1

Question 1a

How to make the diagnosis of primary uveal tract melanoma?

Data base:

Second sift from 722 papers related to primary treatment of uveal

melanoma

Inclusion Criteria:

Human studies, case series >5, phase II trails, all RCTS’s, Cohort

studies, Case control studies

Results:

25 of 722 relevant to answer Question 1a (refined to 12)

Collaborative Ocular Melanoma Study Group. Accuracy of diagnosis of

choroidal melanomas in the Collaborative Ocular Melanoma study. Arch

Ophthalmol 1990;108:1268–73.

RCT early paper in recruitment phase

In 3-year period from 1989, 413 patients diagnosed with UM using

ophthalmoscopy, photography, conventional ocular ultrasonography.

Histology available on all patients. Misdiagnosis rate 0.48%

Ophthalmoscopy (0)

Photography (0)

Ultrasound techniques (6) includes comparison with PET/CT and AS-OCT

Intraocular biopsy techniques (4)

Comparative study (1)

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Ocular Ultrasound and UBM

1. Characteristic Ultrasonographic Findings of Choroidal Tumors. Wang et al

Journal of Medical Ultrasound 2003

Study type Retrospective case notes review

Aims To describe the ultrasound

features of different choroidal tumours

Inclusion criteria Not detailed

Exclusion criteria Not detailed

Method B scan 10 MHz probe and A scan though closed eye lid

Number of patients 27

Outcomes 10 choroidal melanoma

described All classic collar stud shape

50% medium reflectivity and

40% low to medium reflectivity

Conclusions Well described B scan and A

scan ultrasound characteristics

can help to refine the type of intraocular tumour

Comment Useful noninvasive investigation

for choroidal tumours Very small collection of

cases from Taiwan

Unverisity hospital over 4

years!

Purpose: To report the characteristic ultrasonographic findings of choroidal tumors diagnosed at a university hospital between 1999 and 2002.Materials and Methods: The charts of patients with

choroidal tumors diagnosed between January 1999 and December 2002 were reviewed

retrospectively. Age, gender and symptoms were recorded. The characteristic ultrasonographic

findings of choroidal tumors, including shape, internal reflectivity, location and associated retinal detachment, were analyzed.Results: A total of 27 cases of choroidal tumors were reviewed.

Choroidal hemangioma was found in 15 cases (56%), choroidal melanoma in 10 (37%), and

metastatic choroidal tumor in two (7%). Fourteen patients had a dome-shaped tumor mass (14 choroidal hemangiomas), 11 had a collar-button tumor (10 choroidal melanomas and 1 choroidal

hemangioma), and two had an irregular/bumpy tumor (metastatic choroidal tumors). Retinal

detachment was noted in 14 cases. Thirteen choroidal hemangiomas (86.7%) were located adjacent to the optic nerve, while eight choroidal melanomas (80%) were not located at the

posterior pole. High internal reflectivity was noted in 13 choroidal hemangiomas (86.7%). Five

cases of choroidal melanoma (50%) had medium to high internal reflectivity, and four cases

(40%) showed low to medium internal reflectivity.Conclusions: Ultrasonography is a non-invasive examination for choroidal tumors. However, not all choroidal tumors had the typical

pictures described by previous studies. From our study, the shape, location, reflectivity, and

associated retinal detachment might be helpful indicators for differential diagnosis of choroidal tumors.

