Malignant intraocular tumors

Unilateral leukemic infiltration and acute angle closure as the first sign of B-cell acute lymphoblastic leukemia relapse

Objective: Unilateral ocular leukemic infiltration with acute angle closure is an infrequent complication of B-cell acute lymphoblastic leukemia (ALL-B). We present a clinical case of leukemic ocular infiltration as the sole manifestation of ALL-B relapse.

Methods: Case description

Results: A 15-year-old female with a history of acute lymphoblastic leukemia in remission for 2 years and pulmonary tuberculosis treated in the past year presented with ocular redness and decreased visual acuity in the left eye (LE) with 5 days of evolution. Visual acuity was 20/20 in the right eye (RE) and absence of light perception in the left eye (LE). Biomicroscopy of LE showed a small hypopion, anterior chamber cells 4+, vitreous cells 3+, and a large white mass in the vitreous with associated vitreous hemorrhage in organization. In LE fundoscopy, the vitreous mass occupying most of the vitreous cavity and associated hemorrhage prevented retina visualization. B-scan ultrasound showed a multilobulated mass occupying virtually the entire vitreous cavity with associated choroidal detachment. Forty-eight hours later, she developed acute angle closure of LE with an IOP of 55 mmHg. A flow cytometric analysis of the anterior chamber and vitreous showed leukemic tumor cells. The microbiologic exam and PCR for Mycobacterium tuberculosis were negative. No other signs of relapse of the disease were identified after investigation by the oncology department. Rescue treatment of the underlying disease was started, with symptomatic improvement.

Conclusion: Leukemic ocular infiltration can be the only manifestation of ALL-B relapse.

Choroidal Metastasis from Carcinoma of the Hypopharynx: A Case Report

Choroidal metastasis from primaries other than breast or lung cancer is a rare event. There is no documented case in the literature of choroidal metastases in patients with hypopharynx carcinoma. Early treatment with radiation therapy provides effective palliation by preserving visual function and preventing the need for enucleation. Chemotherapy alone does not seem to be as effective as radiation therapy for patients with choroidal metastases. In this paper a case of choroidal metastasis arising from a primary hypopharynx carcinoma is presented.

Radiotherapeutic Treatment for Breast Cancer Choroidal Metastases

A series of 14 eyes (11 patients) with choroidal metastases from breast cancer were reported. The lesions were classified into three grades according to the severity and extent of involvement. Eleven eyes (9 patients) were treated by radiotherapy with two opposed lateral fields using a 4 MeV linear accelerator. The contralateral eye received a prophylactic irradiation. An average dose of 42 Gy was delivered (range, 30-50). Results of radiotherapy were the following: 5 CR and 2 PR in grade II (9 eyes) and 2 PR in grade III (2 eyes). We conclude that radiotherapy is useful to control choroidal metastases of breast cancer. No contralateral metachronous involvement was found. Quality of life of responders showed a marked improvement. Radiation-induced injury was not seen.

Gamma Knife Radiosurgery for Cancer Metastasized to the Ocular Choroid

Objective

Choroidal metastases (CMs) are the most common intraocular tumor. Management is mainly radiation therapy with goals of pain control and visual improvement. However, many radiation-related complications are reported. Since gamma knife radiosurgery (GKS) for CM was first reported in 1995, few cases have been reported. We report 7 cases of CMs treated with GKS.

Methods

From April 2011 to November 2014, 7 patients with CM underwent GKS. Their median age at treatment was 64 years (range, 51–71 years). Four males and three females were treated. Lung cancer was the most common primary pathology, followed by renal cell carcinoma and stomach cancer. Four patients had multiple cerebral lesions and were treated simultaneously for choroidal lesions. The median marginal dose of 20 Gy (range, 15–25 Gy) was administered at the 50% isodose line.

Results

Median follow-up period after GKS was 8 months (range, 2–38.3 months). Four patients expired due to underlying malignancy progression. Except for two patients who were not followed with magnetic resonance image after GKS, all patients showed size reduction in the treated lesions, but a new choroidal lesion appeared in one patient and one recurred. Six of seven patients reported subjectively improved visual symptoms. Visual acuity improved in 2 patients, and 2 were stable upon objective examination. One patient showed no improvement in visual acuity, but ocular pain was relieved; another patient showed improved vision and tumor remission, but visual deterioration recurred.

Conclusion

GKS was shown to be safe and effective and should be considered for CM treatment.

