EPIBULBAR FOREIGN BODY GRANULOMA MASQUERADING AS EXTRASCLERAL EXTENSION FOLLOWING BRACHYTHERAPY FOR CHOROIDAL MELANOMA Bernadete Ayres, MD, Nicholas Iliff, MD, W. Richard Green, MD, James T. Handa, MD, Cathy W. DiBernardo, RN, RDMS

Purpose: To describe a patient with epibulbar foreign body granuloma following brachytherapy for choroidal melanoma and to illustrate the echographic features that aided in the differential diagnosis. Methods: Observational case report. Patient had multiple clinical exams over time to evaluate a treated choroidal melanoma. Patients: A 61-year-old man presented for echographic follow-up examination following treatment for choroidal melanoma. An epibulbar lesion was noted adjacent to the site of the previously treated choroidal melanoma. Incisional biopsy and histologic evaluation were required. Results: Ultrasonography revealed regression of the intraocular tumor; however, an oval epibulbar mass with irregular internal structure, irregular reflectivity, and no vascularity was noted. The echographic features were not typical of extrascleral extension of choroidal melanoma. Histopathologic evaluation showed fibrous connective tissue with an intense infiltrate of histiocytes with occasional giant cells and rare birefringent foreign body materials. Conclusion: Foreign body granuloma should be considered in the echographic differential diagnosis of an atypical extrascleral lesion following uveal melanoma brachytherapy. RETINAL CASES & BRIEF REPORTS 3:326 –328, 2009

From Wilmer Ophthalmological Institute, Johns Hopkins University, Baltimore, Maryland.

an area of extrascleral extension adjacent to the site of a previously treated choroidal melanoma. However, the echographic features using standardized A-scan were not typical for extrascleral extension of a choroidal melanoma. An incisional biopsy was performed and histopathologic examination was consistent with a foreign body granuloma. This case is the first reported of a foreign body as the underlying etiology for a granuloma that developed following plaque radiotherapy.

T

he development of granuloma following Iodine-125 plaque therapy for the treatment of intraocular melanoma is extremely rare, with only one documented case in the literature.1 We describe a 61-year-old man who presented for routine echographic follow-up examination following treatment for a choroidal melanoma. Although the intraocular lesion had regressed, contact B-scan examination revealed an epibulbar lesion masquerading as

Case Report A 61-year-old man was referred to the Wilmer Eye Institute with a history of choroidal nevus in the left eye that had been followed for several years and showed evidence of recent growth that was documented photographically. Best-corrected visual acuity was

The authors report no conflicts of interest. Reprint requests: Bernadete Ayres, MD, Wilmer Ophthalmological Institute, Johns Hopkins University, 600 N. Wolfe St., Wilmer 233, Baltimore, MD 21287; e-mail: [email protected]

326

EPIBULBAR FOREIGN BODY GRANULOMA

327

Fig. 1. A, Transverse Bscan showing the intraocular tumor at initial evaluation (arrow). B, Standardized Ascan showing the low internal reflectivity at initial presentation (arrow).

20/20 in the right eye and 20/400 in the left eye. Intraocular pressures measured 12 mmHg bilaterally. Anterior segment examination was unremarkable. Dilated fundus examination of the right eye was unremarkable. Clinical examination of the left eye showed orange pigment overlying a pigmented mass measuring 8.0 ⫻ 6.0 mm that was present along the superotemporal arcade, adjacent to both the fovea and the optic disk. Subretinal fluid was noted in the macular region. Ultrasound was performed using both contact B-scan and standardized A-scan. B-scan showed a dome-shaped lesion (Figure 1A). On standardized A-scan the lesion had low reflectivity and was regularly structured and vascular. The maximal thickness measured 2.0 mm (Figure 1B). No extrascleral extension was noted. The low internal reflectivity, vascularity, and recent growth supported the diagnosis of choroidal melanoma and the tumor was treated with a 12 mm Iodine-125 plaque using the standard COMS dose rate protocol.2

Fig. 2. A, Transverse B-scan showing the lesion in the orbit (arrow) adjacent to the region of the completely regressed intraocular tumor. B, Longitudinal B-scan showing the lesion in the orbit (arrow). ON signifies the shadow of the retrobulbar optic nerve. C, Standardized A-scan showing the high internal reflectivity (arrow) of the orbital lesion. D, Infiltrate of epithelioid cells with foreign bodies, arrows (hematoxylin and eosin, ⫻340).

