Jakubowska, Barbara

Markiewicz, Anna

Romanowska-Dixon, Bożena

Romanowska-Pawliczek, Anna

Klinika Oczna

English

Jagiellonian Univeristy Repository

9Klinika Oczna 2017, 119 (1)ISSN 0023-2157 Index 362646Characteristic features of choroidal nevus and small choroidal melanoma in Deep Range Imaging Optical Coherence TomographyCechy charakterystyczne guzów wewnątrzgałkowych w Deep Range Imaging optycznej koherentnej tomografiiAnna Markiewicz1,2, Bożena Romanowska-Dixon1,2, Barbara Jakubowska2, Anna Romanowska-Pawliczek31	 Department	of	Ophthalmology	and	Ocular	Oncology	of	the	Jagiellonian	University,	Medical	College,	Cracow,	Poland	Head:	Professor	Bożena	Romanowska-Dixon,	MD,	PhD2	 Department	of	Ophthalmology	and	Ocular	Oncology	University	Hospital	on	Cracow,	Poland	Head:	Professor	Bożena	Romanowska-Dixon,	MD,	PhD3	 University	of	Texas	Health	Science	Center,	Houston,	United	States	Head:	Jenifer	Juranek,	PhD(01)Abstract: Purpose: To determine characteristic features of choroidal nevi and small choroidal melanomas in Deep Range Imaging Optical Coherence Tomography in patients diagnosed and treated at the Department of Ophthalmology and Ocular Oncology of the Ja-giellonian University, Medical College in Cracow within 2014 year. Materrial	and	methods: 71 patients with choroidal nevi or small choroidal melanomas were studied. Choroidal lesions were dia-gnosed clinically based on measurements of cross-sectional ultrasound images, mostly B-scans, and color fundus photography. The Topcon’s Deep Range Imaging Optical Coherence Tomography was used to enable better visualization of choroidal pathologies. Results: 11 patients were diagnosed with small choroidal nevus (<1.0 mm thickness and < 3.0 mm diameter), 42 – with typi-cal nevus (1.0–2.0 mm thickness and 3.0–5.0 mm diameter), 5 – with atypical nevus (≤ 2.0 mm thickness and > 5.0 mm dia-meter) and 13 – with small melanoma (according to Shields’ TFSOM rule). Deep Range Imaging Optical Coherence Tomography demonstrated characteristic features of these lesions: compression of choriocapillaris in all atypical nevi and small melanomas, inner and/or outer choroidal changes in all choroidal lesions. Other features, such as subretinal fluid, photoreceptors changes, macrophages with lipofuscin, were mostly present in atypical nevi and small melanomas. Dome tumor shape and wing border shape were found only in small melanomas. Conclusion: Deep Range Imaging Optical Coherence Tomography enables visualization of all choroidal structures and their pa-thology. It is useful in differential diagnosis of choroidal nevi and small choroidal melanomas.Key words: choroidal nevus, small choroidal melanoma, differential diagnosis, atypical choroidal nevus, Deep Range Imaging Optical Cohe-rence Tomography (DRI-OCT).Abstrakt: Cel: przedstawienie charakterystycznych cech znamion naczyniówki i małych czerniaków naczyniówki w Deep Range Imaging optycznej koherentnej tomografii u pacjentów diagnozowanych i leczonych w Klinice Okulistyki i Onkologii Okulistycznej Uniwer-sytetu Jagiellońskiego Collegium Medicum w Krakowie w 2014 roku. Materiał	i	metody: badaniem objęto 71 chorych, u których rozpoznano znamię naczyniówki lub małego czerniaka. Rozpoznanie zmian naczyniówki było potwierdzone podczas obserwacji z wykonaniem pomiarów ultrasonograficznych, przeważnie w prezen-tacji B, oraz kolorowego zdjęcia dna oka. U wszystkich chorych