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ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 1  |  Page : 190-192
 

Retrospective study of choroidal melanomas at the 1st Department of Ophthalmology, AHEPA hospital, Thessaloniki, from 2002 to 2011


Department of Ophthalmology, University Hospital AHEPA, Thessaloniki, Greece

Date of Web Publication28-Apr-2016

Correspondence Address:
A A Malamas
Department of Ophthalmology, University Hospital AHEPA, Thessaloniki
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.180813

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 » Abstract 

Aim: Retrospective study of cases of choroidal melanoma examined at the 1st Department of Ophthalmology, University Hospital American Hellenic Educational Progressive Association, during the 10-year period, from January 2002 to December 2011. Materials and Methods: The study group consists of 84 patients (84 eyes) with newly diagnosed choroidal melanoma. The documentation of the location and the dimensions of the melanomas, based on B-Ultrasonography findings (apical height, diameter), were included. A total of 58 patients were referred to a specialized center abroad for conservative irradiation therapy. Twenty six eyes were enucleated due to large size of the tumor and the histopathological type was determined. Results: Of the 84 cases, 44 were located at the posterior pole while 40 anteriorly. Based on size, 6% (5/84) were small, 58% (49/84) were medium and 36% (30/84) large. Based on the histopathological analysis of 22 of the 26 eyes enucleated, 36% were mixed-cell, 32% were spindle cell and 27% were epithelioid cell melanomas. Conclusions: Our study is the first documentation and classification of newly diagnosed cases of choroidal melanomas. The large number of mandatory enucleations, due to large size, is surprising. Patients need to be better informed about preventive fundoscopy for diagnosis of asymptomatic melanoma at an earlier stage.


Keywords: Choroidal melanoma, enucleation, malignant


How to cite this article:
Chranioti A A, Malamas A A, Diavati O, Ziakas N G, Maloutas S G, Oikonomidis P K. Retrospective study of choroidal melanomas at the 1st Department of Ophthalmology, AHEPA hospital, Thessaloniki, from 2002 to 2011. Indian J Cancer 2016;53:190-2

How to cite this URL:
Chranioti A A, Malamas A A, Diavati O, Ziakas N G, Maloutas S G, Oikonomidis P K. Retrospective study of choroidal melanomas at the 1st Department of Ophthalmology, AHEPA hospital, Thessaloniki, from 2002 to 2011. Indian J Cancer [serial online] 2016 [cited 2019 Aug 18];53:190-2. Available from: http://www.indianjcancer.com/text.asp?2016/53/1/190/180813



 » Introduction Top


Choroidal melanoma is a malignant neoplasm that arises from neuroectodermal melanocytes within the choroid. It is the most common primary malignant intraocular neoplasm in adults. Studies from various countries have reported annual incidence rates between 6 and 7 cases per million. The average age at detection of melanomas of the choroid and ciliary body is about 55-60 years in most large series.[1],[2],[3],[4]

Choroidal melanomas are routinely classified as small, medium and large.[3],[4] Multiple studies, including the collaborative ocular melanoma study (COMS), have specified tumor size as the strongest indicator for metastasis and therefore survival.[5],[6]

Choroidal melanomas are generally classified as spindle cell melanomas if they contain only spindle cells, mixed-cell melanomas if they are composed of an admixture of spindle cells and epithelioid cells without preponderance of epithelioid cells and epithelioid cell melanomas if they are composed entirely or predominantly of epithelioid cells. In many independent studies, spindle cell melanomas have been shown to be associated with the most favorable survival prognosis, epithelioid cell melanomas with the least favorable survival prognosis and mixed-cell melanomas with an intermediate survival prognosis.[7]

The most reliable diagnostic procedure for choroidal melanomas is B-scan ultrasonography. Standardized A-scan ultrasonography of choroidal and ciliary body melanomas typically reveals low-amplitude internal reflectivity with a characteristic stepwise decremental reduction in echo spike amplitude from the front to the back of the lesion. Moreover, fluorescein angiography, fundus autofluorescence, indocyanine green angiography, computed tomography, magnetic resonance imaging and surgical biopsy can contribute to the diagnosis of choroidal melanomas.[8]

A standard baseline systemic assessment of the extent of disease generally consists of: A complete physical examination; selected blood tests, which usually include at least a complete blood count (CBC) and a serum liver enzyme panel; chest radiograph and computed tomography scan (with contrast), magnetic resonance imaging (MRI) or ultrasound evaluation of the abdominal organs (especially the liver).[9],[10]

The treatment options for choroidal melanomas are: Enucleation, radiation therapy, plaque radiotherapy (iodine-125, ruthenium-106, and palladium-103), proton beam irradiation, gamma knife and stereotactic radiosurgery, microsurgical resection, external transscleral resection, transvitreal endoresection, laser therapy, cryotherapy, observation, exenteration and chemotherapy for metastatic disease clinic protocol for diagnosis and treatment.

