Local Excision of Retinal Metastasis from Cutaneous Melanoma

Uveal Melanoma Metastasis to the Contralateral Eye Structures: A Retrospective Comparative Analysis of 13 Consecutive Patients

PURPOSE

To report uveal melanoma (UM) metastasis to the contralateral ocular and periocular structures.

DESIGN

Retrospective study.

PARTICIPANTS

Thirteen patients with UM metastasis to the contralateral ocular and periocular structures were included.

METHODS

Clinical records were reviewed retrospectively.

MAIN OUTCOME MEASURES

The development and time to onset of contralateral ocular and periocular metastasis, systemic metastasis, and death.

RESULTS

Of the 13 000 treated UM patients, 13 patients were diagnosed with UM metastasis to the contralateral ocular and periocular structures. Mean patient age at primary UM diagnosis was 60 years (median, 60 years; range, 37-87 years). The primary uveal melanoma was in the choroid (n = 11) or ciliary body (n = 2) and was treated with brachytherapy (n = 11), proton beam radiotherapy (n = 1), or enucleation (n = 1). Systemic metastasis developed in 11 patients (85%) at a mean of 66 months (median, 34 months; range, 12-216 months) after diagnosis of the primary UM. All 11 patients (100%) showed liver metastasis and 8 patients (62%) also showed extrahepatic metastasis. The sites of metastasis to the contralateral ocular or periocular structures included the choroid in 4 patients (31%), the orbit in 7 patients (54%), and the eyelid in 2 patients (15%). One patient with eyelid metastasis demonstrated concurrent conjunctival nodule. Mean time to diagnosis of contralateral ocular or periocular metastasis was 94 months (median, 48 months; range, 9-375 months). Contralateral choroidal metastasis was multifocal in 3 of 4 patients (75%). Of 7 patients with orbital metastasis, 5 showed extraocular muscle involvement with restricted ocular motility. Treatment for contralateral choroidal metastasis included brachytherapy (n = 2), transpupillary thermotherapy (n = 1), and observation (n = 1). Treatment for contralateral periocular (orbit or eyelid) metastasis was excision (n = 5), external beam radiotherapy (n = 2), and observation (n = 2). Of 13 patients, death was documented in 11 patients at a mean of 17 months (median, 9 months; range, 3-54 months) as a result of systemic UM metastasis (n = 10) or unrelated cause (n = 1).

CONCLUSIONS

Metastasis resulting from UM to the contralateral ocular and periocular structures is rare and generally occurs in patients with disseminated metastasis. Orbital tissue is the most common site of involvement, and these patients have short life expectancy.

RETINAL METASTASIS FROM SQUAMOUS CELL CARCINOMA OF THE LUNG: A CASE PRESENTATION

BACKGROUND/PURPOSE

To present a case with retinal metastasis from squamous cell carcinoma of the lung.

METHODS

Case report.

RESULTS

A 54-year-old man presented with blurry vision in his left eye. His medical history was significant for Stage IV squamous lung carcinoma. He was undergoing chemotherapy and had a known metastasis. He had a slightly elevated whitish lesion associated with retinal hemorrhages in the left posterior pole. Optical coherence tomography showed a full-thickness retinal mass. No involvement of the choroid could be detected. Further investigation demonstrated a de novo metastasis in the right frontal lobe of the brain.

CONCLUSION

The lesion showed remarkable regression with subsequent systemic chemotherapy.

A CASE OF RETINAL METASTASIS OF LARYNGEAL SQUAMOUS CELL CARCINOMA WITH HISTOPATHOLOGIC CONFIRMATION BY VITRECTOMY-ASSISTED EN BLOCK EXTRACTION

BACKGROUND/PURPOSE

To present a case report of retinal metastasis of laryngeal squamous cell carcinoma that was diagnosed by a histopathologic finding from the surgically extracted tumor tissue.

METHODS

A 66-year-old man, who was suffered from the treatment-resistant laryngeal carcinoma, was referred to our department because of visual field defect in his right eye. A fundus examination revealed a parafoveal white retinal lesion, which rapidly expanded to the central fovea and decreased the visual acuity. A tissue extraction by 27G pars plana vitrectomy was performed to confirm the diagnosis.

