Choroidal Melanoma


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Choroidal Melanoma

  1. 1. Grand RoundsMichele Todman, MD November 3, 2009
  2. 2. HistoryCC: Sudden loss of inferior field of vision of my right eyeHPI: 57 y/o female-2 day h/o inferior altitudinal field loss OD- Noticed when closing OS to apply make-upPMH: HTNPSH: NoneMeds: ASA, HCTZSH: 1PPD smoker x 30 yearsFH: Mother died at 82 y/o of metastatic cancer, primary unknown
  3. 3. ExaminationVA: 20/50 OD; 20/20 OSPupils: Trace APD ODMotility: Full OUConfrontation VF: Inferior field defect OD; WNL OSSLE: 1+NSC OU
  4. 4. Fundus Photography
  5. 5. Fundus Photography
  6. 6. FA23 sec 34 sec 1:301:32 3.51 4.13
  7. 7. UltrasoundA-scan: Medium to high internal reflectivityB-scan: Acoustic solidarity
  8. 8. Differential Diagnosis?
  9. 9. A-scan: Low internal reflectivity withreduction in amplitude. High amplitudeSpike = break in Bruch’s membrane.B-scan: Solid mass with mushroomshape
  10. 10. A-scan: High internal reflectivityB-scan: Highly reflective plate-likelesion with orbital shadowingbeyond lesionFA can help distinguish if CNV
  11. 11. A-scan: High internal reflectivityB-scan: Solid elevated mass
  12. 12. B-scan: Thickening ofthe retina, choroid andsclera with fluid beneathTenon’s capsule andsquaring of optic nerveshadow
  13. 13. A-scan: Medium to high internal reflectivityB-scan: Acoustic solidarity
  14. 14. Working Diagnosis• Is this choroidal mass with exudative detachment a primary lesion or a metastatic lesion to the choroid?• Need thorough systemic evaluation – PCP contacted – 1 wk prior pt presented with blurred vision OD & SOB – Found to have 13cm x 15cm left breast mass – Lab Work: Liver function tests wnl – CT Chest: Breast mass, lung nodules, liver lesions – Breast Biopsy: Infiltrating ductal carcinoma, ER/PR Negative – MRI brain: Frontal, occipital, and cerebellar lesions – PET Scan: Breast mass, lung, bone, adrenal, hepatic uptake
  15. 15. Stage 4 Metastatic Breast Cancer
  16. 16. Incidence of ocular metastasis-1872: first description of a metastatic tumor to the eye in a patient with carcinoma-Since then realization that ocular mets are not that rare-Bloch and Gartner (1971) 10% patients with autopsy proven carcinoma had ocular mets- Most common intraocular malignancy- choroidal metastasis-Hard to gauge exact incidence as patients often are asymptomatic or present with advanced CA and eye exam never performed Demirci, Shields C, et al. Uveal Metastasis from breast Cancer in 264 Patients. Ophthalmology 2003 264-271 Shields C, Shields J, et al. Survey of 520 Eyes with Uveal Metastases. Ophthalmology 1997 1265-1273
  17. 17. Epidemiology• For American women lifetime risk breast cancer- one in eight (12.5%) & lifetime risk death from breast cancer is 3.4%• Breast Cancer is the most common malignancy to metastasize to the uvea• Mean age at ocular diagnosis is 58 years, most cases (40-70 yrs)• At time of ocular diagnosis 66% reported a history of a primary cancer and 34% had no history of cancer
  18. 18. Primary Sites of Choroidal MetsMales (N=137) Females (N=287)Lung 40% Breast 68%Unknown 29% Lung 12%GI 9% Unknown 12%Kidney 6% Others 4%Prostate 6% GI 2%Skin 4% Skin 1%Others 4% Kidney <1%Breast 1%
  19. 19. Breast Cancer MetastasesMost Common Sites:• Lung (71%)• Bone (71%)• Lymph nodes (67%)• Liver (62%)• Pleura (50%)• Ocular (9%-37%)
  20. 20. Clinical Features Uveal MetsAppearance: – 99% choroidal mets from breast cancer were yellow in color – 77% plateau-shaped – 65% a/w subretinal fluid – Exudation and hemorrhage rareSymptoms: - 75% Blurred vision - 6% Floaters - 5% Photopsias - 7% AsymptomaticLocation: – 89% Posterior to equator – 62% Unilateral and 38% bilateral to UveaMet Sites: – 85% to Choroid, 3% to Iris, <1% to Ciliary body – Other: 5% Optic nerve; <1% Conjunctiva, Orbit, Retina, Adnexa
  21. 21. Prognosis• Average patient survival: 8-9 months after ocular diagnosis• Primary tumor type determines prognosis• Metastatic malignant melanoma: worst prognosis 1-2 months• Metastatic breast carcinoma: prognosis of 12 months
  22. 22. Survival Rates for Uveal Mets from Breast CA
  23. 23. Treatment Choroidal Mets• Plaque Radiotherapy – Systemically healthy patients with solitary uveal metastasis or those with metastasis that failed other treatment• External beam radiation• Chemotherapy & hormone therapy – Used to manage disseminated systemic disease – Aromatase inhibitors - Estrogen receptor positive breast cancer responded to aromatase inhibitors similar to ERBT with no radiation side effects• Observation – Uveal metastases that are inactive or regressed – Asymptomatic tumors Manquez et al. Management of Choroidal metastases from breast carcinomas using aromatase inhibitors, Current Opinion in Ophthalmology 2006, 251-256
  24. 24. Survival Rates + Brain Mets• Not treated with Whole Brain Radiation Treatment (WBRT) or treated with corticosteroids alone: 1-2 months• Median survival is increased to 3-6 months with WBRT & corticosteroids• WBRT prevents any further deterioration of neurologic function
  25. 25. Back to our patient• Patient was started on Decadron• Radiation-Oncology->Palliative Radiation to whole brain (WBRT) recommended (18 days)• Systemic chemotherapy to follow
  26. 26. Before Radiation TherapyAfter completion of 18 day course of radiation therapy but prior to chemotherapyMass slightly smaller with regularly arranged pigment clumping on tumor surface
  27. 27. Before radiation therapyAfter Radiation Therapy
  28. 28. 1 Month follow-up s/p Radiation• Va 20/50 OD, 20/20 OS• Pupils: Trace APD OD• Motility: Full ou• Confrontation VF: Inferior field defect OD persists
  29. 29. Visual Prognosis Poor• Age > 55 years• Choroidal tumor base diameter > 15mm• Pre-radiotherapy visual acuity 20/40 or worse
  30. 30. Before radiation therapy After radiation therapy