Unilateral Eye Findings: A Rare Herald of Acute Leukemia

BACKGROUND/AIM

Unilateral choroidal infiltration as the initial manifestation of leukemic relapse in adults is rare, particularly after an extended period of remission. This report describes this unique ophthalmic presentation, highlights the associated diagnostic challenges, and reviews the literature.

METHODS

Two cases are described and an extensive literature review was conducted.

RESULTS

A 59-year-old male with acute lymphoid leukemia, in remission for 18 months, presented with unilateral scleritis, exudative retinal detachment, and choroidal thickening. A 57-year-old male with a history of acute myeloid leukemia, in remission for 4 years, presented with unilateral choroidal thickening leading to secondary angle closure. In both cases, there was a significant lag from the onset of eye symptoms to establishing a systemic diagnosis of acute leukemia, leading to a delay in definitive systemic treatment, despite a high suspicion of disease based on ophthalmic findings.

CONCLUSIONS

These two cases illustrate the fundus findings consistent with leukemic choroidal infiltration that can represent the first sign of relapsed leukemia. The successful treatment of these patients hinges on collaboration between ophthalmologists and oncologists to optimize patient outcomes, highlighting the need for both groups to be aware of this rare ophthalmic presentation.

Esophageal metastasis to the iris effectively palliated using stereotactic body radiation therapy and adjuvant intravitreal chemotherapy: case report and literature review

We report a case of isolated iris metastasis from esophageal adenocarcinoma that was successfully managed with local application of stereotactic body radiation therapy (SBRT) and adjunctive intravitreal therapy. A 53-year-old man with locally advanced esophageal adenocarcinoma achieved a complete clinical and radiographic response after surgery and chemotherapy. Four months later, he developed headache and decreased vision and was diagnosed with metastasis to the iris by slit-lamp examination. The decrease in vision was secondary to cystoid macular edema. The metastatic tumor and the patient's symptoms resolved after treatment with SBRT and intravitreal injections of bevacizumab and triamcinolone. We conclude that SBRT combined with intravitreal chemotherapy is an effective and well-tolerated palliative treatment for metastasis of esophageal adenocarcinoma to the iris.

Management of metastatic carcinoma of the uveal tract: an evidence-based analysis

Uveal metastasis from carcinoma is the most common cause of ocular malignancy in adults and represents an increasing problem in the context of an ageing population and enhanced survival of stage IV cancer patients. The reported prevalence of clinically evident uveal metastases in carcinoma patients ranges from 2% to 9%, with breast and lung cancer together accounting for between 71% and 92% of cases. Most patients (66-97%) have a known history of cancer and, although the majority have metastatic lesions elsewhere, up to 33% may present with an isolated ocular metastasis. These lesions may progress rapidly and are potentially sight-threatening. Early diagnosis and appropriate timely treatment are therefore of paramount importance to maintain patients' quality of life. The diagnosis is usually clinical and detailed descriptions of symptomatology and physical characteristics are provided. In 21-50% of patients, involvement is bilateral. External beam radiotherapy (EBRT), chemotherapy, hormone and biological therapies, brachytherapy, transpupillary thermotherapy, laser photocoagulation/photodynamic therapy and enucleation are therapeutic modalities described in the literature for the management of uveal metastases. The strongest evidence favours timely EBRT for the management of sight-threatening uveal metastases. The published evidence supporting EBRT for sight-threatening uveal metastases was given a grade B (strong support for recommendation). Newer alternative therapies are emerging and may have a role in selected patients; however, there are unfortunately few large studies examining such treatments for carcinoma metastatic to the eye. The role of these modalities will be further clarified with the results of larger comparative trials.

Treatment of metastatic tumors of the choroid with proton beam irradiation

OBJECTIVE

To describe the clinical outcomes of patients treated by proton beam irradiation for choroidal metastatic tumors.

DESIGN

Noncomparative case series.

PARTICIPANTS

A retrospective chart review was performed on a series of 63 patients (76 eyes) with choroidal metastases treated with proton beam therapy between December 1989 and September 2000.

METHODS

Patients were treated with 2 fractions of 14 cobalt gray equivalents (CGEs) (CGE = proton Gy x relative biological effectiveness 1.1), each using a nonoperative "light-field" technique. Ophthalmologic follow-up was available for 46 patients (55 eyes), with a mean follow-up time of 10 months. The medical record or the Social Security Death Index was used to obtain survival status, which was available in 94% of cases.

