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MALIGNANT MELANOMA—SO-CALLED SARCOMA—OF UVEA: II. PROBLEMS IN DIAGNOSIS

MALIGNANT MELANOMA—SO-CALLED SARCOMA—OF UVEA: II. PROBLEMS IN DIAGNOSIS Abstract Mistakes in the diagnosis of malignant melanoma1 are numerous. They are of two general types, namely : (1) failure to discover the presence of the tumor and (2) confusion of some other pathologic condition with malignant melanoma. FAILURE TO DISCOVER THE PRESENCE OF THE TUMOR Failure to discover the presence of the tumor appears to be the more common error. In a recent statistical study of 94 cases of tumor2 it was found that 42 of the eyes were enucleated without the surgeon's suspecting that a neoplasm was in the eye. The correct diagnosis was established in the pathologic laboratory. The presence of the tumor always was obscured by some more obvious but usually closely related clinical entity (table 1). The fundus in many instances could not be examined ophthalmoscopically.Glaucoma, a common complication of the neoplasm, was found in 41 of 94 cases (44 per cent). The tumors References 1. Since the origin of this neoplasm may not be from mesodermal tissue, it is best to avoid the term sarcoma. 2. Terry, T. L., and Johns, J. P.: Am. J. Ophth. 18:903 ( (Oct.) ) 1935. 3. Franta ( Ceskoslov. oftal. 3:201, 1937) 4. The weight of the relatively normal eye is from 6.7 to 7.2 Gm., as determined by weighing a series of 147 eyes. Eyes unusually large from myopia or buphthalmos may be increased in weight up to 9 Gm. Eyes of relatively normal size weighing over 7.2 Gm. were found to contain hemorrhage, organized exudate, heavy coagulated subretinal exudate or malignant melanoma of the choroid, the last two conditions being the most frequent. Several eyes containing small tumors weighed well within the average. 5. Wintersteiner, H.: Die Geschwülste des Uvealtraktus , Ergebn. d. allg. Path. u. path. Anat. (supp.) 10:1044, 1907. 6. Scheerer, in discussion on Rönne, H. : Diagnosis of Choroidal Melanosarcoma , Arch. Ophth. 1:397 ( (Jan.) ) 1929. 7. Cohen, M.: Tr. Am. Ophth. Soc. 30:96, 1932. 8. Verhoeff, F. H.: Personal communications to the author. 9. Chance, B.: Am. J. Ophth. 17:48, 1934. 10. Verhoeff, F. H., and Grossman, H. P.: Pathogenesis of Disciform Degeneration of the Macula , Arch. Ophth. 18:561 ( (Oct.) ) 1937.Crossref 11. This unique and important case warrants a more detailed consideration than could be given properly in this paper. It will be reported fully by Gundersen at a later date. 12. Doherty, W. B., Jr.: Am. J. Ophth. 10:1, 1927. 13. Hill, E., and Dart, R. O.: Tr. Am. Ophth. Soc. 34:122, 1936. 14. Lemoine, A. N., and McLeod, J.: Bilateral Metastatic Carcinoma of the Choroid: Successful Roentgen Treatment of One Eye , Arch. Ophth. 16:804 ( (Nov.) ) 1936.Crossref 15. Greenwood, A.: Internat. Cong. Ophth. 1:565, 1922. 16. Reichling, W.: Ocular Metastasis of a Chorionepithelioma , Arch. Ophth. 19:156 ( (Jan.) ) 1938. 17. MacDonald, A. E.: Choroidal Chorionephithelioma Secondary to Teratoma of the Testicle , Arch. Ophth. 16:672 ( (Oct.) ) 1936.Crossref 18. Verhoeff, F. H.: Retinoblastoma: Report of a Case in a Man Aged Forty-Eight , Arch. Ophth. 2:643 ( (Dec.) ) 1929.Crossref 19. Wheeler, J. M.: Am. J. Ophth. 20:368, 1937. 20. Stough, J. T.: Intra-Ocular Neurofibroma: Report of a Case , Arch. Ophth. 18:540 ( (Oct.) ) 1937.Crossref 21. Freeman, D.: Neurofibroma of the Choroid , Arch. Ophth. 11:641 ( (April) ) 1934.Crossref 22. Benign melanoma more probably belongs under the list of conditions resembling malignant melanoma. It is placed here because no specific examples of benign melanoma simulating malignant melanoma are at hand. 23. Moore, R. F.: Roy. London Ophth. Hosp. Rep. ( (pt. 3) ) 19:411, 1914. 