R.A.G.) reviewed the imaging studies, but were not masked. One hundred twenty-five consecutive cases of TAO (29 male, 96 female; mean age 53 ⫾ 12 years) were evaluated. Ninety-two percent of the patients had bilateral enlargement of the horizontal rectus muscles. Data are summarized in Table 1. The most common configurations of tendon-sparing muscle enlargement were cylindrical (37.6% of scans) and fusiform patterns (33.6%). Eight TAO patients (6.4%) in our series had muscle enlargement involving the tendon by CT (six) or MRI (two): five (4%) with fusiform pattern (Figures 1 and 2) and three (2.4%) with cylindrical enlargement. Patients with tendon involvement tended to be older (60 versus 52 years, P ⫽ .009, independent samples t test). Four patients (50%) in this group were males, compared with 25 (21.4%) in the tendon-sparing group (P ⫽ .06, 2). There was a statistically significant increased incidence in primary gaze horizontal diplopia in patients with tendon involvement: 37.5% of the patients with tendon involvement had diplopia in primary gaze, compared with 25.3% of the patients with tendon-sparing muscle enlargement (P ⬍ 0.001, 2) and 15.4% of the patients with no muscle enlargement (P ⬍ 0.001). In our study population we noted eight patients (6.4%) who by CT or MRI demonstrated some degree of tendon involvement, a finding contrary to the generally accepted description of the tendon-sparing nature of TAO. An investigation of the frequency of radiographic tendon involvement in TAO has not been reported previously. We also noted that there was a significantly higher frequency of primary gaze horizontal diplopia in the enlarged tendon group relative to the tendon-sparing and nonmuscle-involving groups. Our study is limited by small size and a retrospective data set, and a better-controlled prospective study would provide a more accurate representation of the frequency of tendon involvement in TAO. Although none of the patients with TAO had typical features of myositis, such as stuttering involvement of multiple muscles and rapid response to corticosteroids, there is a possibility that myositis coexisted with TAO in some of our patients, and this could compromise the validity of our conclusions. Extraocular muscle enlargement occurs in a variety of orbital diseases such as idiopathic orbital inflammation (pseudotumor), arteriovenous malformations or fistula, acromegaly, and neoplasia. Graves disease is the most common cause of extraocular muscle enlargement. In the description of CT characteristics of extraocular muscles in TAO, Rothfus and Curtin2 noted fusiform expansion, uniform enhancement, and sharp delineation of muscle bellies tapering into tendons. Rothfus and Curtin also stated that affected tendons in TAO never reach the degree of thickening seen in myositis.2 VOL. 137, NO. 6
The study by Patrinely and associates3 of muscle and tendon involvement in non-Graves cases revealed heterogeneous morphology. In their study of 15 cases of orbital inflammatory diseases, they found 40% bilateral involvement in inflammatory cases and only 47% tendon involvement. Orbital imaging studies are useful in TAO and other inflammatory orbital diseases to exclude mimicking disorders such as focal neoplasia, contiguous infection, or inflammation from adjoining sinuses or cranial cavities. However, the findings in the study by Patrinely and associates3 and in the current study remind us that the morphology of muscle enlargement, while suggestive, cannot be relied upon to definitively establish the subtype of orbital inflammatory diseases, such as myositis or TAO. Although the tendon is frequently involved in cases of myositis, it may be spared. Conversely, although the tendon is usually spared in TAO, it may occasionally be involved—so this finding on the imaging studies does not preclude the diagnosis of TAO. REFERENCES
1. Bahn RS, Heufelder AE. Pathogenesis of Graves’ ophthalmopathy. N Engl J Med 1993;329:1468 –1475. 2. Rothfus WE, Curtin HD. Extraocular muscle enlargement: a CT review. Radiology 1984;151:677–681. 3. Patrinely JR, Osborn AG, Anderson RL, Whiting AS. Computed tomographic features of nonthyroid extraocular muscle enlargement. Ophthalmology 1989;96:1038 –1047.
