Revised May 2000

Protocol for the Examination of Specimens from Patients with UVEAL MELANOMA:

A Basis for Checklists

Procedures:

Cytology

Biopsy

Resection

 

I. Cytology                  back     Top     Main Page

A. CLINICAL INFORMATION

1. Patient identification

            a. Name

            b. Identification number

            c. Age (birth date)

            d. Gender

2. Responsible physician(s)

3. Date of procedure

4. Other clinical information

            a. Relevant history

                        (1) clinical findings

                        (2) past ocular history

                        (3) previous ocular surgery

                        (4) previous treatment

            b. Relevant findings(eg, liver function tests, ultrasound)

            c. Clinical diagnosis

            d. Procedure (eg, fine needle aspiration, anterior chamber paracentesis)

            e. Operative findings

            f. Anatomic site (right or left eye; part of eye sampled)

 

B. MACROSCOPIC EXAMINATION

1. Specimen

            a. Unfixed/fixed (specify fixative)

            b. Number of slides received

            c. Quantity and appearance of fluid specimen

            d. Other (eg, core of tissue in needle shaft)

            e. Intraoperative/intraprocedure consultation

2. Material submitted for microscopic evaluation (eg, cytocentrifuge, smear, filter preparation)

3. Special studies (specify)  (eg, immunocytochemistry)

 

C. MICROSCOPIC EVALUATION

1. Adequacy of specimen for evaluation (if unsatisfactory for evaluation, specify reason)

2. Tumor, if present

            a. Histologic type, if possible (Note A)

            b. Other characteristics (Note B)

                        (1) presence of pigment

                        (2) cytoplasmic indentation of nucleus

                        (3) cytoplasmic vacuolization

3. Additional pathologic findings, if present (eg, inflammatory cells)

4. Retinal tissue

5. Results/status of special studies (specify)

6. Comments

            a. Correlation with intraprocedural consultation

            b. Correlation with other specimens, as appropriate

            c. Correlation with clinical information, as appropriate

 

II. Biopsy                    back     Top     Main Page

A. CLINICAL INFORMATION

1. Patient identification

            a. Name

            b. Identification number

            c. Age (birth date)

            d. Gender

2. Responsible physician(s)

3. Date of procedure

4. Other clinical information

            a. Relevant history

                        (1) clinical findings

                        (2) past ocular history

                        (3) previous ocular surgery

                        (4) previous treatment

            b. Relevant findings (eg, liver function tests, ultrasound)

            c. Procedure (eg, peripheral iridectomy, iridocyclectomy, sclerouveectomy)

            d. Operative findings

            e. Anatomic site of specimen (right or left eye)

 

B. MACROSCOPIC EXAMINATION

1. Specimen

            a. Unfixed/fixed (specify type)

            b. Orientation(if indicated by surgeon)

            c. Previously opened

            d. Number of pieces

            e. Size(s) (3 dimensions, if possible)

f. Orientation (if designated by surgeon by suture/diagram) – ink posterior margins of iridocyclectomy specimens (excisioned biospy)

            g. Tumor

                        (1) size (3 dimensions, if possible)

                        (2) descriptive features

            h. Other tissues(as appropriate)

            i. Results or intraoperative consultation

2.  Tissue submitted for microscopic evaluation (specify)

3. Special studies (specify) (eg, special histochemical stains, immunohistochemical stains)

 

C. MICROSCOPIC EVALUATION

1. Tumor

            a. Histologic type (Note A)

            b. Histologic grade

            c. Extent

                        (1) involvement of adjacent structures such as ciliary body

                        (2) sclera

                        (3) tumor vessels

            d. Other prognostic features (Note B)

2. Additional pathologic findings, if present

            a. Drusen

            b. Neovascularization

            c. Nevus

            d. Ectropion uveae

            e. Other(s)

3. Results/status of special studies(specify)

4. Comments

            a. Correlation with intraoperative consultation

            b. Correlation with other specimens, as appropriate

            c. Correlation with clinical information, as appropriate

 

 