24. Cattaneo, D.: Ann. di ottal. e clin. ocul. 54:1097, 1926. 25. Cushing, H., and Eisenhardt, L.: Meningiomas , Springfield, Ill., Charles C. Thomas, Publisher, 1938, p. 287. 26. McLean, J. M.: Astrocytoma (True Glioma) of the Retina: Report of a Case , Arch. Ophth. 18:255 ( (Aug.) ) 1937.Crossref 27. Ewing, J.: Neoplastic Diseases , ed. 3, Philadelphia, W. B. Saunders Company, 1928, p. 931. 28. Evaluation of the true importance of the appearance of the fundus and of the faults of transillumination in diagnosis has long been discussed by F. H. Verhoeff in his lectures. So far as I can determine, it has not been published. 29. Friedenwald, J. S.: Clinical Studies in Slitlamp Ophthalmoscopy , Arch. Ophth. 1:575 ( (May) ) 1929.Crossref 30. Ginsberg, in Henke, F., and Lubarsch, O.: Handbuch der speziellen pathologischen Anatomie und Histologie , Berlin, Julius Springer, 1928, vol: 11, pt. 1, p. 515. 31. Wood, C. A.: The American Encyclopedia and Dictionary of Ophthalmology , Chicago, Cleveland Press, 1914, vol. 5, p. 3938. 32. Lancaster, W. B.: Tr. Am. Ophth. Soc. 13:445, 1913. 33. Greenwood, A.: Tr. Am. Ophth. Soc. 13:503, 1913. 34. Burke, J. W.: Tr. Am. Ophth. Soc. , 34:239, 1936. 35. van Manen, J. G.: Die diathermische Behandlung der Netzhautablösung in der Universitätsaugenklinik Utrecht und ihre Ergebnisse im Jahre 1935 , Utrecht, Keminken Zook, 1936. 36. This method was used by Weve and associates as a means of locating accurately on the sclera the correspondence of the hole in the retina for operation on the separated retina. It necessitates an opening into Tenon's capsule and the use of retractors. It may necessitate the cutting of an extraocular muscle if the suspicious area to be tested with transillumination is in the macular region or near the nerve head. Although I have used the method in the diagnosis of malignant melanoma once, with only moderate satisfaction, no doubt it could be developed with practice and refinements, such as use of a laryngeal type of mirror or with a properly developed endoscope to facilitate observation. 37. These observations are based in part on the results of routine transillumination of several hundred enucleated eyes in the laboratory. 38. A description of the transilluminator designed by Mattis and myself will be published (Arch. Ophth.). 39. Zondek, B., and Krohn, H.: Klin. Wchnschr. 11:405, 1932.Crossref 40. Lund, C. C.: Personal communications to the author. 41. Pfeiffer, R. L.: Tr. Am. Acad. Ophth. 40:131, 1935. 42. Ruddock, J. C.: West. J. Surg. 42:392, 1934. 43. Several of the ophthalmologists who supplied me with clinical material are purposely not mentioned. The errors in diagnosis that have arisen seem natural in view of the many hazards of diagnosis which this condition presents. No criticism is intended. 44. Routine fixation is done with a 10 per cent dilution of formaldehyde for forty-eight hours and hydrochloric acid (3 per cent) and alcohol (70 per cent) for sixteen hours. The eye is then opened, dehydrated in graded alcohols and embedded in pyroxylin. When the pyroxylin is sufficiently firm, sections are made and stained, usually with hematoxylin and eosin. This technic was used for all eyes except the eye in case 11, which remained in the solution of formaldehyde for a longer period. 45. Verhoeff and Grossman ( Arch. Ophth. 19:468 [ (March) ] 1938).Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Ophthalmology American Medical Association

