I G Rennie

Proton beam therapy for iris melanoma: a review of 15 cases

AimTo report results of proton beam therapy for iris melanoma.MethodsA retrospective case series of 15 patients with nonresectable iris melanomas treated with proton beam therapy between August 1998 and August 2004. The main outcome measures were (1) local tumour control, (2) complications, and (3) eye retention.ResultsOf the 15 cases, 11 patients showed documented growth (including two cases of local recurrence following iridocyclectomy) while a further three cases were biopsy-proven melanoma. One patient presented with a newly acquired vascular nodule of the iris associated with angle seeding and glaucoma. Tumour control at mean follow-up of 34 months was 93% (14 of 15 eyes). Common complications included glaucoma in 53% (five patients had glaucoma prior to irradiation), dry eye (27%) and cataract in three patients (20%). Eye retention was possible in 80% (12 cases).ConclusionProton beam therapy is an effective treatment for cases of nonresectable iris melanoma. The major complications are cataract and glaucoma.

Outcomes of treatment with stereotactic radiosurgery or proton beam therapy for choroidal melanoma.

AimTo present our experience of the use of stereotactic radiosurgery and proton beam therapy to treat posterior uveal melanoma over a 10 year period.Methods and materialsCase notes of patients treated with stereotactic radiosurgery (SRS), or Proton beam therapy (PBT) for posterior uveal melanoma were reviewed. Data collected included visual acuity at presentation and final review, local control rates, globe retention and complications. We analysed post-operative visual outcomes and if visual outcomes varied with proximity to the optic nerve or fovea.Results191 patients were included in the study; 85 and 106 patients received Stereotactic radiosurgery and Proton beam therapy, respectively. Mean follow up period was 39 months in the SRS group and 34 months in the PBT group. Both treatments achieved excellent local control rates with eye retention in 98% of the SRS group and 95% in the PBT group. The stereotactic radiosurgery group showed a poorer visual prognosis with 65% losing more than 3 lines of Snellen acuity compared to 45% in the PBT group. 33% of the SRS group and 54% of proton beam patients had a visual acuity of 6/60 or better.ConclusionsStereotactic radiosurgery and proton beam therapy are effective treatments for larger choroidal melanomas or tumours unsuitable for plaque radiotherapy. Our results suggest that patients treated with proton beam therapy retain better vision post-operatively; however, possible confounding factors include age, tumour location and systemic co-morbidities. These factors as well as the patient’s preference should be considered when deciding between these two therapies.

Bovine pericardium (Tutopatch) wrap for hydroxyapatite implants

PurposeTo evaluate bovine pericardium (Tutopatch®) as a wrapping material for hydroxyapatite implants in patients undergoing enucleation for uveal melanoma.MethodProspective cohort study of patients who had enucleation for uveal melanoma between January 2003 and August 2003 were included in the study. Any patient with less than 3 months follow-up was excluded. Enucleation was performed under general anaesthesia followed by insertion of hydroxyapatite implants wrapped in bovine pericardium (Tutopatch). The recti muscles were sutured directly to the wrap. The tenons capsule and conjunctiva were closed in two layers. A conformer was inserted at 1 week and artificial eye at 2–3 months. The patients were followed up regularly and were assessed for cosmetic result, exposure of implant, and the need for any further surgical procedures.ResultsA total of 19 patients (seven male and 12 female) were included in the study. Median age at diagnosis was 63 years (range 38–80 years). Median follow-up was 26 months (range 22–30 months). No patient developed postoperative complications of wound dehiscence. The overall cosmetic result was excellent in all the patients. The rate of postoperative complications compared favourably with published data using other wrapping materials/implants.ConclusionTutopatch® is a safe wrapping material for hydroxyapatite orbital implants in patients undergoing enucleation for uveal melanoma.

Conjunctival intra-epithelial neoplasia occurring in young patients with asthma

BackgroundConjunctival intra-epithelial neoplasia (CIN) typically occurs in elderly individuals. A number of aetiological factors are implicated in CIN, including life-long exposure to ultra-violet light and immunodeficiency states, particularly HIV infection. Asthma is a common condition affecting more than 3.5 million individuals in the UK, and is associated with atopy in approximately 70% of cases. In this paper we describe CIN occurring in young patients with asthma.MethodsRetrospective case series: A review of our ocular oncology database helped to identify 11 patients <55 years of age and presenting with CIN. Of these, seven (64%) were noted to have co-existent asthma.ResultsSeven patients were included in the study (six male and one female). Mean age at presentation was 44 years (range 36–54 years). Five patients showed unilateral disease, whereas two showed bilateral. Five patients showed local recurrence; however, there were no cases of metastasis.ConclusionThe occurrence of CIN, particularly bilateral CIN, in younger immunocompetent individuals is very unusual, and the presence of asthma in 64% of our patient cohort suggests that atopic asthma may be a further aetiological factor involved in the development of this rare neoplasm.

