| 본문 : Choroidal melanoma is the most common primary intraocular malignancy with a high potential for site specific metastasis. It is well known to metastasize to the liver, lungs, and bones through hematogenous spread. However, brain metastasis is rare without a prior liver metastasis. In this case report, we present a rare case of choroidal melanoma with extensive leptomeningeal metastasis that occurred a year following intensity modulated radiation therapy (IMRT), and enucleation with hydroxyapatite implantation.
A 49-year-old female visited the clinic in September 2015 for continuous visual deterioration and metamorphopsia over the past 2 months. At initial examination, her best corrected visual acuity was 10/200 exudative RD was noted. Orbital sonography and magnetic resonance imaging (MRI) confirmed an inferior choroidal pigmented mass of 14.73 mm diameter and 7.14 mm height. No other systemic metastasis were found.
The patient refused enucleation, and hence was referred to the radiology department for IMRT. After 8 months, she underwent a vitrectomy with oil injection for retinal detachment, combined with tissue sampling that showed necrotic changes with several atypical cells in the tumor.
Despite close follow-up for 6 months, she developed a recurred melanoma with abrupt rupture through the sclera and extraocular extension into the superior subconjunctival space. In December 2017, an emergent enucleation was performed. After tumor free margins were confirmed by multiple frozen sections. Histopathology showed an epithelioid cell type choroidal malignant melanoma with a tumor free margin of the optic nerve, despite tumor extension through the optic nerve. At the time of enucleation, no systemic or local metastasis was observed.
In January 2019, the patient was admitted to the emergency department with nausea, vomiting, and headache. MRI showed extensive leptomeningeal seeding in the brain and spine, without metastasis to the liver or lungs. The patient agreed to undergo palliative pain control without chemotherapy at a terminal care hospital, and died comfortably after 3 months.
To conclude, in patients with high metastatic potential, we recommend an early and aggressive surgical intervention combined with adjunct therapies, and a regular follow up with brain imaging to detect early spread. |