Fine needle aspiration biopsy in ophthalmology

Primary lacrimal sac melanoma: a case report describing the novel use of fine needle aspiration cytology (FNAC) for diagnosis, together with literature review and immunotherapy treatment update

Primary lacrimal sac melanoma (PLSM) is exceedingly rare and associated with high morbidity and mortality. Unfortunately, PLSM often presents insidiously resulting in delayed detection and poor prognosis. A 69-year-old Black man was suspected of having a lacrimal sac tumour following presentation with a left sided watery eye, bloody tears, and a lacrimal mass. Due to the patient's implantable pacemaker, defibrillator, and high anticoagulation, an ultrasound-guided FNAC was performed instead of incisional biopsy, revealing a PLSM. Diagnosis was confirmed following complete tumour resection with free flap reconstruction and neck dissection. Unfortunately, disease progression ensued despite further neck dissection and three cycles of both pembrolizumab and iplimumab. This is the first description of FNAC to accurately diagnose PLSM and highlights its use as an accurate, rapid, and minimally invasive technique that may allow an earlier screening diagnosis of lacrimal sac tumours. We also discuss the outcome of immunotherapy in recent similar cases.

Histopathologic and MR Imaging Appearance of Spontaneous and Radiation-Induced Necrosis in Uveal Melanomas: Initial Results

Simple Summary

Uveal melanomas may undergo necrosis, both spontaneously or following radiotherapy. Nowadays radiotherapy is the preferred treatment, whereas enucleation of the eye is used in selected cases. In order to differentiate the effects of radiotherapy from spontaneous degenerative changes in uveal melanomas, we compared the appearance of necrosis, both from a histopathological point of view and from the perspective of MR imaging, in two groups of patients with uveal melanoma: a group who had undergone previous proton beam radiotherapy (secondary enucleation); a control group who had undergone enucleation without any previous radiotherapy treatment (primary enucleation). Irradiated and nonirradiated uveal melanomas differ on the basis of the histological appearance, the MR imaging appearance and the distribution of necrosis. We hope that the findings we observed could be extended to all patients with uveal melanomas treated with radiotherapy, and may enhance the accuracy of radiologists in evaluating MR examinations after radiotherapy.

Abstract

Necrosis in uveal melanomas can be spontaneous or induced by radiotherapy. The purpose of our study was to compare the histopathologic and MRI findings of radiation-induced necrosis of a group of proton beam-irradiated uveal melanomas with those of spontaneous necrosis of a control group of patients undergoing primary enucleation. 11 uveal melanomas who had undergone proton beam radiotherapy, MRI and secondary enucleation, and a control group of 15 untreated uveal melanomas who had undergone MRI and primary enucleation were retrospectively identified. Within the irradiated and nonirradiated group, 7 and 6 eyes with histological evidence of necrosis respectively, were furtherly selected for the final analysis; the appearance of necrosis was assessed at histopathologic examination and MRI. Irradiated melanomas showed a higher degree of necrosis as compared with nonirradiated tumors. Irradiated and nonirradiated lesions differed based on the appearance and distribution of necrosis. Irradiated tumors showed large necrotic foci, sharply demarcated from the viable neoplastic tissue; nonirradiated tumors demonstrated small, distinct foci of necrosis. Radiation-induced necrosis, more pigmented than surrounding viable tumor, displayed high signal intensity on T1-weighted and low signal intensity on T2-weighted images. The hemorrhagic/coagulative necrosis, more prevalent in nonirradiated tumors (4 out of 6 vs. 1 out of 7 cases), appeared hyperintense on T2-weighted and hypointense on T1-weighted images. Our study boosts the capability to recognize radiation-induced alterations in uveal melanomas at MRI and may improve the accuracy of radiologists in the evaluation of follow-up MR examination after radiotherapy.

Intraocular biopsy in uveitis

An intraocular biopsy is performed for diagnostic, prognostic and investigational purposes. Biopsies help to confirm or exclude malignancies and differentiate inflammatory from infectious processes. Histopathological analysis is the final verdict in unresponsive uveitis, atypical inflammation, metastases and masquerade syndromes. Advances and refinement of techniques in cytopathology, immunohistochemistry, microbiological and molecular biologic study offer much more than just diagnosis. They provide prognosis based on cell characteristics and are helpful in planning treatment and intervention. Many biopsy procedures have evolved to provide more safety and minimise complications thus improving the quality of specimens or samples available for analysis. The type of biopsy and technique adopted varies based on the clinical suspicion, size and location of lesions. In uveitis, a working diagnosis of intraocular inflammation is made on clinical examination and laboratory investigations and ancillary tests. Malignancy and uveitis is interlinked and masquerade syndromes are among the commonest indications for biopsy and analysis of specimen. The various types of intraocular biopsies include aqueous tap, fine needle aspiration biopsy, vitreous biopsy, iris and ciliary body, and retinochoroidal biopsy. They will be reviewed in this article with respect to current perspective

Indications for Fine Needle Aspiration Biopsy of Posterior Segment Intraocular Tumors

PURPOSE

To define 4 indication categories of fine needle aspiration biopsies (FNABs) of solid intraocular tumors and describe the differences among the patients, tumors, and results of biopsy in these 4 indication categories.

METHODS

Retrospective descriptive analysis of 880 FNABs of a solid intraocular tumor of the posterior ocular segment performed by in the authors' ocular oncology practice during the period July 1980 through July 2014.

