Madhavi Kurli

Whole body PET/CT for initial staging of choroidal melanoma

Aim: To investigate the value of whole body positron emission tomography/computed tomography (PET/CT) in screening for metastatic choroidal melanoma in patients initially diagnosed with choroidal melanoma. Methods: 52 patients with choroidal melanoma underwent whole body PET/CT as part of their metastatic investigation. PET/CT scans were used as a screening tool at the time of their initial diagnosis. A physical examination, liver function tests, and a baseline chest x ray were also obtained. PET/CT images (utilising intravenous18-fluoro-2-deoxyglucose (FDG)) were studied for the presence of metastatic melanoma. The standards for reference were further imaging and/or subsequent biopsies. Results: Two of 52 (3.8%) patients were found to have metastatic melanoma before treatment. The most common sites for metastases were the liver (100%), bone (50%), and lymph nodes (50%). Brain involvement was also present in one patient. One patient (50%) had involvement of multiple sites. Haematological liver enzyme assays were normal in both patients. PET/CT showed false positive results in three patients (5.7%) when further evaluated by histopathology and/or additional imaging. In seven patients (13.4%) PET/CT imaging detected benign lesions in the bone, lung, lymph nodes, colon, and rectum. Conclusion: PET/CT imaging can be used as a screening tool for the detection and localisation of metastatic choroidal melanoma. Liver enzyme assays did not identify liver metastases, while PET/CT revealed both hepatic and extrahepatic metastatic melanoma. PET/CT imaging may improve upon the conventional methods of screening for detection of metastatic disease in patients initially diagnosed with choroidal melanoma.

PET/CT imaging: detection of choroidal melanoma

Aim: To determine the size of untreated choroidal melanomas resolved by whole body positron emission tomography fused with computed tomography (PET/CT). Methods: 50 consecutive patients with untreated choroidal melanomas underwent whole body PET/CT. A functionally fused helical CT scan and 18-fluoro-2-deoxyglucose (FDG) PET scans were employed. The tumours were identified (both quantitatively and qualitatively) and compared with clinical measurements derived from ophthalmoscopic, angiographic, and ultrasonographic imaging. Standardised uptake values (SUV) of more than 2.5 were considered positive. Results: Among the 50 patients with choroidal melanoma, PET/CT scan SUVs of more than 2.5 were noted in 14 (28%) tumours. No AJCC T1 class tumours, 33.3% of T2 melanomas, and 75% of T3 melanomas were physiologically identifiable on PET/CT. With respect to COMS group classifications, no small choroidal tumours, 33% of medium, and 75% of large melanomas were physiologically identifiable. The sole ring melanoma was identifiable on PET/CT imaging. The smallest tumour physiologically identifiable by PET/CT had basal dimensions of 3×5.9 and an apical height of 2.9 mm. Conclusion: Though PET/CT was found to be capable of physiologically identifying certain medium (T2) and most large sized (T3) choroidal melanomas, physiological imaging was not completely dependent upon tumour size. Functionally fused PET/CT localised the tumours within the eye and assessed their physiological activity.

The Finger iridectomy technique: small incision biopsy of anterior segment tumours

Aims: To develop a minimally invasive, maximally effective method to biopsy anterior segment tumours. Methods: A 25 gauge aspiration cutter (vitrector) was used to biopsy anterior segment tumours. The probe was introduced under sodium hyaluronate 1% and through a 1 mm incision. Aspiration (600 mm Hg) cutting (300 cpm) was performed to obtain specimens for cytology and histopathology. Results: Diagnostic material was obtained in nine of 10 (90%) cases. Diagnoses included iris naevus, iris stroma, malignant melanoma, melanocytoma, epithelial inclusion cyst, and sarcoid granuloma. All corneal wounds were self sealing. One patient developed a transient postoperative increase in intraocular pressure. Within the follow up of this study, no patients suffered intraocular haemorrhage, infection, cataract or vision loss. Conclusion: The Finger iridectomy technique was a minimally invasive and very effective biopsy technique. Aspiration cutting yielded relatively large pieces of tissue (and cells) used for cytopathological and histopathological evaluation. Small incision surgery allowed for rapid rehabilitation and no significant complications.

