Amit K. Arora

Primary photodynamic therapy with verteporfin for small pigmented posterior pole choroidal melanoma

PurposeThe purpose of the study was to investigate the outcomes of primary photodynamic therapy (PDT) for small pigmented posterior pole choroidal melanoma.Patients and methodsProspective interventional consecutive case series of 15 patients with small pigmented posterior pole choroidal melanoma, who were treated with three sessions of PDT and followed-up thereafter. Risk factors for failure were assessed and outcome measures at presentation were compared to those at last follow-up visit.ResultsTumor control was achieved in 12 (80%) patients in a median follow-up time of 15 months (mean 14, range 8–18). Three patients failed treatment, diagnosed in a median time of 5 months (mean 4, range 3–6), after first PDT. In all failed cases, lesions were 100% pigmented; de novo melanoma rather than transformed nevi and showed a radial growth pattern rather than increased thickness. All failed cases were subsequently successfully treated with radiotherapy. In this cohort, subretinal fluid (SRF) was significantly reduced (P<0.001), vision did not deteriorate (P=0.11) and even improved in patients with subfoveal SRF at presentation (P=0.018), tumor height significantly decreased (P=0.037) and no complications were recorded.ConclusionPrimary PDT was found to be a safe and efficient treatment modality for small pigmented posterior pole choroidal melanoma, achieving short-term tumor control in 80% of patients. PDT offers patients the opportunity to preserve vision by avoiding the retinopathy associated with conventional radiation treatments for choroidal melanoma. However, the long-term local control of these tumors remains uncertain.

Intravitreal bevacizumab monotherapy for choroidal neovascularisation secondary to choroidal osteoma

PurposeThe purpose of this study is to present the outcomes of a series of patients with choroidal neovascular membrane (choroidal neovascularisation (CNV)) secondary to a choroidal osteoma undergoing anti-VEGF monotherapy.Patients and methodsRetrospective series of patients with choroidal neovascularization secondary to choroidal osteoma. All patients underwent clinical and imaging assessment (fundus photo, B-scan ultrasonography, fluorescein angiography, and optical coherence tomography—where available), and were managed with intravitreal anti-VEGF injections (Bevacizumab). Visual acuity and central retinal thickness were recorded pre treatment and at the end of the follow-up period.ResultsEight patients were included in this study. Of this, 6/8 had predominantly classic or classic and 2/8 patients had minimally classic or occult CNV. Each patient received 3–10 injections of bevacizumab. Median follow-up was 9 months (3–15 months). Visual acuity improved in 5 patients, by 2–6 Snellen lines. CNV completely regressed in 5 cases and partially regressed in 3 cases. Mean CRT reduction was 122 μm (6 to −230 μm).ConclusionIntravitreal bevacizumab can be an effective treatment modality in the management of vision threatening CNV secondary to choroidal osteoma.

Choroidal Metastasis from Follicular Cell Thyroid Carcinoma Masquerading as Circumscribed Choroidal Haemangioma

Choroidal metastases from follicular thyroid carcinoma are uncommon and usually present as an amelanotic lesion against a background of known systemic disease. We present the case of a 56-year-old woman with a thyroid metastatic focus with unusual clinical presentation, systemic involvement, and early response to systemic treatment. A review of the literature accompanies this case presentation.

Primary photodynamic therapy with verteporfin for pigmented posterior pole cT1a choroidal melanoma: a 3-year retrospective analysis

Aims To investigate the outcomes of primary photodynamic therapy (PDT) for pigmented posterior pole cT1a choroidal melanoma. Methods Retrospective interventional consecutive case series of 26 patients (26 eyes) with pigmented posterior pole cT1a choroidal melanoma, who were treated with 3 sessions of PDT and followed-up thereafter. Results Included were 11 males and 15 females that presented at a median age of 66 years (mean: 64) with transformed naevi (n=11) or suspicious lesions (n=15) with ≥3 risk factors for growth, with lipofuscin in all. In all cases, diagnosis was clinically based (no tissue biopsy). Tumour control was achieved in 16 (62%) patients in a median follow-up time of 29 months (mean: 27). Ten patients failed treatment by form of radial expansion, diagnosed in a median time of 13 months (mean: 12) from last treatment. By Kaplan-Meier analysis, success rate after 1, 2 and 3 years was 85%, 59% and 51%, respectively. On statistical analysis, number of suspicious features was found to be the only risk factor predicting failure (P=0.046). One patient developed macula-sparing branch retinal artery occlusion after treatment. Following PDT, subretinal fluid resolved in all cases and visual acuity significantly improved in all treatment-success cases (P=0.043). There were no cases of metastatic spread. Conclusion Primary PDT resulted in tumour regression of small, pigmented choroidal melanoma in 62% after a mean of 27 months. Treatment was more effective in tumours with three or less risk factors for growth, and resulted with fluid elimination and significant improvement in vision in treatment-success cases.

MALIGNANT TRANSFORMATION OF A CHOROIDAL NEVUS IN AN EYE TREATED FOR CHOROIDAL MELANOMA.

Purpose: To report a case of a choroidal melanoma and a discrete choroidal nevus that has transformed into a malignant melanoma 5 years after initial diagnosis. Methods: Retrospective case report. Results: A diffuse macular choroidal melanoma and a discrete choroidal nevus located superonasal to the optic disk were diagnosed in the right eye of a 63-year-old woman in 2009. The patient was treated by ruthenium plaque radiotherapy for the choroidal melanoma, which consequently flattened and scarred. On a routine eye check in 2014, the nevus was found to have been transformed into a choroidal melanoma. It was treated with ruthenium plaque radiotherapy. Conclusion: Although extremely rare, patients with a uveal melanoma can develop an additional discrete uveal melanoma. This case highlights the importance of monitoring benign choroidal nevi in patients with a history of choroidal melanoma.