RESULTS

FNABs were performed as a separate procedure in 372 cases (42.3%), at plaque implantation in 279 (31.7%), post-enucleation in 225 (25.6%), and post-resection/pre-laser in 4 (0.4%). FNABs were categorized as diagnostic in 292 (33.2%), confirmatory in 121 (13.8%), investigational in 187 (21.3%), and prognostic in 280 (31.8%). Prior to the biopsy, all patients who underwent diagnostic FNAB had a tumor of uncertain pathologic type, while all patients who underwent confirmatory FNAB had a clinically diagnosed malignant intraocular neoplasm. In contrast, all patients who underwent a prognostic FNAB had an unequivocal primary posterior uveal melanoma clinically, while patients who underwent an investigational biopsy all had an unequivocal or probable malignant intraocular tumor of a specific type. Most diagnostic FNABs were performed transvitreously (n = 255, 87.3%) compared to prognostic FNABs (n = 143, 51.1%) (P < .001). Overall, 733 FNABs (83.3%) yielded a sufficient specimen for cytologic diagnosis. Diagnostic and confirmatory FNABs were the most likely to yield an insufficient aspirate (28.4% and 20.7%, respectively), while investigational and prognostic FNABs were most likely to yield sufficient specimens (94.7% and 90.0%, respectively) (P < .001). Mean post-FNAB follow-up of the entire group was 62.7 months (standard deviation [SD] = 59.8, 95% confidence interval [CI] = 58.7-66.6). Mean posttreatment follow-up or total follow-up of untreated patients was 53.7 months (SD = 58.7, 95% CI = 49.8-57.6).

CONCLUSIONS

Because of the substantial differences shown among FNAB cases performed for different indications, it seems appropriate to report results of FNAB or other biopsy methods according to the category (indication) of the biopsy. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Uveal Melanoma Biopsy: A Review

Intraocular tumor diagnosis is based on clinical findings supported by additional imaging tools, such as ultrasound, optical coherence tomography and angiographic techniques, usually without the need for invasive procedures or tissue sampling. Despite improvements in the local treatment of uveal melanoma (UM), the prevention and treatment of the metastatic disease remain unsolved, and nearly 50% of patients develop liver metastasis. The current model suggests that tumor cells have already spread by the time of diagnosis, remaining dormant until there are favorable conditions. Tumor sampling procedures at the time of primary tumor diagnosis/treatment are therefore now commonly performed, usually not to confirm the diagnosis of UM, but to obtain a tissue sample for prognostication, to assess patient's specific metastatic risk. Moreover, several studies are ongoing to identify genes specific to UM tumorigenesis, leading to several potential targeted therapeutic strategies. Genetic information can also influence the surveillance timing and metastatic screening type of patients affected by UM. In spite of the widespread use of biopsies in general surgical practice, in ophthalmic oncology the indications and contraindications for tumor biopsy continue to be under debate. The purpose of this review paper is to critically evaluate the role of uveal melanoma biopsy in ophthalmic oncology.

Fine Needle Aspiration Biopsy: Its Use in the Management of Orbital and Intraocular Tumors

In the management of 29 patients by needle aspiration biopsy, a 100 % accuracy was obtained in the diagnosis of intra- and extra-bulbar orbital lesions. The technique did not produce any important traumatic complications; there was moderate subconjunctival hemorrhagic suffusion, which spontaneously resolved. The technique proved to be positive in the diagnostic approach to lesions with a difficult access. Its importance in the choice of treatment is discussed, and its effect on the prognosis of intraocular tumors is emphasized. It can indeed give specific indications for early treatment of malignant lesions and avoid radical surgery of pseudoneoplastic benign lesions. As in other sites, the technique is reliable if it is applied in cooperation with an experienced pathologist. It is simple and rapid, inexpensive and well accepted by patients more than other invasive diagnostic procedures.

In vivo Detection of Monosomy 3 in Eyes with Medium-Sized Uveal Melanoma using Transscleral Fine Needle Aspiration Biopsy

PURPOSE

Cytogenetic prognostication of choroidal melanoma, particularly monosomy 3 detections, is limited to enucleated eyes or resected tumors. The authors developed an in vivo technique to detect monosomy 3 using transscleral fine needle aspiration biopsy (FNAB).

METHODS

Eight eyes with medium-sized choroidal melanoma were included in this prospective study. A 25-gauge transscleral FNAB was performed during surgical procedure for brachytherapy, just before applying the radioactive plaque over the tumor base. Sampled material underwent fluorescence in situ hybridization (FISH) with centromeric probes for chromosome 3. Follow-up was >12 months.

RESULTS

Transscleral FNAB yielded sufficient material in 7 of 8 eyes (87.5 %). Five of seven eyes had monosomy 3. No early or late complications were detected.

CONCLUSIONS

This study demonstrates that medium choroidal melanomas may be safely sampled by intraoperative transscleral FNAB to detect monosomy 3 in vivo.

TWENTY-FIVE-GAUGE CANNULA-ASSISTED FINE-NEEDLE ASPIRATION BIOPSY OF CHOROIDAL MELANOMA: Cytopathological Analysis

PURPOSE

To report cytopathological observations on the cells retrieved from the 25-G cannula used during prognostic transvitreal fine-needle aspiration biopsy of choroidal melanoma.

METHODS

Transvitreal fine-needle aspiration biopsy of choroidal melanoma was performed through a 25-G valved cannula. Twenty samples from 20 consecutive patients were obtained. Most tumors were treated with plaque radiation therapy (16/20, 80%) following standard clinical guidelines. Four enucleated globes (4/20, 20%) were subjected to a similar transvitreal biopsy before enucleation.

RESULTS

Cytopathological analysis of the cells retrieved from the cannula revealed the absence of any cells in 4 of 20 samples (20%). In the remaining 16 samples, definite melanoma cells and atypical cells (probable melanoma cells) were observed in 2 samples each (total 4, 25%). Histiocytes (4/16, 25%) and lymphocytes (1/16, 6%) were also observed. Thirteen samples (13/16, 81%) contained conjunctival epithelial epithelium. Prognostication could be performed on all fine-needle aspiration biopsy samples (20, 100%).

CONCLUSION

Use of a 25-G valved cannula offers potential advantages by isolating the needle tract and by allowing retrieval of the contaminating cells without affecting the prognostic yield of the fine-needle aspiration biopsy sample.

Management of posterior uveal melanoma: past, present, and future: the 2014 Charles L. Schepens lecture

PURPOSE

To review the management of ciliary body and choroidal melanoma (posterior uveal melanoma [PUM]) over the last century with an emphasis on changing concepts.

DESIGN

Retrospective review.

PARTICIPANTS

Review of personal experience over 40 years and pertinent literature on management of PUM.

METHODS

Diagnosis and therapy for PUM.

MAIN OUTCOME MEASURES

Patient survival.

