Primary transpupillary thermotherapy for small choroidal melanoma

Ultrasound-assisted laser therapy for selective removal of melanoma cells

The current study explores the potential of ultrasound-assisted laser therapy (USaLT) to selectively destroy melanoma cells. The technology was tested on an ex vivo melanoma model, which was established by growing melanoma cells in chicken breast tissue. Ultrasound-only and laser-only treatments were used as control groups. USaLT was able to effectively destroy melanoma cells and selectively remove 66.41% of melanoma cells in the ex vivo tumor model when an ultrasound peak negative pressure of 2 MPa was concurrently applied with a laser fluence of 28 mJ/cm2 at 532 nm optical wavelength for 5 min. The therapeutic efficiency was further improved with the use of a higher laser fluence, and the treatment depth was improved to 3.5 mm with the use of 1,064 nm laser light at a fluence of 150 mJ/cm2. None of the laser-only and ultrasound-only treatments were able to remove any melanoma cells. The treatment outcome was validated with histological analyses and photoacoustic imaging. This study opens the possibility of USaLT for melanoma that is currently treated by laser therapy, but at a much lower laser fluence level, hence improving the safety potential of laser therapy.

Uveal Melanoma: Comprehensive Review of Its Pathophysiology, Diagnosis, Treatment, and Future Perspectives

Uveal melanoma (UM) is the most common intraocular malignancy in adults. Recent advances highlight the role of tumor-derived extracellular vesicles (TEV) and circulating hybrid cells (CHC) in UM tumorigenesis. Bridged with liquid biopsies, a novel technology that has shown incredible performance in detecting cancer cells or products derived from tumors in bodily fluids, it can significantly impact disease management and outcome. The aim of this comprehensive literature review is to provide a summary of current knowledge and ongoing advances in posterior UM pathophysiology, diagnosis, and treatment. The first section of the manuscript discusses the complex and intricate role of TEVs and CHCs. The second part of this review delves into the epidemiology, etiology and risk factors, clinical presentation, and prognosis of UM. Third, current diagnostic methods, ensued by novel diagnostic tools for the early detection of UM, such as liquid biopsies and artificial intelligence-based technologies, are of paramount importance in this review. The fundamental principles, limits, and challenges associated with these diagnostic tools, as well as their potential as a tracker for disease progression, are discussed. Finally, a summary of current treatment modalities is provided, followed by an overview of ongoing preclinical and clinical research studies to provide further insights on potential biomolecular pathway alterations and therapeutic targets for the management of UM. This review is thus an important resource for all healthcare professionals, clinicians, and researchers working in the field of ocular oncology.

Cancer stem-like cells in uveal melanoma: novel insights and therapeutic implications

Uveal melanoma (UM) is the most common primary ocular tumor in the adult population. Even though these primary tumors are successfully treated in 90% of cases, almost 50% of patients ultimately develop metastasis, mainly in the liver, via hematological dissemination, with a median survival spanning from 6 to 12 months after diagnosis. In this context, chemotherapy regimens and molecular targeted therapies have demonstrated poor response rates and failed to improve survival. Among the multiple reasons for therapy failure, the presence of cancer stem-like cells (CSCs) represents the main cause of resistance to anticancer therapies. In the last few years, the existence of CSCs in UM has been demonstrated both in preclinical and clinical studies, and new molecular pathways and mechanisms have been described for this subpopulation of UM cells. Here, we will discuss the state of the art of CSC biology and their potential exploitation as therapeutic target in UM.

Laser treatment for choroidal melanoma: Current concepts

Laser treatment has offered a relatively nonsurgical alternative for eye, life, and vision-sparing treatment of malignant melanoma of the choroid. Historically, the most commonly used forms of lasers were xenon-arc, argon laser, krypton laser, and the more recent transpupillary thermotherapy (TTT) and photodynamic therapy (PDT). Melanomas selected for laser treatment tend to be smaller and visibly accessible, which means these tumors are usually located in the posterior choroid. Laser treatments have been associated with both local tumor destruction and side effects. Unlike radiation therapy, laser treatment has been commonly associated with retinal traction, hemorrhage, chorioretinal neovascularization, and extra scleral tumor extension, as well as higher rates of local treatment failure. In addition, however, laser-treatment has been successfully used to treat tumor-related retinal detachments, radiation retinopathy, and neovascular glaucoma. We review the world's experience of ophthalmic laser treatment for choroidal melanoma, offer safety and efficacy guidelines, as well as a comparison of laser treatment to radiation therapy outcomes.