MAIN OUTCOME MEASURES

Tumor regression, recurrence, treatment-associated complications, and visual acuity were evaluated by ophthalmologic examination and ultrasonography. Eye retention and length of survival also were assessed.

RESULTS

At the time of ocular diagnosis, 49 patients reported a history of a primary cancer. Median survival time after ocular diagnosis was 16 months through May 2003. Most choroidal metastases were dome shaped (62%) and located at the posterior pole (95%). Mean tumor height was approximately 3.5 mm, and serous retinal detachment was seen in 63% of cases. Eighty-four percent of treated tumors regressed completely within 5 months of treatment, and none of these recurred. Retinal detachment resolved in 82% of patients within 3.8 months after treatment, and visual acuity was preserved or improved in 47% of the patients. Complications occurred in 56% of cases and included madarosis, keratitis, dry eye syndrome, cataract, neovascular glaucoma, chorioretinal atrophy, radiation papillopathy, and radiation maculopathy. None of the treated eyes required enucleation.

CONCLUSIONS

Proton beam irradiation is a useful therapeutic approach for choroidal metastases; it allows retention of the globe, achieves a high probability of local tumor control, and helps to avoid pain and visual loss. Although complications occur in most cases, many of these are minor and are not associated with a change in function. This modality is accurate and efficient, because it only entails 2 treatment fractions and does not require surgery for tumor localization.

Choroid metastases: clinical features and treatments in 123 patients

BACKGROUND

The current study was performed to analyze the effects of radiotherapy and chemotherapy on visual improvement in patients with choroid metastases (CM), and to determine the clinical factors potentially related to the risk of death.

METHODS

One hundred twenty-three consecutive patients were diagnosed with CM at the Institut Gustave-Roussy between 1966 and 1992. Treatment failure was defined as the absence of tumor regression or choroid tumor progression documented at the time of last ophthalmologic examination. The Cox proportional hazards model was used to estimate the risk of treatment failure associated with analyzed covariates.

RESULTS

Approximately 81% of the patients were women. The most frequent primary tumors were breast carcinoma (71%) and lung carcinoma (9%). Bilateral CM were found in 25% of patients. Sequential vinca alkaloid-based chemoradiotherapy was reported to be significantly associated with a decreased rate of treatment failure compared with radiotherapy alone (relative risk [RR] = 0.3; 95% confidence interval [95% CI], 0.03-2.2). However, when considered separately, each type of treatment also decreased the risk of treatment failure (RR = 0.5 [95% CI, 0.3-0.8] for radiotherapy and RR = 0.4 [95% CI, 0.3-0.7] for chemotherapy). The total dose of radiotherapy (< 30 grays [Gy] vs. > or = 30 Gy) was not found to modify treatment results. The 2-year overall survival rate was 25% (95% CI, 17-34%). The risk of death was found to be correlated with the presence of metastases in the liver (P = 0.02) or lung pleura (P = 0.04) at the time of the diagnosis of CM.

CONCLUSIONS

Sequential combination radiotherapy and vinca alkaloid-based chemotherapy appear to be the most beneficial treatment modality. However, because treatments were not prescribed randomly, the results of the current study should be interpreted with caution.

Stereotactic radiation therapy for malignant choroidal tumors: preliminary, short-term results

PURPOSE

To evaluate the role of stereotactic radiation therapy (SRT) in the treatment of malignant choroidal tumors.

DESIGN

Prospective, noncomparative case series.

PARTICIPANTS

Ten patients with unifocal choroidal metastasis (three lung carcinoma, three breast carcinoma, three colon carcinoma, one cutaneous melanoma) and five patients with primary choroidal melanoma underwent single-dose or fractionated SRT.

METHODS

Before treatment, computed tomography (CT) scans of the orbit were obtained with the patient wearing an individualized immobilization mask. An integrated macro-CCD-camera system viewed the eye for detection of movements. Three-dimensional computer-based treatment planning was carried out. Dose distribution was calculated and displayed in isodose lines on the CT data set. For SRT, a dedicated stereotactic linear accelerator (6 MV) was used. Total doses for choroidal metastases were 12 to 20 Gy in a single dose or 30 Gy over 10 days (3 Gy each session), and total doses for choroidal melanoma were 50 Gy over 5 or 10 days (10 or 5 Gy each session).

MAIN OUTCOME MEASURES

Best corrected visual acuity (ETDRS-chart), biomicroscopy, ultrasound examination, fluorescein angiography, and magnetic resonance imaging (MRI) were performed before treatment and at regular intervals after completion of SRT.