RESULTS

In the early 1900s, most patients presented with a large symptomatic melanoma that necessitated enucleation, and the systemic prognosis was poor. In the 1970s, controversy erupted regarding the role of enucleation for PUM. Some authorities advocated prompt enucleation, and others proposed that enucleation promoted metastasis, known as the "Zimmerman hypothesis." Others recommended observation, withholding treatment until tumor growth was documented. During the 1970s, there was a trend toward eye-saving procedures, including laser photocoagulation, surgical removal of tumor, and techniques of radiotherapy. Despite local treatment success, systemic prognosis remained guarded with approximately 40% mortality overall. However, there was convincing evidence that smaller tumors offered a significantly better prognosis. Currently, there is a movement toward earlier identification and treatment of small melanomas using clinical factors predictive of malignant potential, in keeping with similar philosophy regarding other cancers. Further understanding of melanoma cytogenetics and molecular pathways have helped to recognize patients at risk for metastasis. At-risk patients are offered systemic therapeutic trials to prevent metastasis. We anticipate that the future management of PUM will focus on detection of clinical and imaging clues for earliest diagnosis, prompt local tumor treatment, and systemic targeted therapies for microscopic metastasis or prevention of metastasis. Personalized evaluation of patient-specific melanoma molecular pathway signature could allow for therapeutic intervention at a site specific to the pathway abnormality that leads to the development of melanoma.

CONCLUSIONS

Management of PUM has made major strides over the past century from the days of enucleation for massive, fatal tumor to early detection of smallest tumors with a more favorable prognosis. Current and future targeted specific tumor pathway interruption using systemic agents could improve survival.

Sufficiency of FNAB aspirates of posterior uveal melanoma for cytologic versus GEP classification in 159 patients, and relative prognostic significance of these classifications

Objective

To determine the relative sufficiency of paired aspirates of posterior uveal melanomas obtained by FNAB for cytopathology and GEP, and their prognostic significance for predicting death from metastasis.

Methods

Prospective non-randomized IRB-approved single-center longitudinal clinical study of 159 patients with posterior uveal melanoma sampled by FNAB in at least two tumor sites between 09/2007 and 12/2010. Cases were analyzed with regard to sufficiency of the obtained aspirates for cytopathologic classification and GEP classification. Statistical strength of associations between variables and GEP class was computed using Chi-square test. Cumulative actuarial survival curves of subgroups of these patients based on their cytopathologic versus GEP-assigned categories were computed by the Kaplan–Meier method. The endpoint for this survival analysis was death from metastatic uveal melanoma.

Results

FNAB aspirates were insufficient for cytopathologic classification in 34 of 159 cases (21.9 %). In contrast, FNAB aspirates were insufficient for GEP classification in only one of 159 cases (0.6 %). This difference is statistically significant (P < 0.001). Six of 34 tumors (17.6 %) that yielded an insufficient aspirate for cytopathologic diagnosis were categorized as GEP class 2, while 43 of 125 tumors (34.7 %) that yielded a sufficient aspirate for cytopathologic diagnosis were categorized as GEP class 2. To date, 14 of the 49 patients with a GEP class 2 tumor (28.6 %) but only five of the 109 patients with a GEP class 1 tumor (5.6 %) have developed metastasis. Fifteen of 125 patients (12 %) whose tumors yielded sufficient aspirates for cytopathologic classification but only four of 34 patients (11.8 %) whose tumors yielded insufficient aspirates for cytopathologic classification developed metastasis. The median post-biopsy follow-up time for surviving patients in this series was 32.5 months. Cumulative actuarial 5-year probability of death from metastasis 14.1 % for those with an insufficient aspirate for cytopathologic classification versus 22.4 % for those with a sufficient aspirate for cytopathologic classification (log rank P = 0.68). In contrast, the cumulative actuarial 5-year probability of metastatic death was 8.0 % for those with an insufficient/unsatisfactory aspirate for GEP classification or GEP class 1 tumor, versus 45.0 % for those with a GEP class 2 tumor (log rank P = 0.005).

Conclusion

This study confirmed that GEP classification of posterior uveal melanoma cells obtained by FNAB is feasible in almost all cases, including most in which FNAB yields an insufficient aspirate for cytodiagnosis. The study also confirmed that GEP classification is substantially better than cytologic classification for predicting subsequent metastasis and metastatic death.

Fine needle aspiration biopsy of ophthalmic tumors

A majority of intraocular tumors can be diagnosed based on clinical examination and ocular imaging studies, which obviate the need for diagnostic ophthalmic fine needle aspiration biopsy (FNAB). Overall, diagnostic accuracy of ophthalmic FNAB is high but limited cellularity can compromise the diagnostic potential of ophthalmic aspirate samples. The role of ophthalmic FNAB is limited in retinal tumors. Orbital FNAB should be considered in the evaluation of lacrimal gland tumors, orbital metastasis, and lymphoproliferative lesions. Negative cytologic diagnosis of malignancy should not be considered unequivocal proof that an intraocular malignancy does not exist. With improved understanding of genetic prognostic factors of uveal melanoma, ophthalmic FNAB is gaining popularity for prognostic purposes in combination with eye conserving treatment of the primary tumor. In special clinical indications, ancillary studies such as immunohistochemistry and FISH can be performed on ophthalmic FNAB samples. Assistance of an experienced cytopathologist cannot be overemphasized.

Biopsy pathology in uveitis

Uveitis is fraught with speculations and suppositions with regard to its etiology, progress and prognosis. In several clinical scenarios what may be perceived as due to a systemic infection may actually not be so and the underlying etiology may be an autoimmune process. Investigations in uveitis are sometimes the key in identification and management. Invasive techniques could be of immense value in narrowing down the etiology and help in identifying the cause. This article updates one on the invasive techniques used in biopsy such as anterior chamber paracentesis, vitreous tap and diagnostic vitrectomy, iris and ciliary body biopsy, choroidal and retinochoroidal biopsy and fine needle aspiration biopsy (FNAB). In populations where certain infections are endemic, the clinical scenario does not always respect a known presentation and the use of biopsy is resorted to as a sure way of confirming the etiology. Biopsies have a role in diagnosis of several inflammatory and infectious conditions in the eye and are pivotal in diagnosis in several dilemmas such as intraocular tumors and in inflammations. Appropriate and timely use of biopsy in uveitis could enhance the diagnosis and provide insight into the etiology, thus enabling precise management.

