INFUSION PORT SITE TUMOR SEEDING AFTER PARS PLANA VITRECTOMY-ASSISTED BIOPSY OF CHOROIDAL MELANOMA

PURPOSE

To report a rare case of infusion port site tumor seeding of choroidal melanoma after pars plana vitrectomy-assisted biopsy and successful treatment with second plaque brachytherapy.

METHODS

Observational case report with clinical data and diagnostic images.

RESULTS

A 55-year-old White woman diagnosed with choroidal melanoma of the left eye was found to have a second intraocular tumor 30 months after plaque brachytherapy and pars plana vitrectomy-assisted tumor biopsy. The second melanoma developed at the 5 o'clock vitrectomy infusion port site. The tumor regressed after plaque brachytherapy, and the patient has not developed systemic metastasis 5 years after diagnosis of intraocular seeding.

CONCLUSION

Intraocular seeding into the infusion port site, although rare, may be encountered after pars plana vitrectomy-assisted biopsy of choroidal melanoma.

A Case Series of Choroidal and Orbital Neuroendocrine Tumors: Metastasis: 2 Patients Treated with PRRT

ABSTRACT

Neuroendocrine tumors are rare cancers with heterogenous histologies, response to treatments and prognoses. Majority of these cancers originate in the gastrointestinal tract and metastasize to the liver. We are reporting 5 patients with low-grade neuroendocrine tumor disease with rare metastases to the choroids. Two of the patients were treated with peptide receptor radionuclide therapy (Lutitium-177). This is the first report confirming PRRT safety in patients with low grade NET with ocular metastases.

Intravitreous Cutaneous Metastatic Melanoma in the Era of Checkpoint Inhibition: Unmasking and Masquerading

PURPOSE

Cutaneous melanoma metastatic to the vitreous is very rare. This study investigated the clinical findings, treatment, and outcome of patients with metastatic cutaneous melanoma to the vitreous. Most patients received checkpoint inhibition for the treatment of systemic disease, and the significance of this was explored.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

Fourteen eyes of 11 patients with metastatic cutaneous melanoma to the vitreous.

METHODS

Clinical records, including fundus photography and ultrasound results, were reviewed retrospectively, and relevant data were recorded for each patient eye.

MAIN OUTCOME MEASURES

Clinical features at presentation, ophthalmic and systemic treatments, and outcomes.

RESULTS

The median age at presentation of ophthalmic disease was 66 years (range, 23-88 years), and the median follow-up from diagnosis of ophthalmic disease was 23 months. Ten of 11 patients were treated with immune checkpoint inhibition at some point in the treatment course. The median time from starting immunotherapy to ocular symptoms was 17 months (range, 4.5-38 months). Half of eyes demonstrated amelanotic vitreous debris. Five eyes demonstrated elevated intraocular pressure, and 4 eyes demonstrated a retinal detachment. Six patients showed metastatic disease in the central nervous system. Ophthalmic treatment included external beam radiation (30-40 Gy) in 6 eyes, intravitreous melphalan (10-20 μg) in 4 eyes, enucleation of 1 eye, and local observation while receiving systemic treatment in 2 eyes. Three eyes received intravitreous bevacizumab for neovascularization. The final Snellen visual acuity ranged from 20/20 to no light perception.

CONCLUSIONS

The differential diagnosis of vitreous debris in the context of metastatic cutaneous melanoma includes intravitreal metastasis, and this seems to be particularly apparent during this era of treatment with checkpoint inhibition. External beam radiation, intravitreous melphalan, and systemic checkpoint inhibition can be used in the treatment of ophthalmic disease. Neovascular glaucoma and retinal detachments may occur, and most eyes show poor visual potential. Approximately one quarter of patients demonstrated ocular disease that preceded central nervous system metastasis. Patients with visual symptoms or vitreous debris in the context of metastatic cutaneous melanoma would benefit from evaluation by an ophthalmic oncologist.

Visual acuity, oncologic, and toxicity outcomes with 103Pd vs. 125I plaque treatment for choroidal melanoma

PURPOSE

To evaluate outcomes of choroidal melanoma patients treated with ¹²⁵I or ¹⁰³Pd plaque brachytherapy.

METHODS AND MATERIALS

From 1993 to 2012, our institution treated 160 patients with ¹⁰³Pd (56.1%) and 125 patients with ¹²⁵I (43.9%) plaque brachytherapy. Tumor outcomes, visual acuity (VA), and toxicity were compared. Multivariate analyses (MVAs) and propensity score analysis were used to help address differences in baseline characteristics.

