|Ahead of print publication
F-18 fluorodeoxyglucose positron emission tomography/computed tomography in conjunctival melanoma with recurrence
Anurag Jain, Arun Ravi John, Braj Kishore, MG Vishnoi, Aniruddha G Pandit, Amit Sharma, Abhinav Jaimini, Mayuri Jain, Anirudh Singh
Department of Nuclear Medicine, Army Hospital R and R, New Delhi, India
Arun Ravi John,
Army Hospital R and R, New Delhi - 110 010
Source of Support: None, Conflict of Interest: None
Ocular melanoma is classified under the category of noncutaneous melanomas. Noncutaneous melanomas are relatively rare. Ocular melanoma commonly arises from choroid. Conjunctival melanoma is a rare but potentially lethal form of ocular melanoma. It can invade locally. Systemic spread is seen in up to 25% of cases, often associated with lymph node involvement. Metastatic sites include the lungs, liver, gastrointestinal tract, and the central nervous system. F-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET-CT) scanning is indicated for staging cutaneous melanoma patients. However, few studies have evaluated its role in the management of conjunctival melanoma. This case highlights the use of F-18 FDG PET/CT for imaging, preoperative staging, and evaluation for metastasis in conjunctival melanoma.
Keywords: Conjunctival melanoma, fluorodeoxyglucose positron emission tomography/computed tomography, metastases
|How to cite this URL:|
Jain A, John AR, Kishore B, Vishnoi M G, Pandit AG, Sharma A, Jaimini A, Jain M, Singh A. F-18 fluorodeoxyglucose positron emission tomography/computed tomography in conjunctival melanoma with recurrence. J Can Res Ther [Epub ahead of print] [cited 2019 Aug 17]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=263862
| > Introduction|| |
Conjunctival melanoma is a rare ocular tumor with an incidence of 0.2–0.5 cases per million in Caucasians. It arises from primary acquired melanosis in 75% of cases, the rest arising de novo. Prognosis is poor in the presence of multifocal tumors, mixed cell types, thickness >4 mm, unfavorable tumor location (forniceal, caruncle, and corneal), previous excision without adjuvant therapy, higher TNM grade, and scleral extension., Metastases to lymph nodes, lungs, liver, etc. are seen in up to 25% of patients. F-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET-CT) is used for staging cutaneous melanoma. However, there is limited literature regarding FDG PET/CT in the management of conjunctival melanoma. This case highlights the role of FDG PET/CT for imaging and staging in conjunctival melanoma.
| > Case Report|| |
A 60-year-old male patient had presented to our hospital in August 2016 with the recurrence of conjunctival melanoma. For about a month, he had a progressively increasing painless, protruding mass in the left eye initially in the temporal quadrant of bulbar conjunctiva [Figure 1]. He had a mass at the same site earlier in January 2016 and had undergone an excisional biopsy. Histopathology had confirmed it as conjunctival melanoma. Postprocedure, the patient was lost to follow-up till the recurrence. Ophthalmologic examination revealed a polypoidal pigmented mass in the left eye involving both the palpebral margins and bulbar conjunctiva (more than two quadrants). It was firm and had a dark pigmented base. Posterior edge of mass was palpable superiorly but not temporally [Figure 1]. The distant visual acuity in the left eye was 6/24. Examination of the anterior chamber, pupil, lens, and fundoscopy of the left eye was normal.
|Figure 1: Ophthalmological examination of the patient revealing a polypoidal pigmented lesion encompassing both palpebral margins of the left eye and bulbar conjunctiva (more than two quadrants)|
Click here to view
Ophthalmologic examination of the right eye and systemic examination were unremarkable. Hospital tumor board discussed the case and planned a staging workup to consider excision of the mass. F-18 FDG PET-CT and brain magnetic resonance imaging (MRI) were done. F-18 FDG PET-CT revealed a metabolically active ill-defined exophytic mass lesion in the preseptal region of left orbit (maximal standardized uptake value [SUVmax] 13.9 with respect to SUVmax of 0.9 on the contralateral side). The lesion extended anteromedially up to the cornea, causing irregular contour and extended posterolaterally to involve the lateral rectus muscle into the postseptal extraconal soft tissue. Involvement of upper eyelid was also noted [Figure 2]. There was a solitary metabolically active left pre-auricular lymph node [Figure 3]. In addition, multiple hypodense hypermetabolic lesions were noted in both the lobes of the liver [Figure 4]. Based on the PETCT findings, the disease was staged as cT3N1M1. Chemotherapy with oral Temozolomide followed by excisional biopsy was planned. Exenteration was ruled out in view of metastatic disease and the presence of useful vision in the affected eye. The use of interferon and other targeted therapies were not considered in the presence of associated chronic kidney disease.
|Figure 2: (a) Axial computed tomography image revealing an ill-defined exophytic mass lesion in the preseptal region of left orbit. (b) Axial fused positron emission tomography/computed tomography images revealing hypermetabolism in this lesion. (c) Sagittal fused positron emission tomography/computed tomography images showing metabolic involvement of the left upper eye lid. (d) Coronal fused positron emission tomography/computed tomography images revealing the relation of the tumor with the structures of the eye|
Click here to view
|Figure 3: Axial fused positron emission tomography/computed tomography image revealing a metabolically active left preauricular lymph node|
Click here to view
|Figure 4: Axial noncontrast computed tomography and fused positron emission tomography/computed tomography image revealing multiple hypodense hypermetabolic metastatic lesions in the liver|
Click here to view
| > Discussion|| |
Melanoma is uncommon in India. It commonly occurs on the trunk followed by head and neck in males. However, the most common site is the lower limbs in females. The tumor grows in two phases, an initial radial phase (horizontal) and later a vertical growth phase. The vertical phase gives rise to cell population that can metastasize. Distant metastases are related to the number of involved lymph nodes, whereas the risk of recurrence depends on the extracapsular extension of the nodal disease. Ocular melanoma usually presents earlier than cutaneous melanoma. It presents with visual disturbance, pigmented swelling, bleeding, ulceration, and regional lymph node enlargement. The median duration of symptoms is 5 months. In an Indian study of 72 patients, an eye was the most common site of extracutaneous melanoma. The majority of patients in this study presented with solitary lesion and regional lymph node enlargement.