Minimally invasive anterior orbitotomy biopsy: finger's aspiration cutter technique (FACT)

PURPOSE

To evaluate aspiration cutter-assisted small-incision anterior orbitotomy.

METHODS

Three patients with orbital adnexal tumors underwent orbital biopsy through a 3-mm incision in the eyelid skin (n = 2) or conjunctival fornix (n = 1). Standard aspiration cutters were introduced into anterior and posterior orbital tumors utilizing a bimanual technique. Multiple passes were made into the tumor. Fresh specimens were analyzed for adequacy prior to the end of surgery. Cytopathology, histopathology, and immunohistochemical analysis were performed.

RESULTS

Aspiration cutter technique biopsies were diagnostic in 2 of 3 cases. Diagnoses were orbital lymphoma, metastatic endometrial adenocarcinoma, and metastatic prostate cancer. The 20-G aspiration cutter yielded the most tissue. No sutures were required for the small incisions.

CONCLUSIONS

Sutureless, aspiration cutter biopsy offered benefits commonly associated with fine needle aspiration biopsy, controlled aspiration, and enclosed mechanical cutting.

Anterior segment tumor aspiration cutter-assisted biopsy: experience with pathology

PURPOSE

To report pathologic evaluation and diagnostic yield of an aspiration cutter-assisted biopsy of anterior segment tumors.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Fifty-five eyes of 55 patients with iris and iridociliary tumors underwent an aspiration cutter-assisted biopsy at a single institution. Cytospin and cell-block preparations were performed on all biopsy samples. Bleached preparations and a panel of immunohistochemical stains were performed in selected cases. Cytologic diagnosis was correlated with clinical diagnosis and with histopathologic diagnosis, when available. Main outcome measures were (1) specimen cellularity, (2) diagnostic studies performed, (3) cytopathologic diagnosis, and (4) concordance with histopathologic diagnosis.

RESULTS

Specimen cellularity was adequate for cytopathologic interpretation of cytospin preparations in 55 (98.2%) of 56 biopsies. Twenty-three (41%) of 56 biopsy samples had diagnostic material in cell-block preparations. The most common cytopathologic diagnoses were melanoma (n = 39/56; 69.6%), melanocytoma (n = 4/56; 7.1%), nevus (n = 4/56; 7.1%), lymphoma (n = 2/56; 3.6%), and epithelial implantation cyst (n = 2/56; 3.6%). One biopsy sample (1.8%) yielded nondiagnostic material. Wide incisional or excisional biopsy confirmation was available in 13 (23.2%) of 56 aspiration cutter-assisted biopsy cases. Cytopathologic diagnoses were consistent with histopathologic diagnosis in 12 (92.3%) of 13 cases.

CONCLUSIONS

Although specialized pathologic techniques were necessary to maximize material available for diagnosis, all biopsies yielded cellular material and 41% yielded diagnostic tissue in cell block preparation. Although lower than the yield of wide incisional or excisional biopsy, aspiration cutter-assisted biopsy of anterior segment tumors achieved a diagnostic yield of 98.2%.

Anterior segment tumor biopsy using an aspiration cutter technique: clinical experience

PURPOSE

To report the results and complications of an aspiration cutter-assisted anterior segment tumor biopsy performed under viscoelastic.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Fifty-five patients with anterior segment tumors underwent aspiration cutter-assisted biopsy at a single center. Fifty-six biopsies were performed, because 1 eye underwent biopsy twice. Indications for biopsy included: suspected anterior segment malignancy, patient's desire for pathologic confirmation before treatment, atypical tumor, and genetic tumor analysis. The main evaluated outcomes were the perioperative visual acuity, the biopsy technique, and related complications.

RESULTS

The initial sample comprised 55 consecutively biopsied patients, from which a minimum 1-month follow-up existed for 52 biopsy samples. The median total follow-up was 30.4 months (range, 1 to 190 months). The mean initial visual acuity was 20/50 before and 20/50 1 month after biopsy. No patient lost vision. Most cases were suspected iris melanoma (n = 39/56; 69.6%), followed by suspicious iris nevi (n = 4/56; 7.1%) and melanocytoma (n = 4/56; 7.1%). Seven (n = 7/52; 13.4%) wounds required a single 10-0 nylon suture to achieve negative Seidel test results at the corneal entry site. Postoperative surgical findings included transiently increased intraocular pressure (n = 6/52; 11.5%), 1 hyphema, 1 flare, and 1 persistent pupillary defect. All but the pupillary defect resolved within 4 weeks of the biopsy procedure. There were no secondary infections or cataracts.

CONCLUSIONS

This study suggests that small-incision, aspiration cutter-assisted anterior segment biopsy seems to be a safe and effective procedure. No short- or long-term complications that would prevent its use were noted.

Fine-needle aspiration biopsy and other biopsies in suspected intraocular malignant disease: a review

