Reirradiation of the eye with plaque brachytherapy: A single institution experience report of eight consecutive patients submitted to retreatment after local relapse of malignant disease of the eye

Re-treatment of locally recurrent uveal melanoma with repeat eye plaque I-125 brachytherapy: A single institution experience

PURPOSE

Eye plaque brachytherapy (EPBT) is the most common treatment for uveal melanoma with high local control rates of 95-100%. When local recurrences occur following EPBT, salvage options include enucleation, transpupillary thermotherapy (TTT), external beam radiation, or re-irradiation with EPBT. The purpose of this study is to report our institution's experience with EPBT re-irradiation for locally recurrent uveal melanoma.

METHODS AND MATERIALS

Patients were included if they were previously treated for uveal melanoma with EPBT, experienced local recurrence, and were subsequently treated at our institution with EPBT from 2016- 2020.

RESULTS

A total of 5 patients with median age 68 years were included. All patients were initially treated at an outside institution (OSI) with Iodine-125 or Ruthenium-106 EPBT. Mean time between EPBT at the OSI and EPBT at our facility was 130 months (range 28-231 months). Patients were re-irradiated with Iodine-125 EPBT prescribed to 85 Gy over 168 hours. Median follow up after re-treatment at our center was 24 months. Local control among this cohort was 100%. Metastasis occurred in two patients after re-treatment, at 8 months and 7 months. At last follow up, all treated lesions were decreased in size. Four patients experienced worsening visual acuity. Four patients developed cataracts, while two patients developed radiation retinopathy with cystoid macular edema requiring anti-VEGF injections. One patient developed radiation retinopathy but did not require injections. No patients required enucleation.

CONCLUSIONS

Re-treatment of locally recurrent uveal melanomas with EPBT is a feasible alternative to enucleation with a high local control rate. Ocular toxicities have not been significant enough to require enucleation.

Personalized re-treatment strategy for uveal melanoma local recurrences after interventional radiotherapy (brachytherapy): single institution experience and systematic literature review

Purpose

To report the results of a patient’s tailored therapeutic approach using a second course of interventional radiotherapy (brachytherapy) in patients with locally recurrent uveal melanoma.

Material and methods

Patients who had already undergone ocular brachytherapy treated at our IOC (Interventional Oncology Center) were considered. Five patients who has received a second course of treatment with a plaque after local recurrences were included in our study. Re-irradiation was performed with Ruthenium-106 (prescribed dose to the apex 100 Gy) or with Iodine-125 plaques (prescribed dose to the apex 85 Gy). Moreover, a systematic literature search was conducted through three electronic databases, including Medline/PubMed, Scopus, and Embase.

Results

All patients were initially treated with Ruthenium-106 plaque; the re-irradiation was performed with Ruthenium-106 plaque in three cases and with Iodine in two cases. Mean time between the first and the second plaque was 56.8 months (range, 25-93 months). Local tumor control rate was 100%, no patient underwent secondary enucleation owing to re-treatment failure. Distant metastasis occurred in 1 patient after 6 months from re-treatment. After a median follow-up of 44.2 months (range, 26-65 months) from re-treatment, all patients experienced worsening of the visual acuity (median visual acuity was 0.42 at time of recurrence and decline to 0.24 at the most recent follow-up); cataract occurred in two cases, no patient developed scleral necrosis. We considered 2 papers for a systematic review.

Conclusions

In selected cases, especially in presence of marginal local recurrence, a personalized re-treatment strategy with a plaque may offer high probability of tumor control and organ preservation but worsening of visual acuity.

Prior non-irradiative focal therapies do not compromise the efficacy of delayed episcleral plaque brachytherapy in retinoblastoma

BACKGROUND/AIMS

Non-irradiative local therapies have shown promise in delaying or supplanting external beam radiotherapy (EBRT) and enucleation in patients with retinoblastoma. We hypothesised that prior focal therapy does not compromise the efficacy of delayed episcleral plaque brachytherapy (epBRT).

