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Jabbarli L, Biewald E, Guberina M, Rating P, Fiorentzis M, Flühs D, Le Guin CHD, Sokolenko E, Sauerwein W, Bornfeld N, Stuschke M, Bechrakis NE. Prognostic factors for surgical treatment of radiation-induced scleral necrosis after brachytherapy for uveal melanoma. Eur J Ophthalmol 2024:11206721241257979. [PMID: 38807558 DOI: 10.1177/11206721241257979] [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: 05/30/2024]
Abstract
PURPOSE Radiation-induced scleral necrosis (RISN) is a less frequent complication of brachytherapy for uveal melanoma, and may require surgical treatment in selected cases. We aimed to identify the prognostic factors for RISN treatment. METHODS All patients with brachytherapy for uveal melanoma treated at our institution between 01/1999 and 12/2016 who developed RISN were followed until 02/2021. Various parameters were evaluated through univariable and multivariable Cox regression analysis. The surgical intervention due to RISN was the principal outcome event of this study. RESULTS Of 115 patients in the final cohort, 51 individuals (44%) underwent RISN treatment (conjunctival revision [n = 2], patching [n = 46] or enucleation [n = 3]) at median 1.80 months after RISN occurrence. Significant RISN characteristics were summarized into a novel RISN severity scale - Grade I: largest diameter ≤ 5 mm and no progression; Grade II: largest diameter > 5 mm or any progression during the follow-up; Grade III: presence of uveal prolapse; and Grade IV: leakage through open eyewall perforation. In the multivariable analysis, the RISN severity scale (aHR = 2.37 per grade increase, p = 0.01) and the time between brachytherapy and RISN occurrence (<15 months, aHR = 6.33, p < 0.0001) were independently associated with the study endpoint. The RISN severity scale showed high diagnostic accuracy for prediction of RISN treatment (AUC = 0.869). CONCLUSIONS In our series, about the half of RISN cases underwent surgical treatment. The presented novel severity scale for RISN might become a helpful tool for clinical management of individuals with RISN. We recommend external validation of the diagnostic accuracy of the presented scale.
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Affiliation(s)
- Leyla Jabbarli
- Department of Ophthalmology, University Hospital, Essen, Germany
| | - Eva Biewald
- Department of Ophthalmology, University Hospital, Essen, Germany
| | - Maja Guberina
- Department of Radiotherapy, University Hospital Essen, Germany
| | - Philipp Rating
- Department of Ophthalmology, University Hospital, Essen, Germany
| | | | - Dirk Flühs
- Department of Radiotherapy, University Hospital Essen, Germany
| | | | | | | | - Norbert Bornfeld
- Department of Ophthalmology, University Hospital, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, University Hospital Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Heidelberg, Essen, Germany
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Lalos F, Flühs D, Guberina M, Bornfeld N, Stuschke M, Sauerwein W, Bechrakis NE. Treatment-Related Complications and Functional Results after Ruthenium-106 Brachytherapy in Small to Medium Size Uveal Melanomas (Part 2). Klin Monbl Augenheilkd 2024. [PMID: 38395138 DOI: 10.1055/a-2275-5575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
PURPOSE To analyze the treatment-related complications after ruthenium-106 brachytherapy in patients with uveal melanoma in terms of radiation-induced optic neuropathy, maculopathy and retinopathy, radiation-related vitreous hemorrhage, and retinal detachment, as well as secondary glaucoma and radiogenic cataract. In addition, the course of visual acuity was analyzed. PATIENTS/METHODS AND MATERIALS This retrospective study included 608 patients treated with ruthenium-106 brachytherapy between January 2008 and December 2010 at the Department of Ophthalmology, University Hospital Essen. The follow-up time was 11 years. The occurrence of the radiation-induced complications was analyzed using the Kaplan-Meier method. Cox regression was used for univariate and multivariate risk factor analyses. Hazard ratios were calculated for each variable. RESULTS Regarding the complications, 34% (N = 207) of the patients had no reported side effects or complications during follow-up. Radiation optic neuropathy was observed in 18.8% (N = 114) of the patients, with a median time to onset of 16 months (range: 3 - 78 months). Radiation maculopathy occurred in 8.2% (N = 50) after a median time of 17 months (range: 3 - 67 months). Radiation retinopathy was observed in 20.1% (N = 122), with a median time to onset of 21 months (range: 6 - 67 months). Secondary glaucoma developed in 9.7% of the patients (N = 53) and radiogenic cataract in 46.8% (N = 227). Vitreous hemorrhage (11.8%, N = 72) and scleral necrosis (2.1%, N = 13) occurred relatively rarely. CONCLUSION The observed radiogenic complication rate is comparable with that reported in previous studies.