Ocular oncologists require a strong indication for intraocular biopsy before the procedure can be performed because it carries a risk for serious eye complications and the dissemination of malignant cells. The purpose of this review is to evaluate the extent to which this restricted practice is supported by evidence from previous reports and to outline our main indications and contraindications. The different intraocular biopsy techniques in the anterior and posterior segment are discussed with a focus on our preferred method, fine-needle aspiration biopsy (FNAB). In the literature, complications are typically under-reported, which reduces the possibilities of evaluating the risks correctly and of making fair comparisons with other biopsy methods. In FNAB, the exact placement of the needle is critical, as is an accurate assessment of the size of the lesion. Fine-needle aspiration biopsy is usually not a reliable diagnostic tool in lesions < 2 mm in thickness. It is very advantageous to have a cytopathologist present in the operating theatre or close by. This ensures adequate sampling and encourages repeated biopsy attempts if necessary. This approach reduces false negative results to < 3%. Adjunct immunocytochemistry is documented to increase specificity and is essential for diagnosis and management in about 10% of cases. In some rare pathological processes the diagnosis depends ultimately on the identification of specific cell markers. An accurate diagnosis may have a decisive influence on prognosis. The cytogenetic prognostications made possible after FNAB are reliable. Biopsy by FNA has a low complication rate. The calculated risk for retinal detachment is < 4%. Intraocular haemorrhage is frequently observed, but clears spontaneously in nearly all cases. Only a single case of epibulbar seeding of malignant cells at the scleral pars plana puncture site of transvitreal FNAB has been documented. Endophthalmitis has been reported and adequate standard preoperative preparation is obligatory. An open biopsy is still an option in the anterior segment, but has been abandoned in the posterior segment. Although vitrectomy-based procedures are becoming increasingly popular, we recommend using FNAB as part of a stepwise approach. A vitrectomy-assisted biopsy should be considered in cases where FNAB fails. In any adult patient with suspected intraocular malignancy in which enucleation is not the obvious treatment, the clinician should strive for a diagnosis based on biopsy. When the lesion is too small for biopsy or the risks related to the procedure are too great, it is reasonable to be reluctant to biopsy. The standards applied in the treatment of intraocular malignant diseases should be equivalent to those in other fields of oncology. Our view is controversial and contrary to opinion that supports current standards of care for this group of patients.

Fine-needle aspiration biopsy of iris tumors in 100 consecutive cases: technique and complications

OBJECTIVE

To evaluate the technique and complications of fine-needle aspiration biopsy (FNAB) for iris tumors.

DESIGN

Retrospective, nonrandomized, single-center case series.

PARTICIPANTS

One hundred eyes of 100 patients with diagnostically challenging iris tumors evaluated with FNAB.

MAIN OUTCOME MEASURES

Biopsy technique and complications.

RESULTS

Of more than 1400 patients referred with an iris tumor over a 24-year period, 100 underwent FNAB for diagnostic purposes. The median patient age was 44 years. The median basal dimension of the lesion was 9.0 mm and median thickness was 2.5 mm. A limbal entry with transaqueous approach parallel to the iris was used in 100% of patients. Entry was from the superotemporal (52%) or inferotemporal (42%) direction. Needle gauge size was 22 (9%), 25 (55%), 27 (25%), or 30 (9%), depending on the friability and vascularity of the tumor. Adequate tumor sample was achieved in 99 eyes (99%). At the time of FNAB, the only immediate complication was partial hyphema (34%). Two weeks after FNAB, persistent hyphema was found in 6 eyes (6%), requiring surgical washout in 1 patient. There were no cases of recurrent hyphema, vitreous hemorrhage, prolonged hypotony, lens damage, endophthalmitis, or extraocular tumor seeding. At mean follow-up of 5 years, there was no incident of tumor recurrence on the iris, along the needle tract, or on the corneal or epibulbar surface.

CONCLUSIONS

Using our technique, FNAB for diagnostically challenging iris tumors can achieve high yield with relatively few complications.

Fluorescent in situ hybridization for monosomy 3 via 30-gauge fine-needle aspiration biopsy of choroidal melanoma in vivo

OBJECTIVE

To report the feasibility of intraoperative transscleral fine-needle aspiration biopsy at plaque surgery to obtain cells for monosomy 3 analysis in patients with choroidal melanoma.

DESIGN

Consecutive interventional case series.

PARTICIPANTS

Eighteen patients (18 eyes) with choroidal melanoma who had fine-needle aspiration biopsy performed with a 30-gauge needle at time of iodine 125 plaque placement.

INTERVENTION

Cytology and cytogenetic analysis for monosomy 3 were obtained from biopsy specimens.

MAIN OUTCOME MEASURES

Cytology, cytogenetic analysis for monosomy 3, and complications and feasibility of transscleral fine-needle aspiration biopsy of choroidal melanoma in vivo.

RESULTS

Fine-needle aspiration biopsy was diagnostic of choroidal melanoma in 14 of 18 cases and resulted in viable cell cultures for fluorescent in situ hybridization (FISH) analysis in 9 cases. Fluorescent in situ hybridization for monosomy 3 was positive in 4 of the 9 cases. One patient had a mild vitreous hemorrhage. Tumors between 2 and 3 mm in height and those that yielded cells that did not attach in culture were most likely to have insufficient growth for FISH analysis.

CONCLUSIONS

Transscleral fine-needle aspiration biopsy and FISH for monosomy 3 may provide important prognostic information on patients who undergo plaque radiotherapy for choroidal melanoma.

Choroidal biopsies for intraocular tumors of indeterminate origin

PURPOSE

To evaluate the role of pars plana vitrectomy-assisted incisional biopsies in the management of choroidal tumors of unclear origin.

DESIGN

Retrospective, noncomparative, consecutive interventional case series.

METHODS

Ten consecutive patients with indeterminate choroidal tumors underwent a standardized three-port pars-plana vitrectomy-assisted subretinal biopsy using a bimanual approach with standard intraocular forceps and a diamond knife. Specimens were fixed in formaldehyde embedded in paraffin and further subjected to histopathological and immunohistochemical analyses.

RESULTS

A histologic diagnosis was obtained in all (10 of 10) cases including choroidal melanoma (five of 10), metastasis (two of 10), subretinal hemorrhage (two of 10), and nodular scleritis (one of 10). Five eyes were enucleated as a result of the histologic diagnosis. Three cases of postoperative complications were seen in three patients (newly formed rhegmatogenous retinal detachment, increased serous retinal detachment, and vitreous hemorrhage). No cases of intra- or extraocular tumor spread were detected through follow-up periods ranging from 3 to 29 months.

CONCLUSIONS

Pars plana vitrectomy-assisted incisional biopsy is a valuable diagnostic procedure for cases of choroidal tumors of unknown origin in selected patients. However, the relatively high frequency of postoperative complications noted in the present study and the potential risk of dissemination of tumor cells underscores the importance of rigorous case selection.

The Finger iridectomy technique: small incision biopsy of anterior segment tumours

AIMS

To develop a minimally invasive, maximally effective method to biopsy anterior segment tumours.