Intravitreal aflibercept combined with transpupillary thermotherapy in the treatment of refractory macular edema due to primary uveal melanoma

We reported a 74 year old Asian female with a uveal tumor with subretinal fluid (SRF) and cystoid macula edema. Since she declined biopsy, multimodal imaging study was performed, including fundus photography, ultrasonography, optical coherence tomography, fluorescein angiography, and magnetic resonance imaging. Uveal melanoma was diagnosed. However, despite aggressive treatment with TTT and three adjuvant intravitreal bevacizumab doses, SRF, and cystoid macula edema were persistent. Therefore, aflibercept was administered, resulting in anatomical and functional improvement within 1 month, which lasted for 12 months. Aflibercept offered great efficacy in improving refractory macular edema in this case of primary uveal melanoma. Multimodal imaging can provide us with more diagnostic clues in differentiating the nature of intraocular tumors.

Uveal melanoma diagnosis and current treatment options (Review)

Uveal melanoma is a rare condition accounting for only 5% of all primary melanoma cases. Still, it is the most frequently diagnosed primary intraocular malignant tumor in adults. Almost 90% of the tumors involve the choroid and only a small percentage affects the ciliary body or the iris. There is a consistent difference in incidence between different regions with individuals of northern European descent having a significantly higher risk as compared to Hispanics, Asians, and Blacks. Among the many risk factors, mutations in the G protein subunit alpha Q (GNAQ) or G protein subunit alpha 11 (GNA11) genes and different receptors are highly suggestive. While iris melanoma can easily be noticed by the patient itself or diagnosed at a routine slit-lamp evaluation, a consistent percentage of posterior uveal tumors are incidentally diagnosed at funduscopic evaluation as they can evolve silently for years, especially if located in the periphery. Uveal melanoma classifications rely on the tumor size (thickness and basal diameter) and also on intraocular and extraocular extension. The differential diagnosis with pseudomelanomas is carried out according to the tumor aspect and position. Iris melanoma has a better prognosis and a lower mortality rate as compared to choroidal melanoma that has a much higher rate of metastasis (50% of the patients) and a subsequent limited life expectancy from 6 to 12 months. While conservative therapeutic options for the primary tumor, relying on different surgical excision techniques and/or irradiation therapies, offer good local tumor control, the treatment options for metastatic disease, although numerous, are still inadequate in preventing a fatal outcome.

Transpupillary thermotherapy of choroidal melanoma

A retrospective analysis of the immediate and long-term effectiveness of the treatment of the choroidal melanoma using transpupillary thermotherapy (TTT) was carried out. The study included 84 patients with choroidal melanoma (C69.3) who received treatment between 2007 and 2018. Patients were sampled from the Belarusian Cancer Register. The average values of the thickness of the tumor were 2.6±1.3 mm, the diameter of the base - 7.2±3.3 mm. TTT was carried out using a diode laser with a wavelength of 860 nm and radiation power of 200 - 800 mW, the exposure time was 60 s, and the diameter of the laser spot was varied between 1 and 3 mm. The entire surface of the tumor was thermally treated with overlapping fields from the periphery to the top. 75 patients underwent a single session of TTT, while 9 - two sessions with an interval of 3–4 weeks. As a result of the treatment, 51 (60.7%) patients showed complete tumor resorption, 28 (33.3%) patients had stabilization of the tumor process, and 5 (6.0%) patients had no effect. In the group of patients with stabilization of the tumor process, continued growth was recorded in 16 (19.1%) patients with follow-up periods of 3 months to 4 years. In 19 (37.3%) patients from the group with complete tumor regression, relapse was observed 1 to 8 years after TTT. Metastatic disease (disease progression) developed in 5 (5.9%) patients, of which in 1 patient during the first 12 months, in 1 patient - after 4 years, and in 3 patients more than after 5 years of the follow-up observation. Analysis of the effectiveness of TTT of choroidal melanoma showed that an increase in the thickness and diameter of the base of the tumor focus results in the decrease of immediate effectiveness, and the rise of the likelihood of continued tumor growth.

