Usefulness of colour Doppler flow imaging in the management of lacrimal gland lesions.

OBJECTIVE: To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions. METHODS: Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003-2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination. RESULTS: The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p < 0.001), hypoechogenicity (p < 0.001), high vascular intensity (p < 0.001), both central and peripheral vascularization (p < 0.001), tree-shape vascularization (p < 0.05) and a low resistance index (RI) (p < 0.0001). EL were significantly more likely to present with the presence of cysts (p < 0.001), and a higher RI. Receiver operating characteristic curves identified a RI value of 0.72 as the best cut-off to differentiate NEL from EL, with a sensitivity and specificity of 100 %. CONCLUSION: CDFI is a valuable tool in the differential diagnosis of lacrimal fossa lesions. Resistance index measurement enables substantial distinction between EL and NEL, thus providing crucial data for surgical management. KEY POINTS: • CDFI is a valuable tool in lacrimal fossa lesions. • Resistance Index measurement enables substantial distinction between epithelial and non-epithelial lesions. • Management of patients becomes more appropriate.

In aged mice, outgrowth of intraocular melanoma depends on proangiogenic M2-type macrophages.

Macrophages are part of the tumor microenvironment and have been associated with poor prognosis in uveal melanoma. We determined the presence of macrophages and their differentiation status in a murine intraocular melanoma model. Inoculation of B16F10 cells into the anterior chamber of the eye resulted in rapid tumor outgrowth. Strikingly, in aged mice, tumor progression depended on the presence of macrophages, as local depletion of these cells prevented tumor outgrowth, indicating that macrophages in old mice had a strong tumor-promoting role. Immunohistochemistry and gene expression analysis revealed that macrophages carried M2-type characteristics, as shown by CD163 and peroxisome proliferator-activated receptor gamma expression, and that multiple angiogenic genes were heavily overrepresented in tumors of old mice. The M2-type macrophages were also shown to have immunosuppressive features. We conclude that tumor-associated macrophages are directly involved in tumor outgrowth of intraocular melanoma and that macrophages in aged mice have a predisposition for an M2-type profile.

Hematolymphoid malignancies with intraocular intravascular involvement: report of 2 cases.

The interaction between the endothelium and malignant hematolymphoid cells within vessels of the eye can result in focal or diffuse intravascular pathology. As a result, correlation of these findings with specific clinical and ophthalmologic features can vary. We review the ophthalmic findings in two cases of hematolymphoid malignancies limited to the intravascular space and review published literature on this topic. In cases of intravascular large B-cell lymphoma, underexpression of ß1-integrin and intercellular adhesion molecule-1 by the cells of intravascular large B-cell lymphoma results in diffuse ocular vascular involvement. The widespread degree of intravascular involvement correlates with clinical ophthalmologic findings and may lead to retinal and choroidal detachment that is observed postmortem. Conversely, in the context of acute leukemia, induced overexpression of certain adhesion molecules (intercellular adhesion molecule-1 and vascular cell adhesion molecule-1) in the endothelium of certain vascular beds may result in leukostasis with only selective (choroidal) ocular vessel involvement. As a result of only focal vascular activation and adhesion in the orbit, the gross findings in these cases are minimal and may not correlate with clinical ophthalmologic findings.

[Angiogenesis and antiangiogenesis in intraocular tumors]. / Angiogeneza si antiangiogeneza în tumorile intraoculare.

Angiogenesis, fundamental process that consists in the formation of new vessels, is essential physiologically in the tissue maintenance and of the homeostasis, having in this sense a few positive and negative regulators. Vascular endothelial growth factor and other angiogenical proteins play a major role in the ocular and general angiogenesis. The solid tumors need new vessels in order to survive and grow, therefore the anti-angiogenic agents can represent important instruments in the ocular oncological therapy The intravitreal administration of the anti-VEGF agents delay the growth of the intraocular tumors, decreases the odds of their methastasis at distance, increases the therapeutical effects of the conservative treatment by irradiation and can limit the ocular complications of radiotherapy.

A pilot study of vasculogenic mimicry immunohistochemical expression in intraocular melanoma model.

