Ocular tumour part 1 and 2 Flashcards
What does the term tumour mean ?
abnormal swelling
-any mass of tissue formed by new cells or swelling due to inflammation
What does neoplasm mean?
‘new growth’
What is a neoplasm (real definition)?
An abnormal tissue that grows by cellular proliferation more rapidly than normal and continues to grow after the stimuli that initiated the new growth cease. Neoplasms show partial or complete lack of structural organization and [lack] functional coordination with the normal tissue”
-May be malignant or benign
What does benign mean?
lacks the ability to invade neighbouring tissue or metastasize
self limiting e.g mole
- does not spread
What does malignant mean?
- Anaplasia (poor cellular differentiation, lack specialisation of mature cells),
- Invasive with capacity for metastasis e.g. melanoma (invades local tissues and grows)
- capacity to spread throughout the body
What is the differential diagnosis on basis of a benign and malignant tumour ?
Anaplasia
Rate of Growth
Local Invasion
Metastasis
What does the term cancer refer to ?
a malignant neoplasm
How do we know tumours are malignant (cancerous) ?
have the prefix ‘car’ at the start or middle
What is melanosis ?
a melanoma
which is increased melanin pigmentation
it is the most aggressive form of skin canceras it can:
Grow and spread rapidly
Can develop from normal looking skin, or in a mole
Can grow anywhere in the body - not just areas exposed to the sun
If treated early 95% of melanomas can be cured
How can we detect between a benign and malignant melanoma?
ABCDE Asymmetry Border Colour Diameter Evolution
What is a superficial spreading melanoma?
Characterized by an irregular outline and variable pigmentation.
Often stays in situ for months/years and grows horizontally on skin surface.
What is a Nodular melanoma ?
A lump that has been rapidly enlarging
Malignant cells proliferate downwards (vertical growth).
What is a Squamous Cell Papilloma?
Common benign epithelial tumour (skin tag)
Narrow or broad based or pedunculated
What is a basal cell carcinoma?
Most common type of skin cancer - 75% Incidence 0.25% population/year – 3-4x higher in Australia More prevalent in elderly 90% of BCC affect head and neck – 9% affect the eyelid. 90% of eye lid tumours are caused by BCC Locally invasive Slow growing Non metastasizing
What do basal cell carcinoma appear as?
Usually small, round or flattened spots that are red, pale or pearly in colour
Can bescaly like a patch of eczema
May look like an ulcer or sore that doesn’t heal
What are the clinical features of BCC?
signs
features
Signs: Ulceration Lack of tenderness Induration – Hardening of normally soft tissue Irregular borders Destruction of lid margin architecture
Features/types
Nodular
Noduloulcerative
Sclerosing
What does Nodular BCC look like?
Shiny, firm, pearly nodule with small dilated blood vessels on its surface
Growth is slow and it may take the tumour 1–2 years to reach a diameter of 0.5 cm.
What does Noduloulcerative BCC (rodent ulcer) look like?
-Central ulceration with pearly rolled edges and dilated blood vessels at the edges (telangectasia).
With time it may erode a large portion of the eyelid.
What does Sclerosing BCC look like?
Infiltrates laterally beneath the epidermis as a hardened plaque
More extensive on palpation than inspection.
Could be mistaken for a localized area of chronic blepharitis
What is Squamous Cell Carcinoma?
Less common than BCC - 5-10% of eyelid tumours
More aggressive (20% metastasise)
Prefers lower lid
Increased risk if immunocompromised
More common in older people with fair complexion and history of chronic sun exposure
What is the difference between BCC and SCC?
It may resemble a BCC but:
- Surface vascularization is usually absent.
- Growth is more rapid
- Hyperkeratosis is more often present (excess development of keratin)- IMPORTANT SIGN OF SCC
What are the features of SCC?
Nodular SCC
Ulcerating SCC
Cutaneous horn
What does the Nodular SCC look like?
Characterized by a hyperkeratotic nodule(nodule with excess keratin in it) which may develop crusting erosions and fissures
What does the Ulcerating SCC look ike?
- Has a red base and sharply defined, indurated (hardened) and everted borders
- has Pearl margins and telangiectasia are not usually present (unlike noduloulcerative BCC).
What is Cutaneous horn ?
Keratinic projection.
Cutaneous horns are associated with other benign and malignant conditions too. - not just SCC
What is Kaposi Sarcoma?
Rare cancer caused by human herpes virus 8 (HHV-8)
Mainly seen in immunosuppressed patients (especially HIV) – very fast progressing
Also seen in middle aged men of Mediterranean or Ashkenazi Jewish descent (v slow progressing)
What is the treatment for EYE LID MALIGNANT TUMOURS ?
Biopsy Surgical Excision Reconstruction Radiotherapy For melanoma and SCC general oncological examination and biopsy on lymph nodes in neck to check for metastases.
What is Conjunctival naevus?
