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Ehret F, Fürweger C, Liegl R, Schmelter V, Priglinger S, Subedi G, Grimm D, Foerster P, Muacevic A, Grimm J. Tumor Control Probability and Time-Dose Response Modeling for Stereotactic Radiosurgery of Uveal Melanoma. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00688-6. [PMID: 38838993 DOI: 10.1016/j.ijrobp.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 05/10/2024] [Accepted: 05/24/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Uveal melanoma (UM), while a rare malignancy, stands as the most prevalent intraocular malignancy in adults. Controversies persist regarding the dose dependency of local control (LC) through radiotherapy. This study seeks to elucidate the significance of the prescription dose by employing time-dose response models for UM patients receiving photon-based stereotactic radiosurgery (SRS). MATERIALS AND METHODS Inclusion criteria comprised UM patients treated between 2005 and 2019. All patients underwent single-fraction SRS. Datapoints were separated into three dose groups, with Kaplan-Meier analysis performed on each group, from which time-dose response models for LC were created at 2, 4, and 7 years using maximum-likelihood fitted logistic models. RESULTS Outcomes from 594 patients with 594 UM were used to create time-dose response models. The prescribed doses and the number of patients were as follows: 17-19 Gy (24 patients), 20 Gy (122 patients), 21 Gy (442 patients), and 22 Gy (6 patients). Averaged over all patients and doses, LC rates at 2, 4, and 7 years were 94.4%, 88.2%, and 69.0%, respectively. Time-dose response models for LC demonstrated a dose-dependent effect, showing 2-year LC rates of more than 90% with 20 Gy and 95% with 22 Gy. For four years and a LC of 90%, a dose of approximately 21 Gy was required. After seven years, the 21 Gy prescription dose is predicted to maintain a LC above 70%, sharply declining to less than 60% LC with 19 Gy and less than 40% with 18 Gy. CONCLUSION In contrast to prior findings, the time-dose response models for UM undergoing photon-based SRS emphasize the critical role of the prescription dose in achieving lasting LC. The dose selection must be carefully balanced against toxicity risks, considering tumor geometry and individual patient characteristics to tailor treatments accordingly.
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Affiliation(s)
- Felix Ehret
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, Berlin, Germany; Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), Heidelberg, Germany; European Radiosurgery Center Munich, Munich, Germany.
| | - Christoph Fürweger
- European Radiosurgery Center Munich, Munich, Germany; Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Cologne, Germany
| | - Raffael Liegl
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Valerie Schmelter
- Department of Ophthalmology, Ludwig-Maximilians University Munich, Munich, Germany
| | - Siegfried Priglinger
- Department of Ophthalmology, Ludwig-Maximilians University Munich, Munich, Germany
| | - Gopal Subedi
- Department of Radiation Oncology, Wellstar Kennestone Hospital, Marietta, Georgia, USA
| | - David Grimm
- Department of Physics and Astronomy, University of Pittsburgh, Pittsburgh, USA
| | - Paul Foerster
- Department of Ophthalmology, Ludwig-Maximilians University Munich, Munich, Germany
| | | | - Jimm Grimm
- Department of Radiation Oncology, Wellstar Kennestone Hospital, Marietta, Georgia, USA
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Semeniuk O, Yu E, Rivard MJ. Current and Emerging Radiotherapy Options for Uveal Melanoma. Cancers (Basel) 2024; 16:1074. [PMID: 38473430 DOI: 10.3390/cancers16051074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
What treatment options are there for patients having uveal melanoma? A randomized, prospective, multi-institutional clinical trial (COMS) showed no difference in survival between brachytherapy and enucleation for medium-sized lesions. With the obvious benefit of retaining the eye, brachytherapy has flourished and many different approaches have been developed such as low-dose-rate sources using alternate low-energy photon-emitting radionuclides, different plaque designs and seed-loading techniques, high-dose-rate brachytherapy sources and applicators, and low- and high-dose-rate beta-emitting sources and applicators. There also have been developments of other radiation modalities like external-beam radiotherapy using linear accelerators with high-energy photons, particle accelerators for protons, and gamma stereotactic radiosurgery. This article examines the dosimetric properties, targeting capabilities, and outcomes of these approaches. The several modalities examined herein have differing attributes and it may be that no single approach would be considered optimal for all patients and all lesion characteristics.
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Affiliation(s)
- Oleksii Semeniuk
- Department of Radiation Oncology, Warren Alpert Medical School, Brown University and Rhode Island Hospital, Providence, RI 02903, USA
| | - Esther Yu
- Department of Radiation Oncology, Warren Alpert Medical School, Brown University and Rhode Island Hospital, Providence, RI 02903, USA
| | - Mark J Rivard
- Department of Radiation Oncology, Warren Alpert Medical School, Brown University and Rhode Island Hospital, Providence, RI 02903, USA
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Sreenivasa S, Wösle M, Gager Y, Vordermark D, Grajewski L, Krause L, Ciernik IF. Impact of tumour volume and treatment delay on the outcome after linear accelerator-based fractionated stereotactic radiosurgery of uveal melanoma. Br J Ophthalmol 2024; 108:457-464. [PMID: 36894300 PMCID: PMC10894830 DOI: 10.1136/bjo-2022-322750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/19/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND/AIMS Primary radiation therapy is used to treat malignant uveal melanoma (UM). We report our single-centre experience with fractionated radiosurgery (fSRS) with a linear accelerator (LINAC) after specific adaptation for small target volumes with HybridArc. METHODS From October 2014 to January 2020, 101 patients referred to Dessau City Hospital with unilateral UM underwent fSRS with 50 Gy given in five fractions on five consecutive days. Primary endpoints were local tumour control, globe preservation, metastasis and death. Potential prognostic features were analysed. Kaplan-Meier analysis, Cox proportional hazards model and linear models were used for calculations. RESULTS The median baseline tumour diameter was 10.0 mm (range, 3.0-20.0 mm), median tumour thickness 5.0 mm (range, 0.9-15.5 mm) and median gross tumour volume (GTV) 0.4 cm³ (range, 0.2-2.6 cm³). After a median follow-up of 32.0 months (range, 2.5-76.0 months), 7 patients (6.9%) underwent enucleation: 4 (4.0%) due to local recurrence and 3 (3.0%) due to radiation toxicities, and 6 patients (5.9%) revealed tumour persistence with a GTV exceeding 1.0 cm³. Of 20 patients (19.8%) who died, 8 (7.9%) were tumour-related deaths. Twelve patients (11.9%) suffered from distant metastasis. GTV showed an impact on all endpoints, and treatment delay was associated with reduced odds of eye preservation. CONCLUSION LINAC-based fSRS with static conformal beams combined with dynamic conformal arcs and discrete intensity-modulated radiotherapy results in a high tumour control rate. The tumour volume is the most robust physical prognostic marker for local control and disease progression. Avoiding treatment delay improves outcomes.
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Affiliation(s)
- Shanthala Sreenivasa
- Department of Radiation Oncology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - Markus Wösle
- Department of Radiation Oncology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - Yann Gager
- Department of Research and Development, PathoNext GmbH, Leipzig, Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, Martin Luther Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Luise Grajewski
- Department of Ophthalmology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - Lothar Krause
- Department of Ophthalmology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - I Frank Ciernik
- Department of Radiation Oncology, Städtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane, Dessau, Germany
- Department of Radiation Oncology, Martin Luther Universität Halle-Wittenberg, Halle (Saale), Germany
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Synoradzki KJ, Paduszyńska N, Solnik M, Toro MD, Bilmin K, Bylina E, Rutkowski P, Yousef YA, Bucolo C, Zweifel SA, Reibaldi M, Fiedorowicz M, Czarnecka AM. From Molecular Biology to Novel Immunotherapies and Nanomedicine in Uveal Melanoma. Curr Oncol 2024; 31:778-800. [PMID: 38392052 PMCID: PMC10887618 DOI: 10.3390/curroncol31020058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/09/2023] [Accepted: 12/19/2023] [Indexed: 02/24/2024] Open
Abstract
Molecular biology studies of uveal melanoma have resulted in the development of novel immunotherapy approaches including tebentafusp-a T cell-redirecting bispecific fusion protein. More biomarkers are currently being studied. As a result, combined immunotherapy is being developed as well as immunotherapy with bifunctional checkpoint inhibitory T cell engagers and natural killer cells. Current trials cover tumor-infiltrating lymphocytes (TIL), vaccination with IKKb-matured dendritic cells, or autologous dendritic cells loaded with autologous tumor RNA. Another potential approach to treat UM could be based on T cell receptor engineering rather than antibody modification. Immune-mobilizing monoclonal T cell receptors (TCR) against cancer, called ImmTAC TM molecules, represent such an approach. Moreover, nanomedicine, especially miRNA approaches, are promising for future trials. Finally, theranostic radiopharmaceuticals enabling diagnosis and therapy with the same molecule bring hope to this research.
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Affiliation(s)
- Kamil J. Synoradzki
- Environmental Laboratory of Pharmacological and Toxicological Research, Mossakowski Medical Research Institute, Polish Academy of Sciences, 5 Pawinskiego Str., 02-106 Warsaw, Poland;
| | - Natalia Paduszyńska
- Faculty of Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (N.P.); (M.S.)
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 5 Roentgen Str., 02-781 Warsaw, Poland; (E.B.); (P.R.)
| | - Malgorzata Solnik
- Faculty of Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (N.P.); (M.S.)
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 5 Roentgen Str., 02-781 Warsaw, Poland; (E.B.); (P.R.)
| | - Mario Damiano Toro
- Chair and Department of General and Pediatric Ophthalmology, Medical University of Lublin, 1 Chmielna Str., 20-079 Lublin, Poland;
- Eye Clinic, Public Health Department, Federico II University, Via Pansini 5, 80131 Naples, Italy
| | - Krzysztof Bilmin
- Research and Development Centre Novasome Sp. z o.o., 51-423 Wrocław, Poland;
| | - Elżbieta Bylina
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 5 Roentgen Str., 02-781 Warsaw, Poland; (E.B.); (P.R.)
- Department of Clinical Trials, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 5 Roentgen Str., 02-781 Warsaw, Poland; (E.B.); (P.R.)
| | - Yacoub A. Yousef
- Department of Surgery (Ophthalmology), King Hussein Cancer Centre, Amman 11941, Jordan;
| | - Claudio Bucolo
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via S. Sofia 97, 95123 Catania, Italy;
| | - Sandrine Anne Zweifel
- Department of Ophthalmology, University Hospital Zurich, 8091 Zurich, Switzerland;
- Faculty of Human Medicine, University of Zurich, 8032 Zurich, Switzerland
| | - Michele Reibaldi
- Department of Surgical Sciences, Eye Clinic Section, Citta della Salute e della Scienza, Turin University, 10122 Turin, Italy;
| | - Michal Fiedorowicz
- Small Animal Magnetic Resonance Imaging Laboratory, Mossakowski Medical Research Institute, Polish Academy of Sciences, 5 Pawinskiego Str., 02-106 Warsaw, Poland
| | - Anna M. Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 5 Roentgen Str., 02-781 Warsaw, Poland; (E.B.); (P.R.)