Vasculogenic mimicry (VM) has been recognized as a new form of angiogenesis. However, some previous studies have demonstrated the absence of VM channel in a uveal melanoma xenograft mice model. This study investigated the pattern and distribution of microcirculation in an intraocular animal model. C57Bl/6 mice were randomly divided into 3 groups used for the blood supply models of malignant melanoma. The right eyes of the mice received subretinal injections with B16 melanoma cells and the left eyes were the control. One experimental group mice was randomly sacrificed at days 3, 7 and 14 to evaluate the tumor size and microcirculation by immunostaining with anti-CD34 antibodies, PAS staining and electronic microscopy (EM). Activated-carbon tracing was used to confirm whether the VM structure connected to the host blood circulation at day 14. We observed 3 types of microcirculation patterns in this model. The tracer was used to confirm whether VM structure connected to the host blood circulation. The distribution of VM and MV was not uniform and appeared in patches. As the area of tumor tissue expands, the number of endothelium increases and that of VM decreases. The number of endothelium-dependent vessels correlated with the tumor size (r=0.805, P=0.000), while the number of VM was inversely correlated (r=0.47, P=0.03). The EM results validated the presence of 3 patterns. In conclusion, VM along with endothelium-dependent vessels and MV sustained the blood supply. Tumor cells can obtain oxygen and nutriment through VM and MV besides endothelium-dependent vessels. VM may be a way to adapt to rapid tumor growth and invasiveness.

The effect of intralesional steroid injections on the volume and blood flow in periocular capillary haemangiomas.

AIM: To examine the effect of steroid therapy on the volume estimates and blood flow characteristics of childhood periorbital capillary haemangiomas. PATIENTS AND METHODS: Children at risk of amblyopia due to periorbital haemangiomas were treated with intralesional steroid injections (between 1 and 4 courses) and serial assessment of the volume and blood-flow characteristics of the lesions measured using colour Doppler ultrasonography. The characteristics of the haemangiomas in these children were compared with a cohort of untreated cases. RESULTS: Eight of nine treated children were female, this proportion being significantly different from the equal sex distribution of an untreated cohort (p < 0.05). All children in the steroid-treated group presented within 1 month of birth, compared to the untreated children, who presented at an average of 2.1 months of age (range 0-14, median 2.9 months) (p = 0.04) and they required significantly longer follow-up in the Orbital service (mean 65 months, range 26-105), compared with an average of 35 months (range 4-92, median 23) in the untreated group (p = 0.002). The maximum estimated volume of the lesions were significantly larger in the treated group (treated group mean 8.9 ml, untreated group mean 4.1 ml; p = 0.016), with a trend towards higher maximum measured blood velocities in the treated group (treated mean 64 cm compared with untreated mean 52 cm; p = 0.1). Steroid injections appear to reduce the volume and blood flow of haemangiomas, this suppression persisting for several months (between 5 and 20) before the lesion later displays the cyclic fluctuations in volume and flow seen with untreated lesions. All treated haemangiomas had some residual vascular anomaly, detectable on ultrasonography, at last follow-up--this being despite absence of clinical signs in most cases. CONCLUSION: Periorbital capillary haemangiomas requiring steroid therapy for risk of amblyopia were significantly commoner in females, were larger lesions and presented at an earlier age. Intralesional steroids appear to cause a reduction of blood flow, with a transient reduction in volume and a suppression of the natural cyclic variation seen without treatment. The changes after a course of steroid therapy appear to last for between 5 and 20 months, this period of suppression of the lesion probably being particularly useful during infancy and early childhood when the child is at greatest risk of amblyopia.

Identification of Feeder Vessels in Ocular Surface Neoplasia Using Indocyanine Green Angiography.

PURPOSE: To evaluate indocyanine green angiography (ICGA) for the identification and characterization of afferent (feeding) and efferent (draining) vessels in patients with ocular surface neoplasia. MATERIALS AND METHODS: Consecutive patients with biopsy-proven benign, pre-invasive, or invasive ocular surface tumors of the bulbar conjunctiva were included. Patients underwent anterior segment optical coherence tomography, ICGA, and color photography for the evaluation of the thickness, location, number, and diameter of afferent and efferent vessels of the lesions. RESULTS: Twenty-two eyes of 22 patients with papillomas (n = 4), intra-epithelial neoplasia lesion (n = 2) in situ or invasive carcinomas (n = 6), nevus (n = 5), conjunctival melanocytic intra-epithelial neoplasia lesion (n = 1), and in situ or invasive melanomas (n = 4) were investigated. Afferent (feeder) vessels were identified in all lesions. There were fewer afferent (3.1 ± 1.6) than efferent (7.5 ± 3.5) vessels per lesion (p < 0.001) and the mean diameter was smaller for afferent (101 ± 62 µm, 28-281) than efferent vessels (137 ± 51 µm, 31-652; p = 0.017). The number of afferent and efferent vessels was associated with the thickness of the lesion (p = 0.037, p < 0.01). Lesion filling times differed between benign and invasive or pre-invasive lesions (p = 0.018). CONCLUSIONS: ICGA is a useful adjunctive in vivo imaging method for the assessment of the vasculature in patients with suspected ocular surface neoplasia.

