Accuracy of diagnosis of choroidal melanomas in the Collaborative Ocular Melanoma Study. COMS report no. 1

Scintigraphic imaging of uveal melanoma with 99Tcm-glutathione

A prospective study with a new tumour-seeking agent, 99Tcm-glutathione (GSH), was performed on 17 patients with choroidal melanoma. Planar and SPECT images using 99Tcm-GSH clearly demonstrated melanotic melanoma but failed to show amelonotic melanomas. Following confirmation of our results by concurrent ultrasonography and magnetic resonance imaging or computed tomography, patients were managed by either 125I plaque brachytherapy, diode laser transpupillary thermotherapy or enucleation depending on the site and location. In combination with other diagnostic tests, 99Tcm-GSH scintigraphy may play a role in the detection of uveal melanoma and its possible distant metastases.

Eye color and cutaneous nevi predict risk of ocular melanoma in Australia

Ethnicity, cutaneous nevi and eye color are generally accepted risk factors for melanoma of the eye, although case-control studies have produced conflicting results. We sought to determine the constitutional risk factors for melanomas of the choroid, ciliary body, iris and conjunctiva in Australia. A population-based case-control study was conducted, with case ascertainment from a prospective national incidence survey and randomly selected community controls. Two hundred and ninety cases aged 18-79 years and diagnosed between 1st January 1996 and 31st July 1998 were enrolled with 916 controls frequency matched by age, sex and State or Territory of residence. Risk of choroidal and ciliary body melanoma (n = 246) was increased in people with grey (OR 2.9, 95% CI 1.5-5.5), hazel (OR 2.2, 95% CI 1.4-3.7) and blue eyes (OR 1.7, 95% CI 1.0-2.7) compared with brown eyes. Risk was also increased in those with 4 or more nevi on their back, those unable to tan, and those who squinted when outdoors as a child. Risk was reduced in people born other than in Australia and New Zealand (OR 0.7, 95% CI 0.5-1.0). Non-brown eye color was a risk factor for iris melanoma (n = 25). No risk factors were identified for conjunctival melanoma (n = 19). Eye color is the strongest constitutional predictor of choroidal and ciliary body melanoma, and may indicate a protective effect of melanin density at these sites. An independent association with cutaneous nevi suggests a role for other genetic factors.

Enucleation

The three most common indications for enucleation are intraocular malignancy, trauma, and a blind, painful eye. Recommending enucleation is one of the most difficult therapeutic decisions in ophthalmology. In some cases of malignancy, cryotherapy, laser photocoagulation, diathermy, chemotherapy, and radiation therapy may be viable alternatives to surgery. When surgery is chosen, evisceration or exenteration may be alternatives to enucleation. Once the decision is made to perform enucleation or evisceration, the surgeon must choose from several types of implants and wrapping materials. These devices can be synthetic, autologous, or eye-banked tissues. With certain implants, the surgeon must decide when and if to drill for subsequent peg placement. In this review, the authors discuss choices, techniques, complications, and patient consent and follow-up before, during, and after enucleation. Controversies and results of the Controlled Ocular Melanoma Study are summarized.

Proton therapy for uveal melanomas and other eye lesions

Charged particle beams are ideal for treating intra-ocular lesions, since they can be made to deposit their dose in the target, while significantly limiting dose received by non-involved ocular and orbital structures. Proton beam treatment of large numbers of uveal melanoma patients consistently achieves local control rates in excess of 95%, and eye retention rates of approximately 90%. Visual preservation is related to initial visual acuity, tumor size and location, and dose received by the macula, disc, and lens. The probability of distant metastasis is increased by larger tumor diameter, more anterior tumor location, and older patient age. Proton therapy is also effective treatment for patients with ocular angiomas, hemangiomas, metastatic tumors, and retinoblastomas, and may be beneficial for patients with exudative ("wet") age-related macular degeneration.

The Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation of large choroidal melanoma III: local complications and observations following enucleation COMS report no. 11

PURPOSE

To summarize local complications and observations following enucleation of eyes with large choroidal melanoma that were reported prospectively at scheduled examinations of patients enrolled in the Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation.

METHODS

Of 1,003 patients with large choroidal melanoma who were assigned randomly at time of enrollment to enucleation alone or to pre-enucleation radiation, 994 were treated as assigned. Complications and observations were reported to the Coordinating Center on standard forms completed at the time of enucleation surgery and during the immediate 24-hour postsurgery period, 1 to 6 weeks following surgery, 6 and 12 months after enucleation, and at examinations scheduled at 12-month intervals thereafter.

