Prognostic factors in uveal melanoma

Liver function tests in metastatic uveal melanoma

PURPOSE

To evaluate trends in liver function tests before detection of liver metastases from uveal melanoma.

DESIGN

Retrospective, comparative, observational case control study.

METHODS

SETTING

The Israel uveal melanoma center at the Hadassah University Hospital.

PATIENT POPULATION

A total of 307 uveal melanoma patients who were diagnosed with uveal melanoma and followed between the years 1988 and 1998. Of them, 30 metastatic patients who had regular follow-up by liver function tests (LFTs) and liver imaging were included in this study. Eighty nonmetastatic patients were randomly chosen as controls.

OBSERVATION PROCEDURE

The medical records of the metastatic and control groups were reviewed documenting LFTs and liver imaging results.

MAIN OUTCOME MEASURES

The mean level of each LFT, its sensitivity, specificity, and likelihood ratio at various time periods before the detection of metastases by liver imaging.

RESULTS

At the time of diagnosis of liver metastases by imaging, 50% of patients had at least one abnormal LFT (compared with only 5% of the control group). While no change was noted in the mean serum levels of bilirubin, mean lactate dehydrogenase (LDH), alkaline-phosphatase, gamma glutamyl transpeptidase (gamma GTP) aspartate-aminotrasferase, and alanine-aminotrasferase levels seem to rise, even within normal limits, during the 6 months before the detection of metastases. Based on likelihood ratios, alkaline-phosphatase and lactate dehydrogenase were the most predictive tests. Lactate dehydrogenase and aspartate-aminotransferase were already predictive at 80% of the upper normal limit, whereas alkaline-phosphatase and gamma-glutamyltransferase were most predictive at the upper normal limit.

CONCLUSIONS

Monitoring the changes in selected LFTs, even within normal limits, can help predict metastatic uveal melanoma.

Mélanomes uvéaux impliquant le corps ciliaire. Analyse de la survie après protonthérapie ou bêta-curiethérapie par ruthénium-106

INTRODUCTION

Our main goals were to study the survival of patients with uveal melanomas involving the ciliary body 5 and 10 years after treatment and to review prognosis.

MATERIAL AND METHODS

This study investigated 106 tumors (27 ciliary body melanomas and 79 choroidal-ciliary melanomas) of patients treated between June 1983 and April 1998. Seventy-two patients were treated with 106-ruthenium applicators and 34 were treated with proton therapy. Some large tumors or recurrences required a second treatment. The mean follow-up period was 91 months.

RESULTS

The mean tumor sizes before treatment were 6,6mm for melanoma thickness and 10.3mm for mean largest basal melanoma diameters (LTD). Of the patients studied, 71% were still alive at 5 years, 35% had metastasis and 27.7% developed recurrences. Multivariate analysis showed that the risk factors for melanoma-related death were LTD greater than 13mm, presence of exudative retinal detachment, macroscopic iris root involvement at the time of diagnosis, and choroidal-ciliary location.

DISCUSSION AND CONCLUSION

With 71% of patients still alive at 5 years, this review shows that melanomas involving the ciliary body do not seem less severe than more posterior uveal tumors. Because of size differences between ciliary body melanomas and choroidal-ciliary melanomas, we cannot come to the conclusion that choroidal-ciliary melanomas have a poorer prognosis than ciliary body melanomas. Largest tumor diameter over 13mm, presence of exudative retinal detachment, and macroscopic iris root involvement at the time of diagnosis are important risk factors for melanoma-related death, as shown by the multivariate analysis.

Melanoma-associated spongiform scleropathy: biochemical changes and possible relation to tumour extension

PURPOSE

To investigate biochemical changes of the sclera in eyes with melanoma-associated spongiform scleropathy (MASS), and to analyse possible relationships between these changes and tumour extension.

METHODS

Sections from 364 eyes, enucleated for choroidal and ciliary body melanoma, were examined for MASS and scleral tumour extension. Biochemical analysis was also performed on eight scleral specimens with MASS and eight specimens (controls) from morphologically normal sclera of the same eyes. The scleral thickness of each specimen was measured. Samples were delipidized, dried and weighed. The weight ratios of collagen-related amino acids were calculated based on quantitation by liquid chromatography. Amounts of glycosaminoglycans (GAGs) were determined by electrophoresis.