- Department of Experimental Pharmacology, Mossakowski Medical Research Institute, Polish Academy of Sciences, 5 Pawinskiego Str., 02-106 Warsaw, Poland
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Tsui MC, Chia-Hsien Cheng J, Lin CP. Stereotactic radiosurgery for medium and large uveal melanoma with a non-invasive eye immobilization device, a single institutional case series. J Formos Med Assoc 2023; 122:1117-1124. [PMID: 37258323 DOI: 10.1016/j.jfma.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 06/07/2022] [Accepted: 04/19/2023] [Indexed: 06/02/2023] Open
Abstract
PURPOSE To investigate the treatment outcome, visual outcome, and adverse effects of five-fraction stereotactic radiosurgery (SRS) to medium- and large-sized uveal melanoma with a non-invasive eye immobilization device. METHODS Medical records of 14 patients with uveal melanoma receiving SRS with a total dose of 50 Gy in five fractions from 2008 to 2017 were retrospectively reviewed. A non-invasive eye fixation device was used to achieve and monitor eye immobilization. RESULTS Local tumor control rates were 85.7% and 75.0% at 2 and 5 years, respectively. The average tumor diameter decreased significantly from 10.0 ± 3.21 mm to 8.36 ± 3.71 mm (p = 0.038) 15 months after SRS, while the average tumor thickness decreased significantly from 5.45 ± 2.21 mm to 4.34 ± 2.29 (p = 0.036) 21 months after SRS. The 5-year metastasis-free survival was 87.5%. The mean best-corrected visual acuity (BCVA) deteriorated from logMAR 0.296 at baseline to logMAR 1.112 at the last individual follow-up visits (p < 0.001). Adverse effects of SRS were comparable to those reported with proton-beam radiotherapy or Gamma knife therapy. CONCLUSION SRS combined with a non-invasive eye immobilization device is an effective and safe alternative eye-preserving treatment for medium- to large-sized uveal melanoma. BCVA at 3 months may be a predictor for BCVA at 1 year.
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Affiliation(s)
- Mei-Chi Tsui
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan; An Nan Hospital, China Medical University, Tainan, Taiwan
| | - Jason Chia-Hsien Cheng
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taiwan; Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taiwan
| | - Chang-Ping Lin
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan; Department of Ophthalmology, College of Medicine, National Taiwan University, Taiwan.
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Asplund E, Fili M, Pansell T, Brautaset R, Nilsson M, Stålhammar G. The prognostic implication of visual acuity at the time of uveal melanoma diagnosis. Eye (Lond) 2023; 37:2204-2211. [PMID: 36434284 PMCID: PMC10366190 DOI: 10.1038/s41433-022-02316-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 10/15/2022] [Accepted: 11/11/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Visual outcomes after primary tumour treatment of uveal melanoma (UM) have been investigated repeatedly. This study evaluates the correlation between best-corrected visual acuity (BCVA) before treatment with clinicopathological factors and patient survival. SUBJECTS/METHODS Pre-treatment BCVA was examined in relation to tumour dimensions and location, and survival in a retrospective cohort of 1809 patients who underwent plaque brachytherapy. BCVA was also correlated to tumour histological factors in a second cohort of 137 enucleated eyes. RESULTS The mean BCVA of the tumour eye prior to plaque brachytherapy was LogMAR 0.42 (SD 0.46). Patients with low BCVA (LogMAR ≥ 1.00) did not differ in age (p = 0.19) and had similar frequency of ciliary body involvement (p = 0.99) but had tumours with greater apical thickness (p < 0.0001), greater diameter (p < 0.0001) and shorter distance to the optic disc and fovea (p < 0.0001). There were no significant relations between low BCVA and any of 13 examined tumour histological factors at a Bonferroni-corrected significance level (p > 0.004). Patients with low BCVA had greater incidence of UM-related mortality in competing risk analysis (p = 0.0019) and shorter overall survival (p < 0.0001). Low BCVA was also associated with increased hazard ratio (HR) for UM-related mortality in univariate analysis (HR 1.5, 95% confidence interval 1.2 to 1.9), but not in multivariate analysis with tumour size and location as covariates. CONCLUSIONS UM patients with low BCVA before primary tumour treatment have a worse prognosis, likely related to increased tumour dimensions. Future studies should examine the prognostic significance of BCVA in relation to macula-involving retinal detachment and genetic factors.
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Affiliation(s)
- Elin Asplund
- Department of Clinical Neuroscience, Division of Ophthalmology and Vision, Unit of Optometry, Karolinska Institutet, Stockholm, Sweden
| | - Maria Fili
- Department of Clinical Neuroscience, Division of Ophthalmology and Vision, Unit of Ocular Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- St. Erik Eye Hospital, Stockholm, Sweden
| | - Tony Pansell
- Department of Clinical Neuroscience, Division of Ophthalmology and Vision, Marianne Bernadotte Centre, Karolinska Institutet, Stockholm, Sweden
| | - Rune Brautaset
- Department of Clinical Neuroscience, Division of Ophthalmology and Vision, Unit of Optometry, Karolinska Institutet, Stockholm, Sweden
| | - Maria Nilsson
- Department of Clinical Neuroscience, Division of Ophthalmology and Vision, Unit of Optometry, Karolinska Institutet, Stockholm, Sweden
| | - Gustav Stålhammar
- Department of Clinical Neuroscience, Division of Ophthalmology and Vision, Unit of Ocular Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden.
- St. Erik Eye Hospital, Stockholm, Sweden.
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Mazzini C, Vicini G, Di Leo L, Massi D, Rizzo S, Giansanti F. Anatomical and Functional Outcomes after Endoresection and Adjuvant Ruthenium Brachytherapy for Uveal Melanoma: A Single-Center Experience. Life (Basel) 2023; 13:902. [PMID: 37109431 PMCID: PMC10146230 DOI: 10.3390/life13040902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/19/2023] [Accepted: 03/24/2023] [Indexed: 03/31/2023] Open
Abstract
PURPOSE To evaluate the anatomical and functional outcomes of endoresection and adjuvant ruthenium (Ru)-106 brachytherapy for uveal melanoma (UM). METHODS Retrospective case series of 15 UM patients (15 eyes) treated at our center (Careggi University Hospital, Florence). RESULTS Six patients (40%) were male and nine were female (60%). The mean age of patients at the time of treatment was 61.6 years (±19.41). The mean BCVA at baseline was 20/50. In all cases UM originated from the choroid. The mean tumor thickness at baseline was 7.14 mm (±2.05), and the mean largest basal diameter was 11.2 mm (±1.92). A concurrent retinal detachment was diagnosed in 11 patients (73.3%). Two patients (13.3%) showed vitreous seeding at baseline. Eleven patients (73.3%) were treated with primary endoresection, while four patients (26.7%) were treated with a "salvage endoresection" after primary treatment failure (previous radiation treatment). The mean follow-up time was 28.9 months (±10.6). Thirteen out of fifteen patients were alive and showed no evidence of local recurrence or distance metastasis at the last follow-up visit. The treatment achieved local control of the disease in 14 out of 15 cases (93.3%). In one case, the patient underwent enucleation for disease recurrence. The overall survival rate at the end of the follow-up was 93.3%. The mean BCVA at last follow-up visit was 20/40. Treatment was well tolerated, without significant complications. CONCLUSIONS Endoresection and adjuvant Ru-106 brachytherapy is a valuable conservative option for selected UM patients and can be used both as a primary treatment and as a salvage therapy. It can control melanoma and avoid enucleation, reduce radiation-related complications, and provide tumor tissue for chromosomal analysis and prognostic testing.
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Affiliation(s)
- Cinzia Mazzini
- Unit of Ocular Oncology, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
- Eye Clinic, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
| | - Giulio Vicini
- Unit of Ocular Oncology, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
- Eye Clinic, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, 50121 Florence, Italy
| | - Laura Di Leo
- Unit of Ocular Oncology, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
- Eye Clinic, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, 50121 Florence, Italy
| | - Daniela Massi
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, 50121 Florence, Italy
- Section of Pathological Anatomy, Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Stanislao Rizzo
- Ophthalmology Unit, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
- Consiglio Nazionale delle Ricerche (CNR), 56124 Pisa, Italy
| | - Fabrizio Giansanti
- Unit of Ocular Oncology, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
- Eye Clinic, Neuromuscular and Sense Organs Department, Careggi University Hospital, 50134 Florence, Italy
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Liegl R, Schmelter V, Fuerweger C, Ehret F, Priglinger S, Muacevic A, Foerster P. Robotic CyberKnife Radiosurgery for the Treatment of Choroidal and Ciliary Body Melanoma. Am J Ophthalmol 2023; 250:177-185. [PMID: 36642391 DOI: 10.1016/j.ajo.2022.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/15/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE To present the results of robotic-assisted radiosurgery in choroidal and ciliary body melanomas treated at the Department of Ophthalmology of Ludwig-Maximilians-University and the European CyberKnife Center in Munich, Germany. DESIGN Interventional case series METHODS: This retrospective study included 594 consecutive patients referred to our clinic for the treatment of choroidal and ciliary body melanomas with robotic radiosurgery (CyberKnife) from 2005 to 2019. Eye retention, local control and disease-specific survival rates were calculated as Kaplan-Meier and actuarial estimates. The impact of prescription dose, tumor size, and ciliary body involvement was assessed by likelihood ratio tests and Cox regression. RESULTS Among all patients who were staged according to the TNM classification system (8th edition), 22.7% were I, 57.9% were II, 18.9% were III, and 0.5% were IV. Median apical tumor height and base diameter were 5.8 and 11.4 mm. The mean follow-up was 41.7 months. Local control after 3 and 5 years was 92.0% (95% CI = 88.2%-94.7%) and 84.3% (95% CI = 77.9%-89.0%), respectively, for 21 to 22 Gy and 86.9% (95% CI = 79.7%-91.7%) and 77.7% (95% CI = 68.5%-84.6%), respectively, when treated with 20 Gy or less. Eye retention was achieved in 89.9% and 81.0% after 3 and 5 years with 21 to 22 Gy and 85.9% and 80.0% for 20 Gy or less. Disease-specific survival rates were 93.1% (95% CI = 90.2%-95.2%) after 3 years, 89.8% (95% CI = 86.0%-92.6%) after 5 years, and 87.8% (95% CI = 82.8%-91.4%) after 7 years. CONCLUSIONS This is the largest series of patients treated for choroidal and ciliary body melanomas with CyberKnife. Our results reflect an improvement in the outcome of CyberKnife therapy for patients with choroidal and ciliary body melanoma treated with single-session radiosurgery in the last decade.
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Affiliation(s)
- Raffael Liegl
- From the Department of Ophthalmology (R.L., V.S., S.P., P.F.), Ludwig-Maximilians University Munich, Munich, Germany.
| | - Valerie Schmelter
- From the Department of Ophthalmology (R.L., V.S., S.P., P.F.), Ludwig-Maximilians University Munich, Munich, Germany
| | - Christoph Fuerweger
- European Radiosurgery Center Munich (C.F., F.E., A.M.), Munich, Germany; Center for Neurosurgery (C.F.), Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Cologne, Germany
| | - Felix Ehret
- European Radiosurgery Center Munich (C.F., F.E., A.M.), Munich, Germany
| | - Siegfried Priglinger
- From the Department of Ophthalmology (R.L., V.S., S.P., P.F.), Ludwig-Maximilians University Munich, Munich, Germany
| | | | - Paul Foerster
- From the Department of Ophthalmology (R.L., V.S., S.P., P.F.), Ludwig-Maximilians University Munich, Munich, Germany
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Zhou X, Ishikawa H, Gomi F. Macular hole and vitreous hemorrhage subsequent to stereotactic hypofractionated radiotherapy for choroidal melanoma: A case report and review of the literature. Front Oncol 2022; 12:1060307. [PMID: 36483031 PMCID: PMC9723233 DOI: 10.3389/fonc.2022.1060307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
Choroidal melanoma is the leading primary intraocular tumor with potentially fatal outcomes in adults. The coexistence of choroidal melanoma and a macular hole is extremely rare, and treatment strategies and information on the prognosis of associated complications are currently lacking. We report the first case of choroidal melanoma complicated with a macular hole and vitreous hemorrhage after stereotactic hypofractionated radiotherapy in Japan, and review the relevant literature in relation to the possible mechanisms, treatment strategies, and outcomes. An 83-year-old male with choroidal melanoma was treated with stereotactic hypofractionated radiotherapy in January 2021. Five months later, a full-thickness macular hole developed, followed by an acute massive vitreous hemorrhage about 2 weeks later. Following confirmation of tumor regression, the patient underwent a pars plana vitrectomy and internal limiting membrane peeling. The macular hole was closed postoperatively and the patient’s best-corrected visual acuity improved to 20/125. There was no evidence of intraocular tumor dissemination or distant metastases during follow-up. A systematic literature search only identified 10 previous cases of choroidal melanoma with a macular hole in eight reports worldwide, mainly in females. Macular edema may be the primary cause of macular hole formation in these cases. Most patients who underwent vitrectomy for complications after tumor regression achieved a good prognosis. The development of a macular hole is a rare complication associated with choroidal melanoma. Anterior-posterior traction of posterior vitreous detachment and secondary macular edema may have contributed to the formation of the macular hole in the current case.