RESULTS

The most common perioperative complication was pain that prolonged hospital stay, which was reported for six patients (1%) who had standard enucleation and eight patients (2%) who had pre-enucleation radiation. Patients treated with pre-enucleation radiation had somewhat more complications reported at the examination 1 to 6 weeks after surgery than did patients treated with enucleation alone, 36 (8%) and 21 (4%), respectively (P = .03, chi2 test), but all complications were minor. During follow-up, fewer biopsy-confirmed tumor recurrences in the orbit were observed among patients treated with pre-enucleation radiation than with enucleation alone (0 vs 5, respectively; P = .03, Fisher exact test). Patients treated with pre-enucleation radiation also had a lower incidence of severe ptosis than did patients treated with enucleation alone (P = .007, log rank test). Among 307 patients examined 5 years after enucleation, the most frequent complication reported at the 5-year examination was poor prosthetic motility for 24 patients (16%) treated with enucleation alone and 30 patients (19%) treated with pre-enucleation radiation.

CONCLUSIONS

Complications were infrequent during the 5-year period following enucleation surgery. Five-year incidence rates and prevalence at the 5-year examination of most complications were similar in the two treatment arms. There was no indication that pre-enucleation radiation had resulted in more serious complications.

Technetium-99m (V) dimercaptosuccinic acid uptake by choroidal melanoma before and after iodine-125 brachytherapy

PURPOSE

The value of the new tumour-seeking agent technetium-99m (V) dimercaptosuccinic acid (99mTc (V) DMSA), is assessed by the visualization of choroidal melanoma before and after iodine-125 episcleral plaque brachytherapy.

METHODS

A prospective study was conducted on 12 consecutive patients with choroidal melanoma that was to be treated with plaque brachytherapy. The pre-operative mean (+/- SD) maximal tumour basal diameter was 12.9+/-2.9 mm and the mean tumour height was 8.2+/-2.9 mm. Each patient had planar scintigraphy and single-photon emission computed tomography using 99mTc (V) DMSA 2 days before treatment and 8 months following plaque removal. The calculated tumour to background ratios of these two tests were compared.

RESULTS

The pre-operative tumour to background ratio was 1.8+/-0.4 and all tumours could be correctly identified. At the time of postoperative imaging, all melanomas showed varying degrees of regression. The mean tumour height was 4.4+/-2.1 mm. The tumour to background ratio was 1.4+/-0.3. The difference between the two scintigraphic results was statistically significant (P = 0.002).

CONCLUSIONS

Technetium-99m (V) DMSA scintigraphy can accurately detect choroidal melanoma and document tumour response following episcleral radioactive plaque therapy. As such, this test can be an alternative ancillary investigative tool in the rare event of opaque media or diagnostic uncertainty.

Uveal Melanoma

BACKGROUND: Malignant melanoma of the uveal tract is a rare malignancy but a significant cause of mortality and visual loss. Approximately 50% of patients diagnosed with a melanoma of the choroid or ciliary body will die of the disease within 15 years of enucleation. METHODS: The author reviewed the current literature on the clinical findings, epidemiology, and treatment of uveal melanoma. RESULTS: Methods of diagnosis have improved substantially in the past several years, although clinical diagnosis by an experienced examiner remains the standard in eyes with clear media. Ultrasound is the most useful adjunctive technique. While enucleation has been the mainstay of therapeutic intervention, alternative therapies - especially different types of irradiation - offer hope for tumor control and vision preservation. The Collaborative Ocular Melanoma Study, a multicenter national trial, is designed to provide long-term data on the natural history as well as therapeutic intervention. CONCLUSIONS: Malignant melanoma of the uveal tract can be diagnosed clinically with more confidence than ever before. It is also possible in many cases to retain the eye and functional vision while controlling the tumor. However, unanswered questions remain about the natural history and optimal therapy of uveal melanoma.

A Short Atlas of Intraocular Tumors

The evaluation of intraocular tumors differs from almost all other oncologic evaluations because there is little reliance on tissue diagnosis. Definitive therapies such as enucleation and radiation are usually based on the results of ophthalmoscopy and a limited number of ancillary studies without the aid of biopsy. Although biopsies can be performed on most intraocular tumors, the ocular morbidity associated with these procedures is usually not worth the added benefit of a tissue diagnosis. The limited role of intraocular biopsy reflects the high degree of confidence that exists with interpretation of clinical findings. The single most important diagnostic study is visual inspection of the tumor with the slit lamp and/or ophthalmoscope. For this reason, representative illustrations of the most common intraocular tumors are presented.

Histopathologic characteristics of uveal melanomas in eyes enucleated from the Collaborative Ocular Melanoma Study. COMS report no. 6

PURPOSE

To describe the principal histopathologic findings in a series of 1,527 globes with uveal melanoma and the relationship of these findings to each other.

METHODS

All eyes enucleated in the Collaborative Ocular Melanoma Study (COMS) were examined independently by three ophthalmic pathologists and the findings recorded on a data form. A composite of findings was obtained after adjudication.