Examination over the subsequent 3 months showed regression of the tumor and resolution of subretinal fluid. An area of chorioretinal atrophy was seen temporal to the tumor. Ultrasound examination showed an increase in the internal reflectivity and a decrease in thickness to 1.2 mm. The patient continued his follow-up care every 6 months with his local ophthalmologist where serial ultrasound examinations were performed and he returned to our institution 3 years later. Dilated fundus examination showed a flat chorioretinal scar measuring approximately 10 ⫻ 10 mm in the left eye. At that time, ultrasonography was ordered for documentation of tumor regression and only mild fundus thickening in the area of the treated tumor was noted. However, an oval epibulbar mass was noted superiorly near the equator. Standardized A-scan was performed and showed irregular internal structure and reflectivity (Figure 2, A–C). No vascularity was detected. Since the echographic characteristics of this lesion were not typical for extrascleral extension and because the intraocular lesion

RETINAL CASES & BRIEF REPORTSℜ

328

had regressed by both clinical and ultrasonographic examination, the patient underwent an incisional biopsy. During the surgical procedure, a fleshy pink, encapsulated mass was noted. It was diffusely and firmly adherent to the sclera. Microscopic examination disclosed fibrous connective tissue with an intense infiltrate of histiocytes with occasional giant cells and rare birefringent foreign body materials. Cytopathologic analysis was consistent with foreign body granuloma (Figure 2D).

Discussion Extrascleral extension of uveal melanoma is a poor prognostic factor for survival. In addition to its prognostic implication, extrascleral extension is an important determinant in therapeutic options.3 Standardized echography is very useful in detecting extrascleral extension of uveal melanoma, particularly in more posteriorly located tumors where external inspection of the globe is not possible. In 1998, Scott et al demonstrated the high sensitivity of echography in the detection of extrascleral extension of uveal melanoma.4 Typically, extrascleral tumor extension appears as one or more nodules located near the sclera adjacent to the base of the tumor and has the same pattern of low to medium internal reflectivity as the intraocular portion. If the lesion is large enough, blood flow is present and can be detected.5,6 The echographic features of the lesion presented in this case are not features that are typically seen with extrascleral extension. No scleral defect was noted, the internal reflectivity was irregular, and no vascularity was detected. In addition, no intraocular recurrence was noted. This finding is supported by the Collaborative Ocular Melanoma Study report of a nearly 90% rate of successful tumor control following Iodine 125 brachytherapy.2 The development of episcleral granuloma after brachytherapy is extremely rare. Okera et al reported a case of fungal granuloma following ruthenium plaque radiotherapy.1 In our case, the pathology dem-



2009



VOLUME 3



NUMBER 4

onstrated presence of histiocytes and giant cells that are characteristically found in a foreign body granuloma. We presume that the granuloma developed from a retained suture, since the location of the granuloma was adjacent to the region of the treated tumor. There are several instances where ultrasound findings may mimic extrascleral extension of uveal melanoma including intrascleral foreign body and normal anatomic structures like muscle insertions. Unusual foreign body granuloma should be considered in the echographic differential diagnosis of extrascleral extension of uveal melanoma following brachytherapy. However, since contact B-scan alone may not provide sufficient details about the internal characteristics of these lesions, we suggest including standardized Ascan in the evaluation of these cases for definitive diagnosis.

References 1.

2.

3.

4.

5.

6.

Okera S, Dodd T, Selva D. Fungal granuloma following ruthenium plaque radiotherapy of a choroidal melanoma. Clin Exp Ophthalmol 2003;31:159–161. Collaborative Ocular Melanoma Study Group (COMS Group). The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma: IV. Local treatment failure and enucleation in the first 5 years after brachytherapy. COMS report no. 19. Ophthalmology 2002;109:2197–2206. Gunduz K, Shields CL, Shields JA, Cater J, Brady L. Plaque radiotherapy for management of ciliary body and choroidal melanoma with extraocular extension. Am J Ophthalmol 2000; 130:97–102. Scott IU, Murray TG, Hughes JR. Evaluation of imaging techniques for detection of extraocular extension of choroidal melanoma. Arch Ophthalmol 1998;116:897–899. Farah ME, Byrne SF, Hughes JR. Standardized echography in uveal melanomas with scleral or extraocular extension. Arch Ophthalmol 1984;102:1482–1485. DiBernardo C, Schachat AP, Fekrat S. Ophthalmic Ultrasound: A Diagnostic Atlas. New York, NY: Thieme Medical Publishers; 1997:87–107.

Epibulbar foreign body granuloma masquerading as extrascleral extension following brachytherapy for choroidal melanoma.

To describe a patient with epibulbar foreign body granuloma following brachytherapy for choroidal melanoma and to illustrate the echographic features ...
275KB Sizes 0 Downloads 4 Views