III. Resection Specimen (Globe)                  back     Top     Main Page

A. CLINICAL INFORMATION

1. Patient identification

            a. Name

            b. Identification number

            c. Age(birth date)

            d. Gender

2. Responsible physician(s)

3. Date of procedure

4. Other clinical information

            a. Relevant history

                        (1) clinical findings

                        (2) past ocular history

                        (3) previous ocular surgery

                        (4) previous treatment

            b. Relevant findings (eg,  liver function tests, ultrasound)

            c. Clinical diagnosis

            d. Procedure (usually enucleation)

            e. Operative findings

            f. Anatomic site of specimen (right or left eye)

5. Documentation of areas marked by surgeon for orientation (eg, suture, diagram)

 

B. MACROSCOPIC EXAMINATION

1. Specimen

            a. Organ(s)/tissue(s) included

            b. Unfixed/fixed (specify fixative) (Note C)

            c. Orientation (Note D)

            d. Description of other tissues (as appropriate)

            e. Results of intraoperative consultation

2. Sectioning of specimen (globe) (Note E)

3. Globe

            a. Evidence of previous excision or treatment

            b. Previously opened

            c. Size

                        (1) anteroposterior, horizontal, vertical dimensions of globe

                        (2) length and diameter of attached optic nerve

                        (3) corneal horizontal and vertical diameter

                        (4) diameter of pupil (if visible)


d. Transillumination (helpful to identify location of tumor and measure basal dimension prior to sectioning globe)

(1) quality of transillumination (eg, poor light transillumination, transilluminates light well)

                        (2) transillumination defect

                                    i. location

                                    ii. quadrant/relationship to equator of globe

                                    iii. relationship to limbus

                                    iv. clock-hour of iris

                                    v. size (2 dimensions)

            e. Mark outline with marking implement

            f. Extrascleral extension, if present

            g. Mass/tumor, if present

                        (1) location

                        (2) size (Note F and G)

                                    i. base at cut edge (ie, portion of tumor closest to sclera)

                                    ii. height at cut edge

                        (3) distance of anterior margin of tumor base from limbus at cut edge

                        (4) distance of posterior margin of tumor base from edge of optic disc

                        (5) other descriptive features (color, consistency, shape)

                        (6) structures involved and extent (Note G)

                                    i. retinal involvement

                                    ii. optic nerve involvement

                                    iii. macroscopic involvement of vitreous

                                    iv. involvement of ciliary body

            h.  Features of other (uninvolved) ocular tissues

                        (1) cornea (eg, clear, cloudy, opaque)

                        (2) anterior chamber (eg, deep, shallow, flat)

                        (3) angle (eg, open, narrow, closed)

                        (4) iris (eg, color, any abnormalities)

                        (5) ciliary body

                        (6) lens (eg, clear, cataractous)

                        (7) vitreous (eg, color, consistency, hemorrhage)

                        (8) retina (eg, detachment--total, partial; hemorrhages)

                        (9) choroid

                        (10) sclera (eg, thinning, defects)

                        (11) optic nerve (eg, pallor, increased cup/disc ratio)

4. Tissues submitted for microscopic examination (specify)

5. Special studies (specify) (eg, immunohistochemistry)

 

C. MICROSCOPIC EVALUATION

1. Tumor

            a. Site (choroid /ciliary body / iris) (Note G)

            b. Histologic type (Note A)

            c. Histologic grade

            d. Extent of invasion (Note G)

            e. Size (Note F)

            f. Anatomic extent (Note s B and G)

                        (1) anterior margin of tumor

                        (2) retinal or scleral involvement

                        (3) angle involvement

                        (4) vitreal involvement

                        (5) optic nerve involvement

2. Margins

            a. Extrascleral extension 

            b. Surgical margin of optic nerve (Note B)

3. Other prognostic features (Note B)

4. Additional pathologic findings, if present

            a. Cancer-related:

                        (1) cataract

                        (2) vitreous hemorrhage

                        (3) glaucomatous optic atrophy

                        (4) secondary angle closure

                        (5) secondary open-angle glaucoma

                        (6) iris neovascularization

                        (7) retinal atrophy

            b. Other

                        (1) corneal disease

                        (2) diabetic retinopathy

5. Results/status of special studies (specify)

6. Comments

            a. Correlation with  intraoperative consultation

            b. Correlation with other specimens, as appropriate

            c. Correlation with clinical information, as appropriate

 

EXPLANATORY NOTES

A.  HISTOLOGIC TYPE                   back     Top     Main Page

The modified Callender classification shown below is used for determining cell type but has prognostic significance only for tumors of the choroid and ciliary body, not those of the iris, which generally have a benign course.(1-4)

           Spindle cell nevus - slender cells with fusiform nuclei, delicate nuclear chromatin and inapparent nucleoli, no mitoses are found.