RESULTS

The diagnosis was choroidal melanoma in 1,527 (99.7%) of 1,532 cases examined. Misdiagnoses were metastatic adenocarcinoma (four) and hemangioma (one). Spindle cell (9.0%), mixed cell (86.0%), and epithelioid cell (5.0%) types were observed. Medium tumors were located more posteriorly than large tumors. Considerable local invasion was seen: rupture of Bruch's membrane (87.7%), invasion of the retina (49.1%), tumor cells in the vitreous (25.2%), vortex vein invasion (8.9%), invasion of tumor vessels by tumor cells (13.8%), and invasion into emissary canals (55.0%). Overall, 81.1% demonstrated local invasion, excluding rupture of Bruch's membrane. Scleral invasion was present in 55.7% of eyes, and extrascleral extension was present in 8.2%. Mitotic activity was significantly reduced in eyes that had received preenucleation radiation treatment (P < .001). The number of macrophages in the tumor increased with increased pigmentation (P < .001) and increased necrosis (P < .01).

CONCLUSION

The accuracy of diagnosis in the COMS is high, with histopathologic confirmation of the diagnosis at 99.7%. Extensive local invasion of the tumor was seen. Preenucleation irradiation significantly reduced the number of mitotic figures. An association was found regarding the presence of macrophages, the level of pigmentation, and degree of necrosis.

The Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation of large choroidal melanoma II: initial mortality findings. COMS report no. 10

PURPOSE

To report initial mortality findings from the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of pre-enucleation radiation of large choroidal melanoma.

METHODS

Patients were evaluated for eligibility at one of 43 participating centers in the United States and Canada. Eligible consenting patients were assigned randomly at the time of enrollment to standard enucleation or to external radiation of the orbit and globe prior to enucleation. Eligibility was confirmed at the COMS Coordinating Center, Echography Center, and Photograph Reading Center. Adherence to the radiotherapy protocol was monitored at the Radiological Physics Center. The diagnosis of choroidal melanoma was confirmed following enucleation by a three-member Pathology Review Committee. Patient accrual began in November 1986 and was completed in December 1994; 1,003 patients enrolled. Patients have been followed at annual clinical examinations. Cause of death was coded by a Mortality Coding Committee whose members were not involved in the care of COMS patients; the clinical trial was monitored by an independent Data and Safety Monitoring Committee.

RESULTS

A total of 1,003 patients were enrolled; 506 were assigned to enucleation alone and 497 to pre-enucleation radiation. Treatment groups were well balanced on baseline characteristics. Only nine patients were found to be ineligible after enrollment, seven in the interval between randomization and enucleation and two after enucleation based on histopathology. All but nine patients were treated as assigned; in only six of 491 eyes treated with pre-enucleation radiation was there a major deviation from the radiotherapy protocol. With 5-year outcome known for 801 patients enrolled (80%), the estimated 5-year survival rates and 95% confidence intervals (CIs) were 57% (95% CI, 52% to 62%) for enucleation alone and 62% (95% CI, 57% to 66%) for pre-enucleation radiation. Among the baseline covariates evaluated, only age and longest basal diameter of the melanoma affected the prognosis for survival to a statistically significant degree. The risk of death among patients treated with pre-enucleation radiation relative to those treated with enucleation alone after adjustment for baseline characteristics of patients, eyes, and tumors was 1.03 (95% CI, 0.85 to 1.25). Of 435 deaths classified by the Mortality Coding Committee, 269 patients had histologically confirmed melanoma metastases at the time of death. Estimated 5-year survival rates for this secondary outcome were 72% (95% CI, 68% to 76%) for enucleation alone and 74% (95% CI, 69% to 78%) for pre-enucleation radiation.

CONCLUSIONS

No survival difference attributable to pre-enucleation radiation of large choroidal melanoma, using the COMS fractionation schedule, has been demonstrated to date in this randomized trial. The trial had statistical power of 90% to detect a relative difference in mortality rates between the two treatment arms of 20% or larger. A smaller difference is possible, but a clinically meaningful difference in mortality rates, whether from all causes or from metastatic melanoma, is unlikely.

The Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation of large choroidal melanoma I: characteristics of patients enrolled and not enrolled. COMS report no. 9

PURPOSE

To describe the baseline characteristics and status of patients enrolled in the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of pre-enucleation radiation of large choroidal melanoma conducted in the United States and Canada, and to compare characteristics of patients enrolled with those of patients with tumors of eligible size who were not enrolled in order to assess the generalizability of findings from the clinical trial.