Combination therapy targeting the tumor microenvironment is effective in a model of human ocular melanoma.

BACKGROUND: Ocular melanoma is the leading intraocular malignancy. There is no effective treatment for metastatic ocular melanoma. We sought a treatment targeting the tumor microenvironment as well as the tumor cells. METHODS: Migration of HUVEC cells, the ability of HUVEC cells to form tubes, and proliferative capacity of a human ocular melanoma cell line were tested in the presence of lenalidomide and sorafenib alone and in combination. The compounds were also tested in a rat aortic ring assay and were tested in a highly aggressive human ocular melanoma xenograft model. RESULTS: Lenalidomide and Sorafenib inhibit HUVEC ability to migrate and form tubes and when used in combination the inhibition is increased. The agents alone and in combination inhibit outgrowth in the rat aortic ring model. The combination of the agents improved the inhibition over either single agent. In a xenograft model, combination therapy inhibited tumor growth over inhibition by single agent alone in a significant fashion (p < 0.004: lenalidomide and p < 0.0035: sorafenib). Furthermore, spontaneous lung metastasis development was completely inhibited in the combination treated animals. Sixty percent of vehicle treated animals developed lung metastases compared to 50% of lenalidomide treated animals, and 33% of sorafenib treated animals. CONCLUSION: Lenalidomide and sorafenib are effective at targeting endothelial cells, inhibiting growth of ocular melanoma cells and can inhibit growth of tumors in a xenograft model as well as inhibit development of metastases. Combining these agents works in an additive to synergistic way to inhibit the growth of tumors and development of metastases.

Anti-angiogenic therapy: Prospects for treatment of ocular tumors.

The growth of new blood vessels (angiogenesis) within tumors is essential for tumor growth, maintenance, and metastasis. Angiogenesis research has identified a host of pro- and anti-angiogenic factors that regulate an "angiogenic switch," which when turned on, allows tumors to assume a more aggressive form. Angiogensis inhibitors that target this switch are in clinical trials for a wide array of tumor types. Although angiogenesis inhibitors are already widely used to treat ocular disease, only limited case reports are currently available for the use of angiogenesis inhibitors to treat ocular tumors. Evidence for angiogenesis in the growth and spread of uveal melanoma, retinoblastoma, and von Hippel Lindau (VHL) disease exists. The very limited trials of angiogenesis inhibitors in the treatment of uveal melanoma and VHL are promising, although more extensive controlled trials will be needed to confirm their efficacy.

Angiogenic potential of prostate carcinoma cells overexpressing bcl-2.

BACKGROUND: Tumors commonly outgrow their blood supply, thereby creating hypoxic conditions, which induce apoptosis and increase expression of angiogenic growth factors. The bcl-2 oncogene inhibits apoptosis induced by a variety of stimuli, including hypoxia. On the basis of bcl-2's role in regulating apoptosis in response to hypoxia, we hypothesized that this oncogene might affect other responses to hypoxia, such as the expression of angiogenic growth factors. METHODS: Three prostate carcinoma cell lines, PC3, LNCaP, and DU-145, were stably transfected with a bcl-2 complementary DNA (cDNA), and transfectants were analyzed in vitro for the expression of angiogenic factors after exposure to either normoxic (19% O(2)) or hypoxic (1% O(2)) conditions. The in vivo angiogenic potential of the transfected cells was determined by analyzing vessel density in xenografts derived from them and by measuring the ability of these xenografts to induce neovascularization when implanted in mouse corneal micropockets. Statistical tests were two-sided. RESULTS: When exposed to hypoxic conditions, prostate carcinoma cells overexpressing bcl-2 expressed statistically significantly higher levels of vascular endothelial growth factor (VEGF), an angiogenic factor, than control-transfected cells (P = .001 for PC3, P = .04 for DU-145 after 48 hours). This effect of bcl-2 was independent of its antiapoptotic activity because increased expression of VEGF was detected in PC3 cells overexpressing bcl-2 even though PC3 cells are inherently resistant to hypoxia-induced apoptosis. In vivo, xenograft tumors derived from the bcl-2-overexpressing prostate carcinoma cell lines displayed increased angiogenic potential and grew more aggressively than tumors derived from the control cell lines (P =.03 for PC3). Treatment of bcl-2-overexpressing and control tumors with the antiangiogenic drug TNP-470 neutralized the aggressive angiogenesis in bcl-2-overexpressing tumors (P = .04 for PC3, P = .004 for DU-145) and the moderate angiogenesis in control tumors (P = .01 for PC3, P = .05 for DU-145), resulting in similar growth rates for both tumors. CONCLUSIONS: bcl-2 may play a dual role in tumorigenesis by suppressing apoptosis and by stimulating angiogenesis.