RESULTS

During a follow-up period from 1 to 34 months (median, 6.5 months), local tumor control was achieved in all eyes. A decrease in tumor size on ultrasonography or MRI was noted in eight patients. No persistent side effects were observed during follow-up.

CONCLUSIONS

Stereotactic radiation therapy allows steep dose gradients outside the target volume by minimizing the field of exposure. Thus only low radiation doses affect surrounding radiosensitive ocular structures. Our initial findings suggest that this technique may be effective in controlling tumor growth. Further studies are needed to compare treatment efficacy and safety with conventional treatment methods.

Metastatic melanoma from intraocular primary tumors: the Southwest Oncology Group experience in phase II advanced melanoma clinical trials

Ocular melanoma is an uncommon malignancy that, in the presence of metastatic disease, has a poor prognosis for response to treatment and survival. Patients with ocular melanoma are often excluded from clinical trials because of the impression that these patients have a poorer response rate to treatment with anticancer agents and poorer survival, possibly related to the predominance of the liver as a site of metastasis. Sixty-four eligible patients with advanced melanoma arising from ocular primary tumors were entered into seven phase II clinical trials of anticancer therapy activated by the Southwest Oncology Group (SWOG) during the 1980s. Eligible patients with nonocular primaries entered into these trials (420 patients) served as a comparison group for survival, pretreatment characteristics, and response rates. Multivariate Cox model analysis of survival data (with survival from the time of study registration as the primary end-point) was conducted. Among the 484 patients observed, patients with ocular melanoma were older than those with nonocular primary tumors and were more likely to have visceral metastasis, metastasis to the liver, and only one metastatic site at registration, primarily to viscera and liver. The median overall survival after registration to study for both groups was 5 months. There was no significant difference in overall survival between patients with ocular melanoma and those with nonocular melanoma after adjusting for a number of prognostic factor (p = 0.43). Furthermore, the overall objective response rate of patients with ocular melanoma in these studies was not significantly different from that achieved in the nonocular group (9% vs. 11%; p = 1.00). Patients with advanced ocular or nonocular melanoma have similar response rates and survival in this series of cooperative group phase II trials. Patients with ocular primaries should not be excluded from investigational studies in advanced melanoma.

Choroid metastasis of undifferentiated nasopharyngeal carcinoma

Choroid metastasis of primary nasopharyngeal carcinoma is an infrequent event. Here, we report a case of nasopharyngeal carcinoma with metastases to the choroid successfully treated by external beam radiotherapy.

Management of Ocular Metastasis

BACKGROUND: Intraocular metastasis is a significant clinical problem in patients with metastatic cancer. The frequency of intraocular metastasis in all patients dying of cancer is approximately 12%, but in breast cancer patients, the frequency can be as high as 37%. METHODS: A review of pertinent literature and the author's experience are used to describe the epidemiology, diagnosis, and management of metastatic tumors of the eye. RESULTS: Intraocular metastases occur frequently and are diagnosed by ophthalmologic examination. Radiotherapy remains the cornerstone of therapy and allows the majority of patients to maintain useful vision for the remainder of their lives. CONCLUSIONS: The recognition and treatment of intraocular metastasis are important clinical oncologic issues. With proper management, patients with ocular metastasis can maintain vision and thus maximize quality of life.