METHODS

For all patients evaluated for the clinical trial at COMS centers from November 1986 through December 15, 1994, selected data were transmitted to the COMS Coordinating Center. For patients who enrolled in the clinical trial, ophthalmic and medical history, examination findings, and visual acuity measurements were recorded prior to enrollment. Standardized A-scan and contact B-scan echographic examinations were performed prior to enrollment, and photoechograms were submitted for central review for consistency with the diagnosis, independent measurement of the apical height of the tumor, and description of tumor configuration and internal reflectivity for each patient enrolled. Until January 1992, wide-angle fundus photographs and fluorescein angiograms taken prior to enrollment also were submitted for central review to confirm consistency with the diagnosis. All data were integrated and analyzed at the COMS Coordinating Center.

RESULTS

Of 6,078 patients with choroidal melanoma evaluated in COMS centers, 1,860 had tumors of eligible size; of these, 1,302 (70%) were eligible for the clinical trial, and 1,003 (77% of eligible patients) enrolled. The two principal reasons for ineligibility were other primary cancer and predominantly ciliary body melanoma. Ineligible patients were older than eligible patients, had larger choroidal melanoma, and had poorer visual acuity at the time of evaluation for the COMS (P < .01, Wilcoxon rank sum tests). Patients eligible for the clinical trial had a mean age of 60 years; 56% were male; almost all (97%) were non-Hispanic whites. Among eligible patients, mean tumor apical height was 9.5 mm and mean longest basal diameter was 17.2 mm. Eligible patients who enrolled in the trial were similar to eligible patients who did not enroll with respect to most factors considered. Those who enrolled had longer tumor basal diameter and better visual acuity in the fellow eye, more often had their primary residence in Canada, and less often had education beyond high school than did eligible patients who did not enroll (P < .05, Wilcoxon rank sum tests and chi2 tests, respectively).

CONCLUSIONS

The COMS clinical trial of pre-enucleation radiation was designed to yield internally valid treatment comparisons through random treatment assignment at time of enrollment. Findings also have high external validity because a majority (54%) of all patients with tumors of eligible size, and a large majority (77%) of all eligible patients, were enrolled. Furthermore, patient characteristics are similar to those of patients included in other evaluations of this method of treating large choroidal melanoma. Thus, findings from this clinical trial apply to all patients who have large choroidal melanoma and satisfy COMS eligibility criteria.

Radiation therapy for choroidal melanoma

Radiotherapy offers patients with malignant melanoma of the choroid an eye and a vision-sparing alternative to enucleation. The most commonly used forms of radiotherapy are ophthalmic plaque brachytherapy and charged-particle (external beam) radiotherapy. Unfortunately, after all forms of radiotherapy for choroidal melanoma many patients experience sight-limiting side effects, and an average of 16.3% of patients treated with radiotherapy subsequently require enucleation because of tumor regrowth or uncontrollable neovascular glaucoma. The severity, location, and incidence of radiation-induced complications are related to the type of radiation used, its method of delivery, amount of radiation delivered to normal ocular structures, the size and location of the tumor, as well as its response to irradiation. Current research is directed toward developing methods to reduce the amount of radiation delivered to normal structures, e.g., adding heat to radiotherapy. The true viability and metastatic potential of irradiated uveal melanoma cells has not been established, although clinical studies have reported local control of choroidal melanoma in 81-100% (mean = 92.8%) of cases. The purpose of this review is to present the world's experience with radiotherapy for choroidal melanoma, information that will contribute to patient education and informed consent.

The ocular melanoma story. LIII Edward Jackson Memorial Lecture: Part II

PURPOSE

To trace the evolution and status of our knowledge of choroidal melanoma with regard to the nature, cause, and treatment of this tumor.

METHODS

Historical materials beginning with Georg Bartisch's contributions in 1583 through to the Collaborative Ocular Melanoma Study and recent basic research are reviewed.

RESULTS

Many individuals have made important contributions to our knowledge about this tumor. Basic information, however, regarding the natural history of the tumor, the most effective treatment, and its cause is lacking.

CONCLUSION

The Collaborative Ocular Melanoma Study will provide important information regarding the choice of treatment between enucleation and radiotherapy as well as natural history information, quality of life, and definitive pathology findings. Definitive treatment of choroidal melanoma will depend on knowledge of the genetic defects that cause the tumor. Within the next 25 years, it is predicted that genetic defects will be determined and tumor samples will be obtained using small-needle aspiration and DNA probes located on microchips. In addition, treatment will then be based on drugs designed to inhibit molecules related to the genetic defect in the tumor.

Long-term follow-up of proton irradiated malignant melanoma by glucose-fructose enhanced magnetic resonance imaging

MR imaging is frequently used to diagnose uveal melanomas due to the characteristic short T2 relaxation time. T2 may be significantly prolonged within 2 h after ingestion of glucose and fructose due to changed water distribution in the melanoma. This method is used to follow melanomas for up to 6 years after proton beam irradiation. In the tumours, T2 was shortened in parallel in all the lesions during the first 9 months. After this, T2 increased only in tumours which showed recurrence. T2 determination and histopathological examination revealed no signs of recurrence in eyes which were enucleated due to neovascular glaucoma. It is concluded that MR imaging performed with carbohydrate loading, registers metabolic changes induced in the tumour, giving this method great validity in the follow-up of choroidal malignant melanoma after irradiation. Eighteen patients treated with proton beam for uveal melanoma at the cyclotron in Uppsala, Sweden, were followed.

