Conservation of eyes with choroidal melanoma by a multimodality approach to treatment

Prevalence, temporal course and risk factors for phantom eye symptoms in uveal melanoma

BACKGROUND

Phantom eye symptoms (PES), particularly phantom visual sensations (PVS) and phantom eye pain (PEP), are common in enucleated patients and can lead to psychological distress. Current cross-sectional studies cannot examine the temporal course of symptoms, nor can they identify dynamic risk factors or consequences of PES.

METHODS

Cohort study of 105 enucleated uveal melanoma patients returning self-report questionnaires, within 4 weeks of diagnosis and 6-, 12- and 24-months post-treatment. Questionnaires measuring PVS and PEP symptoms in the week prior to completion, pain severity, Hospital Anxiety and Depression Scale scores and the Functional Assessment of Cancer Therapy scale (FACT-G) measuring quality of life.

RESULTS

PVS and PEP emerged after 6 months, were relatively stable over the study and did not remit. PVS showed 6-, 12- and 24-month prevalence rates of 44.6%, 48.2% and 30.2%, and PEP 16.1%, 18.4% and 17.5% respectively. PVS were generally elementary, with only 10-15% of the total cohort experiencing complex sensations. PEP was generally neither prolonged nor intense, except in a small proportion. PVS and PEP were showed moderate associations but did not predict each other prospectively. Anxiety within 4 weeks of diagnosis was a risk factor for the initiation of PEP. Neither PVS nor PEP prospectively predicted anxiety, depression or quality of life.

CONCLUSIONS

PES were prevalent and non-remitting, beginning within 6 months of enucleation. PVS and PEP may not represent symptoms of a coherent syndrome. We discuss findings with reference to theories of phantom sensations, and directions for clinical practise and research.

The Role of Autophagy in Human Uveal Melanoma and the Development of Potential Disease Biomarkers and Novel Therapeutic Paradigms

Autophagy is a form of programmed cell degradation that enables the maintenance of homeostasis in response to extracellular stress stimuli. Autophagy is primarily activated by starvation and mediates the degradation, removal, or recycling of cell cytoplasm, organelles, and intracellular components in eukaryotic cells. Autophagy is also involved in the pathogenesis of human diseases, including several cancers. Human uveal melanoma (UM) is the primary intraocular malignancy in adults and has an extremely poor prognosis; at present there are no effective therapies. Several studies have suggested that autophagy is important in UM. By understanding the mechanisms of activation of autophagy in UM it may be possible to develop biomarkers to provide more definitive disease prognoses and to identify potential drug targets for the development of new therapeutic strategies. This article reviews the current information regarding autophagy in UM that could facilitate biomarker and drug development.

Factors affecting eye conservation and metastasis in posterior uveal melanomas

PURPOSE

To determine the effect of patient and tumor features and different treatments on eye removal (enucleation or exenteration) and metastasis in posterior uveal melanoma (PUM).

METHODS

Retrospective analysis. Patient age (≤60 vs >60 years), sex (female vs male), visual acuity (VA, ≤20/40 vs >20/40), largest tumor basal diameter (LTBD), tumor thickness, tumor stage according to American Joint Committee on Cancer (AJCC) 8th edition, ciliary body involvement, distance to optic disc (OD)/fovea (≤3 mm vs >3 mm), OD involvement, and histopathology were evaluated. Primary treatment options were transpupillary thermotherapy, plaque radiotherapy, Cyberknife radiosurgery, exoresection, and eye removal. Risk factors for primary eye removal were determined using logistic regression test and those for secondary eye removal and metastasis with Cox regression analysis.

RESULTS

Of 387 cases, 153 (39.5%) underwent primary eye removal. Multivariable risk factors for primary eye removal included AJCC tumor stage (p = 0.001, OR:4.586; p < 0.001, OR:34.545; p < 0.001, OR:103.468 for stages T2, T3, and T4 vs stage T1, respectively), and VA≤20/40 (p = 0.014, OR:2.597). Multivariable risk factors for secondary eye removal were VA≤20/40 (p = 0.019, RR:2.817) and AJCC stage T3 vs T1 (p = 0.021, RR:2.666). Eye preservation rates in patients undergoing eye-conserving treatments were 80.3%, 69.6%, and 51.5% at 5, 10, and 15 years, respectively. Metastasis-free survival rates were 81.0%, 73.0%, and 56.7% at 5, 10, and 15 years, respectively. Multivariable risk factors for metastasis included eye removal as primary treatment (p = 0.005, RR:2.828) and mixed type histopathology (p < 0.001, RR:4.804).

DISCUSSION

Early diagnosis is crucial for both eye preservation and survival in PUM. Increasing AJCC tumor stage and lower VA were risk factors for eye removal in this study. Mixed type histopathology and primary eye removal were risk factors for metastasis.

Predictors of emotional distress in uveal melanoma survivors: a systematic review

Uveal melanoma (UM) survivors can experience significant emotional distress, although the factors underpinning this are poorly understood. Systematic reviews of distress in UM only include cross-sectional studies, thereby limiting our understanding of causal factors. This review identified prospective clinical, demographic, social and psychological predictors of distress in UM survivors. A systematic search of the literature for English language prospective studies was conducted. Thirteen papers, reporting data from seven unique datasets were included in a narrative synthesis of the results. Younger age (3 studies from 3 datasets), physical health (including visual impairment, ocular symptoms, and other UM-related factors; 3 studies from 3 datasets), and psychological factors (mainly baseline distress; 3 studies from 3 datasets and worry about recurrence; 2 studies from 2 datasets), significantly predicted distress. There was no consistent evidence for other demographic, clinical or social variables (significant in <50% of datasets). Generally, the quality of the papers was adequate. However, attrition rates were high or not reported in over half of the included studies. The findings of this review emphasise the importance of attempts to prevent and recognise distress immediately post-diagnosis of UM. Particular focus should be given to younger patients, those with physical and psychological health difficulties at the time of diagnosis, and those who develop adverse treatment symptoms during survivorship. More research into potential social and psychological variables and their role in predicting distress in survivors is recommended.