Radiotherapy for palliation of symptoms in incurable cancer

Approximately one half of prescribed radiotherapy is given for palliation of symptoms due to incurable cancer. Distressing symptoms including pain, bleeding, and obstruction can often be relieved with minimal toxic effects. Painful osseous metastasis is common in oncologic practice. Ninety percent of patients with symptomatic bone metastases obtain some pain relief with a lowdose, brief course of palliative radiotherapy. One half of the responding patients may experience complete pain relief. A single dose of 800 cGy in the setting of painful bone metastasis may provide pain control comparable to more protracted treatment at a higher dose of radiation. Patients with lytic disease in weight-bearing bones, particularly in the presence of cortical destruction, should be considered for prophylactic surgical stabilization of their condition. Routinely a brief, fractionated course of radiotherapy is given postoperatively. Pain due to multiple bone metastases uncontrolled by analgesics can be managed with single doses of halfbody irradiation. Doses of 600 cGy delivered to the upper half-body (above the umbilicus) and 800 cGy to the lower half-body (from the umbilicus to the middle of the femur) will provide some pain relief in 73% of patients. Half-body techniques have been investigated as prophylactic treatment, as a complement to local-field irradiation, and as fractionated rather than singledose therapy. Although intravenous administration of strontium 89 has been associated with myelosuppression, this treatment has been shown (a) to relieve pain due to bone metastasis and (b) to delay development of new painful sites. Recent data from phase III trials demonstrated that bisphosphonates have a role in reducing skeletal morbidity due to bone metastasis. Bone pain was reduced, and the incidence of pathologic fracture and the need for future radiotherapy was decreased. Radiotherapy relieves clinical symptoms in 70% to 90% of patients with brain metastases. Brief treatment schedules (e.g., 2000 cGy in five fractions over 1 week) are as effective as more prolonged therapy. Patients with solitary brain metastasis and no extracranial disease or controlled extracranial disease should be considered for surgical resection, because phase III data indicate enhanced survival with such an approach. Whole-brain radiotherapy is routinely administered postoperatively. A phase III study is examining the impact of accelerated fractionated doses of radiotherapy (two treatments per day) on survival of patients with brain metastases. Stereotaxic radiosurgical treatment is becoming increasingly available and permits delivery of radiation to metastatic intracranial tumor with minimal exposure of normal surrounding brain This treatment is most commonly used at the time of a solitary recurrence of disease in patients who previously received whole-brain radiotherapy. A role for this modality in newly diagnosed brain metastases remains to be defined. Chest symptoms are common in patients with locally advanced lung cancer and are effectively palliated with one 1000 cGy or two 850 cGy one fraction doses of radiation to the thoracic inlet and mediastinum. Chest pain and hemoptysis are more effectively palliated than cough and dyspnea. In patients with stage III cancer there is no compelling evidence that radiotherapy confers a survival advantage, and it may be reasonable to administer thoracic radiotherapy only when the patient has significant symptoms and the goal is to achieve control of these symptoms. Approximately 75% of the cases of superior vena cava syndrome are due to lung cancer, and small-cell lung cancer is the most common histologic type. A histologic diagnosis should be obtained before treatment is started, because detection of lymphoma or small-cell carcinoma would necessitate systemic therapy. Eighty percent of the patients with vena cava syndrome due to malignant disease achieve symptom relief with a brief, fractionated, palliative course of rad

External beam irradiation for choroid metastases: identification of factors predisposing to long-term sequelae

PURPOSE

To improve overall quality of life, palliative treatments should attempt to minimize associated complications while effectively controlling specific symptoms. We reviewed our experience treating posterior uveal metastases with external beam radiotherapy (EBRT) to determine the complication rate and to identify the relationship between patient, tumor, or treatment-related factors and the development of ocular complications.

METHODS AND MATERIALS

483 consecutive patients (pts) (578 eyes) were diagnosed with intraocular metastatic disease from solid tumors between 1972-1995. Of these, 233 eyes (188 pts) had lesions of the posterior uveal tract and received EBRT. Median follow-up time was 5.8 months (range: 0.7-170.0 months). Follow-up information regarding the development of complications was documented for 230 eyes. Complete EBRT details were available for 189 eyes. Seventy-two percent of the patients received 30.0-40.0 Gy in 2.0-3.0 Gy fractions. Biologically effective dose (BED) was calculated to allow meaningful comparisons between various fractionation regimens and total doses. Concurrent chemotherapy and/or hormonal therapy was used for 101 eyes (44%).

RESULTS

Median BED was 61 Gy3 (range, 6.7-105 Gy3), and 80% of treated eyes received BED 50-70 Gy3. EBRT energies included photons (70%), 60Co (19%), electrons (6%), mixed energies (3%), and orthovoltage (2%). Lens-sparing techniques were used in 136 eyes (71%). At last follow-up 28 eyes (12%) developed one or more significant complications, including cataracts (16 eyes), radiation retinopathy (6 eyes), optic neuropathy (5 eyes), exposure keratopathy (5 eyes), and neovascularization of the iris (4 eyes). Two eyes developed narrow-angle glaucoma, and one of these required enucleation. On univariate analysis, Caucasian race (vs. Black/Hispanic, p = 0.03), increased intraocular pressure at diagnosis (>21 mmHg, p = 0.02), and diagnosis by biopsy (vs. no biopsy, p = 0.03) predisposed toward the development of complications. Factors not correlated with complications included BED (p = 0.18), energy type (p = 0.81), lens-sparing technique (versus whole globe, p = 0.57), and concurrent systemic treatment (p = 0.60). The small number of complications did not support a multivariate analysis.

