Case #2: Necrotic Choroidal Melanoma

By Paul T. Finger, MD

History

A fundus photograph reveals a marked reduction of subretinal fluid and hemorrhage. Exudates have appeared at the infero-temporal margin, and orange pigment on the inferonasal tumor (as compared to presentation). Note the variably pigmented (mostly amelanotic) subretinal tumor with an associated serous detachment and subretinal hemorrhage.
A fundus photograph reveals a marked reduction of subretinal fluid and hemorrhage. Exudates have appeared at the infero-temporal margin, and orange pigment on the inferonasal tumor (as compared to presentation). Note the variably pigmented (mostly amelanotic) subretinal tumor with an associated serous detachment and subretinal hemorrhage.

A 55-year old female presented to The New York Eye Cancer Center with swelling of her eyelids, signs of scleritis, and pain on eye movement. Her visual acuity was correctable to 20/20 OU, and ophthalmoscopy was significant for a hemorrhagic chorioretinal thickening in the superotemporal quadrant.

Fundus photographs and a Fluorescein angiogram were obtained utilizing Digital Photography (see right).

3D-Ultrasonography is significant for a 13 x 13 mm (base), 5.0 mm height choroidal tumor with moderate internal reflectivity. The tumor’s surface is irregularly shaped, the subjacent sclera was thickened, and a retrobulbar lucency “edema” is evident. However, there was no extrascleral tumor extension.

Fluorescein angiography reveals a small patch of intraretinal microangiopathy, leaking retinal vessels, and diffuse areas of blockage.

The differential includes infectious, inflammatory, neovascular, and neoplastic events. When all testing proved negative our options included biopsy or close serial observation.

Fluorescein angiography reveals a small patch of intraretinal microangiopathy, leaking retinal vessels, and diffuse areas of blockage.
Fluorescein angiography reveals a small patch of intraretinal microangiopathy, leaking retinal vessels, and diffuse areas of blockage.

3 Months after Initial Presentation

A fundus photograph (see right) reveals a marked reduction of subretinal fluid and hemorrhage. Exudates have appeared at the infero-temporal margin, and orange pigment on the inferonasal tumor.

 

 Serial Ultrasound Evaluations
Variable Presentation 2 months 3 months 5 months
Tumor Height 5.0 mm 4.0 mm 1.9 mm 3.2 mm
Reflectivity Medium Medium Variable Low
Surface Irregular Irregular Concave Dome

Impression

Necrotic Choroidal Melanoma

This is an atypical presentation for choroidal melanoma. In this case serial observation over time allowed for clearing of the overlying blood and serous fluid. We were eventually able to view of the tumor’s surface (e.g. orange pigment). Serial ultrasonography demonstrated both resolution of the inflammatory and hemorrhagic components, shrinkage, and finally evidence of growth.

In this case, close observation (together with a careful medical work-up) allowed the choroidal melanoma to evolve into a more recognizable form and to demonstrate its tendency to grow.

Recommendation

After partial resolution of the inflammatory component, an edge of tumor became visible.
After partial resolution of the inflammatory component, an edge of tumor became visible.

Ophthalmic Plaque Radiation Therapy

The risks and benefits of continued observation for growth, enucleation, radiation therapy (both proton versus plaque), as well as currently available alternative therapies were discussed in detail. After a discussion of the comparative dosimetric advantages of palladium-103 versus iodine-125 plaque radiation therapy, she chose palladium-103 as treatment for her choroidal melanoma.

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"Very well treated by Dr. Finger. He explained everything I needed to know about my issue with detail and attention, putting me at ease and giving me confidence to handle this problem for the rest of my life.”
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