Neoplastic diseases of the eye and adnexa MUDr. Michala Karkanová, MUDr. Radoslava Uhmannová MUDr. Igor Vícha, MUDr. Radek Girgle, MUDr. Elena Tokošová Ophthalmology clinic FN Brno, přednostka prof. MUDr. Eva Vlková, CSc MM iris Tumor tissue change, which is a result of the locally noncontrolable growth of autonomous nature. The biological nature of the tumor: benign malignant Separation of eye tumors according to anatomic localization: eyelid tumors tumors of the eye orbital tumors Eyelids tumors Location: anywhere on the cap mainly a cosmetic problem fault status and function lids with symptoms of dry eye syndrome (burning, cutting, more frequent sec. infections, xerosis of the conjunctiva, exposure keratopathy a reduction or even loss of the eye ZO) Treatment: (Depending on size, location and nature of the changes) Early excision with a sufficiently large safety rim histological verification Benign eyelids tumors Location: anywhere on the lid, without age limitation mostly a cosmetic problem Retention cysts sebaceous glands (milium, atheroma) Papilloma - cutaneous horns Verruca, verruca senile Hemangioma Xantelasma Nevus Treatment: Observation (nevi) Surgery - cautery, simple excision, laser therapy (CO2 laser), cryo Histological examination !!! Benign eyelids tumors mazova-cysta papilom Retention cyst Eyelids papiloma Malignant eyelid tumors Location: predilectively lower lid, 6.-7. decade of life basal cell carcinoma (invasion only local) squamous cell carcinoma(metastasizes) malignant melanoma Meibom glands carcinoma Treatment: surgical excision - simple - with plastic finish radiotherapy surgery followed by radiotherapy local application IL Oncologic dispensary! Malignant eyelid tumors PICT0271 PICT0033 PICT0277 Basal cell carcinoma Tumors of the conjunctiva and cornea Location: predilectively range of eye slits, all ages, a shift to a higher age Treatment: dispensary congenital change without progression - photographs (cosmetic point of view) surgical - block excision, lamellar keratectomy, in malignancies completed with cryotherapy - radical excision (up orbit exenteration) additional local radiotherapy local application of antimetabolites Histological examination! Oncological dispensary in melanoma and cancer! Lokalizace: • predilekčně rozsah oční šterbiny, všechny věkové kategorie s posunem do vyššího věku Léčba: • dispenzarizace vrozených změn bez progrese - fotodokumentace ( kosmetické hledisko ) • chirugická - excize bloková, lamelární keratektomie, u malignit doplněno kryalizací - excise radikální (až exenterace očnice) • doplňková lokální radioterapie • lokápní aplikace antimetabolitů Histologické vyšetření ! Onkologická dispenzarizace v případě melanomu a karcinomu! Benign tumors of the conjunctiva and cornea Congenital: Choristoma - dermoid, lipodermoid Hemangioma Epithelial: Hyperplasia Epithelioma (carcinoma in situ, Bowen's disease) Melanotic: Melanosis - congenital - acquired (with or without atypia atypical) Nevus, Melanocytoma (kong. based) Benign tumors of the conjunctiva and cornea dermoliptom_spojivky lymfangiom_spojivky papilom_spojivky conjunctival papiloma conjunctival lipodermoid conjunctival lymfangioma Benign tumors of the conjunctiva and cornea CIN melanoza_spojivky pigmentovy_nevus_karunkuly conjunctival nevus carcinoma in situ conjunctival melanosis Malignant tumors of the conjuntiva and cornea • Malignant melanoma of the conjunctiva • Carcinoma of the conjunctiva ( rare disease)) • Lymfoma of the conjunctiva (Non – Hodgkin type) maligni_melanom_spojivky metastaza_non-Hodkginova_lymfomu conjunctival malignant melanoma conjunctival lymfoma Intraocular tumors Primary: the origin of the uvea (iris, ciliary body, choroid) originate in the retina (exceptionally on adults) Secondary: infiltrative growth of surrounding tissue Metastatic: following generalization of the malignancy most common in the choroid (often the first symptom of malignancy) Metastases - women breast carcinoma 85%, bronchi 