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2. The Use of Ultrasound Biomicroscopy in the Evaluation of Anterior Segment

Tumors and Simulating Conditions Gündüz et al Department of Ophthalmology,

Ankara University Faculty of Medicine, Ankara, Turkey Ophthalmologica

2007;221:305–312. Study type Case series, partly comparative

Aims Report UBM using 50MHz probe for various anterior

segment diagnoses some

confirmed on histopathology

Inclusion criteria Any anterior segment lesion

Exclusion criteria Not stated

Method Prospective analysis of data from

Aug 2002-2006

Comparison with histology where available

Number of patients 35 patients

7 Ciliary Body MM 4 Iris MM

2 Ring Melanoma

Outcomes Ciliary body MM had low to

medium reflectivity Of the 6 CB tumours reported

there was no correlation between

UBM finding and histological subtype

Conclusions Good for detecting small CB

MM and to differenciate iris

naevus from iris melanoma and identify pigment epithelial cysts

Comment Useful sign loss of the acute

angle shape in ring

melanoma

Abstract

Purpose: To report the ultrasound biomicroscopy (UBM) findings of anterior segment tumors

and simulating condi- tions. Methods: Thirty-five patients underwent UBM. Of those, 16 had histopathologically or cytopathologically di- agnosed tumors, and 19 had clinically diagnosed

lesions. Re- sults: The study material comprised 13 iris pigment epithe- lial (IPE) cysts, 7 ciliary

body melanomas, 4 iris melanomas, 4 iris nevi, 3 intraocular invasions of conjunctival squamous cell carcinoma, 2 ring melanomas of the anterior chamber angle, 1 medulloepithelioma and 1 pars

plana cyst. On UBM, all IPE cysts presented as cystic lesions with a thin cyst wall and no solid

components. All ciliary body melanomas showed low to medium reflectivity, with cavitation in one case and extraocular extension in another. Iris melanomas presented as anterior (stromal) iris

lesions with medium to high internal reflectivity. There was irregularity and convex bowing of

the posterior iris plane in iris melanomas, a fea- ture not seen in iris nevi. Intraocular invasion of conjunctival squamous cell carcinoma was evidenced as areas of medium to high reflectivity in

the ciliary body and iris, loss of the acute angle shape and highly reflective spots in the anterior chamber. Conclusions: UBM was particularly useful in the diagnosis of IPE cysts, in the

visualization of small ciliary body melanomas, in the differentiation of iris melanomas from iris

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nevi and in the demonstration of intraocular inva- sion from conjunctival squamous cell

carcinoma. Ultrasound biomicroscopy (UBM) provides high-res- olution in vivo imaging of the anterior segment in a non- invasive fashion. In addition to imaging the tissues easily seen by

clinical methods, it images structures otherwise hidden from clinical visualization, including the

ciliary body and zonules, allowing assessment of their morphol- ogy [1–3]. The purpose of this study was to evaluate the UBM features of anterior segment tumors and simulating conditions.

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3. Assessment of Anterior Segment Tumors with Ultrasound Biomicroscopy versus Anterior

Segment Optical Coherence Tomography in 200 Cases. Carlos Bianciotto et al. Ophthalmology 2011;118:1297–1302

Study type Retrospective non-interventional

case series

Aims Compare UBM with OCT imaging to determine which is

best

Inclusion criteria All anterior segment tumours Not specific to melanoma

Exclusion criteria

Method

Number of patients 200 47 (24%) had melanomas

Outcomes UBM was more favorable for

resolution of the posterior margin of the lesion and for

structures from the pigment

epithelium posteriorly, whereas AS-OCT was more favorable for

anterior margin and ocular

structures anterior to the IPE

Image quality was considered

good with UBM in 80%versus

68% with AS-OCT

Overall, UBM was more

favorable for complete tumor

resolution in IPE cyst and iris melanoma

Conclusions AS-OCT suffers from

optically-related image shadowing with large,

pigmented, IPE and ciliary

body lesions.

Advantage of AS OCT it is

quick and easy to perform

and not uncomfortable for the patient ( no waterbath is

required) It is useful iris MM

anterior to the PE for and conj tumours

Comment UBM is better than AS

OCT for anterior segment

uveal melanoma

Abstract

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Purpose: To compare ultrasound biomicroscopy (UBM) versus anterior segment optical

coherence tomography (AS-OCT) for imaging of tumors of the anterior segment of the eye.Design: Retrospective, noninterventional case series. Participants: We included 200

patients. Methods: Review of medical records of patients who underwent both UBM and AS-

OCT for evaluation of anterior segment tumors. Main Outcome Measures: Comparison of tumor

surface and internal visualization.