Fractionated stereotactic radiotherapy for uveal melanoma: Long-term outcome and control rates

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%.

Development of new therapeutic options for the treatment of uveal melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults. Important cytogenetic and genetic risk factors for the development of UM include chromosome 3 monosomy, mutations in the guanine nucleotide-binding proteins GNAQ/GNA11, and loss of the BRACA1-associated protein 1 (BAP 1). Most primary UMs are treated conservatively with radiotherapy, but enucleation is necessary for large tumours. Despite the effectiveness of local control, up to 50% of UM patients develop metastasis for which there are no effective therapies. Attempts to utilise the targeted therapies that have been developed for the treatment of other cancers, including a range of signal transduction pathway inhibitors, have rarely produced significant outcomes in UM. Similarly, the application of immunotherapies that are effective in cutaneous melanoma to treat UM have also been disappointing. Other approaches that have been initiated involve proteasomal inhibitors and histone deacetylase inhibitors which are approved for the treatment of other cancers. Nevertheless, there have been occasional positive outcomes from these treatments in UM. Moreover, combination approaches in UM have also yielded some positive developments. It would be valuable to identify how to apply such therapies efficiently in UM, potentially via individualised tumour profiling. It would also be important to characterise UM tumours to differentiate the potential drivers of progression from those in other types of cancers. The recent identification of novel kinases and metastatic genes in UM tumours makes the development of new UM-specific treatments feasible.

Current molecular and clinical insights into uveal melanoma (Review)

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.

Hypofractionated stereotactic photon radiotherapy of choroidal melanoma: 20-year experience

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.

Tebentafusp: T Cell Redirection for the Treatment of Metastatic Uveal Melanoma

Metastatic disease from uveal melanoma occurs in almost 50% of patients suffering from this ocular tumour, with median survival from development of symptoms being around 1 year. In contrast to cutaneous melanoma, kinase inhibitors and immune checkpoint inhibitors are usually ineffective in patients with metastatic uveal melanoma. Tebentafusp is a novel form of immunotherapy based on the immune-mobilising monoclonal T cell receptor against cancer (ImmTAC) platform, which comprises a soluble T cell receptor that is fused to an anti-CD3 single-chain variable fragment. The T cell receptor domain of tebentafusp targets cells present a human leukocyte antigen-A*02:01 complexed with a peptide derived from the melanoma-associated antigen gp100, which is expressed strongly by melanoma cells, weakly by normal melanocytes and minimally by other tissues. The anti-CD3 domain recruits CD3+ T cells (and, indirectly, other immune cells), redirecting these to the melanoma cells. The most common adverse events with tebentafusp are manageable and usually transient. Early survival data in patients with metastatic uveal melanoma are promising when considered alongside historical data. Based on these encouraging results, a randomised study comparing tebentafusp to investigator’s choice of therapy in metastatic uveal melanoma is ongoing.

Comparison between patient-reported outcomes after enucleation and proton beam radiotherapy for uveal melanomas: a 2-year cohort study

BACKGROUND

Uveal melanomas affect 2-8 per million Europeans each year. Approximately 35%, are treated by enucleation. Proton beam radiotherapy (PBR) can be an eye-conserving alternative to enucleation for patients who wish to retain the eye. Both treatments have adverse effects, and it is difficult for clinicians and patients to make fully informed choices between them because the relative effects of enucleation and PBR on patient-reported outcomes are unknown.

METHODS

We compared differential effects of enucleation and PBR on patient-reported outcomes on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Ophthalmological module (EORTC QLQ- OPT30) in a consecutive sample of 115 treated patients ~ 6, 12 and 24 months after diagnosis. Pre-treatment demographic variables, unrelated health problems, vision in the fellow eye, tumour characteristics and prognosis for metastatic disease were statistically controlled.

RESULTS

Patients treated by enucleation experienced greater functional problems at 6 months, which abated at 12 and 24 months (P = 0.020). PBR patients reported greater impairments of central and peripheral vision (P = 0.009) and reading difficulties (P = 0.002) over 24 months. Treatment modality did not influence difficulty in driving (P = 0.694), ocular irritation (P = 0.281), headaches (P = 0.640), appearance concerns (P = 0.187) or worry about recurrence (P = 0.899).

CONCLUSIONS

When making treatment decisions, it is important that patients and clinicians consider long-standing difficulties of visual impairment associated with PBR and temporary 6-month difficulties in activities related to depth perception associated with enucleation.

[Management of uveal melanomas, guidelines for oncologists]

Uveal melanomas are the most frequent primary malignant eye tumor. Enucleation was historically the gold standard. Since then, several studies showed that conservative treatments did not increase the risk of metastasis or survival. Choroidal melanomas are both radioresistant and located close to visual structures (the optic nerve and macula) of the eye, which may be preserved in some settings without compromising tumor control, as this is the first priority. Different types of radiation therapy may be used for such tumors: brachytherapy and charged particles, including proton beam therapy. If visual prognosis is dependent to the local treatment, the vital prognosis is dependent on the metastatic risk, with a risk of liver involvement in 20 to 50% of patients, depending on tumor size and genomics. Median survival after the discovery of liver metastases is about 15 months. The management of these patients is often complex. Systemic therapies (chemotherapy, targeted therapies, immunotherapy, etc.) yield limited response rates and although local treatments of liver metastases are promising, they are only feasible in selected patients. The mission of the MELACHONAT national network is to improve the management of patients regardless of the stage of the disease. The patient association ANPACO is dedicated to help uveal melanoma patients in their health care path and to promote knowledge dissemination within the patient community. The aim of this review is to focus on the local treatments of uveal melanomas as well as the management of their metastatic evolution.

Patient-reported Outcomes and Quality of Life After Treatment of Choroidal Melanoma: A Comparison of Enucleation Versus Radiotherapy in 1596 Patients

PURPOSE

To test the hypothesis that patients treated with radiotherapy for choroidal melanoma enjoy better quality of life (QoL) than patients who have undergone enucleation.