Quantitative analysis of Gamma Knife stereotactic radiosurgery for uveal melanoma

The purpose of the study was to analyze single fraction Gamma Knife stereotactic radiosurgery (SRS) for uveal melanoma (UM). In the treatment of UMs, the dose distribution exhibited by an irregular eye surface has more calculation uncertainty. A tissue-equivalent bolus was placed on the left eye surface of a human head-shaped phantom. It was assumed that the treated eye is fixed using retrobulbar anesthesia and suture on extraocular muscles for phantom study. Leksell stereotactic frame was fixed around phantom’s head and the stereotactic computed tomography (CT) was performed. Two sets of scans were acquired (a) without bolus and (b) with a bolus of 1.0 cm thickness. These scans were transferred into a treatment planning system (TPS). The skull contouring was performed using stereotactic CT images. The target, visual pathways, and eye lens were delineated in stereotactic CT space created on TPS. A clinical relevant plan was designed on the CT study set “a” to deliver a radiation dose of 30Gy at tumor margin. The plan superimposed over CT study set “b” and compiled for convincing treatment strategy. The tumor coverage was 95% at 50% prescription isodose line. The conformity index, selectivity and the gradient index were 1.27, 0.80 and 3.28 respectively. The left optic nerve and eye lens received a maximum dose of 11.1 Gy and 11.0 Gy respectively. The treatment plan overlay showed similar planning indices and critical organ doses. The plan comparison showed: an irradiated volume received the radiation dose > 15 Gy varies < 1.0% whereas the volume received < 15 Gy were larger (> 1.0%) in the study set “b”. The distant lateral points from the target volume which describe the phantom’s eyelid showed a radiation dose of 3.2 Gy - 2.5 Gy. The doses to these points were misled and ignored in the CT study set “a”. The eye bolus provides better dosimetric information in the estimation of low dose areas which is commonly misled on TPS in SRS planning for UMs.

The effect of intravitreal bevacizumab and transpupillary thermotherapy on choroidal metastases and literature review

Aims:

To represent the effects of transpupillary thermotherapy (TTT) and intravitreal bevacizumab on choroidal metastases and review the literature.

Settings and Design:

A retrospective, interventional, noncomparative case series.

Materials and Methods:

A retrospective, interventional, noncomparative case series of five eyes in three patients with choroidal metastases was conducted. Fundus findings of choroidal metastases were divided into two types: Solitary or diffuse type. The size of the tumor was termed small (<10 mm diameter), medium (10–15 mm diameter) or large (>15 mm diameter). All eyes received one session of TTT followed by 3 weekly intravitreal bevacizumab injections as an adjuvant therapy. The parameters of treatment for TTT were 1.2–3 mm spot size, 150–300 mW, 60 s with the whole lesion covered confluently. The changes in preoperative and postoperative best-corrected visual acuity (BCVA) were recorded. Serial color fundus photography and optical coherent tomography were performed to measure the treatment efficacy.

Results:

All eight choroidal metastases were solitary type. The size of six tumors was small, the size of one tumor was medium, and the size of one tumor was large. All five eyes of the three patients had improvement of BCVA after treatment. Fundus photos revealed tumor shrinkage and the mean shrinkage percentage was 61.27 ± 21.71%. Optical coherence tomography revealed complete resolution of serous retinal detachment. There was no recurrence after 6 months follow-up.

Conclusions:

TTT combined with intravitreal bevacizumab injections brought about beneficial effects in reducing tumor size and improving vision in all five eyes of the three patients. Despite the retrospective nature of our study, the absence of control group and the size limitation that, of course, limit the statistical power, TTT combined with intravitreal bevacizumab seems to be efficient in providing another cost-reducing and time-saving treatment option for patients with choroidal metastases. The antineoplastic properties of bevacizumab make it a viable adjunctive therapy. Studies with more cases and a longer follow-up period are warranted.

Management of choroidal melanomas less than 10 mm in largest basal diameter with a 10-mm ruthenium plaque

PURPOSE

To assess tumor control, complications, and vision after brachytherapy for posterior choroidal melanoma <10 mm in largest basal diameter with the 10-mm ruthenium plaque.