[Evaluation of color Doppler imaging of ophthalmic tumors based on histopathologic findings]. / Szemészeti daganatok színkódolt ultrahangvizsgálatának értékelése a szövettani eredmény tükrében.

PURPOSE: To examine retrospectively the diagnostic and differential diagnostic value of color Doppler imaging (CDI) in cases of suspected intraocular and orbital tumors. PATIENTS AND METHODS: Color Doppler examination (using Acuson 128, Philips-ATL UM-9, HDI 3000, 5000, Siemens Elegra, GE Logiq9) was performed in a total of 194 patients (177 intraocular, 17 orbital tumors). The results were compared to the clinical findings (routine examination, conventional ultrasound examination) and the results of angiography (FLAG, ICG). Furthermore, in 73 cases histopathology records were obtained for comparison. RESULTS: Signs of blood flow could be detected in 137 cases (71%); the Doppler spectrum was low resistance in the large majority (130) of these cases. In cases where histopathology records were available, 60 of the 73 (82%) showed good concordance between the CDI diagnosis and the pathological results. CDI gave false positive results in 3, and false negative findings in 10 cases; the latter occurred mainly in small iris or ciliary body tumors. CONCLUSIONS: Using CDI, blood flow is demonstrable in the majority of intraocular and orbital tumors, especially if the tumor diameter is larger than 3 mm. CDI flow detection, however, is less reliable for iris or ciliary body tumors.

Retinoblastoma. The relationship of proliferating cells to blood vessels.

In 150 retinoblastomas the authors found a uniform thickness of the cuff of viable retinoblastoma cells that surrounds blood vessels. The mean thickness was 98.7 microns with a standard deviation of 11.9 microns. The cross-sectional area of the cuff was negatively correlated with the mitotic activity in the cuff and positively correlated with the diameter of the central vessel. The mitotic activity in the cuff of cells was inversely related to the distance from the central blood vessel. When the cuff was divided into three concentric rings, the inner ring contained a mean of 6.2 mitotic figures, the middle ring contained a mean of 2.9 mitotic figures, and the outer ring contained a mean of 0.6 mitotic figures. This pattern of growth is similar to that observed in other rapidly growing neoplasms in humans and experimental animals. In these tumors this pattern results from reduction in oxygen tension with increased distance from the central blood vessel.

Vitamin D inhibits angiogenesis in transgenic murine retinoblastoma.

PURPOSE: Vitamin D compounds have been shown to inhibit tumor growth in a transgenic retinoblastoma murine model. The mechanism of action has not been defined clearly, although an antiangiogenic action has been proposed. METHODS: Transgenic retinoblastoma mice received high (0.05 microgram) and low (0.025 microgram) doses of vitamin D3 by intraperitoneal injection 5 times per week for 5 weeks. Control animals were injected with mineral oil vehicle alone. At 5 months of age, the animals were killed and eyes were enucleated and processed for light microscopy. Paraffin-embedded sections were stained with an immunoperoxidase stain (GS-1) specific for mammalian vascular endothelium. Sections were graded by a single masked reviewer, and intraobserver reliability was assessed. Mean vessel counts were made for each group. RESULTS: The high-dose group had the lowest mean vessel count (8.5), followed by the low-dose group (10.1). The control group had the highest mean vessel count (14.1). Vitamin D-treated animals (high- and low-dose groups combined) had significantly fewer vessels P = 0.001) than untreated controls. CONCLUSIONS: These results support the hypothesis that inhibition of angiogenesis is a mechanism of action for vitamin D in the transgenic retinoblastoma mouse model.