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Affiliation(s)
- Xiaoyin Zhou
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroto Ishikawa
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
- Department of Ophthalmology, Mirai Eye & Skin Clinic, Osaka, Japan
- *Correspondence: Hiroto Ishikawa,
| | - Fumi Gomi
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
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Stereotactic irradiation on linear accelerator - ultrasound versus MRI in choroidal melanoma volume calculation. BMC Ophthalmol 2022; 22:333. [PMID: 35931996 PMCID: PMC9356474 DOI: 10.1186/s12886-022-02558-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Stereotactic irradiation is one of the treatment modalities for intraocular uveal melanoma. The study’s purpose was to describe the background of stereotactic one-day session radiosurgery, how the comparison in the difference between the tumor volume measured values from the magnetic resonance imaging (MRI) method and the ultrasound method was related to it, and which method was more precise to be used for tumor regression after irradiation. Methods The group of 147 patients with choroidal melanoma was treated by stereotactic irradiation on the linear accelerator with a single dose of 35.0 Gy. During the standard treatment process the uveal melanoma volumes, needed for dose calculation, were obtained using MRI from the individual stereotactic planning scheme and by ultrasound from the ultrasound device. All volumes were statistically compared using the paired t-test, and for the visualization purpose, the Bland-Altman plot was used. Results In the group of patients, it was 70 (47.6%) males and 77 (52.4%) females. The tumor volume median was from MRI equal to 0.44 cm3 and from ultrasound equal to 0.53 cm3. The difference between the ultrasound and the MRI volume measured values was statistically significant. However, the Bland-Altman plot clearly documents that the two methods are in agreement and can be used interchangeably. In most of the cases, the measured values of the ultrasound-calculated volume achieved slightly higher measured values. Conclusions The calculation of the intraocular uveal tumor volume is a crucial part of the stereotactic irradiation treatment. The ultrasound volume measured values were in most of the cases higher than the measured values from the MRI. Although the methods are comparable and can be used interchangeably, we are recommending using the more precise MRI method not only during the treatment but also on later regular medical checks of tumor regression or progression.
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11
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Schmelter V, Hofmann T, Schneider F, Weber C, Fuerweger C, Muacevic A, Priglinger SG, Foerster P, Liegl R. Robotic CyberKnife radiosurgery for small choroidal melanomas. Melanoma Res 2022; 32:192-199. [PMID: 35404316 DOI: 10.1097/cmr.0000000000000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Plaque brachytherapy is the most common procedure for the treatment of small choroidal melanoma, especially in posteriorly located tumors. However, there is only little information on outcome after treatment with stereotactic radiosurgery, for example, CyberKnife radiosurgery. We reviewed patients with choroidal melanoma (maximum tumor height 4 mm) treated with CyberKnife radiosurgery. Demographic information, tumor dimension, complications, metastasis and overall survival during the whole follow-up were tracked and analyzed with a specific focus on local tumor control and potential risk factors. One hundred eighty-eight patients (102 female, 54.2%) with a median age of 63 years [interquartile range (IQR): 54-73 years] were analyzed over a median of 46 months (IQR: 24-62 months). Metastasis occurred in 14 patients (7.4%) in median of 18 months after treatment (IQR: 13-47 months) and survival was achieved in 178 patients (94.7%). Within the observation period, eye retention was observed in 166 patients (88.3%). Superior local control was achieved in patients who received a prescription dose of at least 21 Gy or more (91.6%; P = 0.04). Other potential risk factors incrementing local control were treatment planning with missing MRI in advance and too small target delineation during the planning process. Radiosurgery (CyberKnife) in a single, outpatient procedure is suitable for the treatment of small choroidal melanoma. We found local control rate after 3 years compared to the standard treatment with plaque brachytherapy. On the study side, 15 years of CyberKnife treatment allowed to identify risk factors that might increment local control and thus improve treatment regimens.
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Affiliation(s)
| | | | - Frederick Schneider
- Department of Anaesthesiology, TUM School of Medicine, Technical University of Munich, Munich
| | - Constance Weber
- Department of Ophthalmology, University Eye Hospital, University of Bonn, Bonn, Germany
| | | | | | | | - Paul Foerster
- Department of Ophthalmology, University Hospital, LMU Munich
| | - Raffael Liegl
- Department of Ophthalmology, University Hospital, LMU Munich
- Department of Ophthalmology, University Eye Hospital, University of Bonn, Bonn, Germany
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12
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Turkoglu EB, Rao R, Celik E. Long term outcome of adjuvant photodynamic therapy after cyberknife radiotherapy for choroidal melanoma. Photodiagnosis Photodyn Ther 2022; 38:102840. [PMID: 35367617 DOI: 10.1016/j.pdpdt.2022.102840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/21/2022] [Accepted: 03/29/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To report the outcome of photodynamic therapy (PDT) for choroidal melanoma as adjuvant treatment with CyberKnife radiotherapy. DESIGN Retrospective interventional case series. METHODS Standard-fluence PDT using verteporfin. OUTCOME MEASURES Regression of tumor; resolution of subretinal fluid (SRF); change in best-corrected visual acuity (BCVA), and complications of PDT. RESULTS The study included 16 choroidal melanomas (3 pigmented, 4 lightly pigmented, 9 amelanotic) treated with adjuvant PDT after CyberKnife radiotherapy. The mean follow up time was 45.5 months after the initial PDT. 13 patients improved completely with PDT sessions and growth was seen in 3 patients. There was seen completely resolution in SRF in 10 eyes, partial resolution in 3 eyes, and stable in 3 eyes. The mean thickness of tumors was 3.9 mm before PDT and 2.3 mm after PDT. Retina pigment epithelium atrophy in 3 patients and subretinal hemorrhage in 1 patient were seen as complication of PDT. Three patients underwent enucleation for recurrence in the tumor. There was not a higher rate of change in BCVA after PDT (37.5% stable; 25% increase; 37.5% decrease. Poor final visual acuity associated with worse initial visual acuity, proximity of the tumor to the foveola and optic disc, and radiation complications. CONCLUSIONS PDT seems to offer a good option for posterior pole choroidal melanoma as adjuvant therapy in suitable cases. Future prospective studies with larger number of patients and with longer follow-up are needed to further investigation.
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Affiliation(s)
- Elif Betul Turkoglu
- Ocular Oncology Service, Department of Ophthalmology, Akdeniz University, Antalya, Turkey.
| | - Raksha Rao
- Oculoplasty and Ocular Oncology, Chaithanya Eye Hospital and Research Institute, Trivandrum, India
| | - Erkan Celik
- Retina Service, Department of Ophthalmology, Sakarya University, Sakarya, Turkey
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13
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Ganz JC. Orbital indications. PROGRESS IN BRAIN RESEARCH 2022; 268:315-327. [PMID: 35074088 DOI: 10.1016/bs.pbr.2021.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
GKNS for uveal melanoma has become a recognized valued treatment which avoids enucleation of the eye. In the early days, the eccentric location of these tumors made treatment difficult, but Gamma Knife Perfexion has solved that problem. It is known that larger tumors and tumors with an anterior location have a worse prognosis. GKNS has also been of rather unexpected benefit in optic nerve gliomas that require treatment. Choroidal hemangiomas may benefit from treatment as can secondary glaucoma. It has also been found to be beneficial in the treatment of thyrotoxic ophthalmopathy.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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Cicinelli MV, Di Nicola M, Gigliotti CR, Battista M, Miserocchi E, Vecchio A, Mortini P, Bandello F, Modorati GM. Predictive factors of radio-induced complications in 194 eyes undergoing gamma knife radiosurgery for uveal melanoma. Acta Ophthalmol 2021; 99:e1458-e1466. [PMID: 33638277 DOI: 10.1111/aos.14814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 01/03/2021] [Accepted: 02/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE To report the factors predictive of radio-induced complications (i.e. radiation retinopathy [RR], radiation papillopathy [RP] and neovascular glaucoma [NVG]) in uveal melanoma (UM) patients undergoing gamma knife radiosurgery (GKR). MATERIALS AND METHODS Longitudinal cohort study on patients with UM treated at the Ocular Oncology Service, San Raffaele Scientific Institute, Milan, between June 1994 and November 2018. Data were retrospectively reviewed. Rates of GKR-related complications were reported. Variables associated with each complication were investigated using multivariable Cox models and confirmed by logistic regression analysis. Hazard ratio (HR) and 95% confidence intervals (CI) were reported for significant associations. RESULTS One hundred ninety-four patients (99 males, 51%) were included, and 184 tumours were primarily located in the choroid (95%). Median follow-up was 57 months (range 6-286). Local control was achieved in 182 eyes (94%), and 152 eyes (78%) experienced at least one radiation-induced complication. Radiation retinopathy was documented in 67 eyes (35%) after a median of 23 months. Older age (HR = 0.97, 95% CI = 0.95-0.99, p = 0.02) had a protective effect for RR. Radiation papillopathy was diagnosed in 35 eyes (18%) after a median of 14 months after GKR. Macular or peripapillary location (HR = 3.06, 95% CI = 1.52-6.16, p = 0.002) was associated with increased risk of RP, while older age was protective (HR = 0.95, 95% CI = 0.93-0.98, p = 0.001). New-onset NVG was found in 53 eyes (27%), and median onset was 28 months. Tumour thickness (HR = 4.41, 95% CI = 2.23-8.72, p < 0.001) and peripapillary location (HR = 2.78, 95% CI = 1.46-5.27, p = 0.002) were the main risk factors associated with NVG. CONCLUSION Understanding factors predictive for radiation-related complications in patients undergoing GKR might help for better counselling and treatment planning.
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Affiliation(s)
- Maria Vittoria Cicinelli
- School of Medicine Vita‐Salute San Raffaele University Milan Italy
- Department of Ophthalmology IRCCS San Raffaele Scientific Institute Milan Italy
| | - Maura Di Nicola
- Ocular Oncology Service University of Cincinnati College of Medicine Cincinnati OH USA
| | | | - Marco Battista
- Department of Ophthalmology IRCCS San Raffaele Scientific Institute Milan Italy
| | | | - Antonella Vecchio
- Department of Medical Physics IRCCS San Raffaele Scientific Institute Milan Italy
| | - Pietro Mortini
- School of Medicine Vita‐Salute San Raffaele University Milan Italy
- Department of Neurosurgery and Gamma Knife Radiosurgery IRCCS San Raffaele Scientific Institute Milan Italy
| | - Francesco Bandello
- School of Medicine Vita‐Salute San Raffaele University Milan Italy
- Department of Ophthalmology IRCCS San Raffaele Scientific Institute Milan Italy
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15
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Guleser UY, Sarici AM, Ucar D, Gonen B, Sengul Samanci N, Özgüroğlu M. Comparison of iodine-125 plaque brachytherapy and gamma knife stereotactic radiosurgery treatment outcomes for uveal melanoma patients. Graefes Arch Clin Exp Ophthalmol 2021; 260:1337-1343. [PMID: 34735632 DOI: 10.1007/s00417-021-05472-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 10/07/2021] [Accepted: 10/15/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To compare the efficacies of iodine-125 brachytherapy (IBT) and gamma knife stereotactic radiosurgery (GKRS) in the treatment of posterior uveal melanoma. METHODS The demographic data and tumor characteristics at diagnosis of 201 patients treated with IBT and 52 patients treated with GKRS were recorded. The two treatments were then compared in terms of complications, local control, eye retention, metastasis, and overall survival rate. RESULTS The median follow-up time was 56 months for the GKRS group and 45 months for the IBT group (p = 0.167). There were no significant differences in demographic data or tumor characteristics between the groups at diagnosis. Radiation retinopathy, radiation optic neuropathy, and neovascular glaucoma occurred at similar rates in both groups. However, radiation maculopathy and cataracts occurred more frequently in the GKRS group. The number of cases that have developed vision loss (worsening of best-corrected visual acuity on three or more lines on the Snellen chart) was significantly higher in the GKRS group (60%) compared to the IBT group (44%) (p = 0.048). Local control, metastasis, and 5-year overall survival rates were statistically similar in both groups. CONCLUSIONS GKRS can be preferred as an eye-sparing treatment option for posterior uveal melanoma in cases where brachytherapy cannot be used.