wykonano badanie Deep Range Imaging optycznej koherentnej tomografii firmy Topcon. Wyniki: u 11 chorych rozpoznano małe znamię naczyniówki (<1,0 mm wysokości i <3,0 mm średnicy podstawy), u 42 cho-rych – typowe (1,0–2,0 mm wysokości i 3,0–5,0 mm średnicy podstawy), a u 5 chorych – atypowe (≤ 2,0 mm wysokości i >5,0 mm średnicy podstawy), u 13 chorych zaś małego czerniaka (według reguły TFSOM opracowanej przez Shieldsów). Stwierdzone przez nas charakterystyczne cechy w badaniu Deep Range Imaging optycznej koherentnej tomografii to: kom-presja choriokapilar we wszystkich atypowych znamionach i małych czerniakach oraz zmiany w warstwach zewnętrznej i/lub wewnętrznej naczyniówki we wszystkich zmianach. Inne stwierdzone cechy to: płyn podsiatkówkowy, zmiany w warstwie fotoreceptorów i makrofagi obładowane lipofuscyną, które są częściej obecne w atypowych znamionach i małych czerniakach. Zaobserwowano, że kopulasty kształt i skrzydlaste granice guza miały jedynie małe czerniaki. Wnioski: Badanie Deep Range Imaging optycznej koherentnej tomografii pozwala uwidocznić wszystkie szczegóły budowy na-czyniówki i ich nieprawidłowości. Te właściwości są bardzo przydatne w diagnostyce różnicowej znamion i małych czerniaków naczyniówki.Słowa kluczowe: znamię naczyniówki, mały czerniak naczyniówki, diagnostyka różnicowa, atypowe znamię naczyniówki, Deep Range Imaging optyczna koherentna tomografia (DRI-OCT).PRACE ORYGINALNE10 Klinika Oczna 2017, 119 (1) ISSN 0023-2157 Index 362646Characteristic features of choroidal nevus and small choroidal melanoma in Deep Range Imaging Optical Coherence TomographyIntroductionThe	 choroid	 can	 be	 affected	 by	 benign	 and	 malignant	 tu-mors.	Benign	melanocytic	tumors	of	the	choroid,	such	as	cho-roidal	 nevi	 are	 very	 common	and	pose	no	health	 risks,	 unless	they	show	signs	of	malignancy,	in	which	case	they	are	conside-red	melanomas.	Many	small	 choroidal	melanomas	are	 located	close	to	optic	disc	and	macula,	so	any	tumor-destructing	treat-ment	modality	is	associated	with	a	high	risk	of	visual	loss.	Ho-wever,	 the	 watchful	 waiting	 approach	 in	 potentially	 malignant	lesions	can	lead	to	metastases.	Therefore,	it	is	crucial	to	find	an	effective	noninvasive	tool	for	differential	diagnosis.Imaging techniquesChoroidal	 lesions	 are	 diagnosed	 clinically	 based	 on	 measure-ments	of	cross-sectional	ultrasound	images,	mostly	A-	and	B-scans.	Color	fundus	photography	is	also	useful	for	documentation.Optical	coherence	tomography	(OCT)	has	become	an	excel-lent,	 noninvasive	 imaging	 technique	 for	 evaluation,	 measu-rement	 and	 observation	 of	 retinal	 and	 optic	 nerve	 disorders.	In	 con	ventional	 OCT,	 light	 scatter	 by	 the	 retinal	 pigment	 epi-thelium	and	choroidal	vasculature	limits	and	degrades	the	cho-roidal	 images.	 Enhanced	 depth	 imaging	 optical	 coherence	 to-mography	 (EDI-OCT)	 enables	 cross	 sectional	 retinal	 imaging	with	a	resolution	approaching	histologic	sections	and	choroidal	mapping.	Noori	et	al.	observed	that	vascular	choroidal	changes	play	 certain	 roles	 in	 the	 development	 of	 choroidal	 disorders.	In	order	to	effectively	detect,	evaluate	and	follow	up	on	choro-idal	neoplasms,	it	is	important	to	better	establish	the	use	of	to-pographic	choroidal	thickness	and	choroidal	volume	in	choroidal	lesions	and	provide	a	normative	database	(1–5).	