Results: There were 200 eyes with anterior segment tumors involving the iris stroma in 96 (48%),

ciliary body in 14 (7%), combined iris and ciliary body in 32 (16%), iris pigment epithelium

(IPE) in 44 (22%), conjunctiva in 6 (3%), sclera in 4 (2%), and others in 6 (1% each). The diagnoses included nevus in 75 eyes (38%), melanoma in 47 (24%), cyst in 48 (24%),

epithelioma (adenoma) in 5 (3%), metastasis, melanocytosis and melanocytoma in 4 eyes each

(2%), and others (1% each). Image analysis (UBM vs AS-OCT) revealed adequate visualization of all tumor margins (189 [95%] vs 80 [40%]), posterior tumor shadowing (9 [5%] vs 144 [72%]),

and high overall image quality (159 [80%] vs 136 [68%]). Comparison for better image

resolution (UBM vs AS-OCT) disclosed UBM provided better overall tumor visualization (138

[69%] vs 62 [31%]) and better resolution of the posterior margin (147 [74%] vs 53 [27%]), whereas AS-OCT provided better resolution of the anterior margin (40 [20%] vs 160 [80%]) as

well as better overall resolution of anterior segment anatomy (41 [21%] vs 159 [80%]). Better

resolution was found with UBM for pigmented tumors (n � 162; 107 [66%] vs 55 [34%]) as well as for nonpigmented tumors (n � 38; 23 [61%] vs 15 [39%]). Regarding location, iris tumor

resolution was similar with each technique (49 [52%] vs 45 [48%]).

Conclusions: For anterior segment tumors, UBM offers better visualization of the posterior margin and provides overall better images for entire tumor configuration compared with AS-OCT.

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4. Anterior segment imaging for iris melanocytic tumors. Razzaq et al

European Journal of Ophthalmology, 2011;21(5): 608-614

Study type Retrospective comparative

cohort

Aims AS-OCT verses UBM for

Inclusion criteria Melanocytic iris lesions

Exclusion criteria

Method Image quality was compared

with UBM as gold standard between 2006 and 2009

Not all OCT machines used

are widely available and therefore this limits

usefulness of this paper

Number of patients 61 ASOCT was compared with

UBM in 42 patients

Outcomes AS OCT compared well with

UBM in 86% of cases

But AS OCT only detected CB extension of iris melanoma in 1

of 3 cases.

Conclusions UBM is superior for detecting

CB extension

Comment Precise tumour measurement

could be made with AS OCT to allow for radiotherapy planning

Abstract

Purpose: To determine the role of anterior segment Optical Coherence Tomography (AS-OCT) and other anterior segment imaging techniques (Pentacam and Slit lamp-OCT) for analysis of iris melanocytic tumors and to compare results with clinical features and ultrasound biomicroscopy (UBM). Methods: Between 2006 and 2009, sixty-one patients with melanocytic iris tumors were examined using a variety of anterior segment imaging techniques, i.e. Pentacam, Slit lamp-OCT (SL-OCT), Anterior segment OCT (AS-OCT) and UBM (50MHz). Pentacam was performed in 17 patients, SL-OCT in 12, AS-OCT in 46 and UBM in 49 patients.Results: The Pentacam images identified the tumor in three of 17 patients (18%), SL-OCT in eight of 12 (67%) and AS-OCT in 44 of 46 patients (96%). AS-OCT results were compared with UBM in 42 patients: in 86% of these, the results were comparable, although AS-OCT demonstrated a ciliary body extension of iris tumors in only one out of three cases analyzed.Conclusion: Iris melanocytic tumors were located by AS-OCT in 96% of cases and results were comparable to UBM imaging, while both SL-OCT and Pentacam were less reliable for detecting and measuring anterior segment lesions. AS-OCT gives precise anterior eye segment diameters, which are useful for calculating brachytherapy dosage using a module developed at the LUMC. Therefore, AS-OCT is a reliable, convenient and non-contact method for demonstrating and measuring pure iris tumors, but UBM is superior in detecting a ciliary body extension of these tumors.