RESULTS

Melanoma-associated spongiform scleropathy was seen in 140 eyes (38.5%). Tumour scleral extension was observed in 82 eyes. Of these 82 eyes, 75 (91.5%) had MASS (p<0.05). Biochemically, the majority of the main amino acids of the scleral collagen and total proteins were significantly lower in areas with MASS than in the control specimens. Specific GAGs and total GAGs were found in significantly higher concentrations in areas with MASS than in the control specimens. Scleral thickness was also significantly higher in areas with MASS than in the control specimens.

CONCLUSIONS

The reduced content of collagen manifested by decreased amino acids and total proteins indicates collagen degradation in the vicinity of the tumour. The concomitant excessive deposition of GAGs accumulates water and may cause loosening of the already degraded collagen bundles, giving a histopathological picture of MASS. These changes could facilitate tumour cell migration and may explain the high incidence of MASS in eyes with scleral tumour extension.

Tumor necrosis factor alpha increases and alpha-melanocyte-stimulating hormone reduces uveal melanoma invasion through fibronectin

Iris melanomas are less likely to metastasize than posterior compartment melanomas. The anterior chamber of the eye is an immunosuppressed microenvironment where a wide range of immunosuppressive factors in aqueous humor contribute to the immune privilege. One such factor is alpha-melanocyte-stimulating hormone, a potent anti-inflammatory neuropeptide that exhibits efficacy in many studies of acute and chronic inflammation. The aim of this study was to investigate whether the different metastatic behavior of iris melanomas versus posterior compartment melanomas might be explained by the differing immunosuppressive/anti-inflammatory environments of these tumors in vivo. To investigate this hypothesis, we studied the effect of human aqueous and vitreous fluids, of the proinflammatory cytokine tumor necrosis factor alpha, and of the anti-inflammatory peptides alpha-melanocyte-stimulating hormone and melanocyte-stimulating hormone 11-13 (KP-D-V) on the invasion of three human uveal melanoma cell lines through human fibronectin. Fresh aqueous humor samples significantly decreased the invasion in two out of three uveal melanoma cell lines. In contrast, vitreous humor did not reduce invasion. Tumor necrosis factor alpha significantly increased the invasiveness of uveal melanoma cell lines by approximately 50%-80% over 20 h. Full-length alpha-melanocyte-stimulating hormone, at concentrations present in the aqueous humor (10-9 M), as well as melanocyte-stimulating hormone 11-13 (KP-D-V) reduced the invasion of cells through human fibronectin by 45%-50% and also protected uveal melanoma cells from the pro-invasive actions of tumor necrosis factor alpha. These data are consistent with inflammation playing a major role in affecting the metastatic ability of uveal melanomas. Thus, ocular microenvironments that differ in their immunosuppressive/anti-inflammatory properties may influence the invasiveness of developing tumors.

Tumour regression of uveal melanoma after ruthenium-106 brachytherapy or stereotactic radiotherapy with gamma knife or linear accelerator

PURPOSE

This study assesses differences in relative tumour regression and internal acoustic reflectivity after 3 methods of radiotherapy for uveal melanoma: (1) brachytherapy with ruthenium-106 radioactive plaques (RU), (2) fractionated high-dose gamma knife stereotactic irradiation in 2-3 fractions (GK) or (3) fractionated linear-accelerator-based stereotactic teletherapy in 5 fractions (Linac).

METHODS

Ultrasound measurements of tumour thickness and internal reflectivity were performed with standardised A scan pre-operatively and 3, 6, 9, 12, 18, 24 and 36 months postoperatively. Of 211 patients included in the study, 111 had a complete 3-year follow-up (RU: 41, GK: 37, Linac: 33). Differences in tumour thickness and internal reflectivity were assessed with analysis of variance, and post hoc multiple comparisons were calculated with Tukey's honestly significant difference test.

RESULTS

Local tumour control was excellent with all 3 methods (>93%). At 36 months, relative tumour height reduction was 69, 50 and 30% after RU, GK and Linac, respectively. In all 3 treatment groups, internal reflectivity increased from about 30% initially to 60-70% 3 years after treatment.