8% - male lung carcinoma 38%, GIT 20% Malignant melanoma of the uvea( MMU ) n ØIris 8% ØCiliary body 12% ØChorioid 80% n Øthe most common primary intraocular tumor of adults Øincidence between 50-70 years Øfeatured mortality 30 -70% most often Ø Øunilateral MMUdoo1 MMU Diagnostics nExamination on the slit lamp nOphthalmoscopy Ø direct Ø indirect Ø biomicroskopye Ø gonioscopy n nSonography Ø B scan Ø standard. echography Ø UBM n MMUdoo1 MMUdoo3 MMU Diagnostics nFAG ( fluorescein angiography ) nICG ( indocyanin angiography ) nNMR, PET n MMUdoo2 Examinations performed in determining the MMU diagnosis ØComplet laboratory examinations including oncomarkers ØLungs radiology ØEchography of parenchymatous organs of the abdomen ØSceleton scintigraphy ØBrain NMR ØComplet inner examinatin ØOncological examinatin Ø ( PET ) n Criteria for selecting therapeutic approach Øindividual Øvision, intraocular tension, status of the affected eye Øsize of the tumor, signs of its activities Ølocalization, shape Øother eye condition, pacients general state Øage of the patient at the time of detection n n n Iris malignant melanoma Ømost common occurrence in the lower half of the iris Øvarious pigment Ødistortion of the pupil Øectopia of pigmented sheet Øpartial cataract MM iris Diferencial diagnosis of the iris tumors Ønevus Øcyst Øleiomyoma Øleaf pigment hyperplasia n n NevusI2 NevusI1 nevus of the iris iris like the tiger Treatment of benign and malignant lesions of the iris Ø monitoring borderline findings (photographs) Ø excision - in suspected lesions notoverlaping 4 hours Ø enucleation of the globe - susp. malignant lesions over 1/2 of the iris, blind bulb, noncorrected secondary glaucoma S000011B S0000139 Ciliary body malignant melanoma Ølong asymptomatic Øextension episcleral vessels Øpressure on the lens (astigmatism, partial cataract, subluxation) Øsecondary retinal detachment Øiris root erosion Øsecondary glaucoma after initial hypotension Øepibulbar meat in place of extrabulbar extension Mm-cc4 MM-CC1 Diferencial diagnosis of ciliary body tumors Øtumors from the pigment and nonpigment epithelium Øcysts Øclinical indistinguishable n n diktyom cyst of ciliary body Therapy of ciliary body melanomas Øcyclectomy Øiridocyclectomy Øradiotherapy - brachytherapy n Lexell gama knife Øenucleation n n n n n n Choroidal malignant melanoma MMUdoo1 MMUdoo2 MMUdoo3 MMUtypy2 MMUtypy4 MMUtypy1 MMUtypy3 Choroidal malignant melanoma - sonography Diferencial diagnosis of choroidal lesions Øexudative form of ARMD Øchorioidal granulomatous scars Øsubretinal haemorrhage Øbig prominent nevi Øhyperplasia of RPE Øablation of the choroid Ømetastases Øcavernous hemangioma Ørear scleritis Ømelanocytoma Øretinoblastoma Age related macular degeneration VPMD Chorioidal exudative scar toxokara Choroidal Névi névus névus fag Melanocytoma melanocytom melanocyt Melanog2 RPE congenital hyperplasia Pigment3 Pigment1 Pigment2 Organization of subretinal haemorrhage DifDg2 DifDg1 DifDg4 Ablation of the choroid Choroidal metastasis metla MetaI1 MetaI2 Choroidal hemangioma horava 01 HORAVA02 Horava ICG OS Retinoblastoma – most common intraocular tumor in childhood Retinob2 Retinob3 pravostranna_leukokorie Histological classification according Callender Øspindle type A Øspindle type B Øepithelioid Ømixed Øfascicular n Prognosis quad vitam according histological type of the tumor: ØSpindle type A: mortality 5% in 5 years ØSpindle type B: 14% in 5 years ØEpithelioid type: 69% in 5 years ØNecrotic type: untill 50% in 5 years nPrognostic factors MM Øcell type Øsize Ølocalization ØBruch membrane state Øextrabulbar extension Metastases nAt the time of finding the MMU has about 11% of metastases simultaneously. n nMost common localization and % behalf: Øliver 60-70 Øsubcutaneus 24 Ølungs 7 Øspine 7 ØCNS 2 Ø Signs of tumor activity nNonactive lesions Øinaccurately bounded Øoccurrence of drusen on the surface nActive lesions Ødocumented growth n ( measured by ultrasound) Øbounded