- Most common conjunctival melanocytic tumour
- Benign
- Risk of becoming malignant – 1%
- Usually noticed in 1st or 2nd decade
What are signs of Conjunctival naevus?
Solitary, discrete moderately elevated pigmented or partially pigmented lesion
Most frequently near limbus
Mobile over the sclera
Grey brown or black in most cases
What is the risk of a conjunctival nevus of becoming malignant increased
?
- Rapid growth or increase in pigmentation
- Develop after 2nd decade
- Prominent feeder vessel
What is a conjunctival melanoma?
rare
when occurred it is invasive of stroma and nerves
-spreads within the epithelium
what is conjunctival squamous cell carcinoma ?
Squamous cell carcinoma with overlying (white) keratinization in the nasal bulbar conjunctiva
What is an iris nevus ?
a benign tumour
Diameter <3-4mm; thickness <2mm
Minimal or no visible vascularity
Inferior location in most cases
The normal iris architecture is disrupted
There may be mild distortion of the pupil
A freckle is smaller and does not distort the iris architecture
What does an iris freckle look like ?
Flat, brown pigmentation on iris surface, with irregular, feathery edges and not distorting the normal architecture
What are some signs of iris nevus ?
can be elevated (show of blurry signs)
ectropion uvae- turning out of iris epithelium
What is an iris melanocytoma ?
another type of naevus
benign
Darkly pigmented nodular mass , mossy granular surface
What is an iris melanoma?
8% of uveal melanomas arise in iris
3x more common in blue/grey eyed people
Features
Pigmented or non pigmented nodule >3mm diameter and > 1mm thick
Usually surface blood vessels
Pupil distortion/ ectropion uveae
May infiltrate the angle and ciliary body
Can cause cataract and secondary glaucoma
What are iris tumours treatment ?
Sector iridectomy
Radiotherapy with radioactive plaque (brachytherapy)
External irradiation with proton beam
Enucleation for diffusely growing tumours
Check for metastases
What is a choroidal nevus ?
- Present in 5-10% white Caucasians
- Very rare in darker skinned individuals
- If growth in adulthood then suspect malignancy
- Usually asymptomatic unless at macula and then can cause distortion
What are the signs of choroidal nevus ?
Brown to slate grey
May contain surface drusen
Oval or circular
Indistinct margins
Diameter usually <3mm (2DD) wide and < 1mm thick
Depigmented halo is common
Secondary choroidal neovascularisation is rare
What is choroidal melanoma prevalence?
Most common intraocular malignancy in adults
80% of all uveal melanoma; peaks at 60yrs
what are the signs of the choroidal melanoma ?
Solitary elevated subretinal grey-brown or amelanotic (colourless) dome shaped mass
60% are within 3mm of the optic disc.
Can be larger than naevi (>2DD)
May have surface orange lipofuscin
What are the symptoms of chorodial melanoma ?
Blurred vision; Visual Field Loss
Floaters; Photopsia
What can you see in a Amelanotic Melanoma?
Colourless, dome shaped elevation, close to disc
What does a Lipofuscin + Melanoma fundus image look like ?
Elevated, >2DD, light grey, close to disc, orange lipofuscin present
What does a Lipofuscin + Melanoma fundus image look like ?
Elevated, >2DD, light grey, close to disc, orange lipofuscin present
What can melanomas do to the retina?
perforate the retina and through into the vitreous chamber
What features are indicative of a choroidal melanoma ?
Thickness greater than 2 mm, (To) Fluid (subretinal) (Find) Symptoms, (Small) Orange pigment (lipofuscin) (Ocular) Margin near disc (Melanoma) Ultrasonographic hollowness (Using) Halo absence (Hints) Drusen absence
How do we investigate these lesions ?
Photograph- colour fundus photograph
OCT – useful to measure lesion thickness
Fundus autofluorescence (lipofuscin pigment fluoresces)
Ultrasound
Baseline photography – reviewed regularly for signs of change, growth
What are some treatment for the choroidal melanoma ?
Brachytherapy (episcleral plaque radiotherapy) Plaque is sutured to sclera for several days
Charged particle therapy High energy charged protons ionising radiation to tumour. Used for smaller tumours
Trans Pupillary Thermotherapy (TTT) IR laser to heat tumour – death by hyperthermia
Cryotherapy – has been used in past but not widely used now
Enucleation Effective and indicated if tumour invades optic nerve
What are metastatic tumours ?
Choroid is the most common site for uveal metastases
Common primary sites are breast and bronchus
Features
Fast growing yellow-ish lesion
Multifocal and bilateral
Large size
What is a benign tumour of the RPE ?
Congenital Hypertrophy of RPE (CHRPE)
-THEY ARE Asymptomatic
What are the signs of CHRPE ?
Solitary – dark grey or black lesion with well defined margins
Multifocal - smaller lesions – “bear-track”
Atypical CHRPE – multiple lesions of variable size with hypopigmented margins (associated with gastrointestinal malignancy/colon cancer)