RESULTS

Median followup was longer for ¹²⁵I patients, 52.7 vs. 43.5 months (p < 0.01). At baseline, ¹⁰³Pd patients had lower rates of VA worse than 20/200 (4.4% vs. 16%, p = 0.002), T3-T4 tumors (17.5% vs. 32.8%, p = 0.03), and transpupillary thermotherapy use (3.1% vs. 9.6%, p = 0.001). Both ¹⁰³Pd and ¹²⁵I provided >90% 3-year overall survival and >93% 5-year secondary enucleation-free survival. On MVA, radionuclide was not predictive for tumor outcomes. A higher percentage maintained vision better than 20/40 with ¹⁰³Pd (63% vs. 35%, p = 0.007) at 3 years. MVA demonstrated ¹⁰³Pd radionuclide (odds ratio [OR]: 2.12, p = 0.028) and tumor height ≤5 mm (OR: 2.78, p = 0.017) were associated with VA better than 20/40. Propensity score analysis matched 23 ¹²⁵I with 107 ¹⁰³Pd patients. ¹⁰³Pd continued to predict better VA at 3 years (OR: 8.10, p = 0.014). On MVA for the development of VA worse than 20/200 or degree of vision loss, radionuclide was not significant. Lower rates of radiation retinopathy were seen with ¹⁰³Pd than ¹²⁵I (3 years: 47.3% vs. 63.9%, p = 0.016), with radionuclide significant in MVA.

CONCLUSIONS

Both ¹²⁵I and ¹⁰³Pd achieve excellent tumor control. An increased probability of long-term VA better than 20/40 and reduced risk of radiation retinopathy is associated with ¹⁰³Pd.

Cortical blindness and choroidal metastases secondary to metastatic breast carcinoma in a male patient

Male breast carcinoma is a rare entity that often goes undiagnosed until advanced stages. The authors describe the case of a patient with profound vision loss who was found to have bilateral choroidal metastases as well as advanced cerebral metastatic disease. Further medical work-up revealed widespread infiltrative ductal breast carcinoma. Given the presence of large occipital lobe lesions, the etiology of the patient's vision loss was thought to be cortical blindness. Prompt diagnosis and neurologic evaluation with this presentation is crucial because it can be associated with significant morbidity and mortality.

M2/M1 ratio of tumor associated macrophages and PPAR-gamma expression in uveal melanomas with class 1 and class 2 molecular profiles

Macrophages have been found to be negative predictors of outcome in patients with uveal melanoma. In particular, recent studies point toward a disease-progressing role of proangiogenic M2 macrophages in melanomas with monosomy 3. Although most studies implicate a protective effect of PPAR-gamma activation in tumors, PPAR-gamma has also been shown to promote the polarization of M1 macrophages toward the M2 phenotype. The purpose of this investigation was first, to characterize the phenotype of tumor infiltrating macrophages and second, to study PPAR-gamma expression in uveal melanomas with molecular gene expression profile as prognostic predictors for patients' outcome. Twenty specimens from patients with uveal melanoma were analyzed for clinical and histologic tumor characteristics. The molecular RNA profile (class 1 or class 2) was commercially determined. Using immunohistochemical techniques, the specimens were dual labeled for CD68 and CD163. CD68 + CD163- M1 macrophages and CD68 + CD163+ M2 macrophages were analyzed in ten high power fields sparing macrophage-poor areas and a mean value was calculated for each tumor. The tumors were immunostained for von Willebrand factor and the micro vascular density (MVD) was analyzed according to Foss. To assess the proliferative rate of each tumor, Ki67 expression was evaluated in ten high power fields followed by calculation of a mean value. Expression of PPAR-gamma was evaluated using a score from 0 (no staining) to 3 (tumor entirely stained). Statistical analysis and a respective correlation were made between histologic characteristics, molecular profile, type of tumor infiltrating macrophages (M1 vs. M2), MVD, proliferative rate, and PPAR-gamma expression. Our results showed a correlation between the ratio of M2/M1 macrophages and the molecular profile with a ratio of approximately 1 corresponding to molecular class 1 and a ratio of approximately 2 corresponding to molecular class 2 (p = 0.01). The ratio of M2/M1 macrophages was higher in tumors with extraocular extension (p = 0.01). PPAR-gamma was predominantly expressed in the cytoplasm of tumor cells. Its expression showed no association with the molecular RNA profile (p = 0.83). This study confirmed that the ratio of M2/M1 macrophages is another prognostic factor in uveal melanoma. Thus, polarization of macrophages plays an important role for patients' outcome. PPAR-gamma is expressed in uveal melanoma tumor cells and further studies are warranted to determine its role in tumor biology.