           Spindle cell melanoma* -

           Spindle A: slender cells with a thin, oval nucleus, indistinct nucleoli and often a longitudinal fold in the nuclear membrane

           Spindle B: larger, plumper nuclei with sharply defined, round nucleoli.

          Mixed cell melanoma: both spindle and epithelioid cells present.

           Epithelioid cell melanoma* - larger, more pleomorphic, polygonal cells with large, sometimes multiple, nucleoli

* Spindle cell melanomas have the most favorable prognosis and epithelioid cell melanomas the least favorable in terms of survival.

 

B. OTHER PATHOLOGIC FEATURES OF PROGNOSTIC SIGNIFICANCE             back     Top     Main Page

Other histologic features with prognostic significance in choroidal and ciliary body melanoma include: mitotic activity, pigmentation, degree of inflammation, growth pattern (diffuse choroidal melanomas and ring melanomas of the ciliary body have a much less favorable prognosis), location of anterior margin of tumor, degree and patterns of vascularity, blood vessel invasion (both tumor vessels and normal vessels), tumor necrosis, extraocular extension and optic nerve involvement.(4-15)

 

C. FIXATIVE             back     Top     Main Page

The minimum recommended fixation time for whole globes with intraocular tumors is 48 hours.  The globe should be fixed in an adequate volume of fixative with a 10:1 ratio of fixative volume to specimen volume recommended. Incisions or windows in the globe are not necessary for adequate penetration of fixative and are not recommended.  Injection of fixative into the globe is also not recommended.

 

D. ORIENTATION               back     Top     Main Page

The orientation of a globe may be determined by identification of extraocular muscle insertions, the optic nerve and other landmarks, as illustrated in Figure 1.  The terms temporal and nasal are generally used in place of lateral and medial with reference to ocular anatomy.

 

E. SECTIONING THE GLOBE                   back     Top     Main Page

The globe is generally sectioned in the horizontal or vertical plane with care to include the pupil and optic nerve in the section to be submitted for microscopic examination.  If the mass cannot be included with horizontal or vertical sectioning, the globe is sectioned obliquely to include the tumor, pupil and optic nerve, as illustrated in Figure 2.  Alternative methods of sectioning have been described.(16)

 

F. TUMOR SIZE                   back     Top     Main Page

Tumor size has prognostic significance.  Many studies of choroidal and ciliary body melanoma have defined small tumors as being less than 10mm in greatest diameter.(4)  More recently, an ongoing study started in 1986, the Collaborative Ocular Melanoma Study (17,18) defined the following size classification based on clinical measurements:

            Small tumors*:           smaller than medium or large tumors defined below

            Medium tumors:         >2.5 mm, <10 mm in height, and <16 mm in basal diameter

Large tumors:            >10 mm in height or >2 mm in height and >16 mm in basal diameter or >8 mm in height with optic nerve involvement

*Small tumors have a more favorable prognosis.(6,7)

 

G.  TNM STAGE GROUPINGS                  back     Top     Main Page

The AJCC/UICC TNM staging systems for uveal melanoma of the iris, ciliary body and choroid are shown below.(19) 

Iris

Tumor (T)

TX       Primary tumor cannot be assessed

TO       No evidence of primary tumor

T1        Tumor limited to the iris

T2        Tumor involves one quadrant or less, with invasion into the anterior chamber angle

T3        Tumor involves more than one quadrant, with invasion into the anterior chamber angle, ciliary body, and/or choroid

T4        Tumor with extraocular invasion

 

Regional Lymph Nodes (N)

