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CORRESPONDENCE
Year : 2015  |  Volume : 11  |  Issue : 4  |  Page : 957-960

Choroidal melanoma of left eye with very early liver metastasis


1 Department of Radiotherapy, Saroj Gupta Cancer Centre and Research Institute, Kolkata, West Bengal, India
2 Department of Pathology, Saroj Gupta Cancer Centre and Research Institute, Kolkata, West Bengal, India

Date of Web Publication15-Feb-2016

Correspondence Address:
Sanchayan Mandal
Near Saroj Gupta Cancer Centre and Research Institute, Thakurpukur, Kolkata - 700 104, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.157349

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 > Abstract 

Uveal melanoma is a cancer (melanoma) of the eye involving the iris, ciliary body, or choroid (collectively referred to as the uvea). The liver is a frequent site for metastasis in patients with uveal melanoma. The interval between the diagnosis of the uveal melanoma and the diagnosis of the metastatic lesion can vary. Despite therapy, the median survival of those with liver metastasis is 5-7 months. We report here a rare case of choriodal melanoma in a 45-year-old male smoker presented with liver metastasis within just 8 months after completion of initial treatments consists of enucleation of eye and 3 Dimensional conformal radiation therapy (3D-CRT). The metastasis is an incidental finding on imaging after having some vague symptoms. This type of very early metastasis after completing initial treatment is very rare and proves the aggressiveness of the disease.

Keywords: Choroid, early metastasis, liver metastasis, uveal melanoma


How to cite this article:
Mandal S, Chaudhuri T, Devleena M, Sil S. Choroidal melanoma of left eye with very early liver metastasis. J Can Res Ther 2015;11:957-60

How to cite this URL:
Mandal S, Chaudhuri T, Devleena M, Sil S. Choroidal melanoma of left eye with very early liver metastasis. J Can Res Ther [serial online] 2015 [cited 2020 Aug 13];11:957-60. Available from: http://www.cancerjournal.net/text.asp?2015/11/4/957/157349


 > Introduction Top


Uveal melanoma is a cancer of the eye involving the iris, ciliary body, or choroid. Tumors arise from the pigment cells (melanocytes) that reside within the uvea giving color to the eye. These melanocytes are distinct from the retinal pigment epithelium cells underlying the retina that do not form melanomas.

Melanomas are the most common primary intraocular malignancy in adults. [1] They represent 5% of all melanomas [1] but, because of the high rate of metastases and poor response to treatment, they account for about 13% of melanoma deaths. [2]

In the Collaborative Ocular Melanoma Study (COMS) the liver was the most common site (89% in patients with metastasis); the death rate following the report of melanoma metastasis was 80% at 1 year and 92% at 2 years. [3],[4] Fifty percent of patients develop metastases within a duration of minimum 5 years to 24 years after treatment of the primary tumor, and the liver is involved 90% of the time. [5]

This report describes a rare case of a patient of choriodal melanoma left eye who developed very early liver metastasis within just 8 months even after completion of initial treatment of the primary tumor consists of enucleation and 3 dimensional conformal radiation therapy (3D-CRT). Hence, metastasis should be zealously sought following treatment of a primary lesion.


 > Case report Top


A 45-year-old male smoker presented with gradual blurring of vision for last 1 month without any other significant abnormality in the month of October 2013. After consulting physicians and ophthalmologists, he underwent Ultrasonography (USG) B scan (16/11/2013) of left eye which showed choriodal mass (14.5 mm × 10.25 mm) overlying the disc showing sound attenuation, with retinal detachment and choroidal excavation s/o choriodal melanoma [Figure 1]. Computed Tomography (CT) scan brain (18/11/13) showed hyperdense mass located on posterior segment of left eyeball, confined within left eyeball and no obvious orbital extension, other segment of brain showing no abnormality [Figure 2]. Then he underwent enucleation of left eye with an implant placement on 6/12/2013. The chest X-ray, USG of whole abdomen and Liver Function Test before the operation were within normal limit.
Figure 1: USG (Ultrasonography) B scan of left eye showing dumbbell shaped choriodal mass (14.5 mm × 10.25 mm) overlying the disc showing sound attenuation, with overlying retinal detachment and choroidal excavation s/o choriodal melanoma

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Figure 2: Computed Tomography (CT) scan of brain showing hyperdense mass located on posterior segment of left eyeball, confined within left eyeball and no obvious orbital extension

