Silent squamous cell carcinoma invading the orbit following the course of the zygomaticotemporal nerve.

PURPOSE: To evaluate the clinical and histopathological characteristics of silent skin squamous cell carcinomas (SCC) with invasion routes to the orbit. METHODS: Retrospective case studies. Clinical records and histopathological material, therapy and complications were evaluated, together with MRI imaging analyses and literature review on the anatomy of the lateral orbital wall in relation to the zygomatico-temporal nerve channel. RESULTS: Two recent cases of metastatic SCC from het lateral zygomatic region to het orbit are reported. Originally the skin tumors of the first case was diagnosed as benign, but a review of the pathology of these skin tumors showed an invasive SCC. The second case was diagnosed as an atypical SCC. Analysis of possible invasion routes, using both computer tomography (CT) and magnetic resonance imaging (MRI), indicated neither skin nor bone involvement. However, the lateral temporal fossa near the entrance of the zygomatico-temporal channel showed small tumors and pseudo-cysts. The original skin tumor specimens did not show malignant tissue in the surgical margins nor intra- or perineural invasion. CONCLUSIONS: Because the course of the zygomatico-temporal nerve bundle was exactly in line with the original skin tumor, the channel and the orbital tumors, this route should be considered when malignant orbital tumors have a history of or a relation with a periorbital skin-tumor.

Squamous cell carcinoma of the lacrimal caruncle: case reports.

PURPOSE: To report 2 cases of squamous cell carcinoma of the lacrimal caruncle. METHODS: Two patients, a 38-year-old man and a 72-year-old woman, presented with a painful mass in the medial angle of the eyelid aperture, with signs of inflammation. Biopsy was performed in both cases. RESULTS: Pathologic examination revealed a keratinized squamous cell carcinoma of the lacrimal caruncle in both cases. CONCLUSIONS: We report 2 more cases of the rarely found squamous cell carcinoma of the lacrimal caruncle.

Concomitant choroidal melanoma and non-hodgkin lymphoma in two adult patients: case report.

OBJECTIVE: To report two cases of concomitant choroidal melanoma and intraocular non-Hodgkin lymphoma in two patients. DESIGN: Case report. PARTICIPANTS: Two patients with yellow creamy infiltrates in fundo. INTERVENTION: Both patients had a complete ophthalmologic evaluation and histology was obtained after enucleation of the affected eye. MAIN OUTCOME MEASURES: Histology findings of the enucleated eyes. RESULTS: One patient showed a choroidal melanoma with a primary non-Hodgkin lymphoma located solely in the affected eye. The other patient showed a systemic non-Hodgkin lymphoma with ocular manifestations concomitant with a choroidal melanoma. CONCLUSIONS: In the presence of yellow creamy infiltrates one should include a choroidal lymphoma in the differential diagnosis even if there is another clear pathologic condition. Furthermore in those cases systemic disease should be excluded.

Changes in immunological markers and influx of macrophages following trans-scleral thermotherapy of uveal melanoma.

PURPOSE: In trans-scleral thermotherapy (TSTT), heat is applied through the sclera in order to target an intraocular uveal melanoma. Previously, it had been shown that in uveal melanoma, hyperthermia and transpupillary thermotherapy influenced expression of immunologically relevant proteins, such as S100, HLA and heat-shock proteins (HSPs). We investigated whether TSTT induced similar changes. METHODS: Experimental TSTT was applied on eleven uveal melanomas prior to enucleation. Each tumour sample was processed for histopathological examination; immunohistochemical analysis was performed to determine expression of S100, HLA, HSPs and macrophage markers. RESULTS: In TSTT-treated areas, expression of S100 and different HSPs was lost, while an upregulated expression of HSP GP96 was observed at the border of these areas. Expression levels of HLA-A and HLA-B varied between tumours and were not influenced by TSTT. The borders of the TSTT-treated areas showed high numbers of infiltrating macrophages, which were predominantly of the M2 phenotype. CONCLUSION: TSTT has an effect on immunological parameters with local loss of expression of HSPs and S100. The influx of M2 macrophages around the TSTT-treated areas indicates the presence of an innate immune reaction against the induced necrosis, suggesting that TSTT-treated tumour cells are removed by a macrophage-mediated tissue repair mechanism.

Monosomy of chromosome 3 and an inflammatory phenotype occur together in uveal melanoma.