METHODS

In this nonrandomized study, patients with choroidal melanoma treated at the Royal Liverpool University Hospital, Liverpool, UK, were invited to complete QoL questionnaires approximately 6 months postoperatively and then on each anniversary of their primary treatment. These instruments consisted of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-OPT30 questionnaire, Hospital Anxiety & Depression Scale, and the Functional Assessment of Cancer Treatment questionnaire. Patient-reported outcomes were correlated with demographics, ocular treatment, social factors, presenting tumor and ocular status, self-reported general health, marital status, and employment status.

RESULTS

The 1596 patients were treated with radiotherapy (72.3%) or enucleation (27.7%). Enucleation was associated with male sex (χ², P = .004), older age (t test, P < .001), larger tumor diameter (t test, P < .001), monosomy 3 (χ², P < .001), depression (linear regression, 95% confidence interval [CI], .17 to 1.01), and reduced physical and functional well-being (linear regression, 95% CI, -1.14 to -0.12 and -1.96 to -0.47), respectively. Poor QoL was attributed to the ocular disease by 21% and 20% of enucleated and irradiated patients, respectively (χ², P = .938).

CONCLUSIONS

Patient-reported outcomes and QoL were worse in patients who had undergone primary enucleation for choroidal melanoma. These outcomes may partly have been caused by factors predisposing to enucleation rather than enucleation itself, because enucleated patients tended to be older, with more advanced disease at presentation, and a worse prognosis for survival. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Porous Versus Nonporous Orbital Implants After Enucleation for Uveal Melanoma: A Randomized Study

PURPOSE

To compare hydroxyapatite with acrylic implants after enucleation for uveal melanoma with respect to eyelid position, ocular motility, implant complications, and patient satisfaction.

METHODS

Patients undergoing primary enucleation for uveal melanoma between May 2005 and November 2012 at the Liverpool Ocular Oncology Centre, United Kingdom, were randomized between hydroxyapatite and acrylic implants. Questionnaires were sent to patients and ocularists to comment on the main outcomes.

RESULTS

A total of 416 patients were recruited in the study, of whom 281 were included, with 49.5% (139/281) and 50.5% (142/281) receiving a hydroxyapatite (HA) or acrylic (AC) implant. Mailed questionnaires completed at ≥18 months by patients showed no significant differences between the groups in eyelid position, prosthetic motility, socket complications, and patient satisfaction. Complications included implant extrusion (1% vs 4%), enophthalmos (26% vs 26%), and superior sulcus deformity (24% vs 24%) with HA and AC implants, respectively, (Fisher exact test p > 0.0125 in all, Bonferroni correction). Questionnaires completed by ocularists indicated no significant differences in eyelid opening, prosthetic motility, and other complications at 6 months (Fisher exact test, p > 0.05 in all); there was a higher prevalence of ptosis with AC than HA implants (46% vs 25%, p = 0.03) and a greater need for ocularists' treatment with HA than AC (50% vs 28%, p = 0.03).

CONCLUSIONS

Patient-reported outcomes after enucleation for uveal melanoma indicate no major differences between hydroxyapatite and acrylic implants in surgical outcomes and patient satisfaction. There was a higher prevalence of ptosis with AC and a greater need of ocularists' visits with HA at around 6 months observed by ocularists.

Increased Levels of miRNA-146a in Serum and Histologic Samples of Patients with Uveal Melanoma

Purpose: To analyze MiRs expression in serum of UM patients, respect to healthy donors, and to compare this data with MiRs expressed in formalin-fixed, paraffin-embedded UM samples. Methods: Expression profile of 754 miRNAs was performed in serum of patients with uveal melanoma who underwent primary enucleation. The level of miRNAs increased in serum was individually analyzed on FFPE UM samples and compared to choroidal melanocytes from unaffected eyes. Results: Fourteen patients with uveal melanoma were included in the study. We found 8 serum miRNAs differentially expressed compared to normal controls: 2 upregulated miRNAs (miRNA-146a, miR-523); 6 downregulated miRNAs (miR-19a, miR-30d, miR-127, miR-451, miR-518f, miR-1274B). When data on upregulated miRNAs were singularly validated only a significant overexpression of miRNA-146a was found. A statistically significant upregulation of miRNA-146a was also found on FFPE UM samples, compared to choroidal melanocytes from unaffected eyes. Conclusions: miRNA-146a is increased in serum of patients with UM and in FFPE tumor samples. Further studies will show if it could be considered a potential marker of UM in the blood.

Transscleral resection without hypotensive anaesthesia vs iodine-125 plaque brachytherapy in the treatment of choroidal melanoma

AimsThe aim of this study was to compare transscleral resection technique performed without hypotensive anaesthesia (TSRWH) with iodine-125 brachytherapy (IBT) in the treatment of choroidal melanoma.Patients and methodsThis was a retrospective surgical cohort study. Nineteen eyes treated with TSRWH were matched with 53 eyes treated with IBT according to: tumour size, distance to fovea, distance to optic nerve, and follow-up time. Best-corrected visual acuity (BCVA), local recurrence, secondary enucleation, metastasis, overall and specific survival, and complications were evaluated.ResultsPatients treated with TSRWH had significantly better BCVA than those treated with IBT. The local recurrence risk was significantly higher when ciliary body was involved (HR=11.4, 95% CI 2.24-49.7, P=0.04). Metastatic disease was observed in 14 of 53 patients (26.4%) in the IBT group vs 3 patients (15.8%) in the TSRWH group (P=0.531). Multivariate analysis showed that iris involvement (HR=16.0, 95% CI 4.2-170.2, P=0.033) and large tumour (HR=2.3, 95% CI 1.2-4.8, P=0.04) increased the probability of metastasis. During follow-up, six patients (11.3%) in IBT group died vs two (10.5%) in the TSRWH group (P≥0.999). Nine patients required secondary enucleation: 5 (9.4%) in the IBT group vs 4 (21.1%) in the TSRWH group (P=0.231). The most common complications in IBT group were radiation-induced retinopathy (45.3%), neovascular glaucoma (28.3%), and macular oedema (24.5%), whereas rhegmatogenous retinal detachment (21.1%), ocular hypertension (21.1%), and submacular haemorrhage (15.8%) were the most frequent complications after TSRWH.ConclusionTSRWH is a technically challenging procedure. However, when performed successfully, this technique achieves better preservation of visual acuity than IBT and without the limitations inherent in hypotensive anaesthesia.