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Affiliation(s)
| | - Ahmet Murat Sarici
- Department of Ophthalmology, Cerrahpasa Medical Faculty, Istanbul Unıversity - Cerrahpasa, Istanbul, 34098, Turkey.
| | - Didar Ucar
- Department of Ophthalmology, Cerrahpasa Medical Faculty, Istanbul Unıversity - Cerrahpasa, Istanbul, 34098, Turkey
| | - Busenur Gonen
- Department of Ophthalmology, Zonguldak Ataturk State Hospital, Zonguldak, Turkey
| | - Nilay Sengul Samanci
- Department of Internal Medicine, Division of Medical Oncology, Cerrahpaşa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Mustafa Özgüroğlu
- Department of Internal Medicine, Division of Medical Oncology, Cerrahpaşa Medical Faculty, Istanbul University - Cerrahpasa, Istanbul, Turkey
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van Beek JGM, van Rij CM, Baart SJ, Yavuzyigitoglu S, Bergmann MJ, Paridaens D, Naus NC, Kiliç E. Fractionated stereotactic radiotherapy for uveal melanoma: Long-term outcome and control rates. Acta Ophthalmol 2021; 100:511-519. [PMID: 34529346 PMCID: PMC9544756 DOI: 10.1111/aos.15029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/07/2021] [Accepted: 08/31/2021] [Indexed: 11/29/2022]
Abstract
Purpose The aim of our study is to evaluate local tumour control rates, radiation side‐effects, visual preservation and disease‐free survival (DFS) of uveal melanoma (UM) patients treated with fractionated stereotactic radiotherapy (fSRT). Methods A retrospective study of UM patients, who were treated with fSRT (N = 189), was performed by the Rotterdam Ocular Melanoma Study group (ROMS), the Netherlands, between 1999 and 2014 with a follow‐up of at least 5 years. Results The 1‐, 3‐, 5‐, 10‐ and 15‐year local tumour control rates were as follows: 99.4%, 92.8%, 92.2%, 89.3% and 89.3%, respectively. Cataract (67.8%) was the most common side‐effect of fSRT followed by retinopathy (35.1%), maculopathy (23.8%), vitreous haemorrhage (20.1%), neovascular glaucoma (NVG) (20.0%) and optic neuropathy (12.4%). Patients with anterior located UMs developed cataract more frequently (p = 0.047, multivariable analysis). By multivariable analysis, significant factors for secondary enucleation were tumour recurrence (p < 0.001) and NVG (p < 0.001). In multivariable analysis, risk factors for a worse DFS were larger UM (p = 0.024) and tumours with subretinal fluid (SRF) at baseline (p = 0.038). The 5‐year DFS was 77.0% and the best corrected visual acuity decreased significantly after treatment. After 5 years, 22.0% of patients and after 10 years 17.6% of patients had a visual acuity of ≤0.3 logMAR. Conclusion Fractionated stereotactic radiotherapy is a good treatment option for small‐, medium‐ and large‐sized tumours with 5‐year local tumour control of 92.2%. After 5 years, 22.0% of the patients had a good vision. Independently of tumour location, the visual acuity decreased significantly after treatment. Overall, the 5‐year DFS was 77.0%.
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Affiliation(s)
- Jackelien G. M. van Beek
- Department of Ophthalmology Erasmus University Medical Centre Rotterdam The Netherlands
- Department of Ophthalmology Ikazia Hospital Rotterdam The Netherlands
- ‘Oog op Zuid’ Eye Clinic Rotterdam The Netherlands
| | - Caroline M. van Rij
- Department of Radiotherapy Erasmus University Medical Centre Rotterdam The Netherlands
| | - Sara J. Baart
- Department of Biostatistics Erasmus University Medical Centre Rotterdam The Netherlands
| | - Serdar Yavuzyigitoglu
- Department of Ophthalmology Erasmus University Medical Centre Rotterdam The Netherlands
| | - Michael J. Bergmann
- Department of Ophthalmology Albert Schweitzer Hospital Dordrecht The Netherlands
| | - Dion Paridaens
- Department of Ophthalmology Erasmus University Medical Centre Rotterdam The Netherlands
- Oculoplastic and Orbital surgery Rotterdam Eye Hospital Rotterdam The Netherlands
| | - Nicole C. Naus
- Department of Ophthalmology Erasmus University Medical Centre Rotterdam The Netherlands
| | - Emine Kiliç
- Department of Ophthalmology Erasmus University Medical Centre Rotterdam The Netherlands
- Department of Clinical Genetics Erasmus University Medical Centre Rotterdam The Netherlands
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Clinical outcomes and secondary glaucoma after gamma-knife radiosurgery and Ruthenium-106 brachytherapy for uveal melanoma: a single institution experience. Melanoma Res 2021; 31:38-48. [PMID: 32826711 DOI: 10.1097/cmr.0000000000000689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We retrospectively analyzed data from records of 48 patients (48 eyes) treated with gamma-knife (n = 18) or Ruthenium-106 brachytherapy (n = 30) for uveal melanoma, in our Ocular Oncology Unit between December 2013 and September 2019, with the aim to evaluate treatment outcomes, and incidence and risk factors for secondary glaucoma. Patients demographics and tumor characteristics at diagnosis were recorded. Follow-up data were collected regarding local tumor control, treatment complications, enucleation need, metastases occurrence and survival status. The median follow-up period was 33.7 months in the gamma-knife group and 26.2 months in the brachytherapy group. The mean tumor thickness, the largest basal diameter and the tumor volume were significantly higher in the gamma-knife group than in the brachytherapy group. The local tumor control rate was 100% in the brachytherapy group and 77.8% in the gamma-knife group. In the gamma-knife group, six patients were enucleated, no patient treated with brachytherapy underwent enucleation. The overall survival rate was 96.7% in the brachytherapy group and 94.44% in the gamma-knife group. Secondary glaucoma occurred in 10 patients after gamma-knife and in one patient after brachytherapy: it should be emphasized that larger lesions were treated with gamma-knife, whereas smaller tumors were selected for brachytherapy. We found a significative correlation of tumor thickness (P value = 0.043) and volume (P value = 0.040) with secondary glaucoma occurrence after gamma-knife treatment. Moreover, secondary glaucoma significantly correlated with radiation retinopathy in the gamma-knife group (P value = 0.009). This study shows preliminary clinical results that could be useful for further studies with more patients and longer follow-up.
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Iatrogenic Ocular Surface Diseases Occurring during and/or after Different Treatments for Ocular Tumours. Cancers (Basel) 2021; 13:cancers13081933. [PMID: 33923737 PMCID: PMC8073875 DOI: 10.3390/cancers13081933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/04/2021] [Accepted: 04/13/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The ocular surface represents a finely regulated system that allows the protection of the eye. It can be affected by therapies used for the treatment of various intraocular tumours, particularly conjunctival cancers and uveal melanoma. In these conditions, treatments are chosen according to the characteristics of the lesion, and include a combination of selective surgery, anticancer eye drops, and/or radiotherapy delivered through different mechanisms. Possible side effects affecting the ocular surface range from transient dry eye or keratitis up to more severe complications such as corneal melting and perforation. These complications deserve careful evaluation for the risk of permanent sight-threatening sequelae. Physicians involved in the management of patients affected by ocular tumours should be aware of this risk in order to reach an early diagnosis and promptly set up an adequate treatment. The present review summarizes acute and chronic complications affecting the ocular surface following different therapies for the treatment of conjunctival cancers and uveal melanoma, and also reports clinical cases of representative patients who experienced these complications. Abstract The ocular surface represents a finely regulated system that allows the protection of the eye. It is particularly susceptible to different treatments for intraocular tumours, such as uveal melanoma and conjunctival cancers. Traditionally, the management of ocular tumours depends on the characteristics of the lesion, and is based on a combination of selective surgery, topical chemotherapy, and/or radiotherapy delivered through different mechanisms (e.g., charged-particle radiotherapy or brachytherapy). Possible complications involving the ocular surface range from transient dry eye disease or keratitis up to corneal melting and perforation, which in any case deserve careful evaluation for the risk of permanent sigh-threatening complications. Clinicians involved in the management of these patients must be aware of this risk, in order to reach an early diagnosis and promptly set up an adequate treatment. The present review of the literature will summarize acute and chronic complications affecting the ocular surface following different therapies for the treatment of ocular tumours.
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Fallico M, Raciti G, Longo A, Reibaldi M, Bonfiglio V, Russo A, Caltabiano R, Gattuso G, Falzone L, Avitabile T. Current molecular and clinical insights into uveal melanoma (Review). Int J Oncol 2021; 58:10. [PMID: 33649778 PMCID: PMC7910016 DOI: 10.3892/ijo.2021.5190] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/30/2020] [Indexed: 12/13/2022] Open
Abstract
Uveal melanoma (UM) represents the most prominent primary eye cancer in adults. With an incidence of approximately 5 cases per million individuals annually in the United States, UM could be considered a relatively rare cancer. The 90-95% of UM cases arise from the choroid. Diagnosis is based mainly on a clinical examination and ancillary tests, with ocular ultrasonography being of greatest value. Differential diagnosis can prove challenging in the case of indeterminate choroidal lesions and, sometimes, monitoring for documented growth may be the proper approach. Fine needle aspiration biopsy tends to be performed with a prognostic purpose, often in combination with radiotherapy. Gene expression profiling has allowed for the grading of UMs into two classes, which feature different metastatic risks. Patients with UM require a specialized multidisciplinary management. Primary tumor treatment can be either enucleation or globe preserving. Usually, enucleation is reserved for larger tumors, while radiotherapy is preferred for small/medium melanomas. The prognosis is unfavorable due to the high mortality rate and high tendency to metastasize. Following the development of metastatic disease, the mortality rate increases to 80% within one year, due to both the absence of an effective treatment and the aggressiveness of the condition. Novel molecular studies have allowed for a better understanding of the genetic and epigenetic mechanisms involved in UM biological activity, which differs compared to skin melanomas. The most commonly mutated genes are GNAQ, GNA11 and BAP1. Research in this field could help to identify effective diagnostic and prognostic biomarkers, as well as novel therapeutic targets.