CONCLUSION

Brachytherapy with ruthenium-106 plaques results in a faster tumour regression as compared to teletherapy with gamma knife or Linac. Internal reflectivity increases comparably in all 3 groups. Besides tumour growth arrest, increasing internal reflectivity is considered as an important factor indicating successful treatment.

Treosulfan and gemcitabine in metastatic uveal melanoma patients: results of a multicenter feasibility study

No effective treatment currently exists for metastatic uveal melanoma. However, recent results obtained by an ATP-based tumor chemosensitivity assay have shown consistent activity of treosulfan+gemcitabine in up to 80% of tumor specimens tested. In this study we describe the first clinical results observed with this drug combination at different European centers in patients with metastatic uveal melanoma. Clinical case series of patients with metastatic uveal melanoma were treated with treosulfan+gemcitabine at seven different centers. Fourteen patients, 13 previously untreated and one pretreated with chemoimmunotherapy, were included in the study. Patients received treosulfan+gemcitabine in four different dose regimens. The response rates, progression-free and overall survival, and toxicity were evaluated. The analysis of 14 patients revealed one complete response, three partial responses and a stable disease in eight cases. The objective response rate was 28.6%, the median overall survival was 61 weeks [95% confidence interval (CI) 54-133 weeks], the progression-free survival was 28.5 weeks (95% CI 13-62 weeks) and the 1-year survival rate was 80%. The drugs were well tolerated. The most common side-effects were leuko- and thrombocytopenia. These preliminary results suggest potential therapeutic benefit of treosulfan+gemcitabine treatment in metastatic uveal melanoma and warrant further controlled studies.

Incidence of uveal melanoma in the United States: 1973-1997

PURPOSE

To determine the incidence of primary uveal melanoma in the United States over a 25-year period from 1973 to 1997.

DESIGN

Systematic review of existing databases.

PARTICIPANTS

Two thousand four hundred ninety-three patients with primary uveal melanoma (International Classification of Oncology [ICDO-2] codes C69.3 [choroid melanoma] and C69.4 [ciliary body and iris]) derived from the Surveillance, Epidemiology, and End Results (SEER) program database in the United States from 1973 to 1997.

METHODS

The significance of trend in age-adjusted incidence rate was determined using chi-square test, and 95% confidence intervals were calculated.

MAIN OUTCOME MEASURES

The age-adjusted incidence rate.

RESULTS

There was a total of 2493 cases of uveal melanoma, representing 2.9% of all recorded cases of melanoma. Almost all cases (99.4%) were reported by the hospitals, and histopathologic confirmation was available in 81.3% of cases. The mean age-adjusted incidence of uveal melanoma in the United States was 4.3 per million (4.1-4.5; 95% confidence interval [CI]). Most cases (97.8%) occurred in the white population. There was significant variation of incidence between genders (males, 4.9 [4.6-5.2] 95% CI interval; females, 3.7 [3.5-3.9] 95% CI interval). There was no significant variation of incidence by the geographic location of the registry and over the entire period of observation (chi-square test).

CONCLUSIONS

The mean age-adjusted incidence of uveal melanoma (4.3 per million) in the United States is similar to that reported from European countries. The age-adjusted incidence rate of uveal melanoma has remained stable for the past 25 years.

Survival rates with uveal melanoma in the United States: 1973-1997

PURPOSE

To determine variations in 5-year relative survival rates with primary uveal melanoma in the United States over a 25-year period from 1973 to 1997.

DESIGN

Systematic review of existing databases.

PARTICIPANTS

Two thousand four hundred ninety-three patients with primary uveal melanoma, International Classification of Oncology [ICDO-2] codes C69.3 [choroid melanoma] and C69.4 [ciliary body and iris]) derived from Surveillance, Epidemiology, and End Results (SEER) program database in the United States from 1973 to 1997.

METHODS

The patients were stratified according to the treatment (surgery or radiotherapy). The relative 5-year survival was calculated for 2054 patients diagnosed between 1973 and 1993 by the life table method using US life expectancy tables.

MAIN OUTCOME MEASURES

The relative 5-year survival rate.

RESULTS

Surgical treatment was performed in 1476 (72%) cases, and radiotherapy was given in 300 (15%) cases. The proportion of cases treated by radiotherapy increased progressively from 2% to 28% in 20 years. Relative 5-year survival rates ranged from 77% to 84% without a statistically significant variation.

