Ocular Tumours Flashcards
What does the term tumour mean?
Abnormal Swelling which can include a mass of tissue formed by new cells ( or swelling due to inflammation).
What is the definition of neoplasm?
The word literally translates as: New Growth Medically referred to as: “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”
True or false - All neoplasms are cancerous.
False - Not all neoplasms are cancerous - they can be both Malignant AND benign
What does the term benign mean? Give an example of a possible benign structure
It lacks the ability to invade neighbouring tissue or metastasize. It is self limiting e.g a mole
What is a malignant growth? Give an example of a malignant growth
A growth that is characterised by Anaplasia (poor cellular differentiation, lack specialisation of mature cells), and with being Invasive with the capacity for metastasis e.g. melanoma
What is the differential diagnosis of a benign and malignant tumour based on?
A differential diagnosis would be based on whether: - Anaplasia is present -The rate of growth -Presence of metastasis -Local Invasion
What does the term cancer refer to?
A malignant neoplasm
How can the name of a tumour be an indication into whether it has a benign or malignant nature?
A tumour that has the prefix ‘Car’ tends to be an indication of a malignant nature e.g. Basal Cell CARcinoma, AdenoCARcinoma, Squamous Cell CARcinoma etc. [Note not all malignant tumours have the ‘Car’ prefix e.g. melanoma]
What is a benign tumour of a melanocyte (a pigment carrying cell) called?
A Naevus
What is a malignant tumour of a melanocyte (a pigment carrying cell) called?
A Melanoma
What is melanosis?
Increased Melanin Pigmentation
True or false- A melanoma is the most aggressive form of skin cancer
True
True or False - Melanomas do not grow from normal looking skin but rather structures such as moles or freckles.
False - Melanomas can grow from normal looking skin as well as structures like moles or freckles.
True or False- Melanomas are only present in areas exposed to sun
False - Melanomas can develop anywhere on your body and are not limited to areas where there is sun exposure
When noticing a dark spot/mole in or around a pateint’s eye or face what are suspicious signs to look out for?
What is a superficial spreading melanoma?
How does it grow?
What does it look like?
What is a nodular melanoma?
What does it look like?
How does it grow?
[This may spread more rapidly than the superficial form]
What is a Squamous Cell papilloma?
Is it benign or malignant?
Is it common?
What is it also referred to as?
What is the most common form of skin cancer?
Basal cell Carcinoma
Which age group are basal cell carcinomas most prevalent?
They are most prevalent in the elderly
True or false - 90% of eyelid tumours are caused by Basal Cell Carcinomas
True
Are basal cell carcinomas fast or slow growing?
Slow growing
Are Basal Cell Carcinomas Metastising?
No - they are non-Metastising.
What does it mean to be pedunculated?
To be growing on a peduncle ( i.e. an elongated stalk of tissue) - basically it means to be growing on a lump of tissue.
Do Basal Cell Carcinomas pose a risk to life?
No as they tend to be slow growing and not metastisize.
What does a Basal Cell Carcinoma look like?
What are the clinical signs of a basal cell carcinoma?
- Ulceration
- Lack of tenderness
- Induration – Hardening of normally soft tissue
- Irregular borders
- Destruction of lid margin architecture
What are the three types of Basal Cell Carcinomas a px can have?
- Nodular
- Noduloulcerative
- Sclerosing
What does a nodular Basal Cell Carcinoma on the eyelid look like?
Is growth of a nodular Basal Cell carcinoma fast or slow?
What does a Noduloulcerative BCC (rodent ulcer) on the eyelid look like?
What does a Sclerosing Basal Cell Carcinoma look like?
How does it spread?
What is it often mistaken for?
It inflitrates and spreads laterally.
Which carcinoma is more common - Basal Cell carcinoma or Squamous cell Carcinoma?
Basal Cell Carcinoma
Which carcinoma is more aggressive - Basal Cell Carcinoma or Squamous Cell Carcinoma?
Squamous Cell Carcinomas as 20% of them Metastisize
True or False - Squamous Cell Carcinomas prefer the upper eyelid?
False - They prefer the lower eye lid.
Which px group is Squamous Cell Carcinoma most prevalent in?
More common in older people with fair complexion and history of chronic sun exposure
True or False- Being Immunosupressed increases the risk of a Squamous cell Carcinoma.