Risk factors associated with secondary enucleation after fractionated stereotactic radiotherapy in uveal melanoma

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.

Phantom Eye Syndrome: Patient Experiences after Enucleation for Uveal Melanoma

PURPOSE

Patients undergoing enucleation for uveal melanoma need to be informed of the possibility of phantom eye syndrome (PES). The number with uveal melanoma in PES studies has been small. Aims were to: (1) determine the prevalence, symptoms, and characteristics of PES and to test associations of PES symptoms with sociodemographic and clinical characteristics; (2) examine the interrelatedness of PES symptoms; and (3) explore the emotional valence of PES and the relationship to anxiety and depression.

DESIGN

Cross-sectional questionnaire.

PARTICIPANTS

Patients (n = 179) with uveal melanoma enucleated 4 to 52 months previously.

METHODS

Questionnaire on PES. Responses to a routine audit of mood obtained from clinical records.

MAIN OUTCOME MEASURES

Patients were asked about 3 symptoms: pain, visual sensations, and a feeling of seeing through the removed eye. Mood was assessed by the Hospital Anxiety and Depression Scale.

RESULTS

Of 179 respondents, 108 (60.3%) experienced symptoms: 86 reported (48%) visual sensations, 50 reported (28%) seeing, and 42 reported (23%) pain; 14 (7.8%) reported all 3 symptoms. At the time of the questionnaire, 31 (17%) experienced 1 or more symptoms daily. Women were more likely to report pain (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.08-4.40). Younger patients at enucleation were more likely to report pain (t = 4.13; degrees of freedom (df), 177; P < 0.001) and visual sensations (t = 2.11; df, 177; P < 0.05). Patients studied sooner after enucleation were more likely to report seeing (Mann-Whitney U, 2343; P < 0.05). Pain and seeing were intercorrelated (chi-square, 5.47; Φ = 0.18; df, 1; P < 0.05), pain with visual sensations (chi-square, 3.91; Φ = 0.15; df, 1; P < 0.05) and seeing with visual sensations (chi-square, 34.22; Φ = 0.45; df, 1; P < 0.001). Twenty of 108 patients (18.5%) found symptoms disturbing, and 21 of 108 (19.4%) pleasurable. Patients reporting pain were more anxious (OR, 3.53; 95% CI, 1.38-9.03) and depressed (OR, 13.26; 95% CI, 3.87-46.21).

CONCLUSIONS

Patients should be informed of PES symptoms. Pain may indicate anxiety or depression; this needs research to determine cause and effect.

Cost-effectiveness of proton beam therapy for intraocular melanoma

Purpose

Proton beam therapy is a commonly accepted treatment for intraocular melanomas, but the literature is lacking in descriptions of patient preferences of clinical outcomes and economic impact. In addition, no economic evaluations have been published regarding the incremental cost-effectiveness of proton beam therapy compared with enucleation or plaque brachytherapy, typical alternative treatments. We, therefore, conducted a cost-utility analysis of these three approaches for the treatment of intraocular melanomas.

Materials and Methods

A Markov model was constructed. Model parameters were identified from the published literature and publicly available data sources. Cost-effectiveness of each treatment was calculated in 2011 US Dollars per quality-adjusted life-year. Incremental cost-effectiveness ratios were calculated assuming enucleation as reference. One-way sensitivity analyses were conducted on all model parameters. A decision threshold of $50,000/quality-adjusted life-year was used to determine cost-effectiveness.

Results

Enucleation had the lowest costs and quality-adjusted life-years, and plaque brachytherapy had the highest costs and quality-adjusted life-years. Compared with enucleation, the base-case incremental cost-effectiveness ratios for plaque brachytherapy and proton beam therapy were $77,500/quality-adjusted life-year and $106,100/quality-adjusted life-year, respectively. Results were highly sensitive to multiple parameters. All three treatments were considered optimal, and even dominant, depending on the values used for sensitive parameters.

Conclusion

Base-case analysis results suggest enucleation to be optimal. However, the optimal choice was not robust to sensitivity analyses and, depending on the assumption, both plaque brachytherapy and proton beam therapy could be considered cost-effective. Future clinical studies should focus on generating further evidence with the greatest parameter uncertainty to inform future cost-effectiveness analyses.

miRNA profiling in vitreous humor, vitreal exosomes and serum from uveal melanoma patients: Pathological and diagnostic implications

Uveal melanoma (UM) represents approximately 5-6% of all melanoma diagnoses and up to 50% of patients succumb to their disease. Although several methods are available, accurate diagnosis is not always easily feasible because of potential accidents (e.g., intraocular hemorrhage). Based on the assumption that the profile of circulating miRNAs is often altered in human cancers, we verified whether UM patients showed different vitreous humor (VH) or serum miRNA profiles with respect to healthy controls. By using TaqMan Low Density Arrays, we analyzed 754 miRNAs from VH, vitreal exosomes, and serum of 6 UM patients and 6 healthy donors: our data demonstrated that the UM VH profile was unique and only partially overlapping with that from serum of the same patients. Whereas, 90% of miRNAs were shared between VH and vitreal exosomes, and their alterations in UM were statistically overlapped with those of VH and vitreal exosomes, suggesting that VH alterations could result from exosomal dysregulation. We report 32 miRNAs differentially expressed in UM patients in at least 2 different types of samples analyzed. We validated these data on an independent cohort of 12 UM patients. Most alterations were common to VH and vitreal exosomes (e.g., upregulation of miR-21,-34 a,-146a). Interestingly, miR-146a was upregulated in the serum of UM patients, as well as in serum exosomes. Upregulation of miR-21 and miR-146a was also detected in formalin-fixed, paraffin-embedded UM, suggesting that VH or serum alterations in UM could be the consequence of disregulation arising from tumoral cells. Our findings suggest the possibility to detect in VH and serum of UM patients "diagnostic" miRNAs released by the affected eye: based on this, miR-146a could be considered a potential circulating marker of UM.