Vitreous inhibition of tumor neovascularization.

Cartilage has been reported to contain a factor that inhibits tumor neovascularization. Rabbit vitreous, another avascular tissue, has also been shown recently to have an inhibitory effect on tumor neovascularization. This report describes our results on the effects of bovine and human vitreous on tumor neovascularization with use of a rabbit cornea model. Inhibition of neovascularization was observed with both bovine and human vitreous in the form of reduced new blood vessel growth over and around the vitreous pellet and subsequent delayed exophytic tumor growth. Stimulation of neovascularization by bovine and human vitreous was also observed as an early, short-lived response.

Fluorescein angiography in pigmented iris tumors.

Three pigmented iris tumors were studied with fluorescein angiography. Two malignant melanomas leaked dye very early in the arterial phase, while blockage of fluorescence was noted in one melanocytoma. The angiographic appearance of these three lesions was consistent with that, which would be anticipated, based on knowledge of similar lesions in the fundus of the eye. We recommend that fluorescein angiography be performed for all pigmented iris tumors as part of the diagnostic evaluation.

Application of fluorescein angiography in retinoblastoma.

Although a slight dilatation of the retinal capillaries is the only significant fluorescein angiographic finding in retinoblastoma when the tumor is less than 0.5 disk diameter in size, microaneurysms become distinct in the tumor after it attains a size of 1 disk diameter. As growth of the tumor progresses, blood vessels within the tumor become thicker and permeability increases; eventually neovascularization occurs. When the tumor exceeds 3 disk diameters in size, the feeder arteries and drainage veins become dilated and tortuous. With healing of the retinoblastoma, light fluorescent stains and thick vessels are no longer demonstrable and the dye is visible in the sclera during later periods. A recurrent tumor is visible as a white fluffy mass in which the fluorescent dye accumulates. Occasionally a thick vessel stemming from the scar can be detected in a recurrent tumor.

Value of fluorescein iridography in diagnosis of tumours of the iridociliary zone.

Fluorescein iridoangiography of 33 eyes with benign tumours and 22 eyes with malignant tumours is discussed. In cases of leiomyoma the tumour vessels have a distinct pattern, and fluorescence of the tumour tissue is mottled and short-lived. Malignant tumours are characterised by distortion of their vessels. Simultaneously the patches of fluorescence appear in the tissue of the tumour and lead to a diffuse confluence. Changes in the architecture of the vessels of the iris near the tumour and absence of fluorescence at the pupil margin indicate growth of the neoplasm.

First experience with a new echographic contrast agent.

The intravenous injection of an ultrasound contrast agent can enhance signals from blood flow. Broad toxicological and pharmaceutical studies in animals confirmed the safety and efficacy of an ultrasound contrast agent made of microparticles of galactose with stabilised microbubbles in watery suspension (SH U 508 A). In this paper 10 patients with different malignant orbital and ocular tumours have been evaluated with an echo colour Doppler machine before and after the injection of SH U 508 A. An enhancement of the Doppler signals in the lesions in different degrees has been detected. This echographic contrast agent seems to be very important not only in the evaluation of vascular lesions, but also in evaluating the effectiveness of radiotherapy in malignant tumours and could spread the echographic indications in several other ophthalmic fields.

Enhancement by androgen of the angiogenic ability of androgen-responsive Shionogi carcinoma 115.

The effects of various steroids on the induction of angiogenesis by androgen-responsive Shionogi carcinoma 115 (SC115) were investigated by implanting a piece of a SC115 tumor tissue into a rabbit cornea together with a pellet containing each steroid (250 micrograms) and by examining neovascularization from the limbus. SC115 tumor tissues induced neovascularization in 42% corneas in the absence of steroids, and in 31, 63, 80 and 4% in the presence of estradiol-17 beta, progesterone, testosterone and dexamethasone, respectively. Only testosterone significantly increased the percentage of corneas with neovascularization, while dexamethasone significantly decreased it. Testosterone itself induced no neovascularization, and dexamethasone also inhibited neovascularization induced by acidic fibroblast growth factor. The present results suggest that androgen increases the secretion of an angiogenic factor(s) by an androgen-responsive SC115 tumor, while dexamethasone inhibits angiogenesis induced by the angiogenic factor(s).