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Affiliation(s)
- Matteo Fallico
- Department of Ophthalmology, University of Catania, I‑95123 Catania, Italy
| | - Giuseppina Raciti
- Department of Drug Sciences, Section of Biochemistry, University of Catania, I‑95125 Catania, Italy
| | - Antonio Longo
- Department of Ophthalmology, University of Catania, I‑95123 Catania, Italy
| | - Michele Reibaldi
- Department of Surgical Sciences, Eye Clinic Section, University of Turin, I‑10122 Turin, Italy
| | - Vincenza Bonfiglio
- Department of Experimental Biomedicine and Clinical Neuroscience, Ophthalmology Section, University of Palermo, I‑90127 Palermo, Italy
| | - Andrea Russo
- Department of Ophthalmology, University of Catania, I‑95123 Catania, Italy
| | - Rosario Caltabiano
- Department 'G.F. Ingrassia', Section of Anatomic Pathology, University of Catania, I‑95123 Catania, Italy
| | - Giuseppe Gattuso
- Department of Biomedical and Biotechnological Sciences, University of Catania, I‑95123 Catania, Italy
| | - Luca Falzone
- Epidemiology Unit, IRCCS Istituto Nazionale Tumori 'Fondazione G. Pascale', I‑80131 Naples, Italy
| | - Teresio Avitabile
- Department of Ophthalmology, University of Catania, I‑95123 Catania, Italy
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Eibenberger K, Dunavoelgyi R, Gleiss A, Sedova A, Georg D, Poetter R, Dieckmann K, Zehetmayer M. Hypofractionated stereotactic photon radiotherapy of choroidal melanoma: 20-year experience. Acta Oncol 2021; 60:207-214. [PMID: 32969745 DOI: 10.1080/0284186x.2020.1820572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND To evaluate the long-term results after hypofractionated stereotactic photon radiotherapy (SRT) in patients with choroidal melanoma treated between 1997 and 2016. MATERIAL AND METHODS A total of 335 patients (183 male and 152 female) with choroidal melanoma unsuitable for ruthenium-106 brachytherapy or local resection were treated with linear accelerator-based SRT at the Medical University of Vienna. All patients received five fractions with either 10, 12 or 14 Gy per fraction. A complete ophthalmic examination including visual acuity and measurement of the tumor base and height using standardized A- and B-scan ultrasonography was performed every 3 months in the first 2 years, every 6 months until 5 years and yearly thereafter. Early and late adverse side effects were assessed at every follow-up visit. RESULTS The median overall follow-up was 78.6 months (39.1 to 113.7 months). Local tumor control was 95.4% after 10 and 12 years, respectively. Fifty-four patients developed metastatic disease, and 31 died during the follow-up. Mean visual acuity decreased from 0.55 Snellen at baseline to 0.05 Snellen at the last individual follow-up. Ischemic retinopathy (192/335cases) and optic neuropathy (174/335cases) were the most common radiogenic side effects, followed by radiogenic cataract (n = 127), neovascular glaucoma (n = 71) and corneal epithelium defects (n = 49). Enucleation was performed in 54 patients mostly due to neovascular glaucoma (n = 41) or tumor recurrence (n = 10) during the study period. The eye retention rate was 79.7% after 10 and 12 years. CONCLUSION Hypofractionated stereotactic photon radiotherapy showed a high rate of local tumor control for choroidal melanoma and an acceptable rate of radiogenic side effects.
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Affiliation(s)
| | - Roman Dunavoelgyi
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Andreas Gleiss
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University Vienna, Vienna, Austria
| | - Aleksandra Sedova
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Dietmar Georg
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Richard Poetter
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Karin Dieckmann
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Martin Zehetmayer
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
- Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
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Systematic Review and Meta-Analysis on the Use of Photon-based Stereotactic Radiosurgery Versus Fractionated Stereotactic Radiotherapy for the Treatment of Uveal Melanoma. Am J Clin Oncol 2020; 44:32-42. [DOI: 10.1097/coc.0000000000000775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Steiner B, Wackernagel W, Vajda L, Georgi T, Langmann G. Gamma-Knife-Radiochirurgie in der Ophthalmoonkologie. SPEKTRUM DER AUGENHEILKUNDE 2020. [DOI: 10.1007/s00717-020-00447-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Quantitative analysis of Gamma Knife stereotactic radiosurgery for uveal melanoma. POLISH JOURNAL OF MEDICAL PHYSICS AND ENGINEERING 2020. [DOI: 10.2478/pjmpe-2020-0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
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.
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Validation of an automatic eye monitoring system for ocular tumours stereotactic radiotherapy. Radiat Phys Chem Oxf Engl 1993 2020. [DOI: 10.1016/j.radphyschem.2019.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Modorati GM, Dagan R, Mikkelsen LH, Andreasen S, Ferlito A, Bandello F. Gamma Knife Radiosurgery for Uveal Melanoma: A Retrospective Review of Clinical Complications in a Tertiary Referral Center. Ocul Oncol Pathol 2019; 6:115-122. [PMID: 32258019 DOI: 10.1159/000501971] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/05/2019] [Indexed: 02/03/2023] Open
Abstract
Introduction Gamma knife radiosurgery (GKR) has shown promising results in the treatment of intraocular uveal melanoma (UM) in terms of local tumor control. However, GKR is not free from potentially sight-threatening side effects, including cataract, dry eye disease, vitreous hemorrhage, radiation retinopathy (RR), radiation maculopathy (RM), optic neuropathy, and neovascular glaucoma. The aim of this paper is to report our 20-year experience in UM management with GKR focusing on the rate of clinical treatment-induced complications. Methods Single-center, retrospective, observational study, including all patients with UM treated at the Ocular Oncology and Uveitis Service, in the Department of Ophthalmology of the San Raffaele Scientific Institute, Milan from September 1993 to September 2018. Clinical charts comprised complete ophthalmological examination with measurement of best-corrected visual acuity, slit-lamp biomicroscopy, intraocular pressure measurement, gonioscopy, and indirect ophthalmoscopy at each visit. B-scan ultrasound (Aviso S, 10 MHz probe; Paris, France), optical coherence tomography (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany), retinography, and fundus fluorescein angiography (standard or ultra-widefield [UWF; California, Optos, Dunfermline, Scotland, UK]) were performed aiding in the diagnosis of complications. Results Overall, 194 patients (100 males, 51.6%) were reviewed. The median age at the time of the treatment was 65 years (range 27-89) and all participants were Caucasian. In 185 eyes (95.4%), the tumor was primarily located at the choroid. The median follow-up was 57.6 months; radiation-induced complications were found in 145 eyes (74.7%). Radiation-induced cataract and RR were the most frequent events, with a relative incidence of 41.2 and 34.5%, respectively, followed by neovascular glaucoma (27.3%), optic neuropathy (18.6%), RM (11.4%), vitreous hemorrhage (14.4%), phthisis bulbi (7.7%), hyphema (0.5%), and corneal melting (0.5%). The shorter onset of side effects involved the optic nerve (median 14.9 months) and the macula (median 13.7 months). Conclusion Despite modern and advanced strategies introduced to limit GKR side effects, cataract and RR still represent a serious limitation of this treatment. Incidence of RR was higher in our cohort compared to other reports, probably due to increased diagnosis rate permitted by UWF retinal imaging.
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Affiliation(s)
- Giulio Maria Modorati
- Department of Ophthalmology, University Vita-Salute, IRCCS San Raffaele, Milan, Italy
| | - Roi Dagan
- Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida, USA
| | - Lauge Hjorth Mikkelsen
- Department of Pathology, Eye Pathology Section, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Ophthalmology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Simon Andreasen
- Department of Pathology and Department of Otolaryngology Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen, Denmark
| | - Alfio Ferlito
- The International Head and Neck Scientific Group, Padua, Italy
| | - Francesco Bandello
- Department of Ophthalmology, University Vita-Salute, IRCCS San Raffaele, Milan, Italy
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Zhao L, He X, Chen X, Shang Y, Mi D, Sun Y. Fitting the Generalized Target Model to Cell Survival Data of Proton Radiation Reveals Dose-Dependent RBE and Inspires an Alternative Method to Estimate RBE in High-Dose Regions. Radiat Res 2019; 192:507-516. [PMID: 31418641 DOI: 10.1667/rr15428.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The imprecise estimation of the relative biological effectiveness (RBE) of proton radiation has been one of the main challenges for further calculating the biologically effective dose in proton therapy. Since dose levels can greatly influence the proton RBE, the relationship between the two should be clarified first. In addition, since the dose-response curves are usually too complex to readily assess RBE in high-dose regions, a reliable and simple method is needed to predict the RBE of proton radiation accurately in clinically relevant doses. The standard linear-quadratic (LQ) model is widely used to determine the RBE of particles for clinical applications. However, there has been some debate over its use when modeling the cell survival curves in high-dose regions, since those survival curves usually show linear behavior in the semilogarithmic plot. By considering both cellular repair effects and indirect effects of radiation, we have proposed a generalized target model with linear-quadratic linear (LQL) characteristics. For the more accurate evaluation of proton RBE in radiotherapy, here we used this generalized target model to fit the cell survival data in V79 and C3H 10T1/2 cells exposed to proton radiation with different LETs. The fitting results show that the generalized target model works as well as the LQ model in general. Based on the fitting parameters of the generalized target model, the RBE of six given doses DT (RBET) could be calculated in the corresponding cell lines with different LETs. The results show that the RBET gradually decreases with increased dose in both cell types. In addition, inspired by the calculation method of the maximum values of RBE (RBEM) in the low-dose region, a novel method was proposed for estimating the RBE in the high-dose region (RBEH) based on the slope ratio of the dose-response curves in this region. Linear regression analysis indicated a significant linear correlation between the proposed RBEH and the RBET in high-dose regions, which suggests that the current method can be used as an alternative tool, which is both simple and robust, to estimate RBE in high-dose regions.
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Affiliation(s)
- Lei Zhao
- Institute of Environmental Systems Biology, College of Environmental Science and Engineering
| | - Xinye He
- Institute of Environmental Systems Biology, College of Environmental Science and Engineering
| | - Xinpeng Chen
- Institute of Environmental Systems Biology, College of Environmental Science and Engineering
| | - Yuxuan Shang
- Institute of Environmental Systems Biology, College of Environmental Science and Engineering
| | - Dong Mi
- College of Science, Dalian Maritime University, Dalian, Liaoning, China
| | - Yeqing Sun
- Institute of Environmental Systems Biology, College of Environmental Science and Engineering
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Cicinelli MV, Marchese A, Bandello F, Modorati GM. 3D Wrap TM Ultra-Widefield Reconstruction in Stereotactic Radiosurgery for Choroidal Melanoma. Ocul Oncol Pathol 2019; 6:20-24. [PMID: 32002400 DOI: 10.1159/000500312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/11/2019] [Indexed: 11/19/2022] Open
Abstract
Choroidal melanoma (CM) is the most commonly diagnosed primary intraocular malignancy in adults. Gamma knife radiosurgery (GKR) has demonstrated reliable results in the treatment of CM, but it is limited by the risk of radiation-induced ocular complications. To optimize the dose of radiation focused on the tumor, and limit side effects, the eye should be properly immobilized before treatment. A recently released ultra-widefield imaging instrument (Optomap California; Optos, Dunfermline, Scotland, UK) allows for an interactive three-dimensional (3D) virtual reconstruction of the globe, called 3D Wrap<sup>TM</sup>. The authors share their experience with this rapid, reliable, and relatively easy support in planning globe positioning before GKR treatment.
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Affiliation(s)
| | - Alessandro Marchese
- Department of Ophthalmology, University Vita-Salute, IRCCS San Raffaele, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, University Vita-Salute, IRCCS San Raffaele, Milan, Italy
| | - Giulio Maria Modorati
- Department of Ophthalmology, University Vita-Salute, IRCCS San Raffaele, Milan, Italy
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Wösle M, Krause L, Sreenivasa S, Vordermark D, Ciernik IF. Stereotactic radiotherapy for choroidal melanomas by means of HybridArc™ : Physics and technique of linac-based photon beam therapy. Strahlenther Onkol 2018; 194:929-943. [PMID: 30116827 DOI: 10.1007/s00066-018-1349-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 08/02/2018] [Indexed: 01/06/2023]
Abstract
PURPOSE Stereotactic radiotherapy (SRT) is suitable to treat ocular tumours. The optimal beam geometry for SRT, however, has not been defined. Here we evaluate a combination technique with dynamic conformal arcs (DCAs) and intensity-modulated static fields (IMRT), known as HybridArc™ (HA). METHODS For the first consecutive 25 cases with choroidal melanomas with volumes of 0.02 to 1.18 cm3 treated with 50 Gy in five fractions, the results with respect to dose conformity, homogeneity, and dose distributions were summarised. To describe the dose distribution at the planning target volume (PTV) boundary, we defined a spatially averaged dose gradient (SADG) and compared it with Paddick's gradient index (GI). We made dosimetric comparisons between HA and other irradiation techniques. RESULTS The PTVs ranged from 0.42 to 3.37 cm3. The conformity index (CI) was 1.25 ± 0.15, and the homogeneity index (HI) 0.08 ± 0.02. The SADG was (-3.5 ± 0.5) Gy/mm or (-7.0 ± 1.0) %/mm between the isodose levels 95 and 20%; local minima reached -11.5 Gy/mm or -22.9%/mm. The coefficient of determination for a nonlinear regression of GI on SADG was 0.072. After a median follow-up time of 19.6 months, local tumour control was 100% without any case of post-therapeutic enucleation. Two patients (8%) developed liver metastases. CONCLUSION SRT of ocular tumours by HA is highly appropriate, and HA is superior to intensity-modulated arc therapy (IMAT) concerning dose reduction in organs at risk (OARs). The novel gradient measure SADG is more informative than Paddick's GI.