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Affiliation(s)
- Fotios Lalos
- Department of Ophthalmology, University Hospital of Essen, Germany
| | - Dirk Flühs
- Department of Radiotherapy, University Hospital of Essen, Germany
| | - Maja Guberina
- Department of Radiotherapy, University Hospital of Essen, Germany
| | - Norbert Bornfeld
- Department of Ophthalmology, University Hospital of Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, University Hospital of Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Partner Site University Hospital Essen, Germany
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Jabbarli L, Biewald E, Guberina M, Le Guin CHD, Thomasen H, Fiorentzis M, Sokolenko E, Flühs D, Bornfeld N, Stuschke M, Bechrakis NE, Rating P. Surgical Outcome After Treatment of Radiation-Induced Scleral Necrosis in Patients With Uveal Melanoma. Cornea 2024:00003226-990000000-00480. [PMID: 38334485 DOI: 10.1097/ico.0000000000003483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/03/2023] [Indexed: 02/10/2024]
Abstract
PURPOSE Surgical repair might be required in patients with uveal melanoma (UM) that develop advanced forms of radiation-induced scleral necrosis (RISN). In this monocentric long-term observational study, we aimed at analyzing the treatment outcome after RISN surgery. METHODS All consecutive cases with UM who underwent surgical intervention for RISN between 1999 and 2020 were included. Achievement of the tectonic stability and evaluation of incidence and the risk factors for a repetitive patch surgery (RPS) were the main endpoints. RESULTS The final analysis included 57 patients (mean age: 58.7 years; 63.2% female patients), where 55 individuals underwent a patch grafting, and 2 cases were treated with conjunctival reconstructive surgery. The mean follow-up time after grafting was 38.5 months (0.03-221.1 months). Tectonic stability was achieved in 56 (98.3%) patients. Scleral graft (38/55, 69.1%) was the most frequent patching material, followed by Tutopatch (7/55, 12.7%), corneal graft (7/55, 12.7%), dura graft (2/55, 3.6%), and fascia lata (FL) graft (1/55, 1.8%). Eleven patients (20%) underwent RPS after the mean time of 12.9 months (0.3-50.3 months). In the final multivariate Cox regression analysis, the use of Tutopatch (5/7; 71.4%, adjusted hazard ratio = 4.66, P = 0.044) and RISN progression after patch grafting (9/11; 81.8%, adjusted hazard ratio = 9.67, P = 0.008) were independent risk factors for RPS. CONCLUSIONS RISN surgery maintains long-term tectonic stability in most of the cases underwent surgical repair for RISN after brachytherapy for UM. Depending on graft material and, particularly, further RISN progression, an RPS might be necessary in certain cases.
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Affiliation(s)
- Leyla Jabbarli
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Eva Biewald
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Maja Guberina
- Department of Radiotherapy, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany, Partner Site University Hospital Essen, Essen, Germany ; and
| | | | - Henning Thomasen
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | | | | | - Dirk Flühs
- Department of Radiotherapy, University Hospital Essen, Essen, Germany
| | - Norbert Bornfeld
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany, Partner Site University Hospital Essen, Essen, Germany ; and
| | | | - Philipp Rating
- Department of Ophthalmology, University Hospital Essen, Essen, Germany
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4
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Shields CL, Silva AMV, Laiton A, Kalafatis NE, Schiller E, Lally SE, Grant-Kels JM, Shields JA. Conjunctival melanoma: Insights into classification, outcomes, and biomarkers. Clin Dermatol 2024; 42:46-55. [PMID: 37858779 DOI: 10.1016/j.clindermatol.2023.10.010] [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: 10/21/2023]
Abstract
Conjunctival melanoma is quite rare, estimated at approximately 0.5 incidence per 1 million persons per year. This malignancy arises from a pre-existing nevus (7%), primary acquired melanosis (74%), or de novo without pre-existing condition (19%) and develops most often in patients with Fitzpatrick skin types I (23%) and II (62%). At initial presentation, the tumor size is approximately 13 mm in cross-sectional diameter and has 3-mm thickness, involving the bulbar (97%), forniceal (30%), tarsal (28%), or caruncular (11%) regions, often with corneal (54%) and rarely with orbital (4%) involvement. According to the eighth edition of the American Joint Committee on Cancer (AJCC), the tumor is classified as T1 (63%), T2 (18%), T3 (20%), and T4 (0%). Outcomes depend on several factors including patient age, AJCC classification, orbital invasion, and type of initial surgery, whereas tumor origin and Fitzpatrick skin type do not appear to impact outcomes. Older patients (≥70 years of age) demonstrate larger