In Thessaloniki, Greece, the 1st Department of Ophthalmology, Aristotle University of Thessaloniki, is considered to be one of the benchmarks for choroidal melanomas cases. Suspected cases of ocular malignancy from the regions of Northern Greece are referred to us for evaluation, diagnosis and management of treatment. The suspected or diagnosed cases of choroidal melanoma are accrued from the 22 provincial hospitals, the 13 central hospitals in Thessaloniki and the private practices located mainly within the regions of Northern Greece.

The clinic protocol, for diagnosis and extension of the tumor includes slit lamp examination of the fundus, fundus photography-fundus autofluorescence-fluorescein angiography (when needed), A and B ultrasonography of the orbit, MRI of the brain and orbits, chest radiograph, ultrasound evaluation of the abdominal organs, bone scintigraphy with total cholesterol, blood tests (CBC, prothrombin time, partial thromboplastin time, INR, sodium, potassium, urea, creatinin, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine phosphokinase, total bilirubin, alkaline phosphatase, amylase, erythrocyte sedimentation, C-reactive protein) and cancer markers: Carcinoembryonic antigen, alpha-fetoprotein, carbohydrate antigen (CA) 15-3, CA 125, CA 19-9, neuron-specific enolase, prostate specific antigen.

After completion of protocol examinations and evaluation, the majority of patients are referred to the University Eye Clinic of Lausanne of Jules Gonin Eye Hospital, where further evaluation is conducted and appropriate treatment is determined. Patients with metastasis or large choroidal melanomas are excluded from this process. If treatment includes radiation and preservation of the eye, the patient remains at Jules Gonin Eye Hospital until the treatment is carried out. If treatment includes enucleation the patient is referred to American Hellenic Educational Progressive Association (AHEPA) Hospital in Thessaloniki were he/she undergoes the surgical procedure. Moreover, all patients who have been diagnosed with choroidal melanoma, after the treatment protocol, are hospitalized in a particular time lag for reevaluation and detection of tumor rebounding or metastasis.


 » Materials and Methods Top


Patients

Medical charts of all patients with diagnosed choroidal melanoma ( first diagnosis upon admittance, prior diagnosis or admittance for reevaluation purposes-treatment management) were retrieved and reviewed. From January 2002 to December 2011, 98 patients with diagnosis of choroidal melanoma were admitted in the Ophthalmologic Clinic of AHEPA Hospital. Of these 98 patients, 14 were excluded. Of the latter 14, 6 patients were with prior to 2002 diagnosis of choroidal melanoma while the remaining 7 were “false alarms” (1 patient with choroidal nevus, 2 with retinal detachment, 2 with macula edema, 1 with vitreous hemorrhage and 1 with choroidal hemangioma). The last patient of exclusion was with metastatic choroidal melanoma (diagnosed with breast cancer 4 years prior to admission in our clinic).

Methods

Based on A and B ultrasonography findings, location (posterior pole or anterior location within the choroid) and size (small, medium or large) of all choroidal melanomas was documented. The number of eyes that underwent plaque radiotherapy, in collaboration with the specialized treatment center, the University Eye Clinic of Lausanne, Jules Gonin Eye Hospital and the number of those that underwent enucleation at our center, were recordered. We retrieved histopathological findings of choroidal melanoma biopsies of eyes enucleated during our 10-year period.


 » Results Top


Of the 84 patients from our study, 41 were male (male to female ratio was 1:1.05) while 50% of choroidal melanomas involved the right eye (42 right eye-42 left eye). Mean age was 64.9 (mean age, male: 67.4 and female: 62.7).