Treatment of primary intraocular melanoma

The treatment of intraocular melanoma has evolved recently. Enucleation has been superseded largely by brachytherapy, proton beam radiotherapy, stereotactic irradiation, trans-scleral local resection, transretinal resection and diode laser phototherapy. Many patients develop metastatic disease, which usually involves the liver and occurs hematogenously. Disseminated disease rarely responds to therapy, and is usually fatal within 1 year of the onset of symptoms. Uveal melanomas develop characteristic chromosomal abnormalities, such as loss of chromosome 3. This is associated with a reduction in the 5-year survival from approximately 95% to less than 50%.

[Ciliary body melanoma presenting as uveitis in a West Indian woman: Case report and review of the literature]

The incidence of uveal melanoma, in particular that of the ciliary body, is very low in black people, including West Indians. When symptomatic, it manifests as decreased or impaired visual acuity and seldom, if ever, pain. We report a case of ciliary body melanoma that is of scientific interest for two reasons: 1) a West Indian melanoderm patient being affected, 2) presentation as a recurrent uveitis with a transient increase of intraocular pressure, and without any decline in visual acuity. We recommend that in any case of uveitis, black patients included, a ciliary body tumor should always be excluded by pupillary dilation.

Genome-wide profiling is a clinically relevant and affordable prognostic test in posterior uveal melanoma

Objective

This study investigated the capacity of genetic analysis of uveal melanoma samples to identify high-risk patients and discusses its clinical implications.

Methods

Patients with posterior uveal melanoma were prospectively enrolled. Tumour samples were derived from enucleated globe, fine-needle aspirates or endoresection. Chromosome 3 and 8 status was determined by array comparative genomic hybridisation (array-CGH). Patients were followed after treatment to detect metastasis.

Results

Four groups were classified by array-CGH. Patients were divided into disomy 3 and normal chromosome 8 (D3/8nl), disomy 3 and 8q gain (D3/8g), monosomy 3 and normal chromosome 8 (M3/8nl) and monosomy 3 and 8 or 8q gain (M3/8g). Median follow-up was 28 months (range: 1–147 months). At the end of the study, 128 patients (33.7%) had developed metastasis and 96 patients had died. Univariate Cox proportional hazard analysis showed that factors associated with metastasis included basal tumour diameter p=0.0007, tumour thickness p=0.01, mixed/epithelioid cell type p=0.0009 and genomic data p<0.0001. High-risk profile was more strongly associated with metastasis than the other prognostic factors p<0.001. Multivariate Cox modelling analysis showed that the status of chromosomes 3 and 8 were the only two variables that independently contributed to prognosis: monosomy 3 alone p=0.001 and monosomy 3 and 8q gain p<0.0001.

Conclusions

Array-CGH allowed identification of three prognostic groups with low, intermediate and high risk of developing metastasis. Array-CGH is a reliable and inexpensive method for uveal melanoma prognosis. This method is now currently used in France.

Brachytherapy and endoresection for choroidal melanoma: a cohort study

AIM

To report and compare the outcomes of brachytherapy and endoresection in the conservative treatment of medium sized choroidal melanoma.

METHODS

A retrospective cohort study. Medium tumours were defined as 2.5-10 mm in height and less than 16 mm in the widest diameter. Consecutive patients undergoing brachytherapy at Groote Schuur Hospital were compared with a cohort undergoing endoresection from a national database.

RESULTS

148 brachytherapy and 22 endoresection patients were followed for a median of 55.4 and 62.4 months, respectively. Tumours undergoing endoresection were thicker (7.3 vs 4.9 mm, p<0.001, Wilcoxon rank-sum test) and further from the fovea (5.2 vs 3.7 mm, p=0.05, Wilcoxon rank-sum test) than those treated with brachytherapy. Visual acuity of 6/18 or better was maintained in 41% of the endoresection group and 35% of the brachytherapy group. The likelihood of achieving a final visual acuity of better than 2/60 was 22% higher in the endoresection group (risk ratio 1.22, 95% CI 1.02 to 1.28, p=0.034). Rates of local recurrence (18.2% vs 14.9%, p=0.75) and metastases or death (18.2% vs 14.2%, p=0.75) were higher in the endoresection group, and the enucleation rate was lower in this group (4.6% vs 10.8%, p=0.70) but these were not statistically significant.

CONCLUSIONS

The outcomes observed in this small cohort of endoresection patients suggest that endoresection of selected tumours may achieve better visual outcomes than brachytherapy. Rates of local recurrence, enucleation and metastases following endoresection require further research. Local recurrence is likely to be influenced by consolidation treatment methods.

Irreversible electroporation of human primary uveal melanoma in enucleated eyes

Uveal melanoma (UM) is the most common primary intraocular tumor in adults and is characterized by high rates of metastatic disease. Although brachytherapy is the most common globe-sparing treatment option for small- and medium-sized tumors, the treatment is associated with severe adverse reactions and does not lead to increased survival rates as compared to enucleation. The use of irreversible electroporation (IRE) for tumor ablation has potential advantages in the treatment of tumors in complex organs such as the eye. Following previous theoretical work, herein we evaluate the use of IRE for uveal tumor ablation in human ex vivo eye model. Enucleated eyes of patients with uveal melanoma were treated with short electric pulses (50–100 µs, 1000–2000 V/cm) using a customized electrode design. Tumor bioimpedance was measured before and after treatment and was followed by histopathological evaluation. We found that IRE caused tumor ablation characterized by cell membrane disruption while sparing the non-cellular sclera. Membrane disruption and loss of cellular capacitance were also associated with significant reduction in total tumor impedance and loss of impedance frequency dependence. The effect was more pronounced near the pulsing electrodes and was dependent on time from treatment to fixation. Future studies should further evaluate the potential of IRE as an alternative method of uveal melanoma treatment.