METHODS

A 25 gauge aspiration cutter (vitrector) was used to biopsy anterior segment tumours. The probe was introduced under sodium hyaluronate 1% and through a 1 mm incision. Aspiration (600 mm Hg) cutting (300 cpm) was performed to obtain specimens for cytology and histopathology.

RESULTS

Diagnostic material was obtained in nine of 10 (90%) cases. Diagnoses included iris naevus, iris stroma, malignant melanoma, melanocytoma, epithelial inclusion cyst, and sarcoid granuloma. All corneal wounds were self sealing. One patient developed a transient postoperative increase in intraocular pressure. Within the follow up of this study, no patients suffered intraocular haemorrhage, infection, cataract or vision loss.

CONCLUSION

The Finger iridectomy technique was a minimally invasive and very effective biopsy technique. Aspiration cutting yielded relatively large pieces of tissue (and cells) used for cytopathological and histopathological evaluation. Small incision surgery allowed for rapid rehabilitation and no significant complications.

Cytopathology of chalazia

Chalazion is a common inflammatory condition of the eyelid, usually treated on the basis of clinical diagnosis alone. Preoperative exclusion of malignancy in chalazia with atypical clinical presentation could prevent unwarranted surgery. This is a retrospective study of aspirates from 16 patients with chalazia having an atypical clinical presentation. Smears were stained with May-Grünwald Giemsa. Two broad patterns of granulomatous inflammation reflecting the spectrum of changes in the course of the disease were seen. Nine smears had mixed-cell granulomas consisting of neutrophils, lymphocytes, plasma cells, macrophages, giant cells, and granulation tissue. Seven smears had suppurating granulomas characterized by epithelioid cell granulomas with numerous neutrophils in a proteinaceous background. Fine-needle aspiration cytology of chalazia with atypical clinical presentation provides a rapid, safe, and reliable means of documenting the diagnosis and excluding malignancy.

Fine needle aspiration biopsy (FNAB) for retinoblastoma

PURPOSE

To determine the incidence of diagnostic fine needle aspiration biopsy (FNAB) in eyes with retinoblastoma (RB) as well as its indications and potential complications.

METHODS

A retrospective study by survey was designed and a questionnaire inquiring on FNAB use in RB diagnosis during the past 15 years was submitted to 12 high-volume ocular oncology clinics.

RESULTS

A total of 3,651 patients with RB have been diagnosed and treated in 12 clinics since 1985. During the same period, eight biopsies were obtained for diagnostic purposes and six of these proved to be RB by cytology; the other two showed inflammatory cells and benign retinal cells. The median age for the biopsied patients was 46 months; 6 of the biopsied children were older than 4 years of age. The average age at the time of biopsy was 46 months. Most of the cases were biopsied with clinical diagnosis of uveitis/endophthalmitis through the limbus and pars plana with 25- and 27-gauge needles. Five of six cases of RB had enucleation and one patient had cryotherapy and I-125 brachytherapy after FNAB. The average follow-up time for biopsy-proven RB cases was 10.8 years with no recurrent disease.

CONCLUSION

The results of this survey suggest that FNAB indication for RB diagnosis is rare; the majority of cases can be diagnosed and treated by ocular oncologists without invasive procedures.

Biopsy in indeterminate intraocular tumors

OBJECTIVE

To describe an intraocular biopsy technique that allows accurate histopathologic diagnosis in cases of clinically unclassifiable uveal tumors.

DESIGN

Retrospective noncomparative consecutive interventional case series.

PARTICIPANTS/METHODS

Intraocular biopsies were performed by a vitreous cutter either by a two-port clear cornea approach in 11 patients with unclassifiable iris tumors or by a three-port pars plana vitrectomy in 23 patients with unclassifiable choroidal tumors. Specimens were formalin fixed and paraffin processed. Hematoxylin-eosin and periodic acid-Schiff stains were performed in all cases, with additional immunohistochemical stains using the alkaline phosphatase, antialkaline phosphatase method in cases that could not be conventionally classified.

MAIN OUTCOME MEASURES

Clinical observation and histopathologic examination of intraocular biopsies.

RESULTS

In 97% of cases (n = 33) a definite diagnosis could be established by the biopsy specimen. A melanoma could be diagnosed in 73% of cases (n = 8) of iris tumors and in 57% of cases (n = 13) of posterior intraocular tumors. Other diagnoses included nevus, metastasis, vasoproliferative tumor, hemorrhage, gliosis, and scleritis. Complications were encountered in four cases: a vitreous hemorrhage occurred twice, an inconclusive biopsy result, and an intraocular tumor spread occurred once, respectively. No increased tumor-related mortality was observed after a mean follow-up of 44 months.

CONCLUSIONS

Intraocular biopsy by a vitreous cutter allows the histopathologic examination of formalin-fixed paraffin-embedded tumor tissue. This increases the diagnostic accuracy, avoiding the risk of extraocular tumor spread seen with transscleral biopsy techniques.

Melanocytoma of the ciliary body diagnosed by fine-needle aspiration biopsy

A 55-yr-old African American man was referred for evaluation of a mass involving the anterior choroid/ciliary body in his left eye. Dilated fundus examination revealed a large, deeply pigmented mass associated with an exudative retinal detachment. Ultrasonography demonstrated an elevated mass which involved the anterior uvea and showed low reflectivity by standardized A-scan. Cytologic examination of fine needle aspiration (FNA) biopsy from the tumor was interpreted as a melanocytoma. The patient developed a total retinal detachment and secondary glaucoma which led to enucleation of the eye. Histopathologic examination confirmed the diagnosis of melanocytoma. To our knowledge, this is the first report in which the diagnosis of uveal melanocytoma was established by FNA biopsy and later confirmed histopathologically.

Diagnostic intraocular fine-needle aspiration biopsy--An experience in three cases of retinoblastoma

Ophthalmoscopically guided intraocular fine-needle aspiration biopsy (FNAB) under general anesthesia was performed in three suspected cases of retinoblastoma (Rb). The first case presented with uveitis and the second with unusual radiological features. The third case had classical clinical features of bilateral Rb but the parents refused enucleation. After a cytologic diagnosis of retinoblastoma, two cases were subjected to enucleation and a histologic confirmation was obtained. The present article discusses the technique of guided intraocular FNAB and its limitations as well as utility in the preoperative diagnosis of retinoblastoma (Rb). The authors are of the opinion that FNAB should be considered a viable diagnostic option in selected cases of leucocoria when conventional investigative modalities prove inconclusive or for tissue diagnosis when a patient of suspected Rb refuses enucleation.