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Affiliation(s)
- Markus Wösle
- Klinik für Strahlentherapie und Radioonkologie, Städtisches Klinikum Dessau, Auenweg 38, 06847, Dessau-Roßlau, Germany.
| | - Lothar Krause
- Klinik für Augenheilkunde und Zentrum für Refraktive Chirurgie, Städtisches Klinikum Dessau, Auenweg 38, 06847, Dessau-Roßlau, Germany
| | - Shanthala Sreenivasa
- Klinik für Strahlentherapie und Radioonkologie, Städtisches Klinikum Dessau, Auenweg 38, 06847, Dessau-Roßlau, Germany.,Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Straße 8, 06108, Halle (Saale), Germany
| | - Dirk Vordermark
- Universitätsklinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle (Saale), Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - Ilja F Ciernik
- Klinik für Strahlentherapie und Radioonkologie, Städtisches Klinikum Dessau, Auenweg 38, 06847, Dessau-Roßlau, Germany
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Akbaba S, Foerster R, Nicolay NH, Arians N, Bostel T, Debus J, Hauswald H. Linear accelerator-based stereotactic fractionated photon radiotherapy as an eye-conserving treatment for uveal melanoma. Radiat Oncol 2018; 13:140. [PMID: 30071857 PMCID: PMC6090919 DOI: 10.1186/s13014-018-1088-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 07/27/2018] [Indexed: 12/15/2022] Open
Abstract
Background The purpose of this retrospective analysis is to analyze clinical outcome, visual acuity and enucleation rates after linear accelerator-based stereotactic fractionated photon radiotherapy for primary uveal melanoma. Methods Twenty-four patients with primary uveal melanoma treated at the Department of Radiation and Oncology of the University Hospital Heidelberg between 1991 and 2015 were analyzed regarding survival and treatment-related toxicity including eye- and sight-preservation. Results Photon radiotherapy (RT) offered good overall local control rates with a local progression-free survival (LPFS) of 82% after 5 years and a median LPFS of 5.5 years at a median follow-up time of 5.2 years. Gender had a significant impact on LPFS yielding a mean LPFS of 8.1 years for women and 8.7 years for men (p = 0.04). Of all local progressions, 80% occurred within the first 5 years after RT. In one case, enucleation as final therapy option was necessary. Enucleation-free survival (EFS) was related to the radiotherapy dose (p < 0.0001). Thus, higher prescribed doses led to a significantly higher enucleation rate. T-stage had no significant impact on EFS, but affected the enucleation rate (p = 0.01). The overall survival (OS) rate was 100% after 2 years and 70% after 5 years with a median OS of 5.75 years. Age (p = 0.046), T stage (p = 0.019), local control rate (p = 0.041) and the time between diagnosis and the first radiation session (p = 0.01) had a significant effect on OS. Applied biologically effective dose (BED) did not significantly influence OS or PFS. A 2-year sight preservation rate of 75% could be achieved. In all patients, irradiation could be applied safely without any interruptions due to side effects. Six significant late toxicities with consequential blindness could be observed, making a secondary enucleation necessary in four patients. An impairment of visual acuity due to chronic optic nerve atrophy was identified in five patients within 2 years after treatment. Conclusions Linear accelerator-based stereotactic fractionated photon radiotherapy is an effective method in the treatment of uveal melanoma with excellent local control rates and a 2-year vision retention rate comparable to brachytherapy (BRT) or proton beam radiotherapy, even available in small centers and easy to implement. Interdisciplinary decision making is necessary to guarantee best treatment for every patient.
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Affiliation(s)
- Sati Akbaba
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.
| | - Robert Foerster
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Nils Henrik Nicolay
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Nathalie Arians
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Tilman Bostel
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Henrik Hauswald
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,National Center for Radiation Research in Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Heidelberg, Germany
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Sorour OA, Mignano JE, Duker JS. Gamma Knife radiosurgery for locally recurrent choroidal melanoma following plaque radiotherapy. Int J Retina Vitreous 2018; 4:23. [PMID: 29942651 PMCID: PMC5998456 DOI: 10.1186/s40942-018-0123-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/09/2018] [Indexed: 02/03/2023] Open
Abstract
Background For the majority of eyes with choroidal melanoma, radiation therapy is the treatment of choice. Local recurrence after radiation therapy can occur, however, and when it does, salvaging the globe with useful vision is atypical. Case presentation We report a case of late, local failure 7 years following previous brachytherapy successfully managed with Gamma Knife radiosurgery (GKR). With 3 years of follow up after GKR, the visual acuity is 20/20 and there is no evidence of systemic metastases. Conclusion To our knowledge, this is the first report of successful salvage GKR therapy after brachytherapy failure in an eye with choroidal melanoma. GKR is an option for select cases of local recurrence after radiation plaque brachytherapy.
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Affiliation(s)
- Osama A Sorour
- 1New England Eye Center, Department of Radiation Oncology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA USA.,2Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - John E Mignano
- 1New England Eye Center, Department of Radiation Oncology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA USA
| | - Jay S Duker
- 1New England Eye Center, Department of Radiation Oncology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA USA
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Retina dose as a predictor for visual acuity loss in 106 Ru eye plaque brachytherapy of uveal melanomas. Radiother Oncol 2018; 127:379-384. [DOI: 10.1016/j.radonc.2017.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 09/22/2017] [Accepted: 11/20/2017] [Indexed: 12/20/2022]
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Mitsch C, Zehetmayer M, Gleiss A, Georg D, Dieckmann K, Pötter R, Sayegh R, Schmidt-Erfurth U, Dunavoelgyi R. Early ultrasonographic tumor regression after linear accelerator stereotactic fractionated photon radiotherapy of choroidal melanoma as a predictor for metastatic spread. Radiother Oncol 2018; 127:385-391. [PMID: 29747872 DOI: 10.1016/j.radonc.2018.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/14/2018] [Accepted: 04/17/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND PURPOSE During extended follow-up (of up to 15 years), approximately fifty percent of patients with choroidal melanoma will develop metastatic disease and eventually die. Thus, continuing research on prognostic factors, early detection and treatment is necessary. Height regression rates both after plaque brachytherapy and proton beam irradiation have been shown to have prognostic value. The purpose of this study was to analyze the influence of early tumor regression rate after treatment of choroidal melanoma with LINAC stereotactic fractionated radiotherapy (SFRT) as an independent risk factor for metastasis. MATERIAL AND METHODS 256 patients with choroidal melanoma treated with LINAC SFRT were included. Follow-up included standardized echography yielding apical height, smallest and largest basal linear diameter, tumor volume and mean reflectivity. The influence of baseline measurements and of a longitudinal, normalized area under the curve coefficient (NAC) of the latter marker on metastasis risk was assessed. RESULTS NAC for tumor thickness at months 3, 6, and 12 had a statistically significant (p < 0.001) non-linear effect on risk of metastasis. Additionally, ultrasonographic baseline tumor dimensions, but not internal reflectivity were found to be statistically significant risk factors for metastasis. CONCLUSIONS Our results demonstrate a non-linear influence of regression rate of choroidal melanoma as independent risk factor of metastatic disease after LINAC SFRT. These prove the clinical experience that, in comparison to rather slow regressions, very quick and very slow early tumor responses to LINAC SFRT are associated with a significantly higher metastasis risk.
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Affiliation(s)
- Christoph Mitsch
- Department of Ophthalmology and Optometry, Medical University of Vienna, Austria
| | - Martin Zehetmayer
- Department of Ophthalmology and Optometry, Medical University of Vienna, Austria.
| | - Andreas Gleiss
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Austria
| | - Dietmar Georg
- Department of Radiotherapy, Medical University of Vienna, Austria
| | - Karin Dieckmann
- Department of Radiotherapy, Medical University of Vienna, Austria
| | - Richard Pötter
- Department of Radiotherapy, Medical University of Vienna, Austria
| | - Ramzi Sayegh
- Department of Ophthalmology and Optometry, Medical University of Vienna, Austria
| | | | - Roman Dunavoelgyi
- Department of Ophthalmology and Optometry, Medical University of Vienna, Austria
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Lin AJ, Rao YJ, Acharya S, Schwarz J, Rao PK, Grigsby P. Patterns of care and outcomes of proton and eye plaque brachytherapy for uveal melanoma: Review of the National Cancer Database. Brachytherapy 2017; 16:1225-1231. [PMID: 28966081 DOI: 10.1016/j.brachy.2017.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/24/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To examine national practice patterns and outcomes of eye plaque brachytherapy compared to proton external beam radiotherapy in the treatment of choroid melanoma. METHODS AND MATERIALS Demographic and clinical data for 1224 patients with choroid melanoma treated with either brachytherapy or proton beam therapy from 2004 to 2013 were obtained from the National Cancer Database. Logistic regression and propensity score matching was used to create a 1:1 matched cohort. Kaplan-Meier and Cox regression analyses were performed to evaluate survival in brachytherapy and proton groups. RESULTS Median followup was 37 and 29 months for brachytherapy and protons, respectively. Most patients were treated with brachytherapy (n = 996) vs. protons (n = 228). Proton patients came from more urban, affluent, and educated zip codes, and they were more likely to be treated at an academic center (all p < 0.004). In the propensity-score matched cohort, 2-year overall survival was 97% vs. 93%, and 5-year overall survival was 77% vs. 51% for brachytherapy and protons, respectively (p = 0.008). Multivariate Cox regression found older age (hazard ratio [HR] = 1.06, 95% confidence interval (CI) = 1.03-1.09), larger tumor diameter (12-18 mm, HR = 2.48, 95% CI = 1.40-4.42, >18 mm, HR = 6.41, 95% CI = 1.45-28.35), and protons (HR = 1.89, 95% CI = 1.06-3.37) were negative prognosticators of survival. CONCLUSIONS Patients selected for proton treatment have inferior survival outcomes compared to brachytherapy in this retrospective analysis. There may be unaccounted variables that influence survival, warranting further prospective studies.
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Affiliation(s)
- Alexander J Lin
- Department of Radiation Oncology, Barnes-Jewish Hospital, St. Louis, MO
| | - Yuan J Rao
- Department of Radiation Oncology, Barnes-Jewish Hospital, St. Louis, MO
| | - Sahaja Acharya
- Department of Radiation Oncology, Barnes-Jewish Hospital, St. Louis, MO
| | - Julie Schwarz
- Department of Radiation Oncology, Barnes-Jewish Hospital, St. Louis, MO
| | | | - Perry Grigsby
- Department of Radiation Oncology, Barnes-Jewish Hospital, St. Louis, MO.