True
A Squamous Cell Carcinoma can look like a Basal Cell carcinoma, however, how can we differentiate them?
In a Squamous Cell Carcinoma:
- Surface vascularization is usually absent.
- Growth is more rapid
- Hyperkeratosis (excess development of keratin)is more often present - IMPORTANT SIGN OF SCC
What are the three types of Squamous Cell Carcinoma?
- Nodular SCC
- Ulcerating SCC
- Cutaneous horn
What does a Nodular Squamous Cell Carcinoma look like and how may it be characterised?
What does an ulcerting Squamous Cell Carcinoma look like?
What does a Cutaneous Horn Squamous Cell Carcinoma look like?
What should you bear in mind when diagnosing?
What does a Kaposi Sarcoma look like?
Is it rare or common?
What is it caused by?
Which Tumour is which?
- nodulo-ulcerative BCC
- Nodular SCC
- Nodular melanoma
- Squamous Cell Papilloma
What is the treatment of malignant eyelid tumours?
A biopsy - to find out which one we are dealing with.
- Surgical Excision
- Reconstruction
- Radiotherapy
- For melanoma and SCC general oncological examination and biopsy on lymph nodes in neck to check for metastases.
Is a conjunctival Naevus a tumour of the anterior or posterior eye?
It is a tumour of the anterior eye (i.e. the conjunctiva lies anteriorly in the eye).
Is a conjunctival Naevus benign or malignant?
Benign
True or false - there is no risk of a conjunctival Naevus becoming malignant.
Technically False as there is a 1% chnace it could develop to become malignant
True or False - A conjunctival Naevus is the most common melanocytic tumour
True
What are the signs of a Conjunctival Naevus?
- Solitary, discrete moderately elevated pigmented or partially pigmented lesion
- Most frequently near limbus
- Mobile over the sclera - if you gently manipulae the sclera
- Grey brown or black in most cases
When is there an increased risk of a Conjunctival Naevus becoming malignant?
- Rapid growth or increase in pigmentation
- Develop after 2nd decade
- Prominent feeder vessel ( is shown by the red arrow)
Are conjunctival melanomas rare or common?
Rare
Describe a Conjunctival Melanoma?
What does a Conjunctival Squamous Cell Carcinoma look like?
Is an iris Naevus Benign or malignant?
Benign
In the event of an Iris Naevus is the iris structure intact or not?
The normal iris architecture is disrupted
Is vascularity associated with an Iris Naevus?
There is little or no vascularity associated with an Iris Naevus
True or False- There may be mild distortion of the pupil in the presence of an Iris Naevus
True
Which location in the Iris is an Iris Naevus typically in?
An inferior location most commonly
How can you differentiate between an iris freckle and an iris Naevus?
A freckle is smaller than an Iris Naevus and does not distort the iris architecture
What does an iris freckle look like?
Is an Iris Melanocyte benign or malignant?
It is benign ( It is a type of Naevus).
What is an Iris Melanocyte and what does it look like?
It is benign and a type of Naevus.
[Nodular implies raised]
True or False- Iris Melanomas are 3x more common in those with blue/grey eyed people
True
What is this picture showing?
Iris Melanoma
What type of ocular tumour are the following features of?
- 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
Iris Melanoma
What are tretaments for Malignant Iris Tumours?
Sector iridectomy - this is a surgical procedure to remove part of the iris
Radiotherapy with radioactive plaque (brachytherapy) - to ensure no cancerous cells remain
External irradiation with proton beam - to kill cancerous cells
Enucleation for diffusely growing tumours - i.e. remove the eyeball
Check for metastases
True or False - Choroidal Naveus are very common - they are present in 5-10% of caucasians
True
True or False - Choroidal Naevus are rare in darker skinned individuals
True
What symptoms are associated with Choroidal Naevus?
None - they are asymptomatic unless at the macula where they may cause distortion.
Are choroidal Naevus malignant or benign?
Normally Benign
[Although if they appear in adulthood then suspect malignancy]
What are the clinical signs of a choroidal Naevus i.e. describe a choroidal Naevus?
Brown to slate grey in colour
May contain surface drusen (deposits below the RPE)
They are Oval or circular
They have Indistinct margins
Their diameter is usually <3mm (2DD) wide and < 1mm thick
Having a Depigmented halo is common
Secondary choroidal neovascularisation is rare with a choroidal Naevus
[Image is a widefield view]
What does a choroidal Naevus look like?