Treatment of invasive ocular surface squamous neoplasia with proton beam therapy

Sir, n nOcular surface squamous neoplasia (OSSN) has the potential for causing significant ocular and systemic morbidity and mortality. We present two cases of invasive OSSN successfully treated with proton beam therapy (PBT). Both were non-resectable due to deeper scleral invasion.

Failure of intravitreal bevacizumab in the treatment of choroidal metastasis

BackgroundMetastasis to choroid is the most common intraocular malignancy, arising most frequently from carcinoma of breast in women and lung in men. Recent case reports have described successful use of intravitreal bevacizumab to achieve local control of such tumours.Materials and methodsFive cases of choroidal metastases from varying primaries: breast, lung, and colon were treated with intravitreal bevacizumab, and tumour response observed and documented with serial photographs and B-scans.ResultsFour of the five tumours were seen to progress despite intravitreal bevacizumab treatment.ConclusionsIntravitreal bevacizumab as the primary treatment of choroidal metastases is not recommended and should not delay more effective alternative treatments.

Ocular surface foreign bodies: novel findings mimicking ocular malignant melanoma

PurposeMalignant melanoma of the eye is an uncommon condition that is important to recognise. We describe three cases in which ocular foreign bodies have masqueraded as ocular malignant melanoma.MethodsInterventional case reports.ResultsCase 1 describes diathermy-induced carbon particle implantation, during plaque therapy for the treatment of uveal melanoma, mimicking recurrence with extra-scleral invasion. Case 2 shows a foreign body called ‘mullite’ mimicking conjunctival melanoma. Case 3 demonstrates a conjunctival foreign body called ‘illite’ that mimicked a limbal melanocytic lesion, clinically thought to be either melanocytoma or melanoma.ConclusionThis report highlights the importance of careful history taking, examination, and appropriate biopsy in cases of suspected malignant melanoma, to prevent unnecessary and potentially radical treatment.

Combined enucleation and orbitotomy for choroidal melanoma with orbital extension

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Fresh frozen amniotic membrane for conjunctival reconstruction after excision of neoplastic and presumed neoplastic conjunctival lesions

PurposeSuspicious neoplastic conjunctival lesions often require wide excision with tumour-free margins, leaving significant conjunctival defects requiring reconstruction. In this study we report the results of using fresh frozen amniotic membrane grafts (AMG) after wide excision of potentially malignant lesions.MethodsRetrospective review of 53 patients; between January 2011 and April 2014. Conjunctival lesions were excised with a non-touch technique (2u2009mm margin) and sent for histopathological analysis. The surgical margins were treated with cryotherapy and a fresh frozen AMG was used to cover the defect. The main features examined were for any signs of recurrence, the conjunctivalisation of the AMG, complications and cosmetic appearance.ResultsFifty-three patients; 35 males and 18 females. Mean age was 54.9 (range 19–88). The mean follow up to January 2015 for all lesions was 21.4 months (range 8–48 months). The most common lesions were invasive malignant melanoma. There were no local surgical complications in 77.3% of patients; minimal scarring (11.3%), symblepharon (11.3%), and granuloma (7.5%). Five patients with conjunctival melanoma developed in-transit metastasis and orbital extension, none of it was at the site of the AMG.ConclusionOur case series is the largest reported to date, with the largest number of melanomas. The use of fresh frozen AMG has improved the local surgical outcomes by improving healing and reducing scarring as well as allowing for a wider surgical margin.

Three cases of intraocular mesectodermal leiomyoma expressing progesterone and androgen receptors

Background/AimsA prospective study identified three patients between 2004 and 2010 with mesectodermal leiomyoma. The study was conducted to analyse the presence or absence of sex steroid hormone receptors in mesectodermal leiomyomas.MethodsThe clinical features were collated. All three patients had operative procedures to either remove or sample the mesectodermal leiomyomas. The tissue was fixed in formalin and exposed to conventional histological processing. Immunohistochemistry using antibodies to androgen (AR), oestrogen (ER), and progesterone (PR) receptors was performed, followed by stain scoring to assess for expression status.ResultsAll three cases were confirmed by histology to be examples of mesectodermal leiomyomas. All three expressed sex steroid hormone receptors. One case expressed both PR and AR, one case PR only and another case AR only. None of the cases expressed ER receptors.ConclusionAll three cases displayed some sex steroid hormone receptor expression. This is supportive evidence that sex steroid hormones may have a role in the pathogenesis of this tumour and suggest that it may be amenable to hormonal manipulation therapy, in a manner similar to conventional uterine leiomyomas.