PURPOSE: In uveal melanoma, different predictors of poor prognosis have been identified, including monosomy of chromosome 3, HLA expression, and the presence of infiltrating leukocytes and macrophages. Each of these parameters can be used to differentiate prognostically the favorable tumors from the unfavorable ones, and thus the hypothesis for the present study was that they are related, and that monosomy of chromosome 3 occurs in the same tumors as the unfavorable inflammatory phenotype. METHODS: Tumor tissue was obtained from 50 cases of uveal melanoma treated between 1999 and 2004. After enucleation, nuclei were isolated from paraffin-embedded tissue for fluorescence in situ hybridization, to determine the chromosome 3 copy number. Each tumor-containing globe was further processed for conventional histopathologic examination and for immunohistochemical analysis with HLA class I and II-specific antibodies and with macrophage marker CD68. RESULTS: Of 50 uveal melanomas, 62% (31/50) were categorized as having monosomy of chromosome 3. Monosomy 3 was associated with the presence of epithelioid cells, an increased density of tumor-infiltrating macrophages, and a higher HLA class I and II expression. Survival analyses showed a correlation between monosomy 3 and decreased survival and identified monosomy 3, ciliary body involvement, and largest basal tumor diameter as the best prognostic markers. CONCLUSIONS: Monosomy 3 in uveal melanoma is associated with the presence of an inflammatory phenotype, consisting of a high HLA class I and II expression as well as an increased number of tumor-infiltrating macrophages. In a multivariate Cox regression analysis, the presence of monosomy 3 was one of the best prognostic markers of metastatic disease and survival, although the follow-up time was short.

Predictive value of exfoliative cytology in pigmented conjunctival lesions.

PURPOSE: Pigmented lesions of the conjunctiva are often difficult to classify clinically. Exfoliative cytology may be helpful, but reliable data regarding the sensitivity and specificity of this test are currently lacking. We determined the value of exfoliative cytology with regard to pigmented conjunctival lesions. METHODS: A total of 294 smears from 182 patients were screened for malignancy within 6 months of exfoliative cytology. Smears were classified according to the following categories: grade 0 = insufficient material for diagnosis; grade 1 = normal conjunctival cells; grade 2 = melanocytes with mild atypia; grade 3 = melanocytes with moderate atypia, and grade 4 = melanocytes with severe atypia. RESULTS: The sensitivity, specificity, positive predictive value and negative predictive value of exfoliative cytology were 85%, 78%, 59% and 93%, respectively. CONCLUSION: Exfoliative cytology is a fast, easy and non-invasive technique that may be used in the evaluation of patients with a pigmented conjunctival lesion.

Conjunctival melanoma in the Netherlands: a nationwide study.

PURPOSE: To evaluate risk factors for local recurrence, regional and distant metastases, and mortality associated with conjunctival melanoma. METHODS: This was a retrospective study of 194 patients with histologically confirmed conjunctival melanoma diagnosed between 1950 and 2002 in the Netherlands. Data were collected from all university centers and many nontertiary hospitals, using the National Pathology and the Leiden Oncologic Registration Systems. Based on the number of incidences, this study included 70% of the conjunctival melanomas in The Netherlands. Clinical and histopathological data for conjunctival tumors were reviewed and compared with data reported in the literature. Risk factors for local, regional, and distant metastases and survival were analyzed using the Kaplan-Meier and Cox regression analyses. RESULTS: Of 194 patients with conjunctival melanoma, 112 had a local recurrence (median, 1; range, 1-9) during follow-up (median, 6.8 years; range, 0.1-51.5). Location was the most important risk factor for development of local recurrence, and significantly more occurred with nonepibulbar (log rank, P=0.044) tumors. Significantly fewer local recurrences occurred with tumors initially treated with excision and adjuvant brachytherapy rather than with excision only (log rank, P=0.008) or with excision and cryotherapy (log rank, P <0.038). Forty-one (21%) patients had regional lymph node metastases, mostly to the parotid or preauricular lymph nodes (n=26; 13%). Risk factors for regional metastases were tumor thickness (log rank, P <0.001) and tumor diameter (log rank, P=0.010). Forty-nine (25%) patients (mean, 4.37 years) had development of distant metastases, mainly in the lung, liver, skin, and brain. Tumor-related survival was 86.3% (95% confidence interval [CI], 81.0-91.6) at 5 years, 72% (95% CI, 79.7-64.4) at 10 years, and 67% (95% CI, 58.9-76.1) at 15 years. The main mortality risk factors were nonepibulbar location (log rank, P <0.0001) and tumor thickness (log rank, P=0.0004). CONCLUSIONS: Nonepibulbar tumors more often recur locally and are associated with a shorter survival independent of other risk factors. Tumor thickness is also an important predictor of regional and distant metastases, as well as survival. A prospective study is needed to compare the effect of excision with radiotherapy and excision with cryotherapy on the number of local recurrences, exenteration rate, and survival.

Prognostic value of the disodium phosphate 32P uptake test in uveal melanoma: a long-term study.

OBJECTIVE: To evaluate whether nuclear activity as measured by the disodium phosphate 32P (32P) uptake test for uveal melanoma is of prognostic value and corresponds to known prognostic factors. METHODS: A retrospective analysis of 121 patients with choroidal and/or ciliary body melanoma, tested with the 32P uptake test before enucleation between January 1, 1973, and December 31, 1976, at the Leiden University Medical Center. We obtained the 25-year follow-up information of this group of patients and compared the 32P test results and histopathological variables with the long-term survival rates. RESULTS: The cumulative 5-, 10-, and 20-year survival for melanoma-related death was 81.4%, 73.3%, and 63.9%, respectively. The results of the 32P uptake test were not significantly correlated with survival (P =.35). Of all prognostic factors under study, tumor diameter, cell type, and mitotic count were identified as the most important prognostic markers for uveal melanoma in this group. CONCLUSIONS: The 32P isotope uptake test has no prognostic value for uveal melanoma. Moreover, the results of this study indicate that it is unlikely that cell activity as determined by 32P uptake involves mitotic activity of the tumor.