Visual Loss from Choroidal Melanoma Mimicking Neurological Syndromes

Melanoma of the eye is rare, but can mimic a range of disorders. This report highlights 2 cases of choroidal melanoma with vision loss mimicking neurological diagnoses. The first patient is a 41-year-old white male with a known history of multiple sclerosis and a previous episode of optic neuritis in the right eye, who presented with a 6-month history of decreased vision in the same eye, and occasional photopsiae. He was treated with 2 courses of oral steroids for presumed recurrent optic neuritis. After a temporary improvement in his symptoms, his vision worsened, following which he had a head MRI, which revealed a solid intraocular mass. He was subsequently diagnosed with a choroidal melanoma for which he was treated successfully with ruthenium-106 plaque brachytherapy. The second patient is a 57-year-old female, who presented with a progressive cerebellar syndrome under investigation by the neurology service, as well as decreased vision in the right eye. Her visual acuity gradually deteriorated and her neurological assessment, which included a PET-CT, revealed uptake in the right eye. The diagnosis of a choroidal melanoma was made, and following conservative treatment with proton beam radiotherapy, she had an enucleation of the eye. Intraocular tumours can masquerade as many different entities. Unexplained unilateral visual loss, especially if it is atypical for a neurological syndrome, should prompt dilated fundoscopy and referral to an ophthalmologist.

Systemic Rituximab for Conjunctival Marginal Zone (Malt) Lymphoma is not Protective for Subsequent Disease Development in the Contralateral Eye

Purpose: We report a case of a 35-year old male who presented with unilateral conjunctival extranodal marginal zone (MALT) lymphoma and underwent systemic Rituximab immunotherapy as primary treatment. After an excellent initial response and four years of complete remission he presents with MALT lymphoma to the contralateral conjunctiva. Methods: MALT lymphoma is the most common lymphoid neoplasm of the conjunctiva, and has an indolent clinical course. Rare cases of spontaneous remission, bilateral involvement, systemic dissemination, and common local and contralateral relapses have been reported. Rituximab is a chimeric anti-CD20 antibody, currently used as first-line treatment of CD20 positive non-Hodgkin’s lymphoma. Several mechanisms can be responsible for rituximab resistance. Transformation of CD20 positive indolent to aggressive CD20 negative form is one of them. Results: In this case, the patient did not demonstrate any systemic or orbital involvement. Both histological reports of the incisional biopsies revealed CD20 positive immunohistochemistry. Conclusion: This is a highly unusual case of new primary conjunctival MALT lymphoma to the contralateral eye after systemic Rituximab treatment. This further supports the assumption that rituximab does not suppress MALT lymphoma formation in the long term in the other eye, suggesting that the predisposing immune factors are not annihilated by the course of rituximab. Long term review of these patients is therefore warranted.

Abstract 1156: Widespread deficiency of ASS1 in uveal melanoma and sensitivity to pegylated arginine deiminase

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA Uveal melanoma, involving the iris, choroid and ciliary body, is the commonest intraocular tumor in adults. Approximately half of these patients will develop metastasis with a high mortality despite currently available systemic therapies including immune checkpoint blockade. The urea cycle enzyme argininosuccinate synthetase 1 (ASS1), responsible for arginine synthesis, is downregulated in melanoma and other cancers and these are therefore sensitive to arginine deprivation therapy. In early phase trials of the arginine depletor pegylated arginine deiminase, ADI-PEG20, uveal melanoma, in particular, was identified with potential for further therapeutic development. Here, we tested uveal melanoma cell lines for sensitivity to ADI-PEG20 and analyzed enucleated tumors for ASS1 expression to assess the extent of ASS1 deficiency. Methods: ASS1 gene and protein expression were assessed in three uveal melanoma cell lines (OMM1, OMM2.5 and Mel270) by real-time quantitative PCR (qPCR) and western blot analysis, respectively. Sensitivity to ADI-PEG20 was performed using the cell viability MTS assay. We screened 102 enucleated choroidal and ciliary body melanomas for ASS1 protein using red chromogen for the immunohistochemistry (IHC) and selected the most positive area for scoring. Results: The uveal melanoma cell lines expressed negligible ASS1 mRNA with a complete absence of ASS1 protein. All three ASS1 negative uveal melanoma cell lines were sensitive to ADI-PEG20 by day 6 of the MTS assay, whereas an ASS1-expressing positive control cell line was resistant. There was a convincing lack of ASS1 expression (<5% staining) in the majority of uveal melanomas (75/102; 74%) and where ASS1 was present (5-30% staining) in the remainder (27/102; 26%) this was due to a mixture of melanoma cells and intratumoral macrophages, the latter being confirmed with CD68 (IHC) in the cases with the highest ASS1 expression. Conclusion: ASS1 is absent in the tested uveal melanoma cell lines and predisposes to arginine sensitivity with ADI-PEG20 in vitro. Most primary uveal melanomas have a marked deficiency of ASS1, representing a good target for exploring arginine deprivation further in the clinic, either alone or in combination with rationally selected agents. A trial of ADI-PEG20 combined with carboplatin and paclitaxel is planned in metastatic malignant melanoma with an expanded cohort in patients with uveal disease. Citation Format: Ramsay S. Khadeir, Melissa M. Phillips, Mandeep S. Sgoo, Amit Arora, Victoria Cohen, Caroline Thaung, Peter W. Szlosarek. Widespread deficiency of ASS1 in uveal melanoma and sensitivity to pegylated arginine deiminase. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1156. doi:10.1158/1538-7445.AM2015-1156