Conjunctival Melanoma Metastasis Diagnosed by Sentinel Lymph Node Biopsy Michael Baroody, MD, John B. Holds, MD, Mimi S. Kokoska, MD, and James Boyd, MD Evaluate the use of sentinel lymph node biopsy (SLNB) in staging and directing treatment of patients with conjunctival malignancy. DESIGN: Retrospective, noncomparative, interventional case reports. METHODS: Two patients with conjunctival melanoma underwent SLNB, which consisted of lymphoscintigraphy with injection of sulfur colloid technetium-99m. Lymphazurin blue was injected intraoperatively into the area of prior excision. The combination of a signal PURPOSE:
Accepted for publication Jan 2, 2004. From the Department of Surgery, Division of Plastic Surgery, Pennsylvania State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Ophthalmology, Saint Louis University, St. Louis, Missouri; Department of Otolaryngology—Head and Neck Surgery, University of Arkansas for Medical Sciences and John L. McClellan Memorial Veterans Hospital, Little Rock, Arkansas; and Department of Otolaryngology—Head and Neck Surgery, Saint Louis University, St. Louis, Missouri. Inquiries to John B. Holds, MD, 450 N New Ballas Rd, No 266, St. Louis, MO 63141; fax: (314) 567-6575; e-mail:
[email protected]
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FIGURE 2. (Top) Fleshy conjunctival mass of the left inferior conjunctival fornix 1 month before excisional biopsy. (Bottom) Lymphoscintigraphy showing drainage from the lateral half of the eyelid to the parotid/preauricular chain and from the medial eyelid to the submandibular nodes.
FIGURE 1. (Top) Clinical appearance of nodular malignant melanoma of the conjunctiva. (Bottom) Superficial parotid sentinel node showing metastatic melanoma filling lymph node (original magnification, ⴛ40).
Lymphatic system mapping determines the SLN location, and 200 Ci of sulfur colloid technetium-99m is injected at the site of previous lesion excision. Serial lymphoscintigraphy outlines the lymphatic drainage. A gamma probe verifies the location, and the overlying skin is marked; then 0.4 to 1.5 ml of lymphazurin blue dye is injected intraoperatively at the lesion site. A skin incision made over the presumed SLN is explored. The gamma probe and blue dye aid in locating and verifying the nodes. The “hot” nodes are excised, confirmed to be “hot” away from the operative field, and the gamma probe is used to verify a “cold” nodal bed. The excised nodes undergo pathologic examination.
through the sulfur colloid technetium-99m and blue staining identified SLNs. RESULTS: In both patients, the SLNs containing metastatic disease were identified and biopsies obtained, aiding staging and optimal therapy. CONCLUSION: Sentinel lymph node biopsy has been recently reported as an aid in evaluating patients with periocular malignancies. These reports of patients with tumor-positive SLNs arising from the lymphatic metastasis of conjunctival malignancies underscore the utility of this important technique in evaluating patients with periocular malignancies. (Am J Ophthalmol 2004; 137:1147–1149. © 2004 by Elsevier Inc. All rights reserved.)
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● CASE 1:
A 33-year-old woman presented with a 4-year history of a pigmented lesion of the right nasal conjunctival fornix (Figure 1, top). The remainder of her ocular examination was unremarkable. There were no palpable lymph nodes of her head and neck. Magnetic resonance imaging of the orbit showed a well-circumscribed 5 ⫻ 5-mm mass. Excisional biopsy identified the lesion as
ENTINEL LYMPH NODE BIOPSY (SLNB) USES LOCAL INJEC-
tions of sulfur colloid technetium-99m and lymphazurin blue to identify appropriate lymph nodes.1 The technique is especially effective in staging malignant melanoma.