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5. Ultrasound biomicroscopy: role in diagnosis and management in 130

consecutive patients evaluated for anterior segment tumours. R M

Conway et al Br J Ophthalmol 2005;89:950–955

Study type

Aims To demonstrate the use if UBM

in imaging anterior

segment/ciliary body lesions

Included cysts and naevi

Inclusion criteria Not stated

Exclusion criteria Not stated

Method

Number of patients 130 (132 eyes) 45 melanomas where UBM

and conventional ocular ultrasound was compared

Outcomes Only 29% anatomical

correspondence between UBM

and conventional ultrasound

For anterior segment /CB

melanoma only

Conclusions UBM preferred for monitoring

and measuring CB tumours.

However A/B-scan can also be

used to demonstrate features

characteristic of melanoma including low internal

reflectivity, internal acoustic

hollowness and sound attenuation, choroidal

excavation, orbital shadowing

and the presence of spontaneous vascular pulsations and is

therefore better than UBM at

diagnosis (haemangioma verses melanoma)

A/B scan (conventional US )

used for posterior melanoma

and to detect posterior extension

Comment Superior to conventional ocular ultrasound for CB and anterior

segment tumours esp good for

serial observation

Largest series of patients

investigated with UBM

Abstract

Background/aim: Ultrasound biomicroscopy (UBM) is an important tool for assessing

anterior segment pathology. This study sought to evaluate UBM in the management of

anterior segment tumours.

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Methods: Retrospective analysis of medical records of consecutive patients referred to

the ocular oncology unit, University of California San Francisco (UCSF), for suspected

anterior segment tumours from 1999 to 2004.

Results: 132 eyes from 130 patients were evaluated, including 55 uveal melanomas (UM),

21 iris naevi, 30 iris cysts, and 26 remaining lesions. Of the melanomas, 45 were also

evaluated with conventional A/B-scan. There was 29% correspondence between the

anatomical structures invaded by melanoma as identified by B-scan v disease extent

defined by UBM. Ciliary body and peripheral iris involvement by melanomas was

significantly more fre- quently observed by UBM than B-scan. Seven of 30 benign cysts

were diagnosed as cystic before UBM evaluation. In three cases, neuroepithelial cysts

were associated with intercurrent pathology including iris naevus (n = 2) and ciliary body

melanoma (n = 1). Two ciliary body melanomas showed cavitation, including one patient

with a pseudocyst. Histopathological correlation was possible in six cases.

Conclusion: UBM is an indispensable tool for the management of anterior segment

tumours. This study demonstrates the superiority of UBM v conventional B-scan for the

precise localisation of uveal melanoma, especially involving the ciliary body and

peripheral iris.

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6.PET/CT imaging: detection of choroidal melanoma S Reddy et al Br J

Ophthalmol 2005;89:1265–1269

Study type Prospective cases

Aims To compare uvea melanoma

dimensions using PET/CT, conventional ocular ultrasound

and ophthalmoscopy

Inclusion criteria SUV>2.5 considered positive

Exclusion criteria Not detailed

Method Comparative study at diagnosis

Based on AJCC classification of

tumour sizes T1, T2, T3 and

COMS group classication

Number of patients 50

Outcomes Smallest tumour

physiologically identifiable by

PET/CT had basal dimensions

of 3x5.9 and an apical height

of 2.9 mm.

No small tumours (T1) could be

detected with PET/CT

Conclusions PET/CT

Comment Unlikely that PET/CT will be able to distinguish between naevi

and melanoma

Imaging not purely dependent on tumour size,

functionally fused PET/CT

was used but not all intraocular MM have

SUV>2.5 some barely have

any metabolic activity

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

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identifiable by PET/CT had basal dimensions of 3x5.9 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.

