Bilateral primary choroidal melanoma treated with bilateral plaque radiotherapy: a report of three cases

Case report: Immunotherapy inducing unexpected overall survival in choroidal melanoma: about a case

Choroidal melanoma (CM) is the most common malignant ocular tumor in adults. The current treatment of metastatic CM is limited by the intrinsic resistance of CM to conventional systemic therapies. Immunotherapy alone or in association with cytotoxic treatment became a realist option treatment. Advancements in molecular biology have resulted in the identification of a number of promising prognostic and therapeutic targets. Herein, we report a rare case of 36-year-old patient with metastatic CM who presented a good long response to treatment with double immunotherapy reaching 3 years of overall survival, which has never been described in the literature.

BAP1 Germline Mutation Associated with Bilateral Primary Uveal Melanoma

Purpose

To describe the occurrence of bilateral primary uveal melanoma in 2 patients with mutation on the gene encoding BRCA1-associated protein 1 (BAP1).

Methods

Retrospective chart review of patients with bilateral primary uveal melanoma and subsequent positive germline BAP1 mutation.

Results

There were 2 patients with bilateral uveal melanoma and BAP1 germline positivity. Neither patient demonstrated oculodermal melanocytosis. Patient 1 underwent enucleation of his right eye (OD) at the age of 44 years for a 9.6-mm-thick choroidal melanoma. He returned 4 years later with a 10.0-mm-thick choroidal melanoma in his left eye (OS) and was treated with plaque radiotherapy. He had a strong family history of cancer, and clinical testing for germline BAP1 mutation identified a pathogenic mutation in BAP1. At the 18-month follow-up, visual acuity was 20/200 OS without evidence of systemic metastasis. Patient 2 initially presented at age 54 years with extensive, diffuse iris melanoma OD, initially treated with plaque radiotherapy, but local recurrence after 3 years necessitated enucleation. Four years later, a 6.0-mm-thick ciliary body melanoma OS was found and successfully treated with plaque radiotherapy. Clinical testing for germline BAP1 mutation identified a pathogenic mutation in BAP1. At the 8-year follow-up, visual acuity was 20/40 OS without evidence of local recurrence or systemic metastasis. The patient expired secondary to an unrelated brain infarction.

Conclusion

Bilateral uveal melanoma is exceedingly rare. Patients with bilateral uveal melanoma, especially when coincident with remote systemic cancers or a family history of cancer, should be evaluated for germline BAP1 mutation. Lifelong monitoring for related systemic malignancies is advised.

Successive Uveal Melanomas with Different Gene Expression Profiles in an Eye with Ocular Melanocytosis

Ocular melanocytosis portends a higher risk of uveal melanoma. Multifocal uveal melanoma has been described previously and has been associated with ocular melanocytosis. Historically, histopathology has been used to differentiate tumors; however, molecular profiling now allows for better prognostication and determination of metastatic risk. The present case describes a patient with ocular melanocytosis who developed two sequential uveal melanomas in the same eye separated by 4 years. The uveal melanoma-specific gene expression profile (GEP) testing for the first tumor was class 1A and the second tumor was class 2. While the first tumor had low metastatic risk, the second tumor had a higher risk of metastasis, demonstrating the importance of GEP testing in cases of multifocal disease.

Primary bilateral uveal melanoma: a population-based study and systematic review

IMPORTANCE

Primary bilateral uveal melanoma (UM) is a rare and incompletely described entity. It is not known how these patients compare to those with unilateral UM.

BACKGROUND

We sought to comprehensively characterize and compare patients with primary bilateral and unilateral UM.

DESIGN

Retrospective, population-based and systematic review.

PARTICIPANTS

Patients with bilateral (n = 52) and unilateral UM (n = 8915).

METHODS

We analysed cases of primary bilateral UM from three data sources: (i) the University Hospitals Cleveland Medical Center pathology database from 1996 to 2016 (n = 1); (ii) the Surveillance, Epidemiology and End-Results (SEER)-18 database from 1973 to 2013 (n = 5) and (iii) a systematic review of the English language literature (n = 46). Cases of unilateral UM were obtained from the SEER-18 database from 1973 to 2013 for comparison (n = 8915).