Topcon’s	DRI--OCT	combines	color	 fundus	photography	with	new	OCT	 tech-nology	 to	capture	a	cross-sectional	 image	of	 the	 fundus	using	light	 interference.	 The	 3D	 OCT	 system	 enables	 three-dimen-sional	 observation	 of	 the	 fundus	 by	 capturing	 images	 of	 both	the	surface	and	deeper	parts	of	the	retina	and	choroid.PurposeTo	 present	 characteristic	 features	 of	 choroidal	 nevus	and	 small	 choroidal	 melanoma	 in	 Deep	 Range	 Imaging	 Opti-cal	 Coherence	 Tomography	 (DRI-OCT)	 in	 patients	 diagnosed	and	trea	ted	at	the	Department	of	Ophthalmology	and	Ocular	On-cology	of	the	Jagiellonian	University,	Medical	College	in	Cracow.Material and methods71	patients	with	choroidal	nevi	and	small	choroidal	melano-mas	were	studied.	Choroidal	lesions	were	diagnosed	clinically	ba-sed	on	measurements	of	cross-sectional	ultrasound	images,	mo-stly	A-	and	B-scans,	and	color	fundus	photography.	The	Topcon’s	Deep	 Range	 Imaging	 Optical	 Coherence	 Tomography (DRI-OCT,	Topcon,	Tokyo,	Japan)	was	used	 to	enable	better	visualization	of	 choroidal	 pathologies	 and	 their	 typical	 features.	 Two	 expe-rienced	examiners	analyzed	OCT	images.Results11	 patients	 were	 diagnosed	 with	 a	 small	 choroidal	 nevus	(thickness	<1.0	mm	and	diameter	<3.0	mm),	42	–	with	a	ty-pical	nevus	(1.0–2.0	mm	thickness	and	3.0–5.0	mm	diameter),	5	 –	 with	 an	 atypical	 nevus	 (thickness	 ≤	 2.0	 mm	 and	 diame-ter	>5.0	mm)	and	13	–	with	a	small	melanoma	 (according	 to	Shields’	TFSOM	rule).	DRI-OCT	 features	of	melanotic	choroidal	lesions	are	presented	 in	Table	 I.	Small	choroidal	nevus	 imaged	with	 DRI-OCT	 displayed	 compression	 (thinning)	 of	 choriocapil-laris	 (91%	 of	 cases),	 inner/outer	 segment	 junction	 irregularity	(82%),	 choroidal	 shadowing	 (91%),	 flat	 contour	 (91%),	 brush	border	shape	(73%)	and	whetstone	shape	(27%)	(Fig.	1).Choroidal	 nevi	 presented	 with	 compression	 of	 choriocapil-laris	 (95%	 of	 cases),	 inner/outer	 segment	 junction	 irregularity	(100%),	subretinal	fluid	(10%),	retinal	pigment	epithelium	(RPE)	changes	 (28%),	photoreceptor	 loss	 (31%),	 inner/outer	segment	junction	 irregularity	 (38%),	 placid	 contour	 (36%),	 flat	 contour	(55%),	 whetstone	 border	 shape	 (55%),	 and	 brush	 border	 sha-pe	(41%).	The	most	common	DRI-OCT	imaging	features	of	both	atypical	 nevi	 as	 well	 as	 small	 melanomas	 were:	 compression	of	choriocapillaris	 (100%),	 inner/outer	segment	 junction	 irregu-larity	(100%),	RPE	changes	(100%	and	77%,	respectively),	 loss	of	photoreceptors	(100%	and	92%,	respectively)	and	wing	bor-der	shape	(60%	and	100%,	respectively).	Only	small	melanomas	had	a	typical	dome	shape	(Fig.	2).c.b.Fig. 1.	 Choroidal	 nevus:	 fundus	 view	 –	 a.,	 and	 b.	 –	 OCT	 view	with	 characteristic	 features:	 compression	 of	 choriocapilaris	(red	arrows),	c.	–	choroid	shadowing	(orange	arrow).Ryc. 1.	 Znamię	 naczyniówki:	 a.	 i	 b.	 –	 DRI-OCT	 z	 typowymi	 dla	 nie-go	 cechami	 –	 kompresja	 choriokapilar	 (czerwone	 strzałki),	c.	