Primitive Neuroectodermal Tumor/Ewing Sarcoma of the Retina

An 11-year-old boy underwent enucleation of his left eye for an intraocular tumor. Examination showed a small, round blue cell tumor arising in the peripheral retina near the ciliary body. Immunohistochemical stain results were positive for neuron-specific enolase, synaptophysin, cluster of differentiation 99 (CD99), Friend leukemia integration 1, and CD56. Ultrastructural findings included occasional intracytoplasmic dense core granules. Polymerase chain reaction of the tumor showed a Ewing sarcoma/Friend leukemia integration gene fusion product. The tumor was classified as a primitive neuroectodermal tumor/Ewing sarcoma of the retina and should be distinguished from retinoblastoma. To our knowledge, this is the first case of primary primitive neuroectodermal tumor of the retina.

Chronic Retinal Detachment Associated with Central Retinal Artery Occlusion

An unusual case of central retinal artery occlusion (CRAO) occurring in the setting of a chronic retinal detachment was reported. A 47-year old woman with a history of slowly declining peripheral vision in her left eye presented with acute painless hand motion vision. She had an extensive chronic retinal detachment in the left eye with multiple demarcation lines and marked whitening of the fovea. Her right eye was normal. A CRAO was confirmed with fluorescein angiography and optical coherence tomography testing. An exhaustive work-up was negative and there was no history of antecedent trauma.

Progressive optical coherence tomography deterioration in chloroquine maculopathy

PURPOSE

To report optical coherence tomography (OCT) progressive changes in chloroquine maculopathy.

DESIGN

Observational case report.

METHODS

Both eyes of a patient with chloroquine maculopathy were examined serially with OCT.

RESULTS

OCT demonstrated diffuse retinal thinning involving the fovea and perifoveal area in each eye, particularly involving the outer retina, with loss of the photoreceptor outer hyperreflective lamina proximal to the lamina corresponding to the retinal pigment epithelium (RPE). The temporal nerve fiber layer was mildly thinned. Repeat OCT showed progressive macular thinning.

CONCLUSIONS

OCT findings are consistent with histopathologic studies that advanced chloroquine toxicity affects the nerve fiber layer and the outer retinal layers, and confirm reports that severe maculopathy may progress despite cessation of therapy. The possible use of OCT in screening of patients at risk for macular toxicity is suggested.

Pathophysiology of ketoacidosis in Type 2 diabetes mellitus

AIMS

Despite an increasing number of reports of ketoacidosis in populations with Type 2 diabetes mellitus, the pathophysiology of the ketoacidosis in these patients is unclear. We therefore tested the roles of three possible mechanisms: elevated stress hormones, increased free fatty acids (FFA), and suppressed insulin secretion.

METHODS

Forty-six patients who presented to the Emergency Department with decompensated diabetes (serum glucose > 22.2 mmol/l and/or ketoacid concentrations > or = 5 mmol/l), had blood sampled prior to insulin therapy. Three groups of subjects were studied: ketosis-prone Type 2 diabetes (KPDM2, n = 13) with ketoacidosis, non-ketosis-prone subjects with Type 2 diabetes (DM2, n = 15), and ketotic Type 1 diabetes (n = 18).

RESULTS

All three groups had similar mean plasma glucose concentrations. The degree of ketoacidosis (plasma ketoacids, bicarbonate and anion gap) in Type 1 and 2 subjects was similar. Mean levels of counterregulatory hormones (glucagon, growth hormone, cortisol, epinephrine, norepinephrine), and FFA were not significantly different in DM2 and KPDM2 patients. In contrast, plasma C-peptide concentrations were approximately three-fold lower in KPDM2 vs. non-ketotic DM2 subjects (P = 0.0001). Type 1 ketotic subjects had significantly higher growth hormone (P = 0.024) and FFA (P < 0.002) and lower glucagon levels (P < 0.02) than DM2.

CONCLUSIONS

At the time of hospital presentation, the predominant mechanism for ketosis in KPDM2 is likely to be greater insulinopenia.