MAIN OUTCOME MEASURES

Demographics, clinicopathological characteristics, treatments and survival.

RESULTS

There were no differences in sex, race, mean age at diagnosis, site of uveal involvement, metastases at diagnosis, or treatment among patients with bilateral as compared to unilateral UM. Additionally, there were no clinicopathological differences between the two UMs in each patient with bilateral disease. Overall survival did not differ between unilateral and bilateral UM patients, or between bilateral UM patients who presented with, or subsequently developed, bilateral disease.

CONCLUSIONS AND RELEVANCE

Bilateral and unilateral UM patients share similar demographics, clinicopathological characteristics, treatments and prognoses. Moreover, the development of bilateral disease does not portend a poorer prognosis and patients should be treated similarly to those with unilateral disease.

Bilateral uveal melanomas with different gene expression detected with 7 years interval

PURPOSE

To report a bilateral uveal melanoma detected in a micrometastasis study.

METHOD

Case report.

RESULTS

At enucleation of a circumpapillary amelanotic mixed melanoma in a patient with ocular melanocytosis, a pigmented lesion in the other eye was detected, thought to be a naevus. BAP1 was positive showing nuclear staining of the tumour cells. Seven years later the naevus showed growth and development of a retinal detachment. FNAB disclosed monosomy 3 in the spindle tumour cells.

CONCLUSION

A case of bilateral melanoma with long-term survival without metastatic diseases is reported. Different gene expressions in the two eyes were revealed. The case is a reminder that follow-up over years is essential in patients with a uveal melanoma, especially with ocular melanocytosis.

[Case report of a 45-year-old man with uveal melanoma and suspect controlateral choroidal nævus]

INTRODUCTION

Uveal melanoma is the most common adult primary intraoculary tumor. Bilateral tumor is very rare, but must not be underestimated because early diagnosis and care improve the survival and the visual prognosis.

OBSERVATION

We report the case of a patient treated for a left parapapillary choroidal melanoma by disk of ruthenium ((106)Ru), and a follow-up every 3 months for an atypical choroidal large-sized controlateral nævus levelling the macular area. This right nævus changed in 2009 leading to suspicion of a growing melanoma. Because the visual acuity of the left eye was limited to 20/2000, we wanted to confirm this growth before beginning a treatment. But for 3 years the tumor has remained stable and asymptomatic, with a disease staging still negative. To this day, no curative treatment has been started on the right eye.

DISCUSSION

In spite of clinical (To Find Small Ocular Melanomas (TFSOM) for example) and paraclinical arguments, it is sometimes difficult to differentiate a large nævus from an early melanoma. Evolution of the tumor often allows to confirm the diagnosis. However, the sole growth of a nævus is not specific of a choroidal melanoma. When confronted with suspicion of a small choroidal melanoma, some authors recommend an immediate treatment for the tumor; others prefer to confirm without a doubt a tumoral growth. It is necessary to weigh out the iatrogenic risks of a conservative treatment on the visual acuity in a monophtalm patient on one side, and the vital risk for the patient on the other side, which seems to be limited in case of small-sized melanoma with a slow evolution.

CONCLUSION

A bilateral choroidal melanoma is rare. Systematic and repeated examinations of both eyes are essential. Management of these complicated cases often leads to discussion.

Bilateral uveal melanoma in an arc welder

PURPOSE

To report sequential bilateral uveal melanoma in an arc welder.

METHODS

Case report.

RESULTS

A 57-year-old Caucasian male, with a 15-year profession of arc welding, was found to have an iridociliary mass in his left eye (OS), measuring 14 × 10 × 4 mm, and proven on fine needle aspiration biopsy to be spindle B-cell melanoma. A coincidental small choroidal nevus was observed in the right eye (OD). There was no ocular melanocytosis. Plaque radiotherapy was applied OS, with regression of the iridociliary melanoma. Four years later, the choroidal nevus OD enlarged into melanoma measuring 8 × 7 × 2.7 mm and was treated successfully with plaque radiotherapy. There was no evidence of systemic metastasis at 56-month follow-up.

CONCLUSION

Arc welding is a known environmental risk for unilateral uveal melanoma, and possibly predisposed our patient to bilateral uveal melanoma.