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Gigliotti CR, Modorati G, Di Nicola M, Fiorino C, Perna LA, Miserocchi E, Franzin A, Picozzi P, Bolognesi A, Mortini P, del Vecchio A, Calandrino R. Predictors of radio-induced visual impairment after radiosurgery for uveal melanoma. Br J Ophthalmol 2017; 102:833-839. [DOI: 10.1136/bjophthalmol-2017-310801] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/01/2017] [Accepted: 08/29/2017] [Indexed: 02/01/2023]
Abstract
AimsThe aim of the present work is to assess the main predictors of the most clinically relevant radio-induced effects after Gamma Knife stereotactic radiosurgery (GKRS) for uveal melanoma (UM).Materials and methodsMedical records and three-dimensional dosimetry data of critical structures of 66 patients were retrospectively reviewed. Cox’s proportional hazard model was used to identify clinical and dosimetric variables as independent risk factor for GKRS-related complications.ResultsThe fraction of the posterior segment receiving more than 20Gy (V20), Bruch’s membrane rupture and tumour thickness were significant prognostic factors for neovascular glaucoma. A clear relationship with the dose received by 1% of the optic nerve (D1%) was found for radiation retinopathy and papillopathy. Multivariables models resulted for visual acuity (VA) reduction >20% of the basal value and for complete VA loss, both including largest tumour diameter and D1% to the optic nerve. The predictive model for complete VA loss includes also Bruch’s membrane rupture. An alternative model for complete visual acuity loss, including the optic nerve-prescription isodose minimum distance, was also suggested.ConclusionsWe found clinical and dosimetric variables to clearly predict the risk of the main side effects after GKRS for UM. These results may provide dose constraints to critical structures, potentially able to reduce side effects. Constraining D1% to the optic nerve below 12-13Gy may result in a dramatic reduction of blindness risk, while reducing V20 of the posterior segment of the bulb could limit the neovascular glaucoma onset.
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Jang BS, Chang JH, Oh S, Lim YJ, Kim IH. Surgery vs. radiotherapy in patients with uveal melanoma. Strahlenther Onkol 2017; 193:931-942. [DOI: 10.1007/s00066-017-1203-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 08/16/2017] [Indexed: 12/18/2022]
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A pilot study on geometrical uncertainties for intra ocular cancers in radiotherapy. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:433-439. [PMID: 28466444 DOI: 10.1007/s13246-017-0551-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 04/14/2017] [Indexed: 10/19/2022]
Abstract
A system for stabilising and monitoring eye movements for linac-based stereotactic radiotherapy associated with the mobile eye, the Eye Tracker, was developed. Whilst the Eye Tracker design is based on a previously reported system, the purpose of this study was to confirm that the modified version can be used with clinically acceptable treatment margins. We report the estimates of the margin required to account for inter- and intra-fraction eye motion based on data from 12 consecutive patients treated with the Eye Tracker system in place. Patients were immobilised in a head and neck mask and were required to fixate on a light source. A camera system monitored eye movements relative to CT simulation baseline measurements. The Exactrac system (Brainlab, Feldkirchen, Germany) combined with the Varian TrueBeamSTx (Varian Medical Systems, Palo Alto, CA) confirmed pre- and intra-treatment setup of the head position. Displacement/rotation of the image of the pupil/iris was determined in the lateral and superior-inferior directions using a video display. A standard margin equation was applied to estimate the margin required to account for inter- and intra-fraction eye movement. The average displacement in both directions was 0.1-0.2 mm (0.36 mm SD). All patients maintained a position within 1 mm of the intended position during treatment. Based on a Bayesian estimation of the systematic and treatment errors, accounting for displacements in two-planes and a standard deviation of the penumbral width of 1.3 mm, the estimated margins to achieve coverage of the GTV with the 95% isodose in 90% of patients was found to be less than 1 mm. Small random and systematic uncertainties due to inter- and intra-fraction movement of the eye were achieved with the Eye Tracker. Whilst the estimated margins are small (<1 mm) they need to be considered in addition to contouring and treatment delivery uncertainties.
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Yazici G, Kiratli H, Ozyigit G, Sari SY, Cengiz M, Tarlan B, Mocan BO, Zorlu F. Stereotactic Radiosurgery and Fractionated Stereotactic Radiation Therapy for the Treatment of Uveal Melanoma. Int J Radiat Oncol Biol Phys 2017; 98:152-158. [DOI: 10.1016/j.ijrobp.2017.02.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 02/05/2017] [Accepted: 02/10/2017] [Indexed: 12/14/2022]
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Heilemann G, Fetty L, Dulovits M, Blaickner M, Nesvacil N, Georg D, Dunavoelgyi R. Treatment plan optimization and robustness of 106 Ru eye plaque brachytherapy using a novel software tool. Radiother Oncol 2017; 123:119-124. [DOI: 10.1016/j.radonc.2017.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 12/13/2016] [Accepted: 01/11/2017] [Indexed: 02/03/2023]
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Gorovets D, Gagne NL, Melhus CS. Dosimetric and radiobiologic comparison of 103Pd COMS plaque brachytherapy and Gamma Knife radiosurgery for choroidal melanoma. Brachytherapy 2017; 16:433-443. [PMID: 28161431 DOI: 10.1016/j.brachy.2016.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 12/16/2016] [Accepted: 12/17/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Plaque brachytherapy (BT) and Gamma Knife radiosurgery (GKRS) are highly conformal treatment options for choroidal melanoma. This study objectively compares physical dose and biologically effective dose (BED) distributions for these two modalities. METHODS AND MATERIALS Tumor and organ-at-risk (OAR) dose distributions from a CT-defined reference right eye were compared between 103Pd COMS (Collaborative Ocular Melanoma Study Group) plaques delivering 70 Gy (plaque heterogeneity corrected) over 120 h to the tumor apex and GKRS plans delivering 22 Gy to the 40% isodose line for a representative sample of clinically relevant choroidal melanoma locations and sizes. Tumor and OAR biologically effective dose-volume histograms were generated using consensus radiobiologic parameters and modality-specific BED equations. RESULTS Published institutional prescriptive practices generally lead to larger tumor and OAR physical doses from COMS BT vs. GKRS. Radiobiologic dose conversions, however, revealed variable BEDs. Medium and large tumors receive >1.3 times higher BEDs with COMS BT vs. GKRS. OAR BEDs have even greater dependence on tumor size, location, and treatment modality. For example, COMS BT maximum BEDs to the optic nerve are lower than from GKRS for large anterior and all posterior tumors but are higher for anterior small and medium tumors. CONCLUSIONS BT and GKRS for choroidal melanoma have different physical dose and BED distributions with potentially unique clinical consequences. Using published institutional prescriptive practices, neither modality is uniformly favored, although COMS BT delivers higher physical doses and BEDs to tumors. These results suggest that lowering the physical prescription dose for COMS BT to more closely match the BED of GKRS might maintain equivalent tumor control with less potential morbidity.
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Affiliation(s)
- Daniel Gorovets
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, MA
| | - Nolan L Gagne
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, MA
| | - Christopher S Melhus
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, MA.
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Osmanovic S, Moisseiev E, Mishra KK, Daftari I, Moshiri A, Morse L, Park SS. Phase I/II Randomized Study of Proton Beam with Anti-Vascular Endothelial Growth Factor for Exudative Age-Related Macular Degeneration: One-Year Results. Ophthalmol Retina 2016; 1:217-226. [PMID: 31047424 DOI: 10.1016/j.oret.2016.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of proton beam therapy (PBT) as an adjunct to intravitreal anti-vascular endothelial growth factor (VEGF) for the treatment of exudative age-related macular degeneration. DESIGN Phase I/II, interventional, prospective, randomized, sham-controlled double-blinded study. PARTICIPANTS Eyes with newly diagnosed exudative age-related macular degeneration with vision between 20/40 and 20/400 were included. Exclusion criteria included diabetes or other ocular comorbidities affecting vision. METHODS Eyes were randomized to receive either 16 GyE, 24 GyE, or sham PBT. All eyes had 3 monthly intravitreal anti-VEGF treatments, followed by monthly visits with treatments as needed. MAIN OUTCOME MEASURES Mean change in best-corrected visual acuity (BCVA), mean number of anti-VEGF injections, proportion of eyes with >15 letters BCVA decrease, proportion of eyes developing radiation retinopathy or papillopathy, proportion of eyes with cataract progression, and mean changes central retinal thickness on OCT and lesion size on angiography at 1 year. RESULTS Of 30 enrolled eyes, 22 completed follow-up monthly for 12 months for analysis. The BCVA improved by a mean of 8 letters (0.48±0.36 logarithm of the minimum angle of resolution) overall from baseline. Overall, central retinal thickness decreased from 340±155 to 246±48 (P = 0.008) at 12 months. The mean change in BCVA and central retinal thickness was not different among the 3 study groups. The mean number of anti-VEGF injections at 12 months was 6.13 for sham irradiation arm, 5.52 in the 16 GyE arm, and 3.83 for the 24 GyE arm (P = 0.004 between sham and 24 GyE). No eye had severe visual loss, radiation retinopathy, or papillopathy. CONCLUSIONS No safety issue was noted associated with combining 16 GyE or 24 GyE PBT with intravitreal anti-VEGF therapy in eyes with exudative age-related macular degeneration. Overall improvements in BCVA and imaging parameters were not affected by the addition of PBT, but the number of anti-VEGF treatments needed was significantly lower with the addition of 24 GyE PBT.
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Affiliation(s)
- Senad Osmanovic
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California
| | - Elad Moisseiev
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California
| | - Kavita K Mishra
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Inder Daftari
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ala Moshiri
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California
| | - Lawrence Morse
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California
| | - Susanna S Park
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California.
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Kaliki S, Shields CL. Uveal melanoma: relatively rare but deadly cancer. Eye (Lond) 2016; 31:241-257. [PMID: 27911450 DOI: 10.1038/eye.2016.275] [Citation(s) in RCA: 338] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 11/01/2016] [Indexed: 01/04/2023] Open
Abstract
Although it is a relatively rare disease, primarily found in the Caucasian population, uveal melanoma is the most common primary intraocular tumor in adults with a mean age-adjusted incidence of 5.1 cases per million per year. Tumors are located either in iris (4%), ciliary body (6%), or choroid (90%). The host susceptibility factors for uveal melanoma include fair skin, light eye color, inability to tan, ocular or oculodermal melanocytosis, cutaneous or iris or choroidal nevus, and BRCA1-associated protein 1 mutation. Currently, the most widely used first-line treatment options for this malignancy are resection, radiation therapy, and enucleation. There are two main types of radiation therapy: plaque brachytherapy (iodine-125, ruthenium-106, or palladium-103, or cobalt-60) and teletherapy (proton beam, helium ion, or stereotactic radiosurgery using cyber knife, gamma knife, or linear accelerator). The alternative to radiation is enucleation. Although these therapies achieve satisfactory local disease control, long-term survival rate for patients with uveal melanoma remains guarded, with risk for liver metastasis. There have been advances in early diagnosis over the past few years, and with the hope survival rates could improve as smaller tumors are treated. As in many other cancer indications, both early detection and early treatment could be critical for a positive long-term survival outcome in uveal melanoma. These observations call attention to an unmet medical need for the early treatment of small melanocytic lesions or small melanomas in the eye to achieve local disease control and vision preservation with the possibility to prevent metastases and improve overall patient survival.
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Affiliation(s)
- S Kaliki
- The Operation Eyesight Universal Institute for Eye Cancer, LV Prasad Eye Institute, Hyderabad, India
| | - C L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
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Tarlan B, Kıratlı H. Uveal Melanoma: Current Trends in Diagnosis and Management. Turk J Ophthalmol 2016; 46:123-137. [PMID: 27800275 PMCID: PMC5076295 DOI: 10.4274/tjo.37431] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/14/2015] [Indexed: 12/25/2022] Open
Abstract
Uveal melanoma, which is the most common primary intraocular malignancy in adults, arises from melanocytes within the iris, ciliary body and choroid. The diagnosis is based principally on clinical examination of the tumor with biomicroscopy and indirect ophthalmoscopy and confirmed by diagnostic techniques such as ultrasonography, fundus fluorescein angiography and optical coherence tomography. The clinical diagnosis of posterior uveal melanomas can be made when the classical appearance of a pigmented dome-shaped mass is detected on dilated fundus exam. Uveal melanomas classically show low to medium reflectivity on A-scan ultrasonography and on B-scan ultrasonography the tumor appears as a hyperechoic, acoustically hollow intraocular mass. Management of a suspicious pigmented lesion is determined by its risk factors of transforming into a choroidal melanoma, such as documentation of growth, thickness greater than 2 mm, presence of subretinal fluid, symptoms and orange pigment, margin within 3 mm of the optic disc, and absence of halo and drusen. Advances in the diagnosis and local and systemic treatment of uveal melanoma have caused a shift from enucleation to eye-conserving treatment modalities including transpupillary thermotherapy and radiotherapy over the past few decades. Prognosis can be most accurately predicted by genetic profiling of fine needle aspiration biopsy of the tumor before the treatment, and high-risk patients can now be identified for clinical trials that may lead to target-based therapies for metastatic disease and adjuvant therapy which aims to prevent metastatic disease.