MALIGNANT MELANOMA—SO-CALLED SARCOMA—OF UVEA: II. PROBLEMS IN DIAGNOSIS

Archives of Ophthalmology , Volume 22 (6) – Dec 1, 1939

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American Medical Association
Copyright
Copyright © 1939 American Medical Association. All Rights Reserved.
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0003-9950
eISSN
1538-3687
DOI
10.1001/archopht.1939.00860120061005
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Abstract

Abstract Mistakes in the diagnosis of malignant melanoma1 are numerous. They are of two general types, namely : (1) failure to discover the presence of the tumor and (2) confusion of some other pathologic condition with malignant melanoma. FAILURE TO DISCOVER THE PRESENCE OF THE TUMOR Failure to discover the presence of the tumor appears to be the more common error. In a recent statistical study of 94 cases of tumor2 it was found that 42 of the eyes were enucleated without the surgeon's suspecting that a neoplasm was in the eye. The correct diagnosis was established in the pathologic laboratory. The presence of the tumor always was obscured by some more obvious but usually closely related clinical entity (table 1). The fundus in many instances could not be examined ophthalmoscopically.Glaucoma, a common complication of the neoplasm, was found in 41 of 94 cases (44 per cent). The tumors References 1. Since the origin of this neoplasm may not be from mesodermal tissue, it is best to avoid the term sarcoma. 2. Terry, T. L., and Johns, J. P.: Am. J. Ophth. 18:903 ( (Oct.) ) 1935. 3. Franta ( Ceskoslov. oftal. 3:201, 1937) 4. The weight of the relatively normal eye is from 6.7 to 7.2 Gm., as determined by weighing a series of 147 eyes. Eyes unusually large from myopia or buphthalmos may be increased in weight up to 9 Gm. Eyes of relatively normal size weighing over 7.2 Gm. were found to contain hemorrhage, organized exudate, heavy coagulated subretinal exudate or malignant melanoma of the choroid, the last two conditions being the most frequent. Several eyes containing small tumors weighed well within the average. 5. Wintersteiner, H.: Die Geschwülste des Uvealtraktus , Ergebn. d. allg. Path. u. path. Anat. (supp.) 10:1044, 1907. 6. Scheerer, in discussion on Rönne, H. : Diagnosis of Choroidal Melanosarcoma , Arch. Ophth. 1:397 ( (Jan.) ) 1929. 7. Cohen, M.: Tr. Am. Ophth. Soc. 30:96, 1932. 8. Verhoeff, F. H.: Personal communications to the author. 9. Chance, B.: Am. J. Ophth. 17:48, 1934. 10. Verhoeff, F. H., and Grossman, H. P.: Pathogenesis of Disciform Degeneration of the Macula , Arch. Ophth. 18:561 ( (Oct.) ) 1937.Crossref 11. This unique and important case warrants a more detailed consideration than could be given properly in this paper. It will be reported fully by Gundersen at a later date. 12. Doherty, W. B., Jr.: Am. J. Ophth. 10:1, 1927. 13. Hill, E., and Dart, R. O.: Tr. Am. Ophth. Soc. 34:122, 1936. 14. Lemoine, A. N., and McLeod, J.: Bilateral Metastatic Carcinoma of the Choroid: Successful Roentgen Treatment of One Eye , Arch. Ophth. 16:804 ( (Nov.) ) 1936.Crossref 15. Greenwood, A.: Internat. Cong. Ophth. 1:565, 1922. 16. Reichling, W.: Ocular Metastasis of a Chorionepithelioma , Arch. Ophth. 19:156 ( (Jan.) ) 1938. 17. MacDonald, A. E.: Choroidal Chorionephithelioma Secondary to Teratoma of the Testicle , Arch. Ophth. 16:672 ( (Oct.) ) 1936.Crossref 18. Verhoeff, F. H.: Retinoblastoma: Report of a Case in a Man Aged Forty-Eight , Arch. Ophth. 2:643 ( (Dec.) ) 1929.Crossref 19. Wheeler, J. M.: Am. J. Ophth. 20:368, 1937. 20. Stough, J. T.: Intra-Ocular Neurofibroma: Report of a Case , Arch. Ophth. 18:540 ( (Oct.) ) 1937.Crossref 21. Freeman, D.: Neurofibroma of the Choroid , Arch. Ophth. 