NX      Regional lymph nodes cannot be assessed

NO      No regional lymph node metastasis

N1       Regional lymph node metastasis

Distant Metastasis (M)

MX      Presence of distant metastasis cannot be assessed

M0       No distant metastasis

M1       Distant metastasis

Ciliary Body

Tumor (T)

TX       Primary tumor cannot be assessed

TO       No evidence of primary tumor

T1        Tumor limited to the ciliary body

T2        Tumor invades into the anterior chamber and/or iris

T3        Tumor invades choroid

T4        Tumor with extraocular invasion

 

Regional Lymph Nodes (N)

NX      Regional lymph nodes cannot be assessed

NO      No regional lymph node metastasis

N1       Regional lymph node metastasis

 

Distant Metastasis (M)

MX      Presence of distant metastasis cannot be assessed

M0       No distant metastasis

M1       Distant metastasis

 

Choroid

Tumor (T)

TX       Primary tumor cannot be assessed

TO       No evidence of primary tumor

T1*      Tumor 10 mm or less in greatest dimension with an elevation of 3 mm or less

            T1a      Tumor 7 mm or less in greatest dimension with an elevation of 2 mm or less

            T1b      Tumor more than 7 mm  but not more than 10 mm in greatest dimension with an elevation of more than 2 mm but not more than 3 mm

T2*      Tumor more than 10 mm but not more than 15 mm in greatest dimension with an elevation more than 3 mm but not more than 5 mm

T3*      Tumor more than 15 mm in greatest dimension or with an elevation more than 5 mm

T4        Tumor with extraocular invasion

* In clinical practice the tumor base may be estimated in optic disc diameters (dd) (average: 1 dd = 1.5 mm).  The elevation may be estimated in diopters (average 3 diopters = 1 mm).  Other techniques used, such as ultrasonography and computerized stereometry, may provide a more accurate measurement.

Note: When dimension and elevation show a difference in classification, the highest category should be used for classification.

 

Regional Lymph Nodes (N)

NX      Regional lymph nodes cannot be assessed

NO      No regional lymph node metastasis

N1       Regional lymph node metastasis

 

Distant Metastasis (M)

MX      Presence of distant metastasis cannot be assessed

M0       No distant metastasis

M1       Distant metastasis

 

TNM Stage Groupings for Uveal Melanoma of the Iris or Ciliary Body

Stage I             T1              N0             M0

Stage II            T2              N0             M0

Stage III           T3              N0             M0

Stage IVA        T4              N0             M0

Stage IVB        Any T         N1             M0

                        Any T         Any N        M1

 

TNM Stage Groupings for Uveal Melanoma of the Choroid

Stage IA           T1a            N0               M0

Stage IB           T1b            N0               M0

Stage II            T2              N0               M0

Stage III           T3              N0               M0

Stage IVA        T4              N0               M0

Stage IVB        Any T         N1               M0

                        Any T         Any N         M1

It should be noted that regional lymph node involvement is rare in uveal melanoma, but metastasis to the liver and direct extension into the orbit are more common.(19)

 

REFERENCES                      back     Top     Main Page

1. Callender GR. Malignant melanotic tumors of the eye: A study of histologic types in 111 cases. Trans Am Acad Ophthalmol Otolaryngol. 1931;36:131-142.

2. McLean IW, Zimmerman LE, Evans RM. Reappraisal of Callenderís spindle A type of malignant melanoma of choroid and ciliary body. Am J Ophthalmol. 1978; 86:557-564.

3. McLean IW, Foster WD, Zimmerman LE. Modifications of Callenderís classification of uveal melanoma at the Armed Forces Institute of Pathology. Am J Ophthalmol. 1983;96:502-509.

4. Zimmerman LE. Malignant melanoma of the uveal tract. In: WH Spencer, ed. Ophthalmic Pathology: An Atlas and Textbook. 3rd ed. Philadelphia, Pa: WB Saunders Co.; 1986:2072-2139.

5. Font RL, Spaulding AG, Zimmerman LE. Diffuse malignant melanoma of the uveal tract: A clinicopathologic report of 54 cases. Trans Am Acad Ophthalmol Otolaryngol. 1968; 72:877-894.