–	cień	naczyniówki	(pomarańczowa	strzałka).a.11Klinika Oczna 2017, 119 (1)ISSN 0023-2157 Index 362646AnnA MArkiewicz, BożenA roMAnowskA-Dixon, BArBArA JAkuBowskA, AnnA roMAnowskA-PAwliczekFeature/ Cecha Small nevus/  Małe znamię (n = 11)Nevus/  Znamię (n = 42)Atypical nevus/  Atypowe znamię (n = 5)Small melanoma/  Mały czerniak (n = 13)Compression of choriocapillaris / Uciśnięcie choriokapilar 91% 95% 100% 100%Inner/ OuterWewnętrzne/ Zewnętrzne 82% 100% 100% 100%Shadowing/ Zacienienie 91% 100% 100% 100%Border line/ Linia graniczna 0% 33% 60% 23%Subretinal fluid/ Płyn podsiatkówkowy 0% 10% 60% 92%Intraretinal fluid/ Płyn śródsiatkówkowy 0% 5% 20% 54%RPE changes/ Zmiany RPE 0% 29% 100% 77%Photoreceptor loss/ Zanik fotoreceptorów 0% 31% 100% 92%Inner/ Outer photoreceptor segment irregularities/ Nieregularności na granicy segmentów wewnętrznych i zewnętrznych fotoreceptorów0% 38% 100% 100%Shaggy/ Frędzlowate 0% 5% 40% 69%Stalagmites/ Stalagmity 0% 0% 20% 69%Stalactites/ Stalaktyty 0% 0% 40% 46%Retracted/ Rozciągnięte 0% 5% 40% 46%Tips swollen/ Obrzęk fotoreceptorów 0% 14% 80% 69%Lipofuscin-laden macrophages/ Makrofagi obładowane lipofuscyną 9% 5% 100% 77%Drusen/ Druzy 0% 5% 0% 15%Lumpy-bumpy contour/ Powierzchnia zmiany wyboista 0% 2% 0% 0%Placid contour/ Powierzchnia zmiany gładka 9% 36% 60% 8%Undulating (rippled) contour/ Powierzchnia zmiany pofalowana 0% 5% 0% 0%Flat contour/ Powierzchnia zmiany płaska 91% 55% 0% 0%Regular dome-shaped contour/ Kształt regularnej kopuły 0% 0% 40% 85%Irregular dome-shaped contour/ Kształt nieregularnej kopuły 0% 0% 0% 8%Whetstone-shaped lateral border/ Kształt granic bocznych osełka 27% 55% 40% 0%Wing-shaped lateral border/ Kształt granic bocznych skrzydła 0% 5% 60% 100%Brush-shaped lateral border/ Kształt granic bocznych pędzel 73% 40% 0% 0%Tab. I. DRI-OCT	features	of	melanotic	choroidal	lesions.Tab. I. Cechy	barwnikowych	zmian	naczyniówki	w	DRI-OCT.12 Klinika Oczna 2017, 119 (1) ISSN 0023-2157 Index 362646Characteristic features of choroidal nevus and small choroidal melanoma in Deep Range Imaging Optical Coherence TomographyDiscussionChoroidal	nevus	is	benign	lesion.	Shah	et	al.	describe	common	EDI-OCT	 features	of	 choroidal	 nevi	 in	104	patients	 (2).	 The	most	common	features	included	partial	(59%)	or	complete	(35%)	choro-idal	shadowing	deep	to	the	nevus,	thinning	of	choriocapillaris	lay-er	overlying	the	nevus	(94%),	RPE	atrophy	(43%),	RPE	loss	(14%),	RPE	 nodularity	 (8%),	 photoreceptor	 loss	 (43%),	 inner	 segment/	outer	segment	(IS/OS)	junction	irregularity	(37%),	IS/OS	loss	(6%),	external	 limiting	 membrane	 irregularity	 (18%)	 and	 subretinal	 fluid	identified	overlying	 the	nevus	 (16%).	A	comparison	of	pigmented	versus	 nonpigmented	 nevus	 showed	 significantly	 more	 intense	choroidal	shadowing	with	pigmented	nevus	(2).Shields	 et	 al.	 report	 gentle	 contour,	 choroidal	 shadowing	(94%),	 compression	 of	 choricapillaris	 (94%),	 photoreceptor	 loss	(43%),	 irregularity	 of	 the	 photoreceptor	 inner/outer	 (IS/OS)	 seg-ment	junction	(37%)	and	RPE	detachment	(8%)	as	typical	of	cho-roidal	nevus	(2,	3).	Subretinal	 fluid	above	nevus	can	sometimes	be	present.	Depending	on	chronicity	of	subretinal	 fluid	overlying	choroidal	 nevus,	 photoreceptors	 can	 appear	 shaggy,	 chronic	with	stalactite	or	chronic	with	retracted	photoreceptors	cleft	(3).In	 our	 material	 (71	 melanotic	 choroidal	 lesions),	 we	 obse-rved	all	discussed	 features	 in	DRI-OCT	(Fig.1).	Our	 findings	 re-garding	choroidal	nevi	summarized	in	Table	I	are	comparable	to	those	 listed	above.	We	also	noticed	different	shapes	and	 loca-tion	(relative	to	choroidal	layer)	of	nevi.	