Block excision of tumors of the anterior uvea. Report on 68 consecutive patients

PURPOSE

This study describes the authors' surgical technique and the results in 68 consecutive patients with tumors of the iris and ciliary body involving the angle removed by block excision and tectonic corneoscleral grafting between 1980 and 1995.

PATIENTS AND METHODS

There were 41 (60.3%) women and 27 (39.7%) men whose ages ranged from 14 to 85 years (median, 41 years). Follow-up ranged from 0.5 to 15.2 years (median, 6.3 years). Tumors of the iris and ciliary body with chamber angle involvement were removed with a modified block excision consisting of simultaneous en bloc removal of the tumor with adjacent iris and cornea and sclera in full-thickness. The resulting defect of 6 to 20 mm (median, 9.0 mm) diameter is covered with a tectonic corneoscleral graft.

RESULTS

Forty-nine tumors (72.1%) were classified as malignant tumors of the iris and ciliary body. Twenty-one (44.7%) of 47 malignant melanomas showed histologic evidence of scleral invasion of more than one third of scleral thickness. Extrascleral extension of the tumor was present in seven (14.9%) patients with malignant melanomas and in four (21.1%) patients with benign tumors of the iris and ciliary body. The 10-year survival probability of patients with malignant melanomas was 91.4%. The main intraoperative complication was vitreous hemorrhage in 24 (35.3%) patients, and the main postoperative complication was complicated cataract, occurring in 22 (32.3%) patients. Two local tumor recurrences (2.9%) were observed. Four eyes (5.8%) had to be enucleated after block excision. Best-corrected postoperative visual acuity was better than 20/60 in 36 (52.9%) patients.

CONCLUSIONS

The authors' results indicate that block excision with tectonic corneoscleral grafting may be the treatment of choice for progressive circumscribed tumors of the iris and ciliary body involving the anterior chamber angle up to 150 degrees of its circumference.

Recurrence of malignant melanoma after irradiation diagnosed by glucose-fructose enhanced magnetic resonance imaging

Two patients who had been given ruthenium plaque treatment for uveal melanoma were MR examined due to suspected recurrence. Spin-echo sequences were applied using a 1.5 T equipment. The examinations were performed in both patients two times with a 2-h interval. Immediately after the first examination the patients were perorally given 20 g glucose and 10 g fructose. An increase of signal intensity (prolongation of the relaxation times) and size of the uveal lesions could be visualized by a subtraction technique in both patients after the carbohydrate loading. In agreement with our previous studies of malignant melanoma the changed metabolism in the uveal lesions indicated recurrence of the tumour. One eye was available for histological examination. The morphological difference between areas of recurring and degenerating tumour was clearly seen. Similar changes were not observed by ultrasound.

Changing indications for enucleations in Hadassah University Hospital, 1960-1989

The frequencies of various indications for enucleations have changed during the past decades. Knowledge of these trends may aid us in assessing the efficacy of early diagnostic techniques and improved modes of treatment. This study was designed to evaluate the indications for enucleations and their changes during a period of thirty years in a major Israeli medical center. We present a retrospective review of 463 enucleations performed between 1960 and 1989 at the Hadassah University Hospital, Jerusalem, Israel, and analyze the changes in the indications for enucleations. In our study, fewer enucleations were performed in the last two decades: 105 in the 1970's and 111 in the 1980's, as opposed to 247 in the 1960's. The incidence of enucleations due to glaucoma and to traumatic complications decreased significantly, from 22.3% in the 1960's to 7.7% glaucoma-related enucleations in the 1970's and 1980's, and 7.2% trauma-associated enucleations in the 1980's as opposed to 11.3% in the 1960's, reflecting improved medical management of these conditions. No significant change was noted in the frequency of enucleations due to inflammation, congenital disease or retinal detachment, nor in the number of malignant melanoma-related enucleations. The number of enucleations due to retinoblastoma rose in our study between 1960 and 1989.

Accuracy of presumed uveal melanoma diagnosis before alternative therapy

AIMS/BACKGROUND

This study was performed to ascertain the diagnostic accuracy rate of non-invasive tests in patients with presumed uveal melanomas scheduled to be treated with either irradiation or cyclochoroidectomy.

METHODS

One hundred consecutive patients who had non-invasive tests followed by fine needle aspiration biopsy (FNAB) as prior alternative treatment were analysed retrospectively.