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nodular malignant melanoma with a Breslow depth of more than 4.5 mm. Reexcision was performed because of narrow negative margins on the initial specimen. Staging computed tomography scans of the neck, chest, abdomen, and pelvis were normal. Sentinel lymph node biopsy revealed a metastatic melanoma in a right superficial parotid gland lymph node (Figure 1, bottom). Lymphoscintigraphy showed no other areas of increased uptake in the neck or thorax on immediate and delayed imaging. She underwent an ipsilateral superficial parotidectomy and modified radical neck dissection, revealing one of 25 lymph nodes positive for tumor, followed by investigational melanoma vaccine therapy. Seven months after presentation, a left-side neck mass, right dermal, and liver metastases developed; the patient died of progressive metastases. ● CASE 2:
A healthy 59-year-old man presented with a 6-month history of an enlarging conjunctival mass (Figure 2, top). He had undergone an excisional biopsy the week before. The eye examination was unremarkable except for the biopsy site. There was no apparent residual tumor and no palpable neck, submandibular, or preauricular lymph nodes. An otolaryngologic consultant reported no clinical evidence of metastasis. He underwent reexcision of the conjunctiva and adjacent tissues. Because of the risk of metastasis (original lesion thickness 8 mm), the patient underwent SLNB. Injection lateral to the excision bed showed drainage to a preauricular node, followed by drainage to a jugulodigastric node. A medial injection drained to a submandibular node (Figure 2, bottom). The preauricular SLN showed a few clusters of large S100⫹ malignant melanoma cells. The submandibular node revealed no tumor. The patient underwent total parotidectomy and neck dissection, revealing no additional tumor. He remains disease free at 18 months. The role of SLNB for staging cutaneous melanoma is established; however, there is little information available regarding conjunctival melanoma. Conjunctival malignant tumors present difficult management choices because of the proximity of the globe and overlapping lymphatic drainage basins. In Case 2, injections lateral to the biopsy site traveled to the preauricular region and those injected medially drained to the submandibular nodes. Sentinel lymph node biopsies were taken from both nodal basins revealing metastasis only in the preauricular basin. The positron emission tomography scan proved falsely negative.2 The utility of the SLNB method is well demonstrated in these overlapping nodal basins. We present two cases that utilized SLNB for patients with melanoma of the conjunctiva and negative nodal disease on clinical examination and preoperative imaging. Sentinel lymph node biopsy frequently replaces prophylactic complete lymph node dissection and selective neck dissection in clinically negative necks.1,3,4 The positive SLN guided the patients’ subsequent treatment course.1,5,6 VOL. 137, NO. 6
Sentinel lymph node biopsy may become the standard of care for evaluating patients with conjunctival malignancies prone to lymphatic spread. Ultimately, larger studies and case series are required to determine if implementation of SLNB in these malignancies will improve overall patient survival. REFERENCES
1. Morton DL, Wen DR, Wong JH, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992;127:392–399. 2. Acland KM, Healy C, Calonje E, et al. Comparison of positron emission tomography scanning and sentinel node biopsy in the detection of micrometastases of primary cutaneous malignant melanoma. J Clin Oncol 2001;19:2674 –2678. 3. Chao C, McMasters KM. Update on the use of sentinel node biopsy in patients with melanoma: who and how. Curr Opin Oncol 2002;14:217–220. 4. Carlson GW, Murray DR, Greenlee R, et al. Management of malignant melanoma of the head and neck using dynamic lymphoscintigraphy and gamma probe-guided sentinel lymph node biopsy. Arch Otolaryngol Head Neck Surg 2000;126: 433–437. 5. Glass FL, Cottam JA, Reintgen DS. Lymphatic mapping and sentinel node biopsy in the management of high-risk melanoma. J Am Acad Dermatol 1998;39:603–610. 6. Wanebo HJ, Harpole D, Teates CD. Radionuclide lymphoscintigraphy with technetium 99m antimony sulfide colloid to identify lymphatic drainage of cutaneous melanoma at ambiguous sites in the head and neck and trunk. Cancer 1985; 15(55):1403–1413.
Radiation-blocking Glasses Allow Vision During Ophthalmic Plaque Radiation Therapy Paul T. Finger, MD, and Andrzej Szechter, PhD To evaluate the use of leaded safety glasses to block radiation and allow for vision during ophthalmic plaque radiation therapy. DESIGN: Interventional case series. METHODS: Eight patients were treated with palladium 103 ophthalmic plaque radiotherapy and measured for emitted radiation while wearing leaded glasses or a lead patch. Radiation emission was measured at 1 m so as to compare the glasses’ ability to block radiation in vivo. RESULTS: In two patients the tumor was in the patients’ only seeing eye, and the leaded radiation safety glasses allowed them to function (feed themselves and walk to the bathroom unassisted). In two additional patients, the PURPOSE:
Accepted for publication Jan 2, 2004. From The New York Eye Cancer Center (P.T.F., A.S.), the New York Eye & Ear Infirmary (P.T.F.), St Vincent’s Comprehensive Cancer Center (P.T.F., A.S.), and New York University School of Medicine (P.T.F.), New York, New York. This study was supported by The EyeCare Foundation, Inc, and Research to Prevent Blindness, New York, New York. Inquiries to Paul T. Finger, MD, New York Eye Cancer Center, 115 E 61st St, New York, NY 10021. e-mail:
[email protected]
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