Nonthyroid causes of extraocular muscle disease

Extraocular muscle involvement in orbital disease is most frequently seen as a feature of thyroid orbitopathy (Graves' disease). However, a wide range of other conditions may alter the size, shape, and function of these muscles, with characteristic clinical manifestations or abnormalities visible on orbital imaging. The differential diagnosis of muscle disease can be narrowed by careful analysis of clinical features and ancillary tests. Imaging facilitates recognition in many cases, but in some instances, accurate diagnosis requires biopsy. This review highlights the differential diagnoses for diseases of extraocular muscles based on the clinical and investigative records of 103 patients at our institution combined with data from the world literature. We found that the most common nonthyroid causes of muscle disease were inflammatory, vascular, and neoplastic processes (in decreasing order of frequency). Emphasis is placed on investigations that provide a logical approach to, and appropriate management of, disease of the extraocular muscles.

Fine needle aspiration (FNA) biopsy of orbital masses: a critical review of 51 cases

FNA biopsy of 51 orbital masses is critically reviewed. Aspiration was performed with a 23 G needle inserted by an ophthalmologist; the smears were prepared by a cytologist. Forty-two cases (83%) were correctly diagnosed as benign or malignant either with (68%) or without (15%) correct specification of the histology. There were two false-negative and seven inadequate cases. Immunocytochemical stains were performed in five cases using the following antibodies: L26 (Pan B), UCHL1 (Pan T), kappa and lambda immunoglobulin light chains (three cases) in order to distinguish inflammatory pseudotumours from low-grade non-Hodgkin's lymphomas. In two cases we used CAM 5.2 (a monoclonal cytokeratin cocktail) and vimentin to ascertain the epithelial origin of two metastatic tumours. In five other cases cytospins were not adequately cellular for immunocytochemistry. Insufficient material and one false-negative sample were obtained from very fibrotic lesions or from posteriorly located lesions. The results are discussed and compared with other series reported in the literature. Orbital FNA biopsy may be considered a useful tool in the diagnostic approach to orbital masses in which the relatively high number of inadequate aspirations is offset by a low cost-benefit ratio.

Transvitreal retino-choroidal biopsy of suspected malignant lesions of the choroid. Follow-up of cases over 7 years

The cases of transvitreal retino-choroidal (TVRC) biopsy from 1987 to 1994 were assembled in order to examine the efficiency, complications and risks to patients. Of 92 biopsies 91 had sufficient material for diagnosis. Eighty (87%) contained malignant tissue, whereas 10 cases were negative and two unsuccessful. Tumours of appropriate size were treated by brachytherapy. Twenty-three large tumours were enucleated primarily. Eight irradiated eyes had to be removed. In 31 cases, therefore, it was possible to examine the whole tumour for changes caused by the biopsy and to compare the typing of the biopsy with that of the whole tumour. In the irradiated eyes histologically viable tumour cells remained mostly in the inner part of the tumour. Scleral necrosis was not found. The technique used appears to be safe. Histological verification is highly recommended before any conservative therapy, inter alia to obtain true statistics of therapeutic results.

The cytological, immunocytochemical and molecular genetic analysis in diagnosis of the neoplasms of the eye, eye adnexa and orbit

The fine needle aspiration biopsy was performed in 91 patients including 57 cases of retrobulbar tumors done under CT control. All aspirates were cytologically examined. In 21 cases immunocytochemical examination was performed in order to distinguish poorly differentiated neoplasms. In 19 cases malignant lymphoma was distinguished from pseudolymphoma. Cytological diagnosis was confirmed by histopathological examination in 77 cases /84%/. One result was false positive, 3-false negative. The value of immunocytochemical methods in differential diagnosis of poorly differentiated neoplasms was stressed.

Cytologic evaluation of tumors of the orbit and ocular adnexa: an analysis of 84 cases studied by the "squash technique"

The cytologic features of 84 ophthalmic lesions were evaluated using the squash technique at the time of frozen section. Of the 84 lesions, 55 were located in the orbit, 17 in the lacrimal gland, and 12 in the ocular adnexa. Lymphoid lesions comprised most of the cases (n = 47). In this group, 34 cases were malignant lymphomas and 13 were lymphoid hyperplasias. Inflammatory/granulomatous lesions and mesenchymal tumors comprised eight cases each. Epithelial neoplasms of the soft tissues of the orbit, lacrimal gland and eyelid constituted 12 cases, of which eight were malignant and four were benign. A total of nine cases were due to neurogenic tumors, neuroendocrine neoplasms, and melanocytic tumors. The squash technique provides a means to evaluate the architectural and cytologic details of ophthalmic lesions, without the intrinsic problem of frozen section artifact. We believe that the squash technique is a simple, quick, and useful method for the diagnosis of orbital/adnexal lesions.

Fine-needle aspiration biopsy of suspected intraocular tumors. The 1992 Urwick Lecture

BACKGROUND

Fine-needle aspiration biopsy recently has been used as a diagnostic modality for selected intraocular tumors and simulating conditions. However, the value of fine-needle aspiration biopsy for intraocular tumors previously has not been clarified.

METHODS

Transocular fine-needle aspiration biopsy was performed on selected patients who had intraocular lesions that were suspected clinically to be neoplasms but in which there was diagnostic uncertainty based on noninvasive clinical evaluation. These cases were analyzed to determine accuracy, complications, and limitations of the technique.

RESULTS

Of 6500 patients referred to the Oncology Service for evaluation of possible intraocular tumor, transocular fine-needle aspiration biopsy was used clinically in 159 cases (2.4%). It proved to be a reliable diagnostic method for intraocular malignancies such as uveal melanoma, uveal metastasis, retinoblastoma, lymphoma, and leukemia. In the 140 cases (88%) in which adequate cytologic material was obtained, the sensitivity rate was 100% and the specificity rate was 98%. In 19 cases where the cytologic material was too scant to render a diagnosis, the sensitivity rate was 84% and the specificity rate was 98%. The problem of insufficient material for cytologic diagnosis has been greatly minimized with the recent use of a 22-gauge needle. The main complication was localized intraocular hemorrhage. Retinal detachment and tumor recurrence have not been observed.

