwent conservative treatment, and of them, 89% retained their eye at 5 years, with success depending on tumor diameter, tumor thickness, disc involvement, and coronal location.

Noncontiguous tumor recurrence of posterior uveal melanoma after transscleral local resection.

To describe the clinical and histopathologic features of noncontiguous tumor recurrence after transscleral local resection of posterior uveal melanoma. Chart review was performed to identify patients with noncontiguous tumor recurrences from a series of 494 consecutive patients treated with transscleral local resection for uveal melanoma. The clinical and histopathologic features of noncontiguous tumor recurrences were studied. Nine cases were identified, for an estimated incidence of 1.8%. The average diameter of the primary tumors was 16.1 mm (range, 9-22 mm) and the average thickness was 9.8 mm (range, 6-14 mm). Noncontiguous tumor recurrences were solitary in 7 cases and multiple in 2 cases, with an average diameter of 5.8 mm (range, 3.0-9.5 mm). Eight of the 9 patients developed tumor recurrences at multiple intraocular sites. With a mean follow-up of 82.1 months (range, 22-171 months), 7 patients had a final visual acuity of counting fingers or worse, and there were 3 deaths from metastatic disease. Noncontiguous tumor recurrence after local resection appears to be related to intraocular dissemination from the primary tumor, either through the natural course of the disease or secondary to surgical manipulation. Eyes with large primary uveal melanomas developing noncontiguous tumor recurrence have a high risk of developing tumor spread to multiple intraocular sites, and aggressive treatment is warranted.

Rhegmatogenous retinal detachment after transscleral local resection of choroidal melanoma

Objective To report on the incidence and outcome of rhegmatogenous retinal detachment after transscleral local resection of choroidal melanoma. Design Prospective, noncomparative, interventional case series. Participants One hundred fifty-six patients with choroidal melanoma treated by transscleral local resection between January 1993 and June 2000. Intervention Transscleral choroidectomy or cyclochoroidectomy for uveal melanoma, with ocular decompression by single-port pars plana vitrectomy and, in most patients, adjunctive ruthenium plaque radiotherapy. Main outcome measures Incidence of rhegmatogenous retinal detachment according to predictive factors and outcomes reported in terms of anatomic success, visual acuity, and ocular conservation. Results Rhegmatogenous retinal detachment occurred in 28 (18%) eyes and was significantly more common in patients with thick tumors (Cox univariate analysis, P = 0.001) and in males (Cox univariate analysis, P = 0.013), with posterior tumor extension being of borderline significance (Cox univariate analysis, P = 0.069). Surgical treatment of the retinal detachment was performed in 25 patients; it was undertaken at our center in 22 patients and at the referring hospital in 3 patients. Anatomic success was achieved in 21 (84%) of these 25 patients, with 7 eyes retaining counting fingers vision, and 3 eyes seeing 6/60 or better. Ten eyes treated for retinal detachment were enucleated because of recurrent tumor (four eyes), retinal detachment (three eyes), wound dehiscence (one eye), phthisis (one eye), and poor visual acuity (one eye). Eleven eyes known to have a retinal tear underwent prophylactic vitreoretinal surgery at the end of the local resection, with only one (9%) of these subsequently developing retinal detachment. Conclusions Rhegmatogenous retinal detachment after transscleral choroidectomy or cyclochoroidectomy for uveal melanoma is a serious complication requiring early vitreoretinal surgery.

Transformation of cell type in uveal melanomas: a quantitative histologic analysis.

To describe the cytologic transformation and tumor progression in a series of uveal melanomas. Fifteen cases of uveal melanoma, treated by primary transscleral local resection without primary adjuvant treatment, needed enucleation because of local tumor recurrence. Cytologic and cell morphometric features of the primary tumor and the intraocular recurrence were compared, with evaluation of the amounts of intermediate cells, epithelioid cells, mitotic figures, and nucleolar area. The cases were categorized into 2 groups, according to their cytologic characteristics. In the first group (5 cases), there was no cytopathological transformation in the recurrent tumor. The nucleolar area was increased in only 1 case. In the second group (10 cases), the recurrent tumors showed transformation into a more epithelioid cell type. In all but 1 case there was an increase in epithelioid cells in the tumor recurrence. The nucleolar area was increased significantly in all cases. The mean local recurrence interval in all cases was 15.3 months, with no difference between the groups. Death from metastases occurred in 7 cases in which the nucleolar area was 4.2 microm(2) in the primary tumor. These findings demonstrate that, in an individual tumor, the cytologic phenotype can change considerably even after a relatively short time, resulting in an increase in tumor-related mortality. Studies on the natural course of uveal melanoma have been very limited and based purely on observations on the progression of melanomas in terms of size and alteration of various clinical characteristics.

Delays in the diagnosis of uveal melanoma and effect on treatment.

To investigate the mode of presentation of uveal melanomas, delays in their diagnosis and the effect of delayed diagnosis on treatment outcome. An analysis was carried out of 50 consecutive patients undergoing treatment for uveal melanoma at the Ocular Oncology Service in Liverpool. The mode of presentation of the tumour, onset of symptoms and subsequent management were determined by interview at the time of treatment. Seventy-two per cent of patients had one or more symptoms directly attributable to the tumour. These included blurred vision (36%), photopsia (22%), visual field loss (16%), floaters (4%) and metamorphopsia (4%). Forty-two per cent of patients experienced delays in the diagnosis and treatment due to misdiagnoses such as macular degeneration and naevus or due to the lesion being missed at the initial visit. Patients who had experienced delays in diagnosis received treatment after a mean of 6.6 months compared with 4.2 weeks for those who did not experience any delay (p = 0.003). Such patients were more likely to be treated by enucleation (52% vs 17%, p = 0.008) than by an eye-conserving method such as radiotherapy or trans-scleral local resection. The primary aim of treatment of uveal melanoma is to reduce the risk of death from metastases and a secondary aim is to conserve the eye with as much vision as possible. This study identifies common reasons for delays in the diagnosis of uveal melanoma. While the effect of early treatment on survival remains controversial, this study shows that patients who have their tumours diagnosed promptly are more likely to be treated by an eye-conserving method than by enucleation.

Endoresection of choroidal melanoma

AIMSThe results of 52 endoresections for choroidal melanoma are reported.METHODSThe current technique involves vitrectomy, retinal incision over or peripheral to the tumour, haemostasis by raising intraocular pressure and by moderate...