|Year : 2015 | Volume
| Issue : 4 | Page : 957-960
Choroidal melanoma of left eye with very early liver metastasis
Sanchayan Mandal1, Tamohan Chaudhuri1, M Devleena1, Subhra Sil2
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 Publication||15-Feb-2016|
Near Saroj Gupta Cancer Centre and Research Institute, Thakurpukur, Kolkata - 700 104, West Bengal
Source of Support: None, Conflict of Interest: None
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
| > Introduction|| |
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.  They represent 5% of all melanomas  but, because of the high rate of metastases and poor response to treatment, they account for about 13% of melanoma deaths. 
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. , 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. 
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|| |
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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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 10: FNAC of liver showing melanoma cell infiltrate within hepatocyte|
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| > Discussion|| |
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". 
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. , Again, a 1986 study by Gragoudas et al.,  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. 
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. 
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%). ,
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).  Previous case studies have shown intervals of 10, 15 and even 24 years. ,,
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. ,
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|| |
We thank the Department of Pathology at the SGCCRI, Kolkata, for providing us enormous support.
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