Personalized treatment of uveal melanoma

Personalized treatment of uveal melanoma involves the tailoring of all aspects of care to the condition, needs, wishes, and fears of the patient, taking account of the individual's circumstances. When selecting between radiotherapy, surgical resection, and phototherapy, or when deciding how best to combine these different therapeutic modalities, it is necessary to understand the patients utilities, with respect to tumour control, visual conservation, and preservation of the eye, so as to prioritize outcomes accordingly. For example, such considerations would influence the width of the safety margins when administering radiotherapy, according to whether the patient considers it more important to conserve vision or to guarantee tumour control. With 'suspicious naevi', the choice between observation, immediate treatment, and biopsy is complicated by the lack of adequate survival data on which to base rational decisions, making it necessary for both patient and doctor to accept uncertainty. Personalized care should involve close relatives, as appropriate. It must also adapt to changes in the patient's needs over time. Such personalized care demands the ability to respond to such needs and the sensitivity to identify these requirements in the first place. Personalized treatment enhances not only the patient's satisfaction but also the 'job satisfaction' of all members of the multidisciplinary team, improving quality of care.

Progress in the management of patients with uveal melanoma. The 2012 Ashton Lecture

Uveal melanomas are diverse in their clinical features and behaviour. More than 90% involve the choroid, the remainder being confined to the ciliary body and iris. Most patients experience visual loss and more than a third require enucleation, in some cases because of pain. Diagnosis is based on slit-lamp biomicroscopy and/or ophthalmoscopy, with ultrasonography, autofluorescence photography, and/or biopsy in selected cases. Conservation of the eye with useful vision has improved with advances in brachytherapy, proton beam radiotherapy, endoresection, exoresection, transpupillary thermotherapy, and photodynamic therapy. Despite ocular treatment, almost 50% of patients develop metastatic disease, which occurs almost exclusively in patients whose tumour shows chromosome 3 loss and/or class 2 gene expression profile. When the tumour shows such lethal genetic changes, the survival time depends on the anatomical stage and the histological grade of malignancy. Prognostication has improved as a result of progress in multivariate analysis including all the major risk factors. Screening for metastases is more sensitive as a consequence of advances in liver scanning with magnetic resonance imaging and other methods. More patients with metastases are living longer, benefiting from therapies such as: partial hepatectomy; radiofrequency ablation; ipilumumab immunotherapy; selective internal radiotherapy; intra-hepatic chemotherapy, possibly with isolated liver perfusion; and systemic chemotherapy. There is scope for improvement in the detection of uveal melanoma so as to maximise any opportunities for conserving the eye and vision, as well as preventing metastatic spread. Patient management has been enhanced by the formation of multidisciplinary teams in specialised ocular oncology centres.

Detection and time to treatment of uveal melanoma in the United Kingdom: an evaluation of 2,384 patients

PURPOSE

To determine the mode of detection of uveal melanoma and time to treatment in the United Kingdom.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 2384 patients diagnosed with uveal melanoma at the Liverpool Ocular Oncology Center between 1996 and early 2011.

METHODS

A questionnaire was completed with every new patient, and the results were correlated with clinical features and treatment.

MAIN OUTCOME MEASURES

Tumor detection, practitioner initiating referral, referral pathway, time to treatment, baseline clinical features, and primary ocular treatment.

RESULTS

The referral process was initiated by an optometrist, family doctor, or ophthalmologist in 68.0%, 18.2%, and 13.8% of patients, respectively. On referral, 30.2% of patients were asymptomatic. Twenty-three percent of patients reported that their tumor was initially missed; these tended to have a more advanced tumor when they reached our center. The time from referral to treatment had a median of 49 days, exceeding 6 months in 19.8% of patients. This delay was longer in patients who reported that their tumor was missed (median, 92 vs. 40 days; Mann-Whitney, P<0.001). Ophthalmologists delayed the referral process by more than 6 months in 10.9% of patients. Primary enucleation was performed in 33.3% of patients and was more likely in those who reported that their tumor was missed (44.8% vs. 29.8%; chi-square, P<0.001).

CONCLUSIONS

Many patients with uveal melanoma experience long delays in treatment because their tumor was missed or misdiagnosed. Such patients tend to have a more advanced tumor by the time they reach an oncology center and are more likely to require enucleation.

Differences in uveal melanomas between men and women from the British Isles

PURPOSE

The purpose of this study is to compare uveal melanomas (UMs) in men and women.

METHODS

The Liverpool Ocular Oncology Centre (LOOC) database was reviewed. Patients treated for UM at the LOOC between 1993 and 2010 were selected. Differences between sexes were identified using the χ (2)-test for categorical variables and the Mann-Whitney test for continuous variables.

RESULTS

The 3380 patients comprised 1685 women and 1695 men. The tumours were considered clinically to have arisen in choroid in 89.5%, ciliary body in 5.3%, and iris in 5.2%. Tumours in women were less likely to originate in choroid (87.2 vs 91.7%; P<0.001) and showed more circumferential spread in ciliary body (P<0.001) and iris (P=0.003). Tumours in men were more likely to extend to within 3 mm of optic disc or fovea (46.3 vs 39.0%, P<0.001), showing more extensive optic-disc involvement (P<0.001). The median largest basal tumour diameter was 12.2 mm in men and 11.9 mm in women (P=0.001). The tumour thickness had a median of 4.4 mm and 3.8 mm in men and women, respectively (P=0.015). The 180 ciliary body tumours occurred in 112 women and 68 men. In these, the prevalence of extraocular spread was higher in women (19.6 vs 8.8%; P=0.052). The 175 iris melanomas were more common in women than men (103 vs 72, respectively).

CONCLUSIONS

In men, UMs tend to be larger and more posterior than in women.

A reappraisal of the significance of largest basal diameter of posterior uveal melanoma

OBJECTIVES

To evaluate the significance of the largest tumour diameter (LTD) of posterior uveal melanomas (ie, involving choroid), correlating this feature with histological and cytogenetic predictors and mortality.

