Letters to the Editor
Recurrent choroidal melanoma after brachytherapy in an eye with scleral calcification
Article first published online: 14 OCT 2010
Copyright © 2011 Acta Ophthalmologica Scandinavica Foundation
Volume 89, Issue 8, pages e657–e658, December 2011
How to Cite
Russo, A., Coupland, S. E., Raja, V. and Damato, B. E. (2011), Recurrent choroidal melanoma after brachytherapy in an eye with scleral calcification. Acta Ophthalmologica, 89: e657–e658. doi: 10.1111/j.1755-3768.2010.02019.x
- Issue published online: 23 NOV 2011
- Article first published online: 14 OCT 2010
A 73-year-old-woman was referred to the Liverpool Ocular Oncology Centre for treatment of a symptomatic choroidal melanoma in the right eye, the lesion being discovered when blurred vision occurred.
The right fundus showed an infero-temporal choroidal melanoma extending to the fovea. On ultrasonography, the tumour measured approximately 15 × 14 mm basally with a thickness of 5.2 mm. Underlying scleral calcification was noted, which cast a shadow into the orbit (Fig. 1A, B). This finding was disregarded in treatment planning and the patient underwent brachytherapy with an eccentrically placed 20- mm ruthenium plaque. A mattress suture was used to ensure good apposition to the sclera. The plaque was removed after 60 hr, thereby delivering 531 Gy to the sclera and 80 Gy to the tumour apex. One year later, the tumour thickness diminished to 3.2 mm. Visible choroidal atrophy surrounding the tumour indicated that the plaque had been positioned adequately (Fig. 1c).
Seven years after brachytherapy, the patient presented with vitreous haemorrhage and ultrasonography showed an increase in the tumour thickness to 5.2 mm. Pars plana vitrectomy was performed and the patient underwent proton beam radiotherapy.
Two years after proton beam radiotherapy, the tumour thickness was 3.5 mm but the patient developed a recurrent vitreous haemorrhage and neovascular glaucoma requiring enucleation.
Pathological examination showed a partially necrotic choroidal melanoma of epithelioid cell type, with vascular hyalinization from the radiotherapy. The mitotic count was 1/40 high power fields. Numerous macrophages were seen. The sclera adjacent to the tumour showed collagen degeneration and calcification (Fig. 2).
Apical tumour recurrence after ruthenium plaque radiotherapy is rare, even with eccentric plaque placement (Damato et al. 2005; Lommatzsch et al. 2000; Summanen et al. 1993). This case therefore raises the possibility that treatment failure occurred because of intrascleral calcification beneath the tumour. We suggest that this finding should prompt a higher dose of brachytherapy or an alternative form of radiotherapy, such as proton beam radiotherapy.
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