6.  McLean IW, Foster WD, Zimmerman LE. Prognostic factors in small malignant melanomas of choroid and ciliary body. Arch Ophthalmol. 1977;95:48-58.

7. Affeldt JC, Minckler DS, Azen SP, Yeh L. Prognosis in uveal melanoma with extraocular extension. Arch Ophthalmol. 1980;98:1975-1979.

8. McLean IW, Foster WD, Zimmerman LE. Uveal melanoma: Location, size, cell type, and enucleation as risk factors in metastasis. Hum Pathol. 1982;13:123-132.

9. Weinhaus RS, Seddon JM, Albert DM, Gragoudas ES, Robinson N. Prognostic factor study of survival after enucleation for juxtapapillary melanomas. Arch Ophthalmol. 1985;103:1673-1677.

10. Gamel JW, McCurdy JB, McLean IW. A comparison of prognostic covariates for uveal melanoma. Inves Ophthalmol Vis Sci. 1992;33:1919-1922.

11. Folberg R, Peíer J, Gruman LM, et al. The morphologic characteristics of tumor blood vessels as a marker of tumor progression in primary human uveal melanoma: a matched case-control study. Hum Pathol. 1992;23:1298-1305.

12. Coleman K, Baak JP, Van Diest P, Mullaney J, Farrell M, Fenton M. Prognostic factors following enucleation of 111 uveal melanomas. Br J Ophthalmol. 1993;77:688-692.

13. Folberg R, Rummelt V, Parys-Van Ginderdeuren R, et al. The prognostic value of tumor blood vessel morphology in primary uveal melanoma. Ophthalmol. 1993;100:1389-98.

14. Folberg R, Rummelt V, Gruman LM, et al. Microcirculation architecture of melanocytic nevi and malignant melanomas of the ciliary body and choroid. A comparative histopathologic and ultrastructural study. Ophthalmol. 1994;101:718-727.

15. Rummelt V, Folberg R, Woolson RF, Hwang T, Peíer J. Relation between the microcirculation architecture and the aggressive behavior of ciliary body melanomas. Ophthalmol. 1995;102:844-851.

16. Folberg R, Verdick R, Weingeist TA, Montague PR. The gross examination of eyes removed for choroidal and ciliary body melanomas. Ophthalmol. 1986;93:1643-1647.

17. The Collaborative Ocular Melanoma Study Group. Design and Methods of a Clinical Trial for a Rare Condition: The Collaborative Ocular Melanoma Study, COMS Report No. 3. Controlled Clinical Trials. 1993;14:362-391.

18. Collaborative Ocular Melanoma Study: COMS Manual of Procedures. Springfield, Va: National Technical Information Service, 1989, NTIS Accession No. PB90-115536

19. Fleming ID, Cooper JS, Henson DE, et al, eds. AJCC Manual for Staging of Cancer. 5th ed, Philadelphia, Pa: Lippincott Raven; 1997.

 

BIBLIOGRAPHY

• Albert DM, Dryja TP: The Eye. In: RS Cotran, V Kumar, SL Robbins, eds. Pathologic Basis of Disease. 4th ed. Philadelphia, Pa: WB Saunders Co; 1998 (in press).

• Albert DM. Principles of Pathology. In: DM Albert and FA Jakobiec, eds. Principles and Practice of Ophthalmology, Vol. 4. Philadelphia, Pa: WB Saunders Co.; 1994:2101-2126.

• Zimmerman LE. Malignant melanoma of the uveal tract. in WH Spencer, ed. Ophthalmic Pathology: An Atlas and Textbook. 3rd ed. Philadelphia, Pa: WB Saunders Co.; 1986:2072-2139.

• Yanoff MF, Fine BS. Ocular Pathology: A text and atlas.  3rd ed. Philadelphia, Pa: JB Lippincott Co.; 1989:652-678.

Authors:  Daniel Albert, M.D. and Nasreen Syed, M.D.

For members of the Cancer Committee, College of American Pathologists

Originally published in the Archives of Pathology & Laboratory Medicine, September 2001.

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