11:641 ( (April) ) 1934.Crossref 22. Benign melanoma more probably belongs under the list of conditions resembling malignant melanoma. It is placed here because no specific examples of benign melanoma simulating malignant melanoma are at hand. 23. Moore, R. F.: Roy. London Ophth. Hosp. Rep. ( (pt. 3) ) 19:411, 1914. 24. Cattaneo, D.: Ann. di ottal. e clin. ocul. 54:1097, 1926. 25. Cushing, H., and Eisenhardt, L.: Meningiomas , Springfield, Ill., Charles C. Thomas, Publisher, 1938, p. 287. 26. McLean, J. M.: Astrocytoma (True Glioma) of the Retina: Report of a Case , Arch. Ophth. 18:255 ( (Aug.) ) 1937.Crossref 27. Ewing, J.: Neoplastic Diseases , ed. 3, Philadelphia, W. B. Saunders Company, 1928, p. 931. 28. Evaluation of the true importance of the appearance of the fundus and of the faults of transillumination in diagnosis has long been discussed by F. H. Verhoeff in his lectures. So far as I can determine, it has not been published. 29. Friedenwald, J. S.: Clinical Studies in Slitlamp Ophthalmoscopy , Arch. Ophth. 1:575 ( (May) ) 1929.Crossref 30. Ginsberg, in Henke, F., and Lubarsch, O.: Handbuch der speziellen pathologischen Anatomie und Histologie , Berlin, Julius Springer, 1928, vol: 11, pt. 1, p. 515. 31. Wood, C. A.: The American Encyclopedia and Dictionary of Ophthalmology , Chicago, Cleveland Press, 1914, vol. 5, p. 3938. 32. Lancaster, W. B.: Tr. Am. Ophth. Soc. 13:445, 1913. 33. Greenwood, A.: Tr. Am. Ophth. Soc. 13:503, 1913. 34. Burke, J. W.: Tr. Am. Ophth. Soc. , 34:239, 1936. 35. van Manen, J. G.: Die diathermische Behandlung der Netzhautablösung in der Universitätsaugenklinik Utrecht und ihre Ergebnisse im Jahre 1935 , Utrecht, Keminken Zook, 1936. 36. This method was used by Weve and associates as a means of locating accurately on the sclera the correspondence of the hole in the retina for operation on the separated retina. It necessitates an opening into Tenon's capsule and the use of retractors. It may necessitate the cutting of an extraocular muscle if the suspicious area to be tested with transillumination is in the macular region or near the nerve head. Although I have used the method in the diagnosis of malignant melanoma once, with only moderate satisfaction, no doubt it could be developed with practice and refinements, such as use of a laryngeal type of mirror or with a properly developed endoscope to facilitate observation. 37. These observations are based in part on the results of routine transillumination of several hundred enucleated eyes in the laboratory. 38. A description of the transilluminator designed by Mattis and myself will be published (Arch. Ophth.). 39. Zondek, B., and Krohn, H.: Klin. Wchnschr. 11:405, 1932.Crossref 40. Lund, C. C.: Personal communications to the author. 41. Pfeiffer, R. L.: Tr. Am. Acad. Ophth. 40:131, 1935. 42. Ruddock, J. C.: West. J. Surg. 42:392, 1934. 43. Several of the ophthalmologists who supplied me with clinical material are purposely not mentioned. The errors in diagnosis that have arisen seem natural in view of the many hazards of diagnosis which this condition presents. No criticism is intended. 44. Routine fixation is done with a 10 per cent dilution of formaldehyde for forty-eight hours and hydrochloric acid (3 per cent) and alcohol (70 per cent) for sixteen hours. The eye is then opened, dehydrated in graded alcohols and embedded in pyroxylin. When the pyroxylin is sufficiently firm, sections are made and stained, usually with hematoxylin and eosin. This technic was used for all eyes except the eye in case 11, which remained in the solution of formaldehyde for a longer period. 45. Verhoeff and Grossman ( Arch. Ophth. 19:468 [ (March) ] 1938).Crossref

Journal

Archives of OphthalmologyAmerican Medical Association

Published: Dec 1, 1939

References