Elevated intraocular pressure following vitreoretinal surgery

Elevated intraocular pressure is a common occurrence following vitreoretinal surgery. The use of silicone oil or intravitreal gas in conjunction with pars plana vitrectomy increases the likelihood of postoperative intraocular pressure elevation. Fortunately, the pressure elevation is usually transient and managed medically. In certain instances, surgical intervention is warranted. Therapeutic intervention should be tailored to the individual patient based on the mechanism of pressure elevation.

Five-Year Evaluation of Implants Placed at Extraction and with Dehiscences and Fenestration Defects Augmented with ePTFE Membranes: Results from a Prospective Multicenter Study

BACKGROUND

Barrier membranes have been used to promote bone ingrowth on implants with dehiscences and fenestrations. Membranes also have been used to protect defects adjacent to implants placed at the time of extraction. The concept of guided bone regeneration relates to preferentially allowing cells from bone to migrate into various defects while excluding fibrous tissue and epithelium. The purpose of these procedures is to enhance bone-to-implant contact at the treated sites and to prevent mucosal complications.

PURPOSE

The purpose of this article is to report clinical outcomes for implants placed at the time of extraction and augmented with expanded polytetrafluoroethylene (ePTFE) and followed for 5 years. The outcomes for implants with dehiscences and fenestrations augmented with ePTFE barriers and followed up to 5 years also are reported.

METHODS AND MATERIALS

Four treatment centers participated in this study (Tucson, Gothenburg, Spokane, and Leuven). In the extraction group, teeth were removed for varying reasons, and Brånemark implants were placed and stabilized within the host bone. Defects present at the coronal implant aspect were covered with ePTFE barrier membranes. Flaps were rotated to cover the membrane-treated sites. If exposure of the material occurred prior to second-stage surgery, the membranes were removed. Barriers remaining unexposed were removed at second-stage surgery. The implants were followed up to 5 years. In the fenestration and dehiscence group, implants with exposed threads were augmented with ePTFE barrier membranes. The barriers were removed at appropriate intervals, and the patients were followed up to 5 years. Radiographic measurements were made from nonstandardized periapical radiographs at abutment connection and 1, 3, and 5-year follow-up visits.

RESULTS

Forty patients participated in the extraction group. They received a total of 49 implants. Three implants failed prior to loading. The 5-year cumulative survival rates for implants placed at the time of extraction were 93.9% and 93.8%, respectively, for maxillary and mandibular implants. The average maxillary mesial and distal marginal bone loss (1-5 yr) was 0.3 mm (standard deviation [SD] = 1.5) and 0.3 mm (SD = 1.0). In mandibles, the average mesial and distal bone loss (1-5 yr) was -0.2 mm (SD = 0.5) and -0.05 mm (SD = 0.6), respectively. The dehiscence and fenestration group included 44 patients. Twenty-six were followed for up to 5 years. Eight patients experienced total implant failure. For dehiscences and fenestrations, the cumulative survival rates were 76.8% and 83.8% for maxillary and mandibular implants, respectively. The average maxillary mesial and distal bone loss (1-5 yr) was 0.4 mm (SD = 0.8) and 0.2 mm (SD = 0.9), respectively. In mandibles, the average mesial and distal marginal bone loss was 0.3 mm (SD = 0.9) and 0.3 mm (SD = 0.8), respectively.

CONCLUSIONS

Implants placed at the time of extraction and augmented with ePTFE barrier membranes have favorable long-term predictability. On the other hand, long-term evaluation of implant dehiscences and fenestrations augmented with barrier membranes indicates that they have less favorable 5-year survival rates. Membrane augmentation of these may be questioned.

Transplant co-ordination services in Europe 1989: a survey by the EDTA Registry

This report contains EDTA Registry data concerning transplant co-ordination services. It is a summary of the results of a special questionnaire mailed in 1989 to all renal transplant centres known to the EDTA Registry in Europe and Mediterranean countries. The response rate to the questionnaire was 86%. A transplant co-ordination service was available in more than 70% of the centres. The larger the transplant activity of a centre, the greater was the likelihood of a co-ordinator service being available. The educational background of the transplant co-ordinator was most commonly that of nurse. More than 70% of the centres had one or two transplant co-ordinators. A service shared by several centres was fairly common in the United Kingdom and France. The most important duties and activities appeared to be the organisation of transportation of donor teams and organs, giving feedback to the donor hospital's staff, and providing information to the public regarding organ donation.