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Intraocular Biopsy

1.Iris ring melanoma: fine needle biopsy. D H Char et al

Br J Ophthalmol 2006;90:420–422

Study type Interventional case series

Aims Describe FNAB for ring

melanoma

Very difficult diagnosis to

make

Very lethal subgroup of uveal melanoma

Often present late having had

glaucoma filtering operations

Inclusion criteria Presumed or suspected ring MM

Exclusion criteria

Method Single centre

Retrospective case not analysis Biopsy performed usings a

transcornal route 1800 degress

away from the tumour

Number of patients 22 patients, 16 of which had FNAB to make the diagnosis

Outcomes 11 of 16 biopsies were positive

5 false negatives paucicellular aspirate

no cases of extra-scleral

extension

Conclusions FNAB can be used to make the diagnosis of ring melanoma

None of the cases were detected with UBM or

conventional ultrasound

Comment Difficult to perform

Difficult to report The author recommends an open

biopsy when a false negative

result is seen

Abstract

Aims: To delineate the diagnostic accuracy of fine needle biopsy in iris ring melanoma

and determine the tumour related mortality of this neoplasm. Methods: A retrospective

analysis of 22 patients with iris melanomas that involve the entire 360 degrees of the

anterior chamber angle.

Results: Iris ring melanomas were correctly diagnosed in all cases. In 11 of 16 cases

(69%) a fine needle biopsy performed 180 degrees away from the main mass was positive

for an iris ring melanoma. The tumour related mortality in iris ring melanoma cases was

four of 22 patients (18%). Actuarial survival analysis showed a 10 year mortality

(Kaplan-Meier) of 15%.Conclusion: A fine needle aspiration biopsy can be used to

diagnose an iris ring melanoma. Iris ring melanomas have significant mortality compared

with focal tumours.

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2.Choroidal Biopsies for Intraocular Tumors of Indeterminate Origin.

Kvanta et al AJO Dec 2005

Study type Retrospective, non comparative

interventional case series

Aims Determine the diagnosis of a choroidal mass

Inclusion criteria Not stated

Exclusion criteria Not stated but “case selection is

important”

Method 3 port pars planar vitrectomy

with diamond knife incisional

biopsy of the tumour post

incision diathermy

Number of patients 10

Outcomes A diagnosis was achieved in all

10 patients. 5 had melanoma

Complications:

Intraocular haemorrhage in 1 of

10 patients (one led to phitisis and loss of the eye)

6 eyes removed

2 eye suffered retinal detachment

Very high complication rate

Specimens fixed and paraffin block sliced at 4 micrometre

intervals

Conclusions Useful technique but high local

complication rate

Comment Due to high risk of complications the authors suggest a needle

biopsy first

Abstract (unable to cut and paste)

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3. DIAGNOSTIC TRANSVITREAL FINE-NEEDLE

ASPIRATION BIOPSY OF SMALL MELANOCYTIC

CHOROIDAL TUMORS IN NEVUS VERSUS MELANOMA

CATEGORY. James J. Augsburger et al. Trans Am Ophthalmol Soc

2002;100:225-234

Study type

Aims To report the use of FNAB to determine the diagnosis of an

indeterminate choroidal mass?

Melanoma or naevus

Inclusion criteria Suspicious choroidal naevi 1.5-

3mm thick ,10mm diameter

Exclusion criteria

Method Retrospective personal series of FNAB with 25G needle

Number of patients 34 between 1983 and 2001

Outcomes The biopsy yielded a sufficient

aspirate for cytodiagnosis in 22 of 34 cases (64.7%)

Therefore in 12 (35%) there were insufficient cells to make the

diagnosis. These patients were

observed. 4 of 12 revealed subsequent growth and the lesion

was reclassified as a melanoma

Follow wide range but

median is 2.6 years. Longer follow up would be better to

prove FNAB was accurate

Conclusions Many of these lesions would

have been termed choroidal

melanoma without diagnostic

biopsy

What about sampling error?