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Affiliation(s)
| | - Hayyam Kıratlı
- Hacettepe University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
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Ruthenium-106 brachytherapy for thick uveal melanoma: reappraisal of apex and base dose radiation and dose rate. J Contemp Brachytherapy 2016; 8:66-73. [PMID: 26985199 PMCID: PMC4793070 DOI: 10.5114/jcb.2016.57818] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/20/2016] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate the outcomes of ruthenium-106 (106Ru) brachytherapy in terms of radiation parameters in patients with thick uveal melanomas. Material and methods Medical records of 51 patients with thick (thickness ≥ 7 mm and < 11 mm) uveal melanoma treated with 106Ru brachytherapy during a ten-year period were reviewed. Radiation parameters, tumor regression, best corrected visual acuity (BCVA), and treatment-related complications were assessed. Results Fifty one eyes of 51 consecutive patients including 25 men and 26 women with a mean age of 50.5 ± 15.2 years were enrolled. Patients were followed for 36.1 ± 26.5 months (mean ± SD). Mean radiation dose to tumor apex and to sclera were 71 (± 19.2) Gy and 1269 (± 168.2) Gy. Radiation dose rates to tumor apex and to sclera were 0.37 (± 0.14) Gy/h and 6.44 (± 1.50) Gy/h. Globe preservation was achieved in 82.4%. Preoperative mean tumor thickness of 8.1 (± 0.9) mm decreased to 4.5 (± 1.6) mm, 3.4 (± 1.4) mm, and 3.0 (± 1.46) mm at 12, 24, and 48 months after brachytherapy (p = 0.03). Four eyes that did not show regression after 6 months of brachytherapy were enucleated. Secondary enucleation was performed in 5 eyes because of tumor recurrence or neovascular glaucoma. Tumor recurrence was evident in 6 (11.8%) patients. Mean Log MAR (magnification requirement) visual acuity declined from 0.75 (± 0.63) to 0.94 (± 0.5) (p = 0.04). Best corrected visual acuity of 20/200 or worse was recorded in 37% of the patients at the time of diagnosis and 61.7% of the patients at last exam (p = 0.04). Non-proliferative and proliferative radiation-induced retinopathy was observed in 20 and 7 eyes. Conclusions Thick uveal melanomas are amenable to 106Ru brachytherapy with less than recommended apex radiation dose and dose rates.
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Eibl-Lindner K, Fürweger C, Nentwich M, Foerster P, Wowra B, Schaller U, Muacevic A. Robotic radiosurgery for the treatment of medium and large uveal melanoma. Melanoma Res 2016; 26:51-7. [DOI: 10.1097/cmr.0000000000000199] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Fort M, Guet S, Husheng S, Calitchi E, Belkacemi Y. Role of radiation therapy in melanomas: Systematic review and best practice in 2016. Crit Rev Oncol Hematol 2016; 99:362-75. [PMID: 26829895 DOI: 10.1016/j.critrevonc.2016.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 12/02/2015] [Accepted: 01/16/2016] [Indexed: 12/11/2022] Open
Abstract
Radiotherapy has been used for skin cancers since early after the discovery of X-rays. The introduction of sophisticated surgery techniques and information of the general population on potential late radiation-induced toxicity and carcinogenesis have led to limiting indications in the dermatologist community. However, radiotherapy (RT) has undergone considerable developments, essentially including technological advances, to sculpt radiation delivery, with demonstration of the benefit either alone or after adding concomitant cytotoxic agents or targeted therapies. Although side effects due to high doses and/or the use of old RT techniques have been significantly decreased, the risk of atrophic scars, ulcerations or secondary cancers persist. In this systematic review, we aim to discuss indications for RT in melanomas with focus on new advances that may lead to rehabilitating this treatment option according to the tumor radiosensitivity and clinical benefit/risk ratio. Melanomas have been considered as radioresistant tumors for many years.
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Affiliation(s)
- Magali Fort
- Radiation Oncology Department of Henri Mondor University Hospital and University Paris-Est Creteil (UPEC), Créteil, France
| | - Saada Guet
- Radiation Oncology Department of Henri Mondor University Hospital and University Paris-Est Creteil (UPEC), Créteil, France
| | - Shan Husheng
- Radiation Oncology Department of Henri Mondor University Hospital and University Paris-Est Creteil (UPEC), Créteil, France
| | - Elie Calitchi
- Radiation Oncology Department of Henri Mondor University Hospital and University Paris-Est Creteil (UPEC), Créteil, France; Henri Mondor Breast Center and University of Paris-Est Creteil (UPEC), Créteil, France
| | - Yazid Belkacemi
- Radiation Oncology Department of Henri Mondor University Hospital and University Paris-Est Creteil (UPEC), Créteil, France; Henri Mondor Breast Center and University of Paris-Est Creteil (UPEC), Créteil, France.
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van den Bosch T, Vaarwater J, Verdijk R, Muller K, Kiliç E, Paridaens D, de Klein A, Naus N. Risk factors associated with secondary enucleation after fractionated stereotactic radiotherapy in uveal melanoma. Acta Ophthalmol 2015; 93:555-60. [PMID: 25879399 DOI: 10.1111/aos.12731] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 03/01/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate risk factors for secondary enucleation after fractionated stereotactic radiotherapy (fSRT) in uveal melanoma. METHODS In this retrospective study, clinical data of 118 consecutive patients who had initially been treated with fSRT between 1999 and 2009 were collected and analysed. The patients who had undergone secondary enucleation were identified and examined for clinical, histopathological and cytogenetical (fluorescence in situ hybridization determined) data. Also, the reasons for secondary enucleation, such as treatment failure (progressive tumour growth or tumour recurrence) or complications following fSRT (painful blind eye), were recorded and examined. RESULTS The secondary enucleation rate was 16% after a median follow-up of 4.7 years, with 5% due to treatment failure and 11% due to complications. In the univariate analysis, large tumour diameter (p = 0.019) and large tumour height (p = 0.001) were associated with secondary enucleation, tumour involvement of the optic disc showed borderline significance (p = 0.068). Cox regression multivariate analysis displayed large tumour height as independent prognostic factor (HR 1.42, 95% CI 1.12-1.81, p = 0.004). Following secondary enucleation, mitotic figures were present in five of 18 tumours, and gain of chromosome 8q was also present in five tumours. Within the subgroup of patients who required secondary enucleation due to failed tumour control by fSRT (N = 6), mitotic figures were present in four of six tumours while gain of 8q was present in three of six tumours. CONCLUSION Secondary enucleation after previous fSRT was associated with large tumour height. High mitotic counts and gain of chromosome 8q were frequently found in secondary enucleations and possibly indicate a more aggressive or radiation-resistant tumour.
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Affiliation(s)
| | - Jolanda Vaarwater
- Department of Clinical Genetics, Ophthalmology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Rob Verdijk
- Department of Pathology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Karin Muller
- Department of Radiotherapy; Deventer Hospital; Deventer The Netherlands
| | - Emine Kiliç
- Department of Ophthalmology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Dion Paridaens
- Ocular Oncology; Rotterdam Eye Hospital; Rotterdam The Netherlands
- Department of Ophthalmology; Geneva University Hospitals; Geneva Switzerland
| | - Annelies de Klein
- Department of Clinical Genetics; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Nicole Naus
- Department of Ophthalmology; Erasmus University Medical Center; Rotterdam The Netherlands
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Schönfeld S, Cordini D, Riechardt AI, Seibel I, Willerding G, Bechrakis NE, Moser L, Joussen AM. Proton beam therapy leads to excellent local control rates in choroidal melanoma in the intermediate fundus zone. Am J Ophthalmol 2014; 158:1184-91. [PMID: 25128597 DOI: 10.1016/j.ajo.2014.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/08/2014] [Accepted: 08/10/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate long-term outcomes of proton beam radiotherapy in the treatment of choroidal melanoma of the intermediate zone of the fundus. DESIGN Retrospective interventional single-center study. METHODS The study was a retrospective analysis with long-term follow-up of 62 patients with a minimum tumor-to-disc and tumor-to-fovea distance of 2 mm of choroidal melanoma in the intermediate zone of the fundus. Mean values of tumor prominence, largest basal diameter, and tumor distances to the optic disc and fovea were 7.6, 12.8, 5.2, and 4.6 mm, respectively. All patients were irradiated with a total proton dose of 60 cobalt gray equivalents. RESULTS After proton beam radiotherapy, 71.0% of the patients received subsequent endoresection of the tumor. Only 18 patients (29.0%) did not require additional tumor resection and were analyzed as a separate group. For the total of patients, the median follow-up time was 70.3 months. The 5-year Kaplan-Meier rates of local tumor relapse, enucleation, and distant metastasis were 3.9%, 3.7%, and 13.4%, respectively. Cataract surgery was the most frequent secondary treatment in our cohort. CONCLUSIONS In this study we demonstrate the effectiveness of proton beam irradiation in tumor control and preservation of the globe in the analyzed patients. The rate of metastasis was not higher than previously described. Nevertheless, consecutive tumor surgery is frequently required to maintain the eye in patients with large-sized choroidal melanomas. In conclusion, proton beam radiotherapy allows preservation of the eye in mid-zone choroidal melanomas.
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Amirouchene-Angelozzi N, Nemati F, Gentien D, Nicolas A, Dumont A, Carita G, Camonis J, Desjardins L, Cassoux N, Piperno-Neumann S, Mariani P, Sastre X, Decaudin D, Roman-Roman S. Establishment of novel cell lines recapitulating the genetic landscape of uveal melanoma and preclinical validation of mTOR as a therapeutic target. Mol Oncol 2014; 8:1508-20. [PMID: 24994677 DOI: 10.1016/j.molonc.2014.06.004] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/05/2014] [Accepted: 06/04/2014] [Indexed: 01/21/2023] Open
Abstract
Uveal melanoma (UM) is the most common primary tumor of the eye in adults. There is no standard adjuvant treatment to prevent metastasis and no effective therapy in the metastatic setting. We have established a unique panel of 7 UM cell lines from either patient's tumors or patient-derived tumor xenografts (PDXs). This panel recapitulates the molecular landscape of the disease in terms of genetic alterations and mutations. All the cell lines display GNAQ or GNA11 activating mutations, and importantly four of them display BAP1 (BRCA1 associated protein-1) deficiency, a hallmark of aggressive disease. The mTOR pathway was shown to be activated in most of the cell lines independent of AKT signaling. mTOR inhibitor Everolimus reduced the viability of UM cell lines and significantly delayed tumor growth in 4 PDXs. Our data suggest that mTOR inhibition with Everolimus, possibly in combination with other agents, may be considered as a therapeutic option for the management of uveal melanoma.
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Affiliation(s)
- Nabil Amirouchene-Angelozzi
- Biophenics Laboratory, Translational Research Department, Institut Curie, 26 rue d'Ulm, 75005 Paris, France.
| | - Fariba Nemati
- Laboratory of Preclinical Investigation, Translational Research Department, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - David Gentien
- Genomics Platform, Translational Research Department, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - André Nicolas
- Department of Tumor Biology, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | | | - Guillaume Carita
- Laboratory of Preclinical Investigation, Translational Research Department, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | | | - Laurence Desjardins
- Department of Ophthalmological Oncology, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - Nathalie Cassoux
- Department of Ophthalmological Oncology, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | | | - Pascale Mariani
- Department of Surgery, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - Xavier Sastre
- Department of Tumor Biology, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - Didier Decaudin
- Laboratory of Preclinical Investigation, Translational Research Department, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - Sergio Roman-Roman
- Translational Research Department, Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
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