RESULTS

In 86 cases the diagnosis of uveal melanoma was confirmed on FNAB. In five cases false negative results were obtained. In nine patients a diagnosis other than a uveal melanoma was made on the basis of cytopathology. No significant morbidity and no evidence of tumour spread occurred.

CONCLUSION

In presumed uveal melanomas eligible for treatment with alternative therapies, the diagnostic accuracy of non-invasive tests is not as good as with larger tumours that require enucleation. Fine needle aspiration biopsy data resulted in correct management of 9% of cases that were thought to have uveal melanomas on non-invasive tests, but had other lesions on cytopathological evaluation.

Ossification in choroidal melanoma

Images

An epidemiological study of posterior uveal melanoma in Israel, 1961-1989

Trends in the incidence rate of uveal melanoma in Israel during the period 1961-1989 among Jews of various geographical origins and among non-Jews were examined, and found to be stable over time. Based on data of the Israel Cancer Registry, 515 cases were included in the final study population after an independent case-finding ascertainment survey. The average annual incidence rate per million for all Jews was 5.7 for both males and females; the rates for non-Jews were: males 1.6, females 1.3. Incidence rates within the Jewish sub-populations show significant differences. The highest rates by sub-population were for Jews born in Europe or America (7.5 for males and for females), followed by Jews born in Israel (males 6.8, females 6.7); and lowest in Jews born in Africa (males 2.1, females 2.3) and Asia (males 1.6, females 2.8). Jews born in Israel had rates lower than Jews born in Europe and America during the 1960s, but in the 1980s the situation was reversed. Results suggest that rate differences between population groups and over time stem from constitutional factors or from the direct or indirect effect of sunlight radiation, whether early in life or from cumulative exposure.

Episcleral iridium-192 wire therapy for choroidal melanomas

PURPOSE

To evaluate the effectivity of high-dose episcleral iridium-192 wires in the treatment of choroidal melanoma.

METHODS AND MATERIALS

In 1983, the Departments of Radiation Oncology and Ophthalmology at the Clínica Puerta de Hierro, Madrid, Spain, initiated a clinical study using removable episcleral iridium-192 wires in the treatment of choroidal melanoma. Sixty-six evaluable patients were treated from January 1983 through July 1992. Two patients had a small sized tumor (3%), 28 had a medium sized tumor (42%), and 36 patients had a large tumor (54%). The mean follow-up was 40 months (6-118 months). The dose to the apex of the tumor ranged from 66 to 97 Gy (mean 76.6 Gy), and the doses at 2 mm depth ranged from 77 to 433 Gy (mean 200 Gy).

RESULTS

Tumor regression or stabilization was observed in 53 of the 66 patients (90%). Visual acuity improved following treatment in 5 out of 54 patients (9%), remaining unchanged in 30 out of 54 (56%), and decreased in 19 out of 54 (35%) patients. The remaining seven patients had undergone enucleation. Late complications have been documented in 20 out of 66 patients (30%), including 6 patients in whom enucleation was required because of radiation-related complications. The probability of survival and survival free of local progression was 93% at 5 years and 79% at 10 years. The probability of retaining the treated eye is 82% after the fifth year posttreatment.

CONCLUSIONS

Treatment of choroidal melanomas with episcleral iridium-192 wires is as effective as treatment with other radioactive applications. We feel that our results using iridium-192 wires are comparable to the other methods. However, we think that our technique is simple to implement, relatively inexpensive, and well tolerated.

Possibilities and limitations of radioimmunoscintigraphy and conventional diagnostic modalities in choroidal melanoma

A prospective clinical study to assess the value of immunoscintigraphy with a monoclonal antibody (MoAb) against high molecular weight melanoma associated antigen (225.28S) was performed in 43 patients with choroidal melanoma; in six patients with a lesion suspected of being choroidal melanoma, and in seven patients with a benign lesion simulating a choroidal melanoma. The results of immunoscintigraphy in choroidal melanoma were compared with results of conventional diagnostic modalities like ultrasonography and fluorescein angiography. Planar scintigraphy showed a detection rate of 49% which is comparable with other studies. The detection with scintigraphy was correlated to the size of the choroidal melanoma. The use of single photon computed tomography did not increase the sensitivity of immunoscintigraphy. Ultrasonography yielded a correct diagnosis in 37 of 42 melanomas (88%). With fluorescein angiography a correct diagnosis was obtained in 11 of 30 melanomas (36.6%). The value of immunoscintigraphy with MoAb 225.28S in small choroidal melanomas is limited; its reliability increases in large tumours. Immunohistochemistry with MoAb 225.28S showed antigen expression in 95% of the stained tissue specimens of choroidal melanoma.