Comment

Abstract

Purpose: To report an experience with fine-needle aspiration biopsy of selected small

melanocytic choroidal tumors during the interval from April 13, 1983, through January 19, 2001.

Methods: Retrospective descriptive case series report of 34 patients with a small melanocytic

choroidal tumor (maximal diameter, mm; thickness, mm but mm) evaluated diagnostically by transvitreal fine-needle aspiration biopsy prior to treatment. None of the tumors

had invasive features at the time of biopsy.Results: Patients ranged in age from 26 to 73 years (mean, 50.9 years). The evaluated choroidal tumors had a mean maximal basal diameter of 8.0

mm and a mean maximal thickness of 2.4 mm. Eighteen of the 34 tumors (52.9%) had been

documented to enlarge prior to biopsy. Biopsy was performed in all cases using a 25-gauge hollow lumen needle and a transvitreal approach via a pars plana puncture site. The biopsy

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yielded a sufficient aspirate for cytodiagnosis in 22 of 34 cases (64.7%). In these cases, the tumor

was classified as malignant melanoma in 16 (47.1% of total), intermediate lesion in 4 (11.8%), and benign nevus in 2 (5.9%). The 12 tumors that yielded an insufficient aspirate and the four

lesions that yielded intermediate cells continued to be classified as “nevus versus melanoma” and

were monitored periodically for growth or other changes. Four of the 12 tumors that yielded an insufficient aspirate for cytodiagnosis and all four lesions that yielded intermediate cells were

eventually reclassified as small choroidal melanomas and treated. The remaining eight tumors

that yielded an insufficient aspirate and the two tumors that yielded benign nevus cells were classified as benign nevi at the most recent follow-up evaluation.Conclusions: Fine-needle

aspiration biopsy showed that a substantial proportion of small melanocytic choroidal tumors

likely to be classified clinically as small choroidal melanomas in many centers were in fact benign nevi or intermediate lesions.

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4. Transvitreal fine needle aspiration biopsy: the influence of

intraocular lesion size on diagnostic biopsy result. Cohen et al. Eye

(2001) 15, 143-147

Study type Retrospective case note analysis

Aims To determine the

Inclusion criteria Indeterminate choroidal masses which underwent pars planar

transvitreal needle biopsy from

1986-1999

Exclusion criteria

Method All tumour heights were

recorded with A scan

ultrasonography.

Number of patients 83

Outcomes There was insufficient material

for cytological examination in 10

cases, and sufficient material in 73 cases (an overall diagnostic

report rate was 88%). Yield

increased significantly with increasing tumour height.

<2= 40% 2-4mm = 90%

>4 =98%

FNAB result correlated with

pathology of enucleated

specimen in 26 of 27 cases (96%)

Transient vitreous haem in 24%

A yield of 88%

96% accurate result

Only 1 false positive FNAB

showed melanoma but

histopathology report was prostate met

No RD

No Seeding

Conclusions

Comment This paper helps guide patients

and surgeons to select which size of tumour to biopsy

Outcome is surgeon and

pathologist specific

Abstract

Purpose To detennine the efficacy of transvitreal biopsy in the diagnosis of suspected intraocular

malignancy and simulating conditions.

Methods We perfonned a retrospective study of the case notes from patients who underwent pars plana transvitreal biopsy from July 1986 to October 1999. We studied the relationship between

lesion thickness as measured by A­ scan ocular ultrasound and the incidence of a successful

diagnostic biopsy. We assessed the diagnostic accuracy by comparing the biopsy result with the histological examination of any subsequently enucleation specimens and noted the incidence and

severity of complications attributable to the biopsy. Results A total of 83 biopsies were performed

