A 54-year-old man with new-onset type 2 diabetes mellitus comes to the physician for his first screening ophthalmologic examination. He has no eye symptoms and describes his vision as excellent. He does not smoke. His family history is significant for obesity and diabetes but negative for cancer. Funduscopic examination shows a small, densely pigmented lesion with irregular borders in the peripheral right choroid. The lesion is about 8 mm in diameter and is minimally raised (1 mm). Comprehensive skin examination is unremarkable.
Which of the following should be the next step in the management of this patient?

Question

A 54-year-old man with new-onset type 2 diabetes mellitus comes to the physician for his first screening ophthalmologic examination.  He has no eye symptoms and describes his vision as excellent.  He does not smoke.  His family history is significant for obesity and diabetes but negative for cancer.  Funduscopic examination shows a small, densely pigmented lesion with irregular borders in the peripheral right choroid.  The lesion is about 8 mm in diameter and is minimally raised (1 mm).  Comprehensive skin examination is unremarkable. 
Which of the following should be the next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: An ocular melanoma is a primary malignant tumor arising from the melanocytes within the uvea (iris, ciliary body, and choroid), usually from a choroidal pigmented nevus. It often remains asymptomatic for a long time and is frequently diagnosed during an examination done for other reasons. When symptoms occur, it usually presents as blurry vision or progressive and painless visual field abnormalities. Some patients may report floaters or pain (occasionally) if the tumor impinges on the nerves. Ultrasound of the eye is the most sensitive imaging modality to diagnose the lesion, while MRI is used to document any extrascleral extensions for staging and treatment decisions. Asymptomatic patients with small pigmented lesions (diameter <10 mm, thickness <3 mm) often experience an extended period of slow growth, during which they may be safely observed without treatment. A common protocol is to repeat the examination in 3 months and every 6 months thereafter. (Choices A and C) Enucleation and radiation therapy are associated with significant functional and psychological morbidity and may be safely deferred in patients with small lesions. (Choice B) Fine needle biopsy of choroidal melanoma with assessment of chromosomal characteristics and gene expression profiling is useful prior to treatment to assess the likelihood of recurrence. However, it does not alter early management for patients with small lesions. (Choice E) Local resection of choroidal melanoma is associated with a significant risk for ocular complications and tumor recurrence. In recent years, it has been considered for select patients with larger tumors, but it is not indicated for small lesions. Educational objective: Ocular melanoma is frequently identified on ophthalmologic examination done for other reasons. Asymptomatic patients with small lesions (diameter <10 mm, thickness <3 mm) may be managed with close follow-up. References: Mortality in patients with small choroidal melanoma. COMS report no. 4. The Collaborative Ocular Melanoma Study Group. (http://www.ncbi.nlm.nih.gov/pubmed/9230829) Mortality after diagnosis of small melanocytic lesions of the choroid. (http://www.ncbi.nlm.nih.gov/pubmed/20696999)

A 54-Year-Old Man with New-Onset Type 2 Diabetes Mellitus Comes