Prognostic value of S-100-beta serum concentration in patients with uveal melanoma.

BACKGROUND: In cutaneous melanoma, the S-100-beta serum level is recognized as a marker of metastatic disease. OBJECTIVES: To determine whether S-100-beta is present in the serum of patients with uveal melanoma and to test whether the serum concentration of S-100-beta is related to known clinical and histopathological prognostic factors in these patients. METHODS: The S-100-beta concentration was measured in serum samples collected from 64 patients with uveal melanoma before enucleation and from 58 healthy control subjects. A 2-site immunoluminometric assay was used to quantify the S-100-beta concentration in serum. S-100-beta concentrations in the serum from patients were compared with clinicopathological tumor variables, sex, occurrence of metastasis, and survival. RESULTS: Thirty-seven (57.8%) of 64 patients with uveal melanoma showed detectable levels of serum S-100-beta. There was, however, no significant difference between serum levels of patients and control subjects (P =.71). Statistical analysis showed no significant correlation between S-100-beta concentration and any of the clinicopathological tumor variables, occurrence of metastases, or survival. Only sex was correlated with S-100-beta serum levels, which was not observed in the control group. CONCLUSIONS: In our study on patients with uveal melanoma, the S-100-beta serum concentration was not correlated with any investigated prognostic factor and was not of prognostic value itself. Female patients appeared to have higher S-100-beta concentrations than male patients.

Heat shock protein expression in the eye and in uveal melanoma.

PURPOSE: Expression of heat shock proteins (HSPs) is of prognostic significance in several tumor types, whereas HSPs may also have clinical use as stimulators in tumor vaccination. HSP expression levels were determined in normal eyes and in uveal melanoma and tested whether HSPs expression was associated with prognostic parameters in the uveal melanoma. METHODS: Expression of HSP27, HSP70, HSP90, and glycoprotein96 (GP96) were determined on paraffin-embedded and frozen sections from seven healthy eyes, 20 primary uveal melanomas without prior treatment, and 18 uveal melanomas after prior treatment. HSP expression was determined by alkaline phosphatase-anti-alkaline phosphatase (APAAP) immunohistochemistry, using appropriate monoclonal antibodies and scored semiquantitatively. Expression of HSPs was validated on retinal tissue of a normal eye and in two uveal melanoma cell lines by Western blot analysis. RESULTS: Expression of HSPs was observed in epithelial and pigment cells of the normal eyes. In uveal melanoma, the level of expression of HSPs varied. Expression of HSP27 and GP96 was noted in more than 30 of 38 uveal melanomas (with, respectively, a mean of 66% and 53% positive cells). HSP70 and HSP90 were expressed in 6% of tumor cells. The amount of expression of any of the HSP types was not significantly associated with known prognostic factors. There was not a significant difference in expression of the HSPs between uveal melanomas with or without any type of prior treatment. CONCLUSIONS: In this study, expression of HSPs in uveal melanoma is not correlated with known histopathologic prognostic factors. The high expression of GP96 indicates that this protein is a potential vector in tumor vaccination in patients with large uveal melanomas.

Transscleral thermotherapy: short- and long-term effects of transscleral conductive heating in rabbit eyes.

OBJECTIVE: To determine the highest safe treatment temperature, at 30- and 60-second exposure durations, for transscleral thermotherapy (TSTT) of choroidal melanoma. METHODS AND DESIGN: Transscleral conductive heating was performed in 15 rabbits at 50 degrees C to 70 degrees C for 30 or 60 seconds. The thermal lesions in the ocular fundus were monitored for 4 months with ophthalmoscopic, photographic, and fluorescein angiographic examination. Histologic examination included polarized light microscopy. RESULTS: The effect of TSTT was similar for both exposure durations. Vascular occlusion in the retina and choroid developed at temperatures of 55 degrees C and higher. After heating at 60 degrees C, scleral collagen fibers developed a minimal undulation; at 65 degrees C, they became clearly undulated. The undulation resolved in the 3 to 4 months after heating. Heating at 70 degrees C caused persistent severe damage to the sclera. Retinal tears developed after heating at 65 degrees C and 70 degrees C. CONCLUSIONS: A temperature of 65 degrees C was found to be the highest temperature that did not cause permanent damage to the sclera at both exposure durations. A temperature of 60 degrees C may be the optimal temperature for TSTT of choroidal melanoma because retinal tears may develop at 65 degrees C. CLINICAL RELEVANCE: In TSTT, the temperature levels reached are cytotoxic for choroidal melanoma as well as intrascleral tumor cells. Occlusion of choroidal vessels induced by TSTT may contribute to tumor necrosis because these vessels serve as feeder vessels for the tumor.