Calcification-like echographic patterns in uveal melanomas treated with brachytherapy

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Design and methods of a clinical trial for a rare condition: the Collaborative Ocular Melanoma Study. COMS Report No. 3

Investigators who conduct clinical trials of treatments for uncommon conditions face special challenges regarding trial design and execution in addition to the challenges faced by all clinical trial investigators. The Collaborative Ocular Melanoma Study (COMS) currently consists of two multicenter, randomized controlled clinical trials designed to investigate the efficacy of radiotherapy compared to surgery in prolonging the survival of patients with choroidal melanoma, a rare intraocular cancer. Patients with unilateral choroidal melanoma classified as "medium" in size are randomized with equal probability to either enucleation (removal of the eye) or radiation delivered to the tumor by means of a radioactive "plaque" attached by sutures to the scleral surface of the eye over the base of the tumor. Patients with large tumors are randomized with equal probability to either enucleation or a 5 day course of external beam radiation therapy followed by enucleation. Time to death is the primary outcome; patients will be followed for at least 10 years or until death. Quality assurance mechanisms for evaluation, treatment, and follow-up have been implemented. This paper describes the design and methods of the trials, highlights the challenges associated with implementing and conducting the study, and summarizes the current status of the study.

Quantification of melanin and iron content in uveal malignant melanomas and correlation with magnetic resonance image

Eleven patients with uveal malignant melanomas (MM) were studied by magnetic resonance (MR) imaging before enucleation. The MR appearances varied, but often were different from those previously reported to be characteristic of these tumours. Using an image analyser to assess quantitatively the melanin and iron content of each tumour, a wide range of tumour melanin concentrations was found, but universally low tumour iron concentrations. These values were compared with MR appearances that were quantified and expressed as contrast to noise ratios. The correlation between T1 and T2 shortening and increasing melanin content did not reach statistical significance. There was no correlation between MR appearances and iron content. The theories postulated to explain the diverse MR appearances of uveal MMs are discussed and variations in tumour melanin content and differences in scanner strengths are suggested as the most likely explanations.

Significance, specificity, and ultrastructural localization of HMB-45 antigen in pigmented ocular tumors

PURPOSE

To evaluate the expression of the monoclonal HMB-45 antibody in melanocytic and nonmelanocytic ocular tumors and seek "activated" cellular subpopulations in an attempt to distinguish between benign and malignant melanocytes, to compare HMB-45 and S100 activity, and to determine the specificity of this tumor marker for melanocytic ocular lesions.

METHODS

Immunohistologic investigations were performed with paraffin-embedded tissue of 10 acquired conjunctival melanoses, 19 conjunctival nevi, 34 conjunctival melanomas, 69 uveal melanomas, 20 basal cell carcinomas of the lid, 20 cystic dermoids, 15 hemangiomas of the lid, 20 conjunctival papillomas, 20 squamous cell carcinomas, 20 pterygia, 11 sebaceous gland carcinomas, 10 retinoblastomas, and 5 choroidal metastatic carcinomas. The avidin-biotin peroxidase technique and monoclonal HMB-45 antibody were used. The distribution of S100 protein was studied in the melanocytic tumors for comparison. To localize the HMB-45 antigen, lowicryl-embedded tissue of uveal melanomas was investigated immunoelectron microscopically.

RESULTS

More than 95% of the conjunctival and choroidal melanomas expressed the HMB-45 antigen, while S100 was found in all melanomas of the conjunctiva and in 91% of the uveal melanomas. In benign melanocytic lesions of the conjunctiva (nevi and melanocytes), especially the intraepithelial and junctional components stained with HMB-45, and at the site of tumor invasion, infiltrating cells showed increased HMB-45 reactivity. On the whole, HMB-45 antigen was less evenly distributed in the melanocytic tumors investigated than S100 antigen. All nonmelanocytic ocular tumors revealed no HMB-45 expression. Retinal pigment epithelium and tumor-free choroid were negative for HMB-45. The HMB-45 antigen was immunoelectron microscopically found in melanosomes at stages II and III.

CONCLUSION

HMB-45 immunohistology helps in distinguishing melanocytic from nonmelanocytic ocular tumors and often clarifies the front of tumor invasion. The stronger HMB-45 reactivity probably reflects melanocytic activation, but a sharp line between benign and malignant melanocytes cannot be drawn.

Scleritis as an initial manifestation of choroidal malignant melanoma

PURPOSE

The purpose of this article is to present the unusual circumstances in which malignant melanoma of the choroid can masquerade as scleritis, thus confounding its diagnosis.

METHODS

Three cases of plaque-like malignant melanomas of the choroid are reported that, on initial examination, had features of scleritis. The events leading to their eventual correct diagnosis also are presented.