CONCLUSIONS

Despite the employment of a variety of EBRT treatment techniques and the proximity of choroidal metastases to radiosensitive structures, significant complications of palliative EBRT were infrequent. Although complications do occur, they are related to host factors and do not appear to be a function of irradiation parameters. We conclude that the potential benefits of vision and globe preservation after palliative EBRT outweigh the small risk of treatment induced complications.

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.

The efficacy of radiotherapy in the treatment of intraocular metastases

From January 1980 to May 1991, 28 patients with intraocular metastases were seen at our Institute. Three presented with bilateral metastases and two developed contralateral involvement. Out of the 33 ocular metastases 27 were managed by radiotherapy. The most common primary tumour sites were breast (18/28 patients) and lung (3/28). 22 patients were treated with an 8 MV linear accelerator, using a 4 x 4 cm anterior direct field. The median dose was 40 Gy/20 fractions (range 28 Gy/14 fractions to 50 Gy/25 fractions). Of the 27 treatments reported, 16 resulted in a complete response (59%), six in a partial response (22%) and five resulted in no change (19%). Complete and partial responses lasted for a median time of 13 months (range of 3-89+ months). The median survival time from the start of ocular treatment was 13 months. The aim of radiation treatment is either to prevent or to postpone the visual loss caused by intraocular metastases.

Improved iodine-125 plaque design in the treatment of choroidal malignant melanoma

The use and development of iodine-125 plaque therapy for choroidal malignant melanoma are described. Since 1975 experience has led to changes in plaque design and insertion techniques. Twenty-one patients were irradiated with local episcleral iodine-125 plaques. Three patients required a second plaque for tumour recurrence. Four eyes were enucleated because of continued tumour growth and a further eye was removed because of glaucoma secondary to radiation retinopathy. Two patients (9.5%) died of metastases. The remaining 19 patients are alive and clinically clear of metastases, with a mean follow up time of 73.1 months (range 43-142 months).

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.

Chemotherapy for retinoblastoma: where do we go from here? A review of published literature and meeting abstracts, including discussions during the Vth International Symposium on Retinoblastoma, October 1990

The history of the application of chemotherapy in the management of retinoblastoma (RB) may conveniently be divided into three eras: initial enthusiasm (from early 1950s to mid 1970s), realism (from late 1970s to mid 1980s) and possibility (from mid 1980s to the future). Available data from each of these eras are reviewed in the clinical categories of: intraocular RB, micrometastatic RB and overt dissemination. The latter is further sub-classified into: orbital invasion, central nervous system involvement and systemic metastases. Experimental models are described with particular emphasis on future directions. Early reports led to initial optimism subsequently dampened by a more critical approach. Recent results with increasingly effective chemotherapeutic regimens offer the possibility of a valid contribution in each of the above clinical settings. A multi-modality approach is recommended optimizing a combination of the most active drugs with continuing refinements of other techniques. In selected patients with intraocular, and particularly bilateral RB, visual outcome may be enhanced by the combined use of non-surgical modalities. Adjuvant treatment of presumed micrometastases needs to be studied within risk categories defined by prognostic factors. Invasion of the ocular coats and/or of the optic nerve are the most relevant factors but there are continued difficulties in defining the extent of involvement and eligibility criteria for such a strategy. Overt dissemination has recently been demonstrated to be curable in each of the three subgroups above. Intensive regimens incorporating cyclophosphamide, vincristine, cisplatinum, etoposide and possibly doxorubicin, plus intrathecal agents in combination with radiation therapy and, in some instances supplemented by bone marrow transplantation have produced promising results. Multi-institutional collaboration has been encouraged by the recently formed International Committee for the Staging and Management of Retinoblastoma, opening the way for prospective clinical trials. At the same time both laboratory and clinical experimental studies are being pursued and may produce further improvements in currently available strategies.

