Int J Clin Oncol (2007) 12:303304 DOI 10.

1007/s10147-006-0651-9

The Japan Society of Clinical Oncology 2007

CASE REPORT James Haddow Danayya Muthapati Ilyas Arshad Mohit Gupta Pradeep Agarwal

Multiple bilateral choroidal metastasis from anal melanoma

Received: August 26, 2006 / Accepted: December 18, 2006

Abstract A 58-year-old Caucasian woman with bleeding per rectum had a melanoma of the anal canal. She subsequently presented with visual disturbance and was noted to have bilateral multiple choroidal metastasis, along with other multiple systemic metastases. Orbital radiotherapy led to near complete resolution of the ocular metastasis. Key words Choroidal Anal melanomas Metastasis

Introduction
We report a case of multiple bilateral choroidal metastasis from anal melanoma, with a brief review of the literature.

Case report
A 58-year-old Caucasian woman with a 2-month history of per rectal bleeding, pain on defecation, and a sensation of a lump in her anal canal was seen by the anorectal surgeon. She had also lost about 7 kg of weight in 2 months. Her past medical history was unremarkable, apart from dry eyes. On biopsy of an ulcerative lesion on the posterior wall of the anal canal, the diagnosis was conrmed as malignant melanoma of the anal canal. Systemic evaluation conrmed a single metastatic deposit in the right lung base. The melanoma was excised through the abdominoperineal approach. Two months after the operation she experienced nonspecic visual disturbances and ashing lights in both eyes. On examination in the eye clinic, her visual acuities were 6/62

in both eyes. Anterior segment and intraocular pressure was normal. Fundus examination after dilating the pupils with tropicamide 1% eye drops showed multiple raised amelanotic choroidal lesions with focal overlying serous elevations of the retina at the posterior pole in both eyes. A diagnosis of multiple bilateral choroidal metastasis was made. A positron emission tomography (PET) scan demonstrated these metastases, as well as additional widespread metastatic foci in the neck, thorax, abdomen, and pelvis. As the patient had multiple systemic metastases, after discussion with her she was started on adjuvant dacarbazine (DTIC) chemotherapy for palliation and radiotherapy to the orbits. On review 4 weeks later, the serous elevations and the choroidal lesions had decreased, with one possible lesion in the macular area in both eyes. Her visual acuity has stayed stable for 3 months since and she is still under follow-up.

Discussion
Primary anorectal melanoma is rare, accounting for 0.5% of all colorectal and anal malignancies1 and only 0.4%1.6% of all melanomas.2 It is more common in Caucasians; Cooper et al.3 reported that 81 out of 85 patients (95%) were Caucasians, 3 were African American, and 1 was mixed Asian and African American. The disease usually presents in the sixth decade of life and is more common in females. Rectal bleeding is the most common symptom at presentation, with others being a mass, tenesmus, suspicion of hemorrhoids, incontinence, inguinal mass, pruritus, change in bowel habit, and loss of weight.4 The diagnosis is often delayed, with a mean time from presentation to diagnosis of 45 months, and it is commonly misdiagnosed as hemorrhoids. Prognosis is poor, with an overall 5-year survival of around 10%.5,6 Metastatic disease is present in 15%38% of patients at the time of presentation,5,6 as it was in our patient, with pelvis, rectum, liver, vagina, lung, bone, skin, brain, colon, perineum, groin,6 and breast7 being the common sites.

J. Haddow I. Arshad P. Agarwal Department of Surgery, Pilgrim Hospital, Sibsey Road, Boston, UK D. Muthapati M. Gupta (*) Department of Ophthalmology, Pilgrim Hospital, Sibsey Road, Boston, UK, PE21 9QS Tel. +44-1205-446493; Fax +44-1205-356137 e-mail: mohiteye@yahoo.co.uk

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The uveal tract is the most common ocular site for primary intraocular malignancy and also for metastasis from other systemic malignancies. Small metastatic foci to the uveal tract can be undiagnosed unless they affect the posterior pole and cause visual symptoms. All metastases to the uvea occur via hematogenous routes because there are no intraocular lymphatic channels. A choroidal metastasis is usually conned by Bruch`s membrane and appears as a creamy yellow-colored sessile or minimally elevated mass; it is often multifocal and bilateral. The tumor sometimes becomes signicantly elevated because it inltrates laterally. Occasionally the deposits assume a globular shape and mimic an amelanotic melanoma. Secondary exudative retinal detachment is frequent and may occur in eyes with relatively small deposits. The common primaries causing choroidal metastasis include breast and bronchial carcinoma, with metastasis also reported from the gastrointestinal tract, kidney, skin melanoma, prostate, ovarian carcinoma, pancreatic carcinoma, testicular embryonal carcinoma, carcinoma of thyroid, urothelial tumors, and primary adrenal lymphoma. The gastrointestinal tract tumors reported previously were adenocarcinoma of the esophagus, carcinoma of the colon, and carcinoma of the rectum.8 Uveal metastasis is best diagnosed by clinical recognition of the typical iris or fundus ndings. In cases where the choroidal lesion is atypical and metastasis is a diagnostic consideration, uorescein angiography, ultrasonography, or ne-needle aspiration biopsy can be used to make a denitive diagnosis.9 Management of uveal metastasis usually involves chemotherapy or irradiation. If the patient is receiving chemotherapy for systemic disease, then the choroidal metastasis can be followed without direct ocular treatment. If systemic chemotherapy does not control the uveal metastasis, then ocular irradiation (approximately 3500 cGy over a 4- to 5-

week period) is advisable. About half of the patients with choroidal metastasis require ocular irradiation, and the other half can be successfully controlled with chemotherapy or hormonal therapy.1012 To the best of our knowledge there is no previous report of choroidal metastasis from an anorectal melanoma. Also, ocular irradiation leading to near total resolution of the ocular metastasis is not very common.

References
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