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The histopathology of the enucleated specimen showed spindle cell type of choroidal melanoma of left eye ball ( P T2 C N X ). Tumor size of 10 × 8.0 mm; involvement of sclera and retina present; extra scleral extension present (less than 5.0 mm) but without ciliary body involvement; cut end of optic nerve-free from malignancy. Slides examination revealed histopathological features of a tumor mass composed of cells arranged in nests. The cells are highly pleomorphic and have large atypical irregular hyperchromatic nuclei, prominent eosinophilic nucleoli and scanty cytoplasm. Melanin pigments are present in between the cells and also within cytoplasm of some cells [Figure 3] and Immunohistochemistry (IHC) showed the cells were reactive to Cytokeratin (CK), HMB45, S100 [Figure 4] [Figure 5] [Figure 6].
Figure 3: Section shows histopathological features of a tumor mass composed of cells arranged in nests. The cells are highly pleomorphic and have large atypical irregular hyperchromatic nuclei, prominent eosinophilic nucleoli and scanty cytoplasm. Melanin pigments are present in between the cells and also within cytoplasm of some cells

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Figure 4: Immunohistochemistry (IHC) study showing cells are reactive to cytokeratin (CK)

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Figure 5: IHC study showing cells are reactive to HMB-45

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Figure 6: IHC study showing cells are reactive to S-100

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He underwent 3 Dimentional-Conformal Radiation Therapy (3D-CRT) at our hospital from 10/01/2014 to 14/02/2014 of total dose 45 Gray and 25 fractions to his left eye. No brachytherapy or boost or concurrent chemo radiations were used [Figure 7].
Figure 7: 3D-TPS (Three Dimentional Treatment Planning System) based planning for 3D-CRT (Three Dimentional Conformal Radiation Therapy)

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He was on follow-up. Around 8 months later, he had developed some vague symptoms like loss of appetite and weakness. USG of whole abdomen (31/10/2014) reported as multiple hypoechoic lesions spread throughout liver [Figure 8] and then contrast enhanced computed tomography (CECT) scan of abdomen (04/11/2014) documented it [Figure 9] as secondary deposits in liver. Fine needle aspiration cytology (FNAC) from the liver lesions proved metastatic choriodal melanoma [Figure 10]. On abdominal examination liver was found to be enlarged around 3 cm from below the lower costal margin, sharp regular margin, smooth surface, mild tenderness of right hypochondrium.
Figure 8: Ultrasound of abdomen showing multiple deposits in liver

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Figure 9: CECT of abdomen showing secondary deposits in liver

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Figure 10: FNAC of liver showing melanoma cell infiltrate within hepatocyte

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 > Discussion Top


Choriodal melanoma is a very aggressive type of tumor. "If you are newly diagnosed with a primary choroidal 'intraocular' melanoma, you are likely to have no signs or symptoms of metastatic melanoma. Even with total body PET/CT imaging, less than 4% of patients are found to have their melanomas spread to other parts of their body at the time of diagnosis of their eye tumor. But, many more will be found to have metastasis over the following years. This is because there is no test that can find microscopic metastatic tumors". [6]

Here, we present a case of very early metastasis (within 8 months of completion of initial treatment) from choroidal melanoma. There are some studies which showed metastasis developed after a short and long disease free interval. [7],[8] Again, a 1986 study by Gragoudas et al., [9] showed a 20% cumulative risk of developing metastasis 5 years after irradiation, based on 128 patients followed for a median of 5.4 years. 780 eyes (which included many of the 128 noted above) followed for a median of 2.2 years, 8% of that study population actually developed metastases, the median time to detection being 2.1 years. [10]

Sixty-five of the 237 patients died of confirmed or suspected metastatic melanoma during the follow-up interval, with 55 of these deaths occurring during the first 5 post-treatment years. The cumulative actuarial survival of this group of patients with posterior uveal melanoma was 75.7% (standard error (SE) =2.9%) at 5 years and 68.5% (SE = 3.5%) at 8 years post treatment. [11]

The cumulative rates of metastases in the Collaborative Ocular Melanoma Study (COMS) at 5 and 10 years after treatment were 25% and 34%, respectively. Common sites of metastases include liver (90%), lung (24%), and bone (16%). [12],[13]

The median time from diagnosis of choroidal melanoma to diagnosis of metastasis was 44.8 months (3.7 years). Ten of the 13 patients with metastasis (76.9%) were diagnosed within the first 5 years after treatment (irradiation). [14] Previous case studies have shown intervals of 10, 15 and even 24 years. [15],[16],[17]

Prognosis after metastatic disease remains poor. Once liver is involved the median survival of patients after diagnosis of liver metastasis ranges from 2-9 months. [18],[19]

No studies are found supporting very early liver metastasis within 8 months after completion of the initial treatment of primary choroidal melanoma of eye. Hence, metastasis should be sincerely addressed in follow-up for earliest identification to increase survival of the patient.


 > Acknowledgements Top


We thank the Department of Pathology at the SGCCRI, Kolkata, for providing us enormous support.