An interactive treatment planning system for ophthalmic plaque radiotherapy

Brachytherapy using removable episcleral plaques containing sealed radioisotope sources is being studied as an alternative to enucleation in the treatment of choroidal melanoma and other tumors of the eye. Encouraging early results have been reported, but late complications which lead to loss of vision continue to be a problem. A randomized national study, the Collaborative Ocular Melanoma Study (COMS) is currently in progress to evaluate the procedure. The COMS specified isotope is 125I. Precise dosimetric calculations near the plaque may correlate strongly with complications and could also be used to optimize isotope loading patterns in the plaques. A microcomputer based treatment planning system has been developed for ophthalmic plaque brachytherapy. The program incorporates an interactive, 3-dimensional, solid-surface, color-graphic interface. The program currently supports 125I and 192Ir seeds which are treated as anisotropic line sources. Collimation effects related to plaque structure are accounted for, permitting detailed study of shielding effectiveness near the lip of a plaque. A dose distribution matrix may be calculated in any subregion of a transverse, sagittal, or coronal planar cross section of the eye, in any plane transecting the plaque and crossing the eye diametrically, or on a spherical surface within or surrounding the eye. Spherical surfaces may be displayed as 3-dimensional perspective projections or as funduscopic diagrams. Isodose contours are interpolated from the dose matrix. A pointer is also available to explicitly calculate and display dose at any location on the dosimetry surface. An interactive editing capability allows new plaque designs to be rapidly added to the system.

A 500 KHz localized current field hyperthermia system for use with ophthalmic plaque radiotherapy

Ophthalmic plaque radiotherapy has been demonstrated to be a useful alternative to enucleation in the treatment of small choroidal melanomas. The prognosis for tumours larger than 8 mm in height, however, continues to be poor. Treatment complications limit the radiation dose which may be delivered to these larger tumours. Hyperthermia has been shown to enhance the effectiveness of radiotherapy for many tumours, particularly malignant melanoma. The use of hyperthermia in conjunction with plaque radiotherapy may improve local tumour control for larger choroidal melanomas, allowing patients to maintain useful vision. We have developed an instrument which enables the combination of localized current field hyperthermia with radiotherapy using an episcleral plaque. The system is simple and inexpensive. We have measured temperature distributions in tissue-like phantoms, in excised bovine eyes, and in vivo in normal rabbits. In each of the cases studied, temperature varied by less than 1 degree C within 3 mm of, and across the concave surface of the plaque. At distances greater than 3 mm, the temperature gradient was approximately -0.3 degree C per millimetre.

Results of high dose 106-ruthenium irradiation of choroidal melanomas

The favored treatment of intraocular melanomas in Germany is 106-ruthenium eye plaque therapy. The Departments of Radiation Therapy and Ophthalmology (University of Münster) initiated a clinical study in 1981 to reveal the effect of high-dose beta irradiation (15.000 cGy to the apex of the tumor) regarding tumor regression, treatment related side effects, visual acuity, and survival. Sixty-seven patients have been treated since 1981. In 12 patients a second course of irradiation has been performed because of insufficient tumor regression or no change after the first plaque treatment. Sixty-five percent (44/67 pts.) were over 60 years of age. Twenty-four patients had a small tumor (up to 3 mm in height), 20 patients had a medium sized tumor (3.1-5 mm in height), and 22 patients had a large tumor (more than 5.1 mm in height). Fifty-one patients had a follow-up of at least 12 months. A total tumor regression was achieved in 34/51 patients (67%), partial tumor regression occurred in 13/51 patients (25%), and in 4/51 patients (8%) there was no change after the first course. After the second course of 106-ruthenium-irradiation 5 of the 12 patients showed total tumor regression, 3 had partial regression, and in 4 patients only an increase of the tumor echogenity could be assessed by ultrasonography, but no change in height. Visual acuity, which depends mostly on the localization of the tumor, was preserved at pretreatment levels in 72% of the patients. Two patients died with documented metastatic disease, one patient died of myocardial infarction. There was only one enucleation because of neovascular glaucoma.

Radiation oncology. Programs for the present and future

Radiation oncology in 1984 continues to make major advances in the multidisciplinary clinical programs. This has been possible by virtue of the radiation oncologist, who is an active participant in these clinical programs. The changing role for the radiation oncologist has dictated a greater participation in the primary management of the patient's disease process and also participation in multidisciplinary research programs.

Precision, high dose radiotherapy: helium ion treatment of uveal melanoma

We report on 75 patients with uveal melanoma who were treated by placing the Bragg peak of a helium ion beam over the tumor volume. The technique localizes the high dose region very tightly around the tumor volume. This allows critical structures, such as the optic disc and the macula, to be excluded from the high dose region as long as they are 3 to 4 mm away from the edge of the tumor. Careful attention to tumor localization, treatment planning, patient immobilization and treatment verification is required. With a mean follow-up of 22 months (3 to 60 months) we have had only five patients with a local recurrence, all of whom were salvaged with another treatment. Pretreatment visual acuity has generally been preserved as long as the tumor edge is at least 4 mm away from the macula and optic disc. The only serious complication to date has been an 18% incidence of neovascular glaucoma in the patients treated at our highest dose level. Clinical results and details of the technique are presented to illustrate potential clinical precision in administering high dose radiotherapy with charged particles such as helium ions or protons.