Anterior chamber paracentesis cytology (cytospin technique) for the diagnosis of intraocular lymphoma.

Aim: To report on the diagnosis of intraocular lymphoma by aqueous cytology. Methods: Four patients suspected of having intraocular lymphoma were evaluated by anterior chamber (AC) paracentesis with cytology (cytospin technique). All had a history of non-ocular lymphoma and presented with at least one plus anterior chamber cells despite intensive glucocorticoid therapy. A 25 gauge needle was inserted through clear cornea (bevel up), over the iris stroma, so as to drain the AC. The aqueous humour was sent for cytopathology (cytospin technique), culture, and sensitivity tests. Results: All procedures were diagnostic. Three were lymphoma and the fourth was culture positive for Propionibacterium endophthalmitis. No secondary glaucoma, hyphaema, cataract or infections were related to AC paracentesis. Conclusions: In this series, AC aspiration cytology enhanced by the cytospin technique was an effective, minimally invasive alternative to vitrectomy based biopsy. This technique should be considered to rule in the diagnosis of intraocular lymphoma in selected cases with cells in the anterior chamber.

Finding malignant change in a necrotic choroidal melanocytoma: a clinical challenge.

Melanocytic intraocular tumours can grow as to exceed their vascular supply, become necrotic, and induce inflammation. They present with atypical signs and become a diagnostic challenge. We present a case of a large melanocytic intraocular tumour that offered an atypical presentation, unexpected cytology, and finally diagnostic histopathology. A 37 year old white woman presented with a painful right eye and vision loss. Exam ination showed no light perception, a relative afferent pupillary defect, a shallow anterior chamber, and an intraocular pressure of 58 mm Hg. Dense vitreous haemorrhage and tumour obscured her fundus. Three dimensional ultrasonography revealed vitreous haemorrhage, a total retinal detachment, and a large choroidal mass (fig 1A, B). Computed tomography and magnetic resonance imaging (MRI) of the orbits showed a 2 cm intraocular mass with a collar-button extension (arrow) consistent with a choroidal melanoma (fig 1C). Figure 1  (A) B-scan ultrasound demonstrated a large intraocular tumour with scleral thickening and retrobulbar oedema. There was almost no intrinsic vascularity noted within the tumour. No …

Whole body PET/CT imaging for detection of metastatic choroidal melanoma

Metastatic choroidal melanoma typically presents in the liver. Therefore, liver enzyme assays are the most common haematological evaluation performed after treatment.1 In 1985, The Collaborative Ocular Melanoma Study required periodic medical evaluations including a physical examination, liver functions studies, a complete blood count, and a chest x ray. If liver enzymes exceeded 1.5 times normal, computed tomography (CT) of the abdomen was required. If low attenuation hepatic nodules suggested metastatic disease, fine needle aspiration biopsy of the liver tumours provided cytopathological confirmation.1 Positron emission tomography (PET) is a molecular imaging technique that uses radiolabelled molecules to image metabolic activity in vivo.2,3 When whole body PET was combined with computed radiographic tomography (CT), PET/CT put anatomy and function on the same page making practical a new era of physiological imaging.2–6 This study examines the …

Whole-body 18 FDG PET/CT imaging for lymph node and metastatic staging of conjunctival melanoma.

Aim: To evaluate 18-fluoro-2-deoxyglucose (FDG) whole-body positron emission tomography/computed radiographic tomography (PET/CT) for lymph node and metastatic staging of patients with conjunctival melanoma. Methods: Fourteen patients with T3 (n = 13) and T4 (n = 1) conjunctival melanoma (as defined in Chapter 42 of the AJCC staging manual) were staged for metastatic disease with PET/CT imaging with fusion. The patients had lymph node and clinical staging evaluations before PET/CT imaging. PET/CT images were studied for the presence and distribution of metastatic conjunctival melanoma (determined by standardised uptake values) and later confirmed by biopsy. MRI imaging was performed if abnormalities were noted on PET/CT images. Results: Fourteen patients with conjunctival melanoma underwent PET/CT imaging. Seven were newly diagnosed (presurgical screening), and seven had undergone prior treatment (follow-up group). Only one patient with conjunctival melanoma (7.1%) was found to have metastatic disease on PET/CT imaging. Abnormal foci were found in the liver, lung, peritoneal cavity, lumbar spine as well as a supraclavicular node (T4N1M4). All liver function tests were normal. The mean length of follow-up after PET/CT imaging was 13 months (range 4–30 months). Conclusions: PET/CT imaging did not reveal any regional or systemic metastasis among 14 patients with advanced, diffuse and multifocal disease.