elevation Øbreaking Bruchs membrane Øproduction of SRF Øoccurrence of lipofuscin on surface of the tunmor Size of the tumor – classification by Shields Ømelanomas to 3mm Ømelanomas to 5mm Ømelanomas to 10mm Ømelanomas above 10mm n Therapy of choroidal MM ØPhotocoagulation ØTTT ØPhotodynamic therapy ØRadiotherapy ØBrachytherapy ØLexell gama knife ØParcial resection of the tumor ØEnucleation of the bulb ØExenteration of the orbit n Brachytherapy n Indication ØHeight to 10 mm ØBases to 15 mm n radioaktivni zaric radioactive source 106Ru Enucleation of the bulb Ø height above 8-10 mm Ø bases above 15 mm Ø small range extrabulbar extension Ø blind and painfull bulbs with secondary glaucoma ocni protezka extraokularni_propagace_difusniho_melanomu Enucleation of the bulb Exenteration of the orbit n Indications: Øretrobulbar extension of the tumor Øsignificant peribulbar extension of the tumor n Dispenzary In a subsequent patient care is extremely important collaboration between an ophthalmologist, internal physician and oncologist who will decide on possible further therapy (cytostatics, interferon ...). Conclusion The aim of all us ophthalmologists is that intraocular tumor was detected in time. Tumors of the orbit A separate group of cancers with similar ocular manifestations. Symptoms: Ø changes in the position of the eye - the eye protrusion or deviations Ø double vision (binocular diplopia) Ø eyelid symptoms - edema of the eyelids, drooping of the eyelid Ø swelling and redness of the conjunctiva Ø pain - a frequent symptom! ( from oppression, sec. glaucoma) Ø decrease in visual acuity from the oppression of the optic nerve Ø visual field changes Tumors of the orbit - distribution Primary – primary formation in orbit tissues Ø Benign - inflammation pseudotumor, vascular – hemangioma, lacrimal gland adenoma Ø Malignant - primary lymfoma, rabdomyosarkoma, meningeoma of the optic nerve, lacrimal gland and sac adenocarcinoma Secondary – ingrowth from sinuses and CNS Ø Benign - dermoid cysta, mucocele and pyocele Ø Malignant – sinuses carcinoma , wedge bone meningeoma, conjunctival and uveal malignant melanoma, eyelids carcinoma Metastatic – blood or lymfatic vessels Ø always malignant – bronchogenic carcinoma, breast carcinoma, GIS carcinoma, haemoblastoma Primary tumors of the orbit lososd lymfoma of the orbit secondary tumors of the orbit Zalesky_Jan_2_2 DSCN1656 adenocarcinoma of the orbit bazalioma of the orbit Metastatic tumors of the orbit CT P1010138 Diagnostics of orbit tumors Ø Complet ophtalmological examinatin Ø Radiodiagnostic methods - RTG, CT, NMR, Digit. substr. angiografie (morphology of the lesion in PNS or CNS) Biopsy Ø Interdisciplinary cooperation Treatment of oncological diseases of the orbit Surgery ( interdisciplinary cooperation) Ø extirpation (boundad lesions) Ø extirpation with resection of surrounding structurs Ø exenteration of the orbit without or with resection of PND Ø Radiotherapy Ø primary ( lymfoma of the orbit, pseudotumors ) Ø aditiv Combined Ø surgery with radiotherapy or chemotherapy Ø Conclusion Early diagnostics of cancer, using modern diagnostic procedures and treatments, will allow patients to survive without abusive surgical procedures while retaining their eye and maintaining useful visual acuity. Závěr V přednášce byly použity materiály a obrazová dokumentace z následujících knih a sdělení: • Nádory oka a očních adnex u dospělých, MUDr. Radoslava Uhmannová, III. celostátní sjezd oftalmologické sekce České asociace sester,10/ 2006, Brno • Nádory oka, Prof. MUDr. Drahomíra Baráková, CSc. a kol., Praha 2002 • Maligní melanom uvey ( současná diagnostika a léčba ), MUDr. R. Girgle, MUDr. Radoslava Uhmannová, MUDr. Igor Vícha • Enukleace bulbu, Eviscerace bulbu, Exenterace očnice, MUDr. Igor Vícha, MUDr. Radoslava Uhmannová, MUDr. Michala Karkanová Závěrem děkuji všem zmíněným autorům za poskytnutí jejich materiálů a všem lékařům Oční kliniky FN Brno za poskytnutí obrazové dokumentace. •