With regard to choroidal location, 44 were located at the posterior pole while 40 were anteriorly localized. The 84 cases of choroidal melanomas were categorized according to size [5],[11],[12] into three groups, based on A and B orbit ultrasonography findings: 6% (5/84) small (1.5-2.4 mm height and 5-16 mm diameter), 58% (49/84) medium (2.5-10 mm apical height and ≤16 mm diameter), and 36% (30/84) large (> mm apical height and >16 mm diameter) [Chart 1].



When taking into consideration location and size, our results showed a tendency for medium sized melanomas to be located at the posterior pole [Table 1].
Table 1: Classification of choroidal melanomas based on location and size

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After the initial evaluation, 60 patients were referred to the University Eye Clinic of Lausanne of Jules Gonin Eye Hospital, where further evaluation was conducted and appropriate treatment was determined. A total of 58 patients underwent plaque radiotherapy while 2 patients returned to our clinic to undergo enucleation, since the choroidal neoplasm was characterized non-treatable. The remaining 26 patients underwent enucleation: 24 due to the existence of a large or non-treatable choroidal melanoma and 2 because of refusal to transfer to a specialized center (enucleation being the desired therapeutic option for them and their family).

The histological type was determined, based on the histopathological analysis of 21 of the 26 eyes enucleated (1 patient had an unusual neoplasm not compatible to choroidal melanoma and we were unable to retrieve 4 of the 26 choroidal melanoma biopsies of eyes enucleated): 36% were mixed-cell 32% were spindle cell and 27% were epithelioid cell melanomas [Chart 2].




 » Discussion Top


In the present study, there was no difference regarding gender in patients affected by malignant choroidal melanoma, suggesting that the disease does not have a special affinity for male or female.[13] The mean age in our study was 64.9. All of our patients had unilateral tumors.

Tumor size and location is critical for the choice of therapeutic option. Large choroidal tumors continue to be managed primarily by enucleation when there is no hope for useful vision. The large tumor trial of the COMS demonstrated neither a positive nor negative effect on 5- and 8-year mortality rates among more than 1000 patients whose eyes containing large choroidal melanomas were randomized to treatment between enucleation alone or enucleation preceded by external radiation.[5],[14] The medium-size tumor trial of the COMS randomized more than 1300 patients between iodine-125 brachytherapy and enucleation. Mortality rates following brachytherapy did not differ from mortality rates following enucleation for up to 12 years after treatment.[11] According to our study, plaque radiotherapy is the preferable option for small and medium size tumors and enucleation for large tumors. Medium tumors were located more posteriorly than large tumors.

Regarding the histological classification, there was a small predominance of mixed-cell melanomas. These findings are in accordance to previously reported results, where mixed cell tumors were most frequently found.[15]

Of the 84 newly diagnosed patients with primary choroidal melanoma, only 25 were periodically admitted in our clinic for evaluation of possible tumor rebounding or metastasis. This lack of consistency limited our study regarding the follow-up period.

Choroidal melanoma has a well-documented capacity to metastasize hematogenously, regardless radiation or enucleation therapy. The liver is the most common site of metastatic disease.[16] Other organs, less common, are the lungs, the brain, the thyroid, the skin, the bones and the colon.[17],[18] Among our 25 remaining patients, four developed liver metastasis and one bone metastasis at some point of the follow-up period.

The early detection and treatment of choroidal melanoma is critical for the patient's prognosis.[19] The survival rate, ocular complications, extraocular metastases, therapeutic alternatives and visual outcome are accordingly to early detection.[19],[20] Unfortunately in our study, none of our patients was diagnosed while still asymptomatic by routine eye examination, which comes to show that they were all diagnosed in advanced stages. Most of them had some kind of ocular manifestation such as blurred vision, sudden visual loss, visual floaters or sparkles, which means that they all suffered complications due to enlargement of the tumor. Some of them were retinal detachment, optic nerve invasion, vitreous hemorrhage as well as macular involvement.

This delay in the initial care bears a disturbing reality as there is inadequate information of the public. On the other hand, clinicians should perform a thorough fundoscopy in routine ophthalmic examinations and be alert for minimal findings, in order to detect the malignancy at an early stage.