The Diagnostic Value of Exfoliative Cytology vs Histopathology for Ocular Surface Squamous Neoplasia

PURPOSE To determine the reliability and role of conjunctival exfoliative cytologic and histopathologic diagnosis of biopsied tissue in ocular surface squamous neoplasia. DESIGN Retrospective review of an interventional case series of patients biopsied and treated for squamous conjunctival and corneal neoplasia. METHODS Forty-nine patients who underwent conjunctival cytologic analysis (n = 36), conjunctival biopsy (n = 35), or both were evaluated. For the purposes of this study, three ocular pathologists reviewed the results of cytologic and biopsied tissue in a masked fashion. RESULTS Evaluation of cytologic smears revealed a 91% concordance in interpretation of conjunctival cytologic material as no dysplasia vs dysplasia. The concordance dropped to 59% in grading the degree of dysplasia. The cytologic material was found to be inadequate for interpretation in 1 case. Evaluation of subsequent biopsy revealed a 98% concordance between the pathologists in interpretation of biopsied tissue as no dysplasia vs any degree of dysplasia. The concordance decreased to 83% in grading the degree of dysplasia. Cytologic evaluation was capable of distinguishing a neoplastic from nonneoplastic process before tissue biopsy in 80% of cases. CONCLUSIONS Ocular surface cytologic analysis is a simple, safe, and relatively noninvasive diagnostic tool. It was found helpful in detecting dysplasia before surgical resection. It was used in the settings of recurrent tumor and for follow-up care of patients treated with topical chemotherapy. Although cytologic smears cannot replace incisional or excisional biopsy for definitive diagnosis, exfoliative cytologic analysis can play an important role in the diagnosis and management of patients with ocular surface squamous neoplasia.

Eyelid-Sparing Adjuvant Radiation Therapy for Renal Cell Carcinoma

Purpose: To describe the use of debulking surgery with adjuvant external beam irradiation as an eyelid-sparing treatment for renal cell carcinoma. Design: Interven tional case report. Methods: A 63-year-old male presented with a right upper lid tumor. He had a history of renal cell carcinoma and pulmonary metastasis treated with surgery and systemic chemotherapy. The eyelid tumor was biopsied, followed by debulking surgery and external beam radiation therapy to treat this metastatic tumor. Results: Histopathological evaluation of the excised tumor revealed a metastatic renal cell carcinoma, clear cell type. At 4 months’ follow-up, he had no evidence of recurrence or radiation oculopathy. He was pleased with his cosmetic result. Conclusions: Meta static renal cell carcinoma presenting in the eye and orbit can be the initial manifestation of the primary tumor. It is important to include this tumor in the differential diagnosis of recurrent eyelid lesions. Debulking surgery followed by external beam radiation therapy can be used to control the tumor with an eyelid-sparing cosmetic result.

3D ultrasound coronal C-scan imaging for optic nerve sheath meningioma

The use of three dimensional (3D) ultrasonography (3DUS) for optic nerve measurements has been described in normal eyes utilising coronal “C-scans.”1,2 This study demonstrates the use of 3DUS generated C-scans for optic nerve measurements in orbits with optic nerve sheath meningioma and compares those with measurements obtained from computed tomography (CT) scans. A 69 year old woman with a left optic nerve sheath meningioma was treated with external beam radiation therapy 6 years earlier. On 3DUS coronal C-scans, an optic nerve sheath diameter (ONSD) 3 mm behind the globe was measured to be 7.4 mm in the left eye (fig 1, top left) and 6.4 mm in the right (fig 1, top right). Figure 1  Case 1. The patient’s left (top left) and right (top right) optic nerve sheath diameters are shown …