RESULTS

The abnormal retinal tissue was extracted en block through 10-mm sclerocorneal tunnel during pars plana vitrectomy. The histopathologic findings revealed that the retinal lesion was retinal metastasis of laryngeal carcinoma.

CONCLUSION

We must keep in mind that retinal metastasis can be one of the differential diagnoses for white retinal lesions of unknown cause.

Intraocular Metastases--A Review

Intraocular metastases almost invariably arise in the uveal tract, mostly in the posterior choroid. They are the most common type of intraocular malignancy and often the first sign of tumor dissemination. Choroidal metastases generally appear as a creamy white or pale yellow mass associated with subretinal fluid and may be multifocal and bilateral. The most common primary sites are breast and lung. Diagnosis is aided by a variety of tests, particularly ultrasonography and optical coherence tomography. Intraocular biopsy is useful in patients with clinical suspicion of uveal metastasis but no evidence of primary malignancy despite systemic evaluation. If systemic treatment fails to control the ocular tumor, a good response is usually achieved with local therapies such as external beam radiation therapy, photodynamic therapy, and transpupillary thermotherapy. The life expectancy of patients with choroidal metastases is generally poor but has been improving thanks to the therapeutic advances taking place.

Retinal metastasis simulating cytomegalovirus retinitis

A 62-year-old man with lung cancer presented with a 2-week history of decreased vision and clinical features of cytomegalovirus retinitis. The patient was empirically treated for viral retinitis, but microbiological testing of the vitreous fluid was negative. Based on the suspicion for retinal metastasis, the patient underwent pars plana vitrectomy with retinal biopsy. Surgical techniques included the use of a chandelier illumination to enable bimanual manipulation of the retinal tissue, creation a focal retinal detachment with a 41-gauge subretinal cannula, diathermy demarcation of the biopsy site, localized retinectomy with vertical scissors, endolaser, and long-acting gas tamponade. Histopathologic examination revealed sheets of tumor cells with pleomorphic nuclei and positive staining for cytokeratins consistent with metastatic adenocarcinoma. The patient subsequently underwent external beam radiation and was alive 10 months after presentation. This surgical technique may be valuable in select patients with retinal metastasis for diagnostic, therapeutic, and counseling purposes.

Systemic melanoma metastatic to the retina and vitreous

PURPOSE

Report of a case of retinal and vitreous metastases of a systemic melanoma, possibly arising in the lung, that responded favourably to radiotherapy.

CASE REPORT

Retinal and vitreous metastases were demonstrated in a 57-year-old woman during routine follow-up after surgical resection of a melanoma presumed to be a primary pulmonary melanoma. After a 7-week observation period, which confirmed the progressive nature of the intra-ocular lesions, the patient was treated by external beam radiotherapy at a dose of 35 Gy delivered in 14 fractions of 2.5 Gy. Complete disappearance of the vitreous invasion and progressive elimination of the retinal invasion were observed over a period of 9 months. Final visual function was 20/25. REVIEW OF PUBLISHED CASES: A review of the literature identified 28 cases of melanoma with metastases to the retina and vitreous. In almost all of these cases, the primary tumour was a cutaneous melanoma and the mean patient survival following the diagnosis of intra-ocular metastases was 22 months. Retinal metastases, as in the case reported here, present a vascular tropism and tend to develop around veins. These metastases are generally unilateral and may be either solitary or multiple. Tumour invasion of the vitreous occurred by means of isolated cells forming a suspension of aggregates or spherules. Vitreous haemorrhage and irreducible neovascular glaucoma leading to functional impairment, which requires enucleation, were both the most frequent and the most serious complications of these metastases. Treatment is always palliative and is effective in cases with limited retinal and vitreous invasion, as in the case reported here.