Table	I	shows	differen-ces	 between	 small	 choroidal	 nevus,	 choroidal	 nevus,	 atypical	choroidal	nevus	and	small	choroidal	melanoma.Shields	et	al.	examined	37	eyes	with	small	choroidal	melanoma	with	EDI-OCT	and	compared	them	with	EDI	tomograms	of	choroidal	nevi,	finding	melanoma	to	be	thicker,	often	with	the	presence	of	sub-retinal	 fluid	and	subretinal	 lipofuscin	deposits,	and	more	 irregular,	including	shaggy	photoreceptors,	which	were	found	in	49%	of	small	choroidal	melanomas.	Shields	et	al.	postulate	 that	shaggy	photo-receptors	represent	swollen	photoreceptors	tips	or	lipofuscin-laden	macrophages	 clinging	 to	 the	 underside	 of	 photoreceptors	 (3,	 4).	In	choroidal	melanoma,	we	also	observed	compression	of	chorio-capillaris,	choroidal	shadowing	and	a	relatively	common	thick	layer	of	subretinal	fluid	(Fig.	2).ConclusionDRI-OCT	enables	precise	visualization	of	small	choroidal	 le-sions,	 and	 improves	 differential	 diagnosis	 of	 choroidal	 nevus,	atypical	choroidal	nevus	and	small	melanoma.	DRI-OCT	is	a	very	useful	 tool	 in	 differential	 diagnosis	 of	 choroidal	 neoplasms.	With	DRI-OCT,	typical	features	of	different	choroidal	lesions	can	be	found,	which	helps	determine	the	correct	diagnosis.References:1.	 Noori	J,	Riazi	Esfahani	M,	Hajizadeh	F,	Zaferani	MM:	Choroidal mapping: a novel approach for evaluating choroidal thickness and volume.	J	Ophthalmic	Vis	Res.	2012	Apr;	7(2):	180–185.2.	 Shah	SU,	Kaliki	S,	Rojanaporn	D,	Ferenczy	SR,	Shields	JA:	Enhan-ced Depth Imaging Optical Coherence Tomography of choroidal ne-vus in 104 cases.	Ophthalmology.	2012;	119(5):	1006–1072.3.	 Shields	 CL:	 EDI-OCT of Intraocular Tumors.	 Retina	 Today	 No-vember/December	2013:	62–65.4.	 Shields	CL,	Kaliki	S,	Rojanaporn	D,	Ferenczy	SR,	Shields	JA: En-hanced depth imaging optical coherence tomography of small choroidal melanoma, comparision with choroidal nevus.	 Arch	Ophthalmol.	2012;	130	(7):	850–856.5.	 Shields	 CL,	 Pellegrini	 M,	 Ferenczy	 SR,	 Shields	 JA:	 Enhanced depth imaging optical coherence tomography of intraocular tumors:from placid to seasick to rock and rolling topogra-phy – the 2013 Francesco Orzalesi Lecture.	Retina.	2014	Aug;	34(8):1495–1512.6.	 Pellegrini	 M,	 Invernizzi	 A,	 Giani	 A,	 Staurenghi	 G:	 Enhanced depth imaging optical coherence tomography features of choro-idal osteoma.	Retina.	2014;	34(5):	958–983.The	paper	was	originally	received	22.02.2016	(KO-00055-2016)/	Praca	wpłynęła	do	Redakcji	22.02.2016	r.	(KO-00055-2016)	Accepted	for	publication	26.03.2017/	Zakwalifikowano	do	druku	26.03.2017	r.Reprint requests to (Adres do korespondencji):dr n. med. Anna MarkiewiczKatedra i Klinika Okulistyki i Onkologii Okulistycznej Wydziału Lekarskiego UJ CM w Krakowieul. Kopernika 3831-501 Krakówe-mail: annamarkiewicz@interia.plc.b.Fig. 2.	 Small	 choroidal	 melanoma:	 fundus	 view	 –	 a.,	 and	 b.	 –	 OCT	view	 with	 characteristic	 features:	 choriocapilaris	 compres-sion	(technically	the	absence	of	choriocapilaris	between	retina	and	small	melanoma),	c.	–	subretinal	fluid	(blue	arrow).Ryc. 2.	 Mały	 czerniak	 naczyniówki:	 a.	 i	 b.	 –	 DRI-OCT	 z	 typowymi	dla	 niego	 cechami	 –	 kompresja	 choriokapilar	 (praktycznie	brak	 choriokapilar	 między	 siatkówką	 a	 małym	 czerniakiem,	c.	–	płyn	podsiatkówkowy	(niebieska	strzałka).a.

Cechy charakterystyczne guzów wewnątrzgałkowych w Deep Range Imaging optycznej koherentnej tomografii

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Cechy charakterystyczne guzów wewnątrzgałkowych w Deep Range Imaging optycznej koherentnej tomografii

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