METHODS

Patients with posterior uveal melanoma were included. LTD was measured by echography and correlated with histological and cytogenetic findings and metastatic death.

RESULTS

The cohort comprised 1776 patients with a median age of 60 years, a median tumour diameter of 14.0 mm, and a median tumour height of 7.5 mm. The LTD was greater in older patients (t-test, P<0.001). The presence of epithelioid cells, closed loops, high mitotic rate, chromosome 3 deletion, and chromosome 8 gains all correlated significantly with LTD (t-test, P<0.001). The 1521 British patients had a median follow-up of 4.9 years, with a disease-specific mortality of 28.9%. Metastatic death correlated with LTD (Cox multivariate analysis, P<0.001). Tumours with the same LTD showed significant variation in survival, according to the presence of epithelioid cells (Log rank, P<0.001), closed loops (Log rank, P=0.002), high mitotic rate (Log rank, P=0.003), and chromosome 3 loss (Log rank, P=0.008).

CONCLUSIONS

The value of LTD as a predictor of survival after treatment of posterior uveal melanoma is enhanced by taking histological and cytogenetic factors into account.

Dose-response effect of charged carbon beam on normal rat retina assessed by electroretinography

PURPOSE

To compare the effects of carbon beam irradiation with those of proton beam irradiation on the physiology of the retina of rats.

METHODS AND MATERIALS

Eight-week-old Wister rats were used. The right eyes were irradiated with carbon beam (1, 2, 4, 8, and 16 Gy) or proton beam (4, 8, 16, and 24 Gy) with the rats under general anesthesia. Electroretinograms were recorded 1, 3, 6, and 12 months after the irradiation, and the amplitudes of the a and b waves were compared with those of control rats.

RESULTS

The amplitude of b waves was reduced more than that of a waves at lower irradiation doses with both types of irradiation. With carbon ion irradiation, the amplitudes of the b wave were significantly reduced after radiation doses of 8 and 16 Gy at 6 months and by radiation doses of 4, 8, and 16 Gy at 12 months. With proton beam irradiation, the b-wave amplitudes were significantly reduced after 16 and 24 Gy at 6 months and with doses of 8 Gy or greater at 12 months. For the maximum b-wave amplitude, a significant difference was observed in rats irradiated with carbon beams of 4 Gy or more and with proton beams of 8 Gy or more at 12 months after irradiation.

CONCLUSIONS

These results indicate that carbon beam irradiation is about two times more damaging than proton beam irradiation on the rat retina at the same dose.

Does ocular treatment of uveal melanoma influence survival?

Treatment of uveal (intraocular) melanoma is aimed at prolonging life, if possible conserving the eye and useful vision. About 50% of patients develop fatal metastatic disease despite successful eradication of the primary intraocular tumour. The effect of ocular treatment on survival is unknown, because the same survival data from case series can be interpreted in different ways. Treatment is therefore based on intuition and varies greatly between centres. Randomised trials of treatment vs non-treatment of asymptomatic tumours are desirable but would be controversial, difficult, expensive and possibly inconclusive. Strategies for coping with uncertainty are needed to avoid unethical care.

Long-term choroidal vascular changes after iodine brachytherapy versus transpupillary thermotherapy for choroidal melanoma

PURPOSE

To compare long-term choroidal vascular changes after iodine-125 brachytherapy (IBT) versus transpupillary thermotherapy (TTT) used as primary treatment of small choroidal melanoma.

METHODS

Ninety-five small choroidal melanomas were randomized: 49 eyes with TTT and 46 eyes with IBT alone. Fluorescein and indocyanine green angiography (ICGA) were performed at 3-month intervals during the first year, and every 6 months thereafter.

RESULTS

Mean follow-up was 56.2 months (range, 24-118 months; SD, 22.6). Tumor regressed in 45 (92%) TTT-treated vs 45 (98%) IBT-treated eyes (p=0.397). Four TTT-treated and one IBT-treated tumor recurred. Occlusion of choriocapillaris was present in all TTT and IBT cases. Closure of medium and large choroidal vessels was observed in 17 (35%) TTT-treated vs 44 (96%) IBT-treated eyes (p<0.001). Choroidal vascular remodeling was detected in 20 (41%) TTT-treated and 16 (35%) IBT-treated eyes (p=0.693). Retinochoroidal anastomosis was present in 4 of the 37 (11%) TTT-treated eyes with patency of medium and large choroidal vessels, but never observed in the IBT-treated eyes, and was associated with tumor recurrence. Among IBT-treated eyes, segments of choroidal vascular wall ICG staining and choroidal aneurysmal changes were detected in 30 (65%) and 7 (15%), respectively. These changes were never detected in TTT-treated cases (p<0.0001 and p=0.015, respectively).

CONCLUSIONS

The pattern of tumor choroidal vascular changes following IBT and TTT differs. TTT is less effective in closing all tumor vasculature. The role of long-term choroidal vascular remodeling observed after these two treatments needs longer follow-up.

Local resection versus combined local resection and plaque radiotherapy in the treatment of choroidal melanoma

PURPOSE

To evaluate the outcome of local resection versus combined local resection and plaque radiotherapy in the treatment of choroidal melanoma.

METHODS

We retrospectively analyzed the records of 60 patients (60 eyes) managed by local resection (group 1, 30 patients, external or internal local resection) or combined local resection and plaque radiotherapy (group 2, 30 patients, both Ruthenium-106 or Cobalt-60), among the 364 melanomas treated at our Department of Ophthalmology, between January 1980 and December 2006. Main outcomes measures were postsurgical complications, visual acuity, local recurrence, reasons for enucleation, and development of metastasis.

RESULTS

The 2 groups of patients were considered sufficiently homogeneous as regards location, cell type, and age. Mean follow-up was 7 years. The median largest basal tumor diameter was 9.8 mm and 10.1, and the median tumor thickness was 7.9 mm and 8, respectively, in groups 1 and 2. No statistically significant differences resulted between group 1 and group 2 as regards postsurgical complications (vitreous hemorrhage, retinal detachment, maculopathy, cataract, and optic neuropathy) (p>0.05), visual acuity (p>0.05), local recurrence (p>0.05), reasons for enucleation (p>0.05), or development of metastasis (p>0.05).