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for choroidal masses. There was insufficient material for cytological examination in 10 cases, and

sufficient material in 73 cases (an overall diagnostic report rate was 88%). There was a strong correlation (p = 0.0004, Mann-Whitney U-test) between a diagnostic biopsy result and the

thickness of the lesion on A-scan ultrasound: a biopsy was diagnostic in only 40% (4 of 10) of

choroidal lesions less than 1.99 mm thick, whereas biopsies taken from lesions between 2.00 and 4.00 mm thick were diagnostic in 90% of cases (27 of 30). In thicker lesions of 4 mm or more the

cell aspirate was sufficient to make a diagnosis in 98% (42 of 43). Following diagnostic biopsy

27 patients had their tumours resected, and the histology results following enucleation confined the cytological diagnosis of malignancy in 96% of these cases (26 of 27). Conclusion Transvitreal

biopsy is a highly accurate diagnostic procedure with a low complication rate. It is a reliable

diagnostic tool in suspicious choroidal lesions greater than 2 mm thick.

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Sensitivity and Specificity of Ultrasonography, Fluorescein

Videoangiography, Indocyanine Green Videoangiography, Magnetic

Resonance and Radioimmunoscintigraphy in the Diagnosis of Primary

Choroidal Malignant Melanoma. Romani et al Ophthalmologica

1998;212(suppl 1):44–46

Study type Comparative small case series

Aims To determine the best diagnostic

test for choroidal melanoma

Inclusion criteria Not stated

Exclusion criteria Not stated

Method Diagnosis compared against

histology in 4 cases and against presumed diagnosis in the rest

Number of patients 12 (9 melanomas) Very small number for

sensitivity specificity study

Outcomes Radioimmunoscintigraphy

(sensitivity>67%) was less

sensitive than ultrasonography, MR and angiography.

Specificity was good for all the

considered examinations; it was 92% for ultrasonography, 87%

for RIS, 83% for MR and 82%

for angiography.

FV and ICFV present a high

sensitivity (100%) and good

specificity (82%), but these examinations cannot be used

when the lesion presents a

pre-equatorial localization or if opacities of dioptric media

are present

MR cannot present a very high specificity; in fact, other

bulbar lesions contain

paramagnetic substances with a signal similar to melanin

Specificity of MR was 83%,

because of the presence of methemoglobin, a

paramagnetic sub- stance, in

2 lesions which were false-positive. The specificity of

MR was very high (100%).

Conclusions In our series of cases ultrasonography is a highly

reliable diagnostic technique:

sensitivity>100%, specificity>92%.

Comment Conventional Ocular Ultrasound

(A/B scan) is the best test to

diagnose choroidal melanoma

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Abstract

The prognosis of primary choroidal malignant melanoma (PCMM) is fatal if

no early reliable diagnosis is performed. Any incisional biopsy is impossible,

and diagnosis is only based on instrumental examinations. The purpose of this

study is to evaluate the reliability of ultrasonography, fluorescein video-

angiography (FV), indocyanine green videoangiography (ICGV), magnetic res-

onance (MR) and radioimmunoscintigraphy (RIS) in the diagnosis of PCMM

in a series of 12 eyes in which the tumor was suspected. A presumed diagnosis

of PCMM was made when a positive result was obtained with 3 or more

methods. The presumed diagnosis was then compared with histological findings

(true value) in 4 enucleated eyes. The sensitivity and specificity of every single

method were evaluated comparing its results with the final presumed diagnosis

and with the histological findings. Sensitivity and specificity of every single

method have been expressed as percentage of correspondence with the presumed

diagnosis. Sensitivity was 100% for ultrasonography, MR, FV, ICGV and 67%

for RIS. Specificity was 92% for ultrasonography, 87% for RIS, 83% for MR

and 82% for FV and ICGV. This study indicates that the ophthalmologist can

obtain a good diagnostic reliability in the case of PCMM using only ultrasono-

graphy, FV and ICGV. Besides MR and RIS are important adjunctive methods

to ophthalmological investigations for the diagnosis of PCMM.

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