 
 » References Top

1.
Singh AD, Bergman L, Seregard S. Uveal melanoma: Epidemiologic aspects. Ophthalmol Clin North Am 2005;18:75-84, viii.  Back to cited text no. 1
    
2.
Egan KM, Seddon JM, Glynn RJ, Gragoudas ES, Albert DM. Epidemiologic aspects of uveal melanoma. Surv Ophthalmol 1988;32:239-51.  Back to cited text no. 2
    
3.
Zimmerman LE, McLean IW, Foster WD. Statistical analysis of follow-up data concerning uveal melanomas, and the influence of enucleation. Ophthalmology 1980;87:557-64.  Back to cited text no. 3
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4.
Shields JA, Shields CL, Donoso LA. Management of posterior uveal melanoma. Surv Ophthalmol 1991;36:161-95.  Back to cited text no. 4
    
5.
The collaborative ocular melanoma study (COMS) randomized trial of pre-enucleation radiation of large choroidal melanoma II: Initial mortality findings. COMS report no. 10. Am J Ophthalmol 1998;125:779-96.  Back to cited text no. 5
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6.
Mooy CM, De Jong PT. Prognostic parameters in uveal melanoma: A review. Surv Ophthalmol 1996;41:215-28.  Back to cited text no. 6
    
7.
McLean IW, Foster WD, Zimmerman LE, Gamel JW. Modifications of callender's classification of uveal melanoma at the Armed Forces Institute of Pathology. Am J Ophthalmol 1983;96:502-9.  Back to cited text no. 7
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8.
Kivelä T. Diagnosis of uveal melanoma. Dev Ophthalmol 2012;49:1-15.  Back to cited text no. 8
    
9.
Albert DM, Wagoner MD, Smith ME. Are metastatic evaluations indicated before enucleation of ocular melanoma? Am J Ophthalmol 1980;90:429-32.  Back to cited text no. 9
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10.
Augsburger JJ, Damato BE, Bornfeld N. BornfeldN. Uveal melanoma: Diagnosis and ancillary testing. In: Yanoff M, Duker JS, editors. Ophthalmology. 3rd ed. Philadelphia:Elsevier Health Sciences; 2008.  Back to cited text no. 10
    
11.
Diener-West M, Earle JD, Fine SL, Hawkins BS, Moy CS, Reynolds SM, et al. The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, III: Initial mortality findings. COMS report no. 18. Arch Ophthalmol 2001;119:969-82.  Back to cited text no. 11
    
12.
Mortality in patients with small choroidal melanoma. COMS report no. 4. The collaborative ocular melanoma study group. Arch Ophthalmol 1997;115:886-93.  Back to cited text no. 12
    
13.
Melia M, Moy CS, Reynolds SM, Hayman JA, Murray TG, Hovland KR, et al. Quality of life after iodine 125 brachytherapy vs. enucleation for choroidal melanoma: 5-year results from the collaborative ocular melanoma study: COMS QOLS report no. 3. Arch Ophthalmol 2006;124:226-38.  Back to cited text no. 13
    
14.
Robertson DM. Changing concepts in the management of choroidal melanoma. Am J Ophthalmol 2003;136:161-70.  Back to cited text no. 14
    
15.
Histopathologic characteristics of uveal melanomas in eyes enucleated from the collaborative ocular melanoma study. COMS report no. 6. Am J Ophthalmol 1998;125:745-66.  Back to cited text no. 15
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16.
Collaborative Ocular Melanoma Study Group. Assessment of metastatic disease status at death in 435 patients with large choroidal melanoma in the collaborative ocular melanoma study (COMS): COMS report no. 15. Arch Ophthalmol 2001;119:670-6.  Back to cited text no. 16
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17.
Koutsandrea C, Moschos MM, Dimissianos M, Georgopoulos G, Ladas I, Apostolopoulos M. Metastasis rates and sites after treatment for choroidal melanoma by proton beam irradiation or by enucleation. Clin Ophthalmol 2008;2:989-95.  Back to cited text no. 17
    
18.
Char DH. Metastatic choroidal melanoma. Am J Ophthalmol 1978;86:76-80.  Back to cited text no. 18
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19.
Shields CL, Shields JA. Clinical features of small choroidal melanoma. Curr Opin Ophthalmol 2002;13:135-41.  Back to cited text no. 19
    
20.
Diener-West M, Reynolds SM, Agugliaro DJ, Caldwell R, Cumming K, Earle JD, et al. Development of metastatic disease after enrollment in the COMS trials for treatment of choroidal melanoma: Collaborative ocular melanoma study group report no. 26. Arch Ophthalmol 2005;123:1639-43.  Back to cited text no. 20
    



 
 
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