METHODS

We performed an institutional review board-approved medical record review of patients with retinoblastoma who were treated with I-125 epBRT prior to (primary) or following chemoreduction (delayed), alone and in combination with non-irradiative focal therapy. Clinical and treatment characteristics were retrieved. Treatment failure was defined as the need for subsequent EBRT and/or enucleation. Event-free and ocular survival rates were calculated from the date of plaque placement. The cumulative incidences (CIs) of treatment failure and enucleation were compared across strata using Gray's test.

RESULTS

We identified 50 patients with retinoblastoma (54 eyes), who received a total of 56 plaques between January 1986 and December 2010, with a median follow-up of 8.3 years (range, 0.8-21.2 years). The median time from diagnosis to plaque placement was 12.7 months (range, 0.1-128 months). The CI and 95% CI of treatment failure and enucleation following epBRT at 5 years was 37%±7.2% and42.2%±7.3%, respectively. The lack of prior diode or green laser therapy was predictive of increased risk for treatment failure (p=0.02 and 0.03). International Classification group C or D was predictive of decreased time to enucleation (p=0.004). The use of any focal therapy was not predictive of time to treatment failure (p=0.33).

CONCLUSIONS

The use of non-irradiative focal therapies prior to or following epBRT does not decrease the time to enucleation or treatment failure.

Local Failure After Episcleral Brachytherapy for Posterior Uveal Melanoma: Patterns, Risk Factors, and Management

PURPOSE

To evaluate the patterns, the risk factors, and the management of recurrence following brachytherapy in patients with posterior uveal melanoma, given that an understanding of the recurrence patterns can improve early recognition and management of local treatment failure in such patients.

DESIGN

Retrospective cohort study.

METHODS

Setting: Multispecialty tertiary care center.

PARTICIPANTS

A total of 375 eyes treated with episcleral brachytherapy for posterior uveal melanoma from January 2004 to December 2014. Exclusion criteria included inadequate follow-up (<1 year) and previous radiation therapy. Main Outcomes and Measures: Local control rate and time to recurrence were the primary endpoints. Kaplan-Meier estimation and Cox proportional hazards models were conducted to identify risk factors for recurrence.

RESULTS

Twenty-one patients (5.6%) experienced recurrence (follow-up range 12-156 months; median 47 months). The median time to recurrence was 18 months (range 4-156 months). Five-year estimated local recurrence rate was 6.6%. The majority (90.5%) of the recurrences occurred within the first 5 years. The predominant site of recurrence was at the tumor margin (12 patients, 57.1%). Univariate analysis identified 3 statistically significant recurrence risk factors: advanced age, largest basal diameter, and the use of adjuvant transpupillary thermotherapy (TTT). Recurrent tumors were managed by repeat brachytherapy, TTT, or enucleation.

CONCLUSIONS

Local recurrences following brachytherapy are uncommon 5 years after episcleral brachytherapy. Follow-up intervals can be adjusted to reflect time to recurrence. Most of the eyes with recurrent tumor can be salvaged by conservative methods.

Repeat Episcleral Plaque Brachytherapy: Clinical Outcomes in Patients Treated for Locally Recurrent Posterior Uveal Melanoma

PURPOSE

To report the outcomes of survival, local control, visual acuity, and eye retention in patients treated with repeat episcleral plaque brachytherapy (EPBT) for locally recurrent posterior uveal melanoma (PUM).

DESIGN

Retrospective, interventional case series.

METHODS

Setting: Institutional.

PATIENT POPULATION

A total of 1201 patients that underwent iodine-125 (I-125) EPBT as primary treatment for PUM between 1985 and 2015.

INCLUSION CRITERIA

Development of locally recurrent disease and retreatment with I-125 EPBT.

OBSERVATION PROCEDURES

Clinical records review.