CONCLUSIONS

Advances made in the local methods of treatment of primary uveal melanoma have not led to an improvement in survival. Systemic approaches to management of uveal melanoma are warranted.

Expression of the c-kit receptor in choroidal melanomas

The KIT gene encodes c-kit, a transmembrane receptor that has tyrosine kinase activity and plays a role in haematopoiesis, gametogenesis and melanogenesis. The c-kit protein is found in normal cutaneous and choroidal melanocytes, and there is evidence that expression is lost in melanoma. Expression of c-kit was analysed in 57 paraffin-embedded sections of choroidal melanoma specimens and three choroidal melanoma cell lines using immunochemistry and Western blotting. Of the tumour specimens, 75% stained positively for c-kit with a membrane pattern of reactivity. Of the six patients who underwent proton beam therapy before enucleation, five tumours exhibited no c-kit immunoreactivity and the other tumour demonstrated weak staining. Of the three melanoma cell lines used, c-kit expression was observed in only one. No correlations between c-kit positivity and parameters such as cell type, largest macroscopic tumour dimension, scleral invasion or pigmentation were observed. In contrast, a significant positive association was found between c-kit staining and mitotic activity (P = 0.02). However, c-kit expression did not significantly influence survival when evaluated by univariate analysis. In conclusion, c-kit is expressed in most choroidal melanoma tumours. Further analysis should provide new insights into the mechanisms underlying the molecular and cellular changes in choroidal melanomas.

Distinct chromosomal aberrations in sinonasal mucosal melanoma as detected by comparative genomic hybridization

Sinonasal mucosal melanomas are the most frequent mucosal melanomas and arise from melanocytes located in the nasal cavity and the paranasal sinuses. The melanoma types, cutaneous melanoma, uveal melanoma, and mucosal melanoma, differ in etiology, geographic distribution, and clinical behavior. Genetic alterations have been previously studied in cutaneous and uveal melanomas but, to the best of our knowledge, not in mucosal melanomas. Comparative genomic hybridization (CGH) was performed on 14 routinely processed sinonasal mucosal melanomas. Furthermore, ploidy analysis was performed on 11 tumors to provide complementary data on the DNA index. The CGH profiles of sinonasal mucosal melanomas show remarkably consistent alterations: chromosome arm 1q is gained in all tumors and gains of 6p and 8q are present in 93 and 57%, respectively. Comparison of CGH data with both the common variants of cutaneous melanoma and uveal melanoma revealed that sinonasal mucosal melanomas harbor a distinct pattern of chromosomal abnormalities. Ploidy analysis also showed that diploid tumors exhibit gains of 1q and alterations of chromosome 6 (3 of 3 cases tested), whereas clear-copy gains and high-copy gains were seen only in triploid and tetraploid tumors (6 of 8 cases tested). This indicates that alteration of chromosomes 1 and 6 may precede polyploidization and formation of clear-copy gains and high-copy gains.

Prognostic factors for malignant melanoma of the squamous mucosa of the head and neck

Primary malignant melanomas of the squamous mucosa of the head and neck are rare. To learn more about the prognostic significance of various histologic parameters we examined the pathologic features of squamous mucosa from 40 patients seen at a single institution and correlated them with clinical outcome. Follow-up information was available on 37 patients. Thirty-five were treated with surgical resection and two were treated with radiotherapy. Twenty-six were dead at follow-up. Twenty-one of them died of disease. The interval between diagnosis and death ranged from 1 month to 16.5 years (median survival, 2.4 years). Eleven patients were alive at 4 months to 19.5 years after the diagnosis: six of them with disease and five of them free of disease (mean follow-up, 3.5 years). Predictors of poor survival by univariate analysis were the presence of vascular invasion (overall survival, p = 0.007; disease-specific survival, p = 0.01), a polymorphous tumor cell population (overall survival, p = 0.007; disease-specific survival, p = 0.008), and necrosis (overall survival, p = 0.007; disease-specific survival, p = 0.056). However, because these three parameters were associated with each other, none of them remained of independent predictive value for outcome by multivariate analysis. No prognostic significance was found for tumor thickness, level of invasion, ulceration, mitotic index, or nerve/nerve sheath involvement. Thus, the histologic parameters relevant for the prognosis of squamous mucosa differ significantly from those of cutaneous melanomas.