CONCLUSIONS

No adjunctive benefits from the combined local resection and plaque radiotherapy can be ruled out from our study.

Choroidal melanoma: natural history and management options

BACKGROUND

Choroidal melanoma is the most common primary malignancy of the eye. Enucleation has been the mainstay of treatment, but new and more effective options have recently been proposed as eye- and vision-sparing alternatives.

METHODS

We reviewed the medical literature for trials and case reports involving the evolution, current uses, and limitations of alternatives to enucleation for treating choroidal melanoma.

RESULTS

Options to treat choroidal melanomas depend on the location and size of the tumor and goals of therapy. Local control with plaque radiotherapy has provided overall survival comparable to enucleation. Transscleral resection may leave behind potentially viable melanoma cells following surgery; adjuvant brachytherapy is recommended to irradiate remaining tumor cells. Elevating tissue temperature potentiates the effect of ionizing radiation, thus reducing the dose of radiation needed to treat uveal melanoma. Transpupillary thermotherapy has been effective only in select circumstances, and long-term results have shown poorer local control rates and similar visual outcomes compared with other conservative treatment methods.

CONCLUSIONS

Treatment therapies for choroidal melanoma warrant further study. Currently, enucleation remains as effective as the eye- and vision-sparing approaches.

Survival from uveal melanoma in England and Wales 1986 to 2001

PURPOSE

To analyse survival from uveal melanoma diagnosed in England and Wales between 1986-1999 and followed up to 2001.

METHODS

Data from the National Cancer Registry at the Office for National Statistics were analysed. The data were compiled from population-based cancer registries covering all of England and Wales for all adults (aged 15-99) diagnosed with primary ocular malignancy, excluding eyelid tumours. Level of poverty was based on the national classification of area of residence at time of diagnosis. Regression models explored the influence of sex, age, and level of poverty on relative survival for patients diagnosed with uveal melanoma during successive calendar periods.

RESULTS

Of 5,519 adults identified with primary ocular malignancy, 4,717 had melanoma, of which 4,308 (91%) were eligible for analysis. Two-thirds (67%) of the ocular melanomas were uveal, 5% conjunctival, and 2% orbital; the subsite was unspecified in 26%. Relative survival from uveal melanoma was 95% at 1 year and 72% at 5 years. There was no statistically significant variation in 1-year or 5-year survival by sex or poverty level and no significant trend over time. Older patients had significantly worse survival (p < 0.001).

CONCLUSIONS

This study provides national population-based survival estimates for England and Wales for uveal melanoma, the most common primary intraocular malignancy in adults. Five-year relative survival, an important indicator of the quality of cancer care, has not improved since the 1980s. Greater age, but not gender or level of poverty, is associated with a poorer prognosis. A standardised classification of uveal melanoma is required to improve reporting to cancer registries. Further research is required to explore reasons for lower relative survival in older persons.

Transscleral local resection versus iodine brachytherapy for uveal melanomas that are large because of tumour height

BACKGROUND

To compare visual outcome and ocular complications of transscleral local resection (TSR) with those of iodine-125 plaque brachytherapy (IBT) for uveal melanomas categorised as large because of tumour height.

METHODS

Retrospective study of 87 patients with a uveal melanoma <or=16 mm by largest basal diameter (median, 12.6 vs 14.0 mm for TSR and IBT, respectively) and large by height (median, 11.0 vs 10.6 mm) by the Collaborative Ocular Melanoma Study (COMS) criteria. Thirty-three patients underwent TSR in the United Kingdom and 54 underwent IBT in Finland. Loss of 20/65 and 20/400 vision, local tumour recurrence, cataract, iris neovascularization, glaucoma, maculopathy, optic neuropathy, persistent retinal detachment, and vitreous haemorrhage were analysed using competing risks and logistic regression to control for confounders.

RESULTS

All patients save one managed with TSR lost 20/70 vision within 3 years. The 2-year cumulative incidence of losing 20/400 vision was 60% (95% CI, 35-75) for TSR and 75% (95% CI, 59-86) for IBT. The 5-year incidence of local tumour recurrence was 41% (95% CI, 17-63) after TSR and 7% (95% CI, 2-17) after IBT. Glaucoma and optic neuropathy were rare after TSR. Cataract, maculopathy, retinal detachment, and vitreous haemorrhage were common after either treatment. The number of patients needed to treat with TSR instead of IBT was four for one additional patient to benefit by avoiding loss of visual acuity 20/400 for at least 2 years, and the corresponding number was three for one additional patient to experience a local recurrence from TSR.

CONCLUSIONS

If TSR is further evaluated as an alternative to IBT in avoiding blindness of an eye with a ciliochoroidal melanoma categorised as large by COMS criteria because of its height, special emphasis must be given to increased risk of local tumour recurrence.

The case for particle therapy

Among the most important decisions facing the British Government regarding the treatment of cancer in the National Health Service (NHS) is the purchase of charged particle therapy (CPT) centres. CPT is different from conventional radiotherapy: the dose is deposited far more selectively in Bragg Peaks by either protons or "heavy" ions, such as carbon. In this way, it is possible to "dose paint" targets, voxel by voxel, with far less dose to surrounding tissues than with X-ray techniques. At present the UK possesses a 62 MeV cyclotron proton facility at Clatterbridge (Wirral), which provides therapy for intraocular cancers such as melanoma; for deeper situated cancers in the pelvis, chest etc., much higher energies, over 200 MeV are required from a synchrotron facility. There is an impressive expansion in particle beam therapy (PBT) centres worldwide, since they offer good prospects of improved quality of life with enhanced cancer cures in situations where conventional therapy is limited due to radioresistance or by the close proximity of critical normal tissues. There is a threat to UK Oncology, since it is anticipated that several thousand British patients may require referral abroad for therapy; this would severely disrupt their multidisciplinary management and require demanding logistical support.