Lack of association between intraocular melanoma and cutaneous dysplastic nevi

The occurrence of uveal and cutaneous malignant melanoma and the dysplastic nevus syndrome in the same individual suggests an etiologic relationship among these diseases. Thus, the dysplastic nevus syndrome could be viewed as marking an increased risk of both cutaneous and ocular melanoma. We postulated that if such a relationship exists, patients with both forms of melanoma should have a high prevalence of dysplastic nevi. We examined 44 patients (31 women and 13 men ranging in age from 20 to 80 years) with uveal melanoma for evidence of cutaneous melanoma and dysplastic nevi. We also examined photographs of 46 patients (24 men and 22 women ranging in age from 19 to 67 years) with nonfamilial cutaneous melanoma to determine the prevalence of dysplastic nevi. We found a 4.5% prevalence of dysplastic nevi in patients with uveal melanoma, significantly lower than the 41% prevalence in patients with cutaneous melanoma (two of 44 patients vs 19 of 46 patients). This study indicates that uveal and cutaneous melanoma are not etiologically linked through dysplastic nevi and suggests that patients with uveal melanoma are no more likely to have cutaneous dysplastic nevi than the general population.

Hematoporphyrin derivative photoradiation induced damage to normal and tumor tissue of the pigmented rabbit eye

Cytotoxicity induced by hematoporphyrin derivative (HpD) photoradiation in both normal and experimental tumor tissue of pigmented rabbit eyes has been examined. In addition, documentation of HpD induced fluorescence in ocular structures has also been obtained. Acute normal ocular tissue toxicity studies demonstrated that HpD (1-10 mg HpD/kg) followed 48 hours later by a transpupil irradiation of red light (635 nm, 36-90 J/cm2) resulted in demarcated areas of retinal damage. Long term (chronic) toxicity studies have shown that the initial damage to the retina was permanent but that no damage to the cornea, lens or vitreous could be observed during a 16 month follow-up. Visual and histological documentation have been obtained, following HpD photoradiation therapy (PRT), in rabbit eyes having heterotransplanted single nodule amelanotic melanomas. A toxic effect characterized by tumor blanching, edema and hemorrhage was observed within 24 hours of treatment. Histological examination obtained 24 hours following HpD PRT illustrated massive tumor tissue necrosis and vascular disruption. HpD PRT at clinically relevant doses was also shown to be effective in selectively curing the highly malignant amelanotic iris melanoma. It is concluded that HpD PRT may prove to be an effective modality for treating certain ocular tumors.

Metastasis of solid tumors in extraocular muscles

Three autopsy cases with discrete metastatic involvement of one or several extraocular orbital muscles by disseminated amelanotic melanoma (one case) and lobular mammary adenocarcinoma (two cases) associated with extensive meningeal involvement are reported. Clinical ocular symptoms including pain, exophthalamus, and diplopia occurred 6 months to almost 5 years after resection of the primary tumor; in two cases CT scan showed spindle-like enlargement of orbital muscles. Pathologic examination disclosed solid localized metastatic deposits in several extraocular muscles of one (breast carcinomas) or both orbits (melanoma), with diffuse invasion of striated muscle, but without necrosis, inflammation, or involvement of other orbital adnexa, eye ball, optic nerves, or orbital bone. Since no continuous invasion of orbital or intraocular structures by diffuse meningeal blastomatosis was histologically observed, rare metastatic involvement of extraocular muscles via hematogenic route is suggested.

Presumed metastatic transitional cell carcinoma of the choroids

Ocular metastases from urinary tract carcinoma are extremely rare. Three previous cases of choroidal metastases from transitional cell carcinoma from the urinary bladder have been described, as have 2 cases of orbital metastases from bladder carcinoma. This is believed to be the first reported case of choroidal metastasis from transitional cell carcinoma of the renal pelvis in a 50-year-old female patient. The tumour, despite the absence of extension beyond the pelvic wall, showed disseminated metastases that proved resistant to chemotherapy. The fluorescein angiographic and ultrasonographic findings are described and the literature is briefly reviewed.