 
 > References Top

1.
Singh AD, Bergman L, Seregard S. Uveal melanoma: Epidemiological aspects. Ophthalmol Clin North Am 2005;18:75-84.  Back to cited text no. 1
    
2.
Albert DM, Ryan LM, Borden EC. Metastatic ocular and cutaneous melanoma: A comparison of patient characteristics and prognosis. Arch Ophthalmol 1996;114:107-8.  Back to cited text no. 2
[PUBMED]    
3.
Diener-West M, Reynolds SM, Agugliaro DJ, Caldwell R, Cumming K, Earle JD, et al. Collaborative Ocular Melanoma Study Group. Development of metastatic disease after enrollment in the COMS trials for treatment of choroidal melanoma: COMS report no. 26. Arch Ophthalmol 2005;123:1639-43.  Back to cited text no. 3
    
4.
Agarwala SS, Panikkar R, Kirkwood JM. Phase I/II randomized trial of intrahepatic arterial infusion chemotherapy with cisplatin and chemoembolization with cisplatin and polyvinyl sponge in patients with ocular melanoma metastatic to the liver. Melanoma Res 2004;14:217-22.  Back to cited text no. 4
    
5.
Spagnolo F, Caltabiano G, Queirolo P. Uveal melanoma. Cancer Treat Rev 2012;38:549-53.  Back to cited text no. 5
    
6.
Available from: http://www.eyecancer.com/conditions/30/metastatic-choroidal-melanoma [Last accessed on 2015 May 13].  Back to cited text no. 6
    
7.
Komatsu T, Sowa T, Takahashi K, Fujinaga T. A case of solitary pulmonary metastasis of choroidal melanoma with an exceptionally long disease-free period. Int J Surg Case Rep 2013;4:849-51.  Back to cited text no. 7
    
8.
Gragoudas ES, Lane AM, Munzenrider J, Egan KM, Li W. Long-term risk of local failure after proton therapy for choroidal/ciliary body melanoma. Trans Am Ophthalmol Soc 2002;100:43-8.  Back to cited text no. 8
    
9.
Gragoudas ES, Seddon JM, Egan K, Glynn R, Munzenrider J, Austin-Seymour M, et al. Long-term results of proton beam irradiated uveal melanomas. Ophthalmology 1987;94:349-53.  Back to cited text no. 9
[PUBMED]    
10.
Gragoudas ES, Seddon JM, Egan KM, Glynn RJ, Goitein M, Munzenrider J, et al. Metastasis from uveal melanoma after proton beam irradiation. Ophthalmology 1988;95:992-9.  Back to cited text no. 10
    
11.
Augsburger JJ, Gamel JW. Clinical prognostic factors in patients with posterior uveal malignant melanoma. Cancer 1990;66:1596-600.  Back to cited text no. 11
    
12.
Diener-West M, Reynolds SM, Agugliaro DJ. Screening for metastasis from choroidal melanoma: The collaborative ocular melanoma study group report 23. J Clin Oncol 2004;22:2438-44.  Back to cited text no. 12
    
13.
Group COMS Assessment of metastatic disease status at death in 435 patients with large choroidal melanoma in the collaborative ocular melanoma study (COMS): COMS report no. 15. Arch Ophthalmol 2001;119:670-6.  Back to cited text no. 13
    
14.
Koutsandrea C, Moschos MM, Dimissianos M, Georgopoulos G, Ladas I, Apostolopoulos M. Metastasis rates and sites after treatment for choroidal melanoma by proton beam irradiation or by enucleation. Clin Ophthalmol 2008;2:989-95.  Back to cited text no. 14
    
15.
Slattery E, O'Donoghue D. Metastatic melanoma presenting 24 years after surgical resection: A case report and review of the literature. Cases J 2009;2:189.  Back to cited text no. 15
    
16.
Grosjean J, Penel N, Gauthier H, Vanseymortier L. Ultra-late metastasis of ocular melanoma: About two cases. Rev Med Interne 2004;25:147-9.  Back to cited text no. 16
    
17.
Brasiuniene B, Sokolovas V, Brasiunas V, Barakauskiene A, Strupas K. Combined treatment of uveal melanoma liver metastases. Eur J Med Res 2011;16:71-5.  Back to cited text no. 17
    
18.
Feldman ED, Pingpank JF, Alexander HR Jr. Regional treatment options for patients with ocular melanoma metastatic to liver. Ann Surg Oncol 2004;11:290-7.  Back to cited text no. 18
    
19.
Kath R, Hayungs J, Bornfeld N, Sauerwein W, Höffken K, Seeber S. Prognosis and treatment of disseminated uveal melanoma. Cancer 1993;72:2219-23.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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