CONCLUSIONS

Metastatic melanoma in the retina and vitreous is a rare entity and can lead to functional impairment and enucleation because of neovascular glaucoma. As treatment is only effective in cases with limited invasion, systematic screening is recommended in all patients with a metastatic cutaneous melanoma presenting with suggestive ocular symptoms.

Metastatic melanoma in the eye and orbit

OBJECTIVE

Presentation of a large series of patients with metastatic melanoma involving the eye and orbit.

DESIGN

Retrospective clinical study.

PARTICIPANTS

Thirteen cases of metastatic melanoma involving intraocular tissues, 6 cases of metastatic melanoma in the orbit, and 1 case of metastatic melanoma involving both the eye and the orbit, treated in Lausanne between 1986 and 2002, were identified from the computer files of the ocular oncology and orbitopalpebral surgery units of Jules Gonin Hospital.

METHODS

The analysis is based on the demographic data concerning these patients, clinical data concerning the tumor, the treatment applied, the outcome, and the follow-up.

MAIN OUTCOME MEASURES

Clinical presentation of intraocular and orbital metastasis, interval between primary tumor and ocular metastasis, survival of the patients, evaluation of various therapeutic protocols.

RESULTS

Intraocular metastases (14 cases, 15 eyes) were situated in the choroid in 11 cases (isolated lesion, 6 cases; multiple lesions, 3 cases; diffuse involvement, 2 cases), in the iris and ciliary body in 2 cases, and in the retina and vitreous in 2 other cases. The primary tumor was a cutaneous melanoma in 8 cases, a melanoma of the contralateral eye in 3 cases, a mucosal melanoma in 1 case, and was unknown in 2 cases. The mean interval between the diagnosis of ocular metastases and the patient's death was 8.8 months (range, 1-48 months). The primary tumor in the 7 cases of orbital metastases was a cutaneous melanoma in 5 cases, a uveal melanoma in the contralateral eye in 1 case, and was unknown in 1 case. The mean interval between the diagnosis of orbital metastases and death was 19.7 months (range, 5-48 months). The patients were treated by various protocols. The best results, in terms of both local tumor control and preservation of visual function, were obtained with circumscribed proton beam radiotherapy or external beam irradiation, depending on the site and extent of the tumor.

CONCLUSIONS

Metastatic melanomas to the eye and orbit are rare and generally occur in patients with disseminated metastases during the terminal stages of the disease, with a short life expectancy. Treatment is palliative and, among the various possible treatment options, circumscribed proton beam radiotherapy or global photon beam radiotherapy, at relatively high irradiation doses, seems to achieve the most favorable results.

Cutaneous melanoma metastatic to the vitreous cavity

OBJECTIVE

The authors report their experience with cutaneous melanoma metastatic to the vitreous and elaborate on the features of this entity.

DESIGN

The study design was a retrospective review.

PARTICIPANTS

Three patients with four affected eyes from cutaneous melanoma metastatic to the vitreous participated.

INTERVENTION

All three patients were white men, and their mean age was 58 years. The previously excised cutaneous melanomas were all Clark level IV. The mean interval from diagnosis of the primary cutaneous melanoma to vitreous metastasis was 25 months. Ocular findings included clumps of cells arranged in sheets or linear strands on the vitreous framework. The vitreous cells were nonpigmented in two cases and pigmented in one case. Neovascular glaucoma was found in all three cases. After the diagnosis of vitreous melanoma was made by cytopathologic examination, external beam irradiation (5000 cGy) was given in all patients.

MAIN OUTCOME MEASURES

Local tumor control and survival were measured.

RESULTS

At a mean follow-up of 14 months from diagnosis of vitreous melanoma, tumor control was achieved in only one of the four affected eyes. One eye was enucleated because of painful neovascular glaucoma, and the other two eyes had progressive vitreous disease. After a mean follow-up of 14 months (from ocular diagnosis), all three patients had died.

CONCLUSION

Cutaneous melanoma metastatic to the vitreous can present with nonpigmented or pigmented cells. Neovascular glaucoma frequently is found. External beam radiation therapy often is unsuccessful in local tumor control, and systemic prognosis is poor.