CONCLUSIONS

Transocular fine-needle aspiration biopsy is a safe and reliable diagnostic method for suspected intraocular tumors and inflammatory conditions in which noninvasive diagnostic modalities have failed to establish the diagnosis and in which cytologic verification of the diagnosis is necessary to institute appropriate treatment. Although the authors have had few complications with fine-needle aspiration biopsy, the technique should be reserved for selected cases where the diagnosis has not been established by less-invasive diagnostic measures.

Management of posterior uveal melanoma

In recent years, there have been a number of advances in the diagnosis and management of patients with malignant melanoma of the posterior uvea (ciliary body and choroid). This review provides a brief update on the current status of diagnostic modalities, such as fluorescein angiography, ultrasonography, computed tomography, magnetic resonance imaging, fine needle aspiration biopsy, and the radioactive phosphorus uptake test. Following that is a more detailed review of the current controversy regarding the natural course of uveal melanomas and the available therapeutic modalities. Current indications, techniques, complications, and results are provided for various forms of management, such as observation, laser photocoagulation, plaque radiotherapy, charged particle radiotherapy, local tumor resection, enucleation, and orbital exenteration.

Fine needle aspiration biopsy in orbital tumours

Fine needle aspiration biopsy (FNAB) was performed in 46 patients with an orbital mass. Positive cytological identification was made in 43 biopsy specimens. In 26 cases with histopathological control the accuracy was 81%. In experienced hands FNAB is safe and appears to be a valuable tool in establishing a diagnosis of malignancy in orbital tumours.

Fine needle aspiration biopsy in clinical management of head and neck tumors

Ninety-five percent (195) of 203 fine needle aspiration biopsies (FNAB) of head and neck specimens contained adequate tissues for histologic evaluation. No complications or needle tract recurrences were identified. Out of 135 patients whose surgical excision followed FNAB, 5% (7/135) of the biopsies were nondiagnostic. Correlation of cytologic and histologic findings of the remaining 128 FNAB revealed a sensitivity rate of 82% (46/56), a specificity rate of 99% (71/72), and a positive predictive of value of 98% (46/47). The diagnostic accuracy of FNAB was better with salivary gland and cervical node specimens than with thyroid, skin, and subcutaneous specimens. Fine needle aspiration biopsy may be considered as the first diagnostic step in the evaluation of the mass of the head and neck region, if the nondiagnostic aspiration rate is low and the diagnostic accuracy is high.

Metastatic breast carcinoma of the orbit

Two Caucasian females in whom an orbital mass was the first sign of metastasis from a breast carcinoma are described. Each subject had undergone a radical mastectomy to treat a primary breast carcinoma, one six years and the other eight years previously. Each presented with ipsilateral proptosis, and restricted upper eyelid action; one had altered ocular motility. In each subject an open biopsy of the orbital mass via an eyelid crease incision revealed metastatic scirrhous adenocarcinoma of the breast. The clinical features, investigations, and treatment of orbital metastases from breast carcinoma are discussed.

Transvitreal retinochoroidal biopsy

Biopsies from retina and/or choroid were performed through a transvitreal approach in 14 patients during the 2-year period 1984-1986. A 20-gauge fine needle was used. The transvitreal approach was chosen because exact location of the biopsy could be documented by video recording and/or by photography. The needle was guided either by a stereotactic micromanipulator or by hand. Immediately after biopsy laser burns were placed around the biopsy hole. Light microscopical and, in selected cases, transmission electron microscopical examination of the material obtained showed malignant melanoma, choroidal haemorrhage, leukaemic infiltration of the choroid, intraretinal fibrosis in detached retina, atrophic retina after vasculitis and malignant lymphoma of the uvea. More than 2 years after biopsy, no retinal detachment due to the biopsy or any tumour-seeding has been observed. Two cases of vitreous haemorrhage cleared spontaneously. No visual impairment was related to the biopsies.

Quantitation of tumor seeding from fine needle aspiration of ocular melanomas

Twenty-two fine needle (30 gauge) aspirations were performed in eyes enucleated for the clinical diagnosis of melanoma. Cytologic preparations were evaluated for adequacy of material, and needle tracts were evaluated for tumor implantation. A scleral marking method was used to identify all needle tracts. The number of tumor cells in tracts of direct transscleral aspirates was compared to those in tracts of indirect aspirates that traversed the anterior chamber or vitreous. Cellular material obtained with 30-gauge needles was sufficient for the diagnosis of malignant melanoma in all but one case. While 14 of 21 (67%) of all fine needle aspiration tracts and eight of 15 (53%) of indirect tracts contained tumor cells, the number of tumor cells was less than that associated with tumor growth in experimental models. Indirect aspirate tracts contained significantly fewer cells than tracts of direct aspirates (P less than .001).

Squamous cell carcinoma of the eyelid

The occurrence of squamous cell carcinoma of the lid is reviewed with emphasis upon the incidence, clinical presentation, pathophysiology and methods of treatment. Squamous cell carcinoma accounts for about 9% of all eyelid malignancies, although it is frequently over-diagnosed by pathologists and confused histologically with other benign entities. This lesion occurs most commonly in elderly, fair-complexioned individuals with a history of chronic sun exposure and skin damage. In the lids, squamous cell carcinoma shows a variety of clinical appearances although it usually presents as a painless, hyperkeratotic lesion that gradually enlarges and eventually ulcerates. There is a tendency for lower lid and lid margin involvement. This potentially lethal neoplasm is capable of aggressive local spread or metastasis to regional lymph nodes. The development of squamous cell carcinoma is thought to progress through phases of intraepithelial squamous dysplasia and intraepidermal squamous cell carcinoma before invasive squamous cell carcinoma occurs. Various treatment modalities have been advocated including surgical extirpation with histologic control, radiation therapy and cryotherapy.