RESULTS

In each case, there was ocular pain, blurred vision, anterior chamber and/or vitreous cavity cellular reaction, and an exudative retinal detachment associated with an ill-defined, relatively flat variably pigmented choroidal mass. In all three cases, the inflammatory component responded promptly to corticosteroid treatment and was accompanied by visual improvement. In two eyes, shrinkage of the choroidal mass accompanied the corticosteroid treatment, lending support to a working diagnosis of scleritis. By demonstrating expansion of the choroidal masses, examination of sequential fundus photographs influenced the decision to enucleate the eyes for presumed malignant choroidal melanoma.

CONCLUSION

Clinicians should be alert to the circumstances in which malignant melanomas of the choroid can masquerade as scleritis. Careful evaluation by ophthalmoscopy, ultrasonography, fundus photography, and subsequent sequential examination is necessary to arrive at the correct diagnosis.

Appearances of choroidal osteomas with diagnostic imaging

The diagnostic imaging appearances of three choroidal osteomas (osseous choristomas) are presented. This rare, benign choroidal tumour is being recognized with increasing frequency, and is important to remember in the differential diagnosis of any unusual mass in the ocular fundus lest it be mistaken for a more sinister lesion. All three osteomas were demonstrated by ocular ultrasound (US), fluorescein angiography (FA) and computed tomography (CT) but none by plain radiography. None of the lesions was visible on magnetic resonance imaging (MRI); the reason for this is probably the bony nature of the tumours. The appearances of choroidal osteomas on US, FA, plain radiography and CT are discussed. To our knowledge this is the first report of a series of choroidal osteomas investigated by MR.

Ultrasound biomicroscopy of anterior segment tumors

BACKGROUND

Ultrasound biomicroscopy is a new method of imaging the anterior segment of the eye at microscopic resolution using high frequency ultrasound.

METHODS

A prospective study was performed to evaluate the use of ultrasound biomicroscopy in imaging anterior segment tumors. Forty-five patients underwent clinical examination followed by slit-lamp photography, anterior segment B-scan ultrasonography, and ultrasound biomicroscopy according to an established protocol.

RESULTS

All lesions were clearly imaged by ultrasound biomicroscopy, while only 17 were detectable by conventional B-scan ultrasound. Ultrasound biomicroscopy allowed precise measurement and visualization of subsurface features in small tumors. Differentiation between solid and cystic lesions was easily achieved. The margins of ciliary body tumors could be more accurately defined. Histopathologic correlation was possible in four cases managed surgically. Ultrasound biomicroscopy images compared favorably with low-power microscopy. No complications were encountered.

CONCLUSION

Ultrasound biomicroscopy proved a valuable new noninvasive technique in the evaluation of anterior segment tumors.

Episcleral plaque radiotherapy in the treatment of uveal melanomas

During an 8-year period, 85 patients with uveal melanomas were treated with episcleral plaque radiotherapy (EPRT). The T-stage was: T1-3 (4%), T2-29 (34%) and T3-53 (62%). The mean tumor elevation was 6.1 mm. Radiation dose was prescribed at the tumor apex and at D5mm. The mean D5mm dose was 150.1 Gy (range 70.5-430 Gy) and the mean dose at the apex was 102.6 Gy (range 29.8-200 Gy). Useful vision (greater than 5/200) was maintained in 73% of patients. The 5-year actuarial survival was 88%. Metastatic disease developed in 9 (11%) patients, 6 of whom died of their disease. Basal tumor dimensions were important factors predicting metastatic disease, p = 0.002. A decrease in tumor evaluation was seen in 82%. There was a much lower incidence of decrease in tumor radial and circumferential dimensions, 47.5 and 46%, respectively, p less than 0.001. Treatment complications were common (56%), particularly in patients with large tumors (72%), p = 0.04. The incidence of complications was higher in patients treated prior to 1988 as compared to those who were treated more recently (67 vs 35%, p = 0.010). There were 13 (15%) patients who had enucleation. This included 12 treated before 1986 and 1 patient treated subsequently (46 vs 2%, p less than 0.001). In a univariate analysis, tumor height and radiation dose at D5mm were important factors predicting enucleation, p = 0.004. In a multivariate analysis, however, the most important factor predicting enucleation was treatment administration prior to 1986, p less than 0.001). A sharp decrease in the incidence of severe complications, including enucleation, as seen after 1985, is likely due to a major effort in treatment optimization.

Management of posterior uveal melanoma

In recent years, there have been a number of advances in the diagnosis and management of patients with malignant melanoma of the posterior uvea (ciliary body and choroid). This review provides a brief update on the current status of diagnostic modalities, such as fluorescein angiography, ultrasonography, computed tomography, magnetic resonance imaging, fine needle aspiration biopsy, and the radioactive phosphorus uptake test. Following that is a more detailed review of the current controversy regarding the natural course of uveal melanomas and the available therapeutic modalities. Current indications, techniques, complications, and results are provided for various forms of management, such as observation, laser photocoagulation, plaque radiotherapy, charged particle radiotherapy, local tumor resection, enucleation, and orbital exenteration.