Ocular melanoma is the most common primary cancer of the eye in adults., It develops from melanocytes that produce melanin. These cells are also present in internal organs and eyes. Ocular melanoma is more prevalent in people with fair skin and blue eyes. Exposure to sunlight is a potential risk factor. However, no direct linkage has been established. Ocular melanoma may arise from uvea or conjunctiva. Uveal melanoma arises from the pigmented cells in the choroid, ciliary body, or iris. Uveal and conjunctival melanomas differ significantly in epidemiological aspects. The average annual incidence of uveal and conjunctival melanoma is 5–6 and 0.6–0.8 per million, respectively. The incidence of ocular melanoma varies according to age, ethnicity, and latitude. The incidence of conjunctival melanoma increases from high to low latitudes due to higher ultraviolet radiation at the low latitudes, whereas, for uveal melanoma, it increases toward high latitudes.
The previous meta-analyses showed that F-18 FDG PET-CT has better sensitivity and specificity in Stage III/IV cutaneous melanoma than conventional imaging. It resulted in a change of patient management in 15%–64% of cases. It is more accurate for detection of skin and subcutaneous metastases than whole-body MRI. A major clinical impact has also been demonstrated in cases of recurrent cutaneous melanoma in up to 41% of patients. The existing literature on F-18 FDG PET-CT in noncutaneous melanoma has been limited. Very few reports discuss its utility for staging/restaging of conjunctival melanoma. Routine staging of uveal and choroidal melanoma consists of general physical and ophthalmic examination. Conventional imaging in the form of chest radiography and regional MRI is carried out. Usually, AJCC TNM staging system is followed. PET-CT is not routinely recommended for staging. However, Kurli et al. evaluated the use of F-18 FDG PET-CT for lymph node involvement and metastatic staging in 14 patients with conjunctival melanoma and reported several metastatic diseases in the liver, lung, peritoneal cavity, lumbar spine, and a single case of supraclavicular node involvement.
| > Conclusion|| |
Malignant melanoma is an uncommon disease in India. It carries a lot of morbidities. Although conventional imaging is currently the mainstay for the staging and restaging, FDG PET-CT can add greater accuracy to the work up as shown by this case. It may be also useful to monitor treatment response in ocular melanomas. F-18 FDG PET-CT may be considered while planning surgical therapy in the setting of presumed localized tumor. Further prospective studies are required to give a more definite recommendation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank Mr. Awadesh Tiwari, chief nuclear medicine technologist and other staff of the Department of Nuclear Medicine Army Hospital R and R, and Staff of Department of Ophthalmology, Army Hospital R and R, Delhi Cantt 110010.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Damian A, Gaudiano J, Engler H, Alonso O. (18)F-FDG PET-CT for staging of conjunctival melanoma. World J Nucl Med 2013;12:45-7.
] [Full text]
Folberg R, McLean IW, Zimmerman LE. Primary acquired melanosis of the conjunctiva. Hum Pathol 1985;16:129-35.
Werschnik C, Lommatzsch PK. Long-term follow-up of patients with conjunctival melanoma. Am J Clin Oncol 2002;25:248-55.
Paridaens AD, Minassian DC, McCartney AC, Hungerford JL. Prognostic factors in primary malignant melanoma of the conjunctiva: A clinicopathological study of 256 cases. Br J Ophthalmol 1994;78:252-9.
Murphy G, Hussey D, Metser U. Non-cutaneous melanoma: Is there a role for (18)F-FDG PET-CT? Br J Radiol 2014;87:20140324.
Cochran AJ, Glapsy JA, Ribas A, Economou JE. Malignant melanoma of the skin. In: Haskell CM, editor. Cancer Treatment. 5th
ed. Philadelphia: W.B. Saunders; 2001. p. 1158-77.
Ballo MT, Ross MI, Cormier JN, Myers JN, Lee JE, Gershenwald JE, et al.
Combined-modality therapy for patients with regional nodal metastases from melanoma. Int J Radiat Oncol Biol Phys 2006;64:106-13.
Sharma K, Mohanti BK, Rath GK. Malignant melanoma: A retrospective series from a regional cancer center in India. J Cancer Res Ther 2009;5:173-80.
Egan KM, Seddon JM, Glynn RJ, Gragoudas ES, Albert DM. Epidemiologic aspects of uveal melanoma. Surv Ophthalmol 1988;32:239-51.
Accuracy of diagnosis of choroidal melanomas in the Collaborative Ocular Melanoma Study. COMS report no. 1. Arch Ophthalmol 1990;108:1268-73.
Kivelä T. Incidence, prevalence and epidemiology of ocular melanoma. In: Murray TG, Boldt HC, editors. Ocular Melanoma: Advances in Diagnostic and Therapeutic Strategies. London: Future Medicine Ltd.; 2014. p. 20.
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, (editors). AJCC cancer staging manual, 7th
edition. France: Springer; 2010.
Kurli M, Chin K, Finger PT. Whole-body 18 FDG PET/CT imaging for lymph node and metastatic staging of conjunctival melanoma. Br J Ophthalmol 2008;92:479-82.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]