MAIN OUTCOME MEASURES

Visual acuity, Kaplan-Meier estimates of survival, local control, metastasis, and loss of the eye over the duration of follow-up.

RESULTS

Twenty-seven patients (13 men) met our inclusion criteria. Median (range) follow-up from initial treatment was 100 months (14-365 months), while median time to local recurrence was 43 months (9-185 months). Median (range) follow-up after retreatment was 47 months (3-120 months). Kaplan-Meier estimate for local control at 5 years was 77.2% (95% confidence interval [CI], 53.29%-89.91%). All marginal recurrences were successfully retreated whereas 6 of 15 patients with central recurrence developed subsequent re-recurrence following salvage EPBT. Median (range) visual acuity was 20/70 (20/20 to counting fingers at 1 foot) at time of recurrence and declined to counting fingers (20/25 to hand motion) at the most recent follow-up examination. Kaplan-Meier estimate for absence of metastatic disease at 5 years was 78.5% (95% CI, 54.77%-90.70%).

CONCLUSIONS

Repeat I-125 EPBT offers a viable alternative to enucleation in patients with local recurrence of PUM, yielding high rates of local control with predictable decline in visual acuity.

Secondary Enucleations for Uveal Melanoma: A 7-Year Retrospective Analysis

PURPOSE

To describe the indications for secondary enucleations in uveal melanoma and analyze associations and outcomes.

DESIGN

Retrospective interventional case series.

METHODS

Data of patients who underwent secondary enucleation for uveal melanoma in the London Ocular Oncology Service, between 2008 and 2014, were retrieved from medical records analyzed. Cox regression model was performed to analyze associations with secondary enucleation and metastases and Kaplan-Meier estimates to assess the probability of metastatic spread and death.

RESULTS

During the study period 515 enucleations were performed for uveal melanoma, 99 (19%) of which were secondary enucleations. Tumors were located at the ciliary body in 21 eyes (21%), juxtapapillary in 31 (31%), and choroid elsewhere in 47 (48%). Primary treatment included Ru(106) plaque radiotherapy, proton beam radiotherapy, and transpupillary thermotherapy in 85, 11, and 3 eyes, respectively. Indications for secondary enucleation were tumor recurrence in 60 (61%), neovascular glaucoma in 21 (21%), and tumor nonresponse in 18 eyes (18%). Twenty patients (20%) were diagnosed with metastasis and 12 out of 20 died of metastatic spread. On multivariate analysis, juxtapapillary tumor location was found to associate with tumor nonresponse (P = .004) and nonresponding patients with metastatic spread (P = .04).

CONCLUSIONS

Indications for secondary enucleations for uveal melanoma were tumor recurrence, neovascular glaucoma, and tumor nonresponse. This review identified a possible high-risk group (nonresponse), which proved radioresistant to treatment. These tumors were more frequently found in the juxtapapillary location and were associated with metastatic spread.

Update on Ophthalmic Oncology 2013: Retinoblastoma and Uveal Melanoma

PURPOSE

The aim of this study was to discuss the clinical and translational content of the literature as well as advancement in our knowledge pertaining to retinoblastoma and uveal melanoma that were published from January to December 2013.

DESIGN

This study is a literature review.

METHODS

The search terms retinoblastoma and uveal melanoma were used in a MEDLINE literature search. Abstracts were studied, and the most relevant articles were selected for inclusion and further in-depth review.

RESULTS

In retinoblastoma, fewer eyes are lost because of the expanded use of ophthalmic artery chemosurgery and intravitreal melphalan, and the past year marks a deepening in our understanding of these modalities. Knowledge on the genetic underpinnings of uveal melanoma has broadened to include genes associated with a favorable prognosis. This is accompanied by promising results in the treatment of metastatic uveal melanoma.

CONCLUSIONS

This past year, there were important advancements in our knowledge of retinoblastoma and uveal melanoma.