What can be seen in the image below?
A Choroidal Naevus with overlying Drusen
True or False- 80% of all uveal Melanomas are Choroidal Melanomas.
True
At what age does the prevalence for Choroidal Melanomas peak?
60 years
What are the symptoms associated with Choroidal Melanomas?
Blurred vision; Visual Field Loss
Floaters; Photopsia
What are some clinical signs of Choroidal Melanomas?
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 – if you see this its an immediate red flag that you are dealing with a melanoma
What can be seen in the following photo?
A Choroidal Melanoma - you can tell as it is Elevated, >2DD, light grey.
[You can tell it is elevated from the blurryness of the blood vessels as they go over the top).
What is the following photo showing and what makes you sure of your diagnosis?
It is a choroidal melanoma - reasons for this diagnosis are as follows:
- Marked elevation
- muchgreater in size than 2DD (Disk Diameters)
- light grey in colour
What is the following photo showing and what are the reasons behind your diagnosis?
Amelanotic Melanoma
Reasons for this diagnosis:
It is a Colourless, dome shaped elevation, close to disc.
What is the following photo showing you and what are the reasons behind your diagnosis?
A Choroidal Melanoma
Reasons for this diagnosis:
It is >2DD, dark grey, close to disc
What can be seen in the follwoing photo and what are the reasons behind your diagnosis?
Choroidal Melanoma ( and orange lipofusin)
Reasons for the diagnosis:
It is Elevated, >2DD, light grey, close to disc and orange lipofuscin present
Can a Melanoma proliferate through the retina to grow through to the vitreous humour?
Yes - it can be seen in the images attached.
How can you determine whether you are looking at a Naevus or Melanoma?
If the following are present it is indicative of a Melanoma.
How are suspected lesions ( suspected to be tumours) investigated?
Photography
OCT – useful to measure lesion thickness
Fundus autofluorescence (lipofuscin pigment fluoresces indicating whether it is a melanoma)
Ultrasound to look for melanotic characteristics
Baseline photography – reviewed regularly for signs of change, growth
What are the possible treatments for a Melanoma?
Brachytherapy (episcleral plaque radiotherapy) - This is where a radioactive plaque is sutured (stitched) to the sclera for several days - this will effectively obliterate the melanoma
Charged particle therapy High energy charged protons ionising radiation to tumour. Used for smaller tumours
Trans Pupillary Thermotherapy (TTT) IR laser to heat tumour to death – death by hyperthermia
Cryotherapy – has been used in past but not widely used now
Enucleation - this treatment is used if there is evidence that the tumour is invading the optic nerve or surrounding structures -
What is enucleation?
What is a metastic tumour?
When tumour cells metastisize, the new tumour is called the secondary or metastic tumour.
True or False- the choroid is the most common site for uveal metases (i.e. for a metastic tumour to grow)
True
What are common primary sites ( i.e. place of the original tumour) for choroidal Metastic tumours?
Common Primary sites are the breast and bronchus
What are features of Choroidal Metastic Tumours?
Fast growing yellow-ish lesion
Multifocal and bilateral
Large in size
What is Congenital Hypertrophy of the RPE (CHRPE)?
A term used to describe benign tumours of the RPE
Is Congenital Hypertrophy of the RPE (CHRPE) symptomatic or asymptomatic, and if so what symptoms are present?
Asymptomatic
What are clinical Signs of Congenital Hypertrophy of RPE (CHRPE)?
Solitary – dark grey or black lesion with well defined margins
[There are two types of CHRPE you can have - Multifocal and Atypical]
For Multifocal clinical signs include:
- smaller lesions
– “bear-track”
For Atypical CHRPE, clinical signs include:
– multiple lesions of variable size with hypopigmented margins (associated with gastrointestinal malignancy/colon cancer)
Which of the following do you think is a:
A. Choroidal Melanoma
B. CHRPE
C. Choroidal Naevus
D. Choroidal Melanoma
Number 1 - CHRPE
Number 2 and 4 are Choroidal Melanomas
Number 3 - Choroidal Naevus
[Structures in the RPE tend to look more grey and Hazy]
True or False - Presence of Drusen can make you confident that a pigmented spot is a Naevus
True