METHODS

This was a retrospective cohort study of consecutive choroidal melanomas <10 mm by largest basal diameter in a national ocular oncology service in 1998 to 2010. The median dose was 116 Gy (range, 80-194 Gy) to the apex and 327 Gy (range, 201-824 Gy) to the sclera. The median tumor height and largest basal diameter were 1.9 mm (range, 0.4-5.2 mm) and 7.0 mm (range, 3.3-9.6 mm), respectively. The median distance to disk and foveola was 3.0 mm (range, 0-7.5 mm) and 2.0 mm (range, 0-8.5 mm), respectively.

RESULTS

Four recurrences occurred at a median of 1.4 years (range, 0.6-3.1 years) after irradiation. Five-year cumulative incidence of local recurrence was 9% (95% confidence interval [CI], 3-20). Six patients died at a median of 4.2 years (range, 0.28-8.6 years) after treatment, one with evidence of metastases. At 5 years, 57% (95% CI, 31-79), 72% (95% CI, 58-85), and 97% (95% CI, 88-100) of eyes were free of any maculopathy, radiation maculopathy, and optic neuropathy, respectively. Cumulative incidence of developing low vision and blindness were 17% (95% CI, 7-31) and 3% (95% CI, 2-12) at 5 years, respectively. Thickness >3.0 mm, largest basal diameter >7.0 mm, and location ≤ 1.5 mm of foveola were associated with visual loss.

CONCLUSION

Local tumor control and vision outcomes support the use of 10-mm ruthenium plaques in managing smallest choroidal melanomas.

Primary transpupillary thermotherapy for choroidal melanoma in 391 cases: importance of risk factors in tumor control

PURPOSE

To report the long-term outcome of primary transpupillary thermotherapy (TTT) for choroidal melanoma.

DESIGN

Retrospective review of medical records.

PARTICIPANTS

We included 391 patients with choroidal melanoma treated between 1995 and 2012 at the Oncology Service, Wills Eye Hospital, Philadelphia.

METHODS

We delivered TTT with an infrared diode laser.

MAIN OUTCOME MEASURES

Local tumor recurrence, Snellen visual acuity after TTT, and distant metastasis.

RESULTS

Of 391 patients, 311 (80%) were treated from 1995 to 2000 and 80 (20%) from 2001 to 2012. Tumors in the 2001 to 2012 group were ultrasonographically thinner (2.2 vs. 2.7 mm), more distant from the optic disc (3.2 vs. 2.5 mm) and foveola (4.0 vs. 2.0 mm), were less often located in the macular area (14% vs. 40%), and had lower rates of acoustic hollowness on B-scan ultrasonography (63% vs. 84%), subretinal fluid (58% vs. 90%), and orange pigment (50% vs. 70%). Kaplan-Meier estimates for tumor recurrence in the 1995 to 2000 group were 29% at 5 years and 42% at 10 years, whereas estimates for tumor recurrence in the 2001-2012 group were 11% at 5 years and 15% at 10 years. Of 108 recurrent tumors 20 were controlled with additional TTT and 62 required plaque radiation (n=60) or proton beam radiation (n=2), with enucleation necessary in 26 patients. Tumor recurrence correlated with the number of high-risk tumor features: 10-year recurrence was 18% in those with 1 or 2 risk factors, 35% in those with 3 to 5 factors, and 55% in those with 6 or 7 factors. On multivariate analysis, features predictive of tumor recurrence were presence of symptoms (P<0.001), shorter distance between the tumor and the optic disc (P=0.026), subretinal fluid (P=0.035), thickness of residual tumor scar (P<0.001), and elevation of residual tumor scar (P<0.001). The only factor predictive of extraocular tumor extension was intraocular tumor recurrence after TTT treated with additional TTT (P=0.007). Presence of orange pigment before TTT (P=0.019), tumor recurrence (P=0.002), and extraocular tumor extension (P=0.017) were predictive of distant metastasis.

CONCLUSION

This study shows a direct correlation between a larger number of high-risk tumor features and higher rates of tumor recurrence after primary TTT of (small) choroidal melanoma. We advise that, when possible, small choroidal melanomas with multiple risk factors be treated with methods other than TTT.