Combination of multimodal imaging features predictive of choroidal nevus transformation into melanoma

Abstract

AimTo characterise combinations of multimodal imaging risk factors and predictive value for choroidal nevus transformation into melanoma.MethodsThis is a retrospective review of multimodal imaging features for 3806 choroidal nevi from 1 January 2007 through 1 January 2017. Kaplan-Meier estimates and Cox regression analyses were used to calculate 5-year percentages of growth to melanoma and HR.ResultsUsing multimodal imaging, six risk factors predictive of choroidal nevus transformation into melanoma were identified, namely tumour thickness >2 mm, subretinal fluid, symptoms of visual acuity loss to 20/50 or worse, orange pigment, hollow acoustic density and tumour largest basal diameter >5 mm. Kaplan-Meier 5-year estimated tumour growth was found in 1% of nevi with no risk factors, 11% (range 9%–37%) with one factor, 22% (12%–68%) with two factors, 34% (21%–100%) with three factors, 51% (0%–100%) with four factors and 55% (0%–100%) with five factors. HR for growth was 0.1 with no factor, 2.1–7.8 with one factor, 1.8–12.1 with two factors, 4.0–24.4 with three factors, 4.6–170.0 with four factors and 12.0–595.0 with five factors. The highest HR with each combination of two, three, four or five risk factors always included symptoms of visual acuity loss and orange pigment.ConclusionSix risk factors for choroidal nevus transformation into melanoma by multimodal imaging have been identified. Risk for transformation into melanoma is 1% when no factors are present, and approaches 100% with specific combinations of three or more risk factors. Understanding how combinations of factors influence risk of transformation into melanoma can guide counselling and treatment decisions.

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“…Low internal acoustic reflectivity (i.e., ‘ultrasonographic hollowness’) can aid the differentiation of choroidal nevi from melanomas [ 25 , 33 , 34 ] and is helpful in a sub-specialty ocular oncology practice when weighing the risks and benefits of treatment versus observation. With respect to echographic changes over time, Doro et al found that nevi < 1.5 mm thick showed no change, whereas a progressive increase in hollowness on B-scan occurred in 18% of tumors with thickness > 1.5 mm [ 35 ].…”

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“…While the presence of various combinations of the risk factors for future growth are the basis for counselling and treatment decisions [15], their role in determining the urgency of referrals to an ocular oncologist has not been studied. There will be fears that the MOLES scoring system will delay the treatment of some patients with choroidal melanoma, because the likelihood of malignancy is underestimated.…”

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“…The overall mean 5‐year estimates for transformation were 1% for those with no risk factor, 11% with one factor, 22% with two factors, 34% with three factors, 51% with four factors and 55% with five risk factors 3 . A further report identified that not all risk factors inferred the same risk for growth, with the highest hazard ratio with each combination of factors always including symptoms of visual acuity loss and orange pigment 4 . Furthermore, the risk of growth into melanoma increased with each millimetre increase in naevus thickness, emphasizing the importance of lesion thickness when monitoring pigmented uveal lesions 5 .…”