tumors, greater recurrence, and greater vision loss. Analysis of 425 patients by AJCC classification (T1 versus T2 versus T3) revealed increasing T category with greater lymph node metastasis (3% versus 13% versus 25%; P < .001), tumor-related systemic metastasis (13% versus 45% versus 40%; P < .001), and tumor-related death (8% versus 22% versus 37%; P < .001). Data of patients with orbital invasion revealed significantly greater 10-year rates of exenteration (P < .001), distant metastasis (P = .0005), and death (P = .001). Studies have demonstrated biomarkers related to conjunctival melanoma include mutations in BRAF, NRAS, ATRX, and NF1. Future therapies might be directed against these mutations or with small-molecule inhibitors and/or immunotherapy. In summary, conjunctival melanoma is a rare but ominous malignancy, imparting moderate risk for lymph node and systemic metastasis as well as death, depending on tumor features and classification. The first surgery is highly important in prevention of tumor seeding, recurrence, and metastasis.
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Affiliation(s)
- Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Ana Maria Velasco Silva
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Andrea Laiton
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas E Kalafatis
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Emily Schiller
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sara E Lally
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA; Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jerry A Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Chen YC, Chao YJ, Tsai CC, Chen SJ, Hwang DK. Sympathetic ophthalmia following radiation-induced scleral necrosis in choroidal melanoma. Taiwan J Ophthalmol 2023; 13:548-551. [PMID: 38249496 PMCID: PMC10798396 DOI: 10.4103/2211-5056.360046] [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: 06/16/2022] [Accepted: 08/24/2022] [Indexed: 01/23/2024] Open
Abstract
Sympathetic ophthalmia (SO) is a bilateral granulomatous panuveitis. We report a rare case of SO presenting after scleral necrosis as a late complication of Gamma Knife radiotherapy for choroidal melanoma. A 55-year-old woman presented with primary choroidal melanoma in the right eye and has been treated with Gamma Knife radiotherapy with stable tumor size. Five years after radiotherapy, a pigmented protrusive uveal mass was visibly noted over the superior sclera of the same eye, corresponding to periocular soft tissue enhancement on computed tomography. Biopsies of the pigmented mass showed the absence of malignancy. One month later, acute blurred vision with signs of sympathetic ophthalmia developed in the left eye. The patient received high-dose systemic corticosteroids and immunomodulatory therapy. The intraocular inflammation in the left eye subsided with improving vision, and the uveal mass in the right eye flattened after the anti-inflammatory therapy. Scleral necrosis is a rare complication following radiotherapy for choroidal melanoma and may incite sympathetic ophthalmia, for which prompt and aggressive treatment is important to save vision, especially for the fellow eye.
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Affiliation(s)
- Yen-Cheng Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Jang Chao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Ophthalmology, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Chieh-Chih Tsai
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - De-Kuang Hwang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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6
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Casciano F, Zauli E, Busin M, Caruso L, AlMesfer S, Al-Swailem S, Zauli G, Yu AC. State of the Art of Pharmacological Activators of p53 in Ocular Malignancies. Cancers (Basel) 2023; 15:3593. [PMID: 37509256 PMCID: PMC10377487 DOI: 10.3390/cancers15143593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
The pivotal role of p53 in the regulation of a vast array of cellular functions has been the subject of extensive research. The biological activity of p53 is not strictly limited to cell cycle arrest but also includes the regulation of homeostasis, DNA repair, apoptosis, and senescence. Thus, mutations in the p53 gene with loss of function represent one of the major mechanisms for cancer development. As expected, due to its key role, p53 is expressed throughout the human body including the eye. Specifically, altered p53 signaling pathways have been implicated in the development of conjunctival and corneal tumors, retinoblastoma, uveal melanoma, and intraocular melanoma. As non-selective cancer chemotherapies as well as ionizing radiation can be associated with either poor efficacy or dose-limiting toxicities in the eye, reconstitution of the p53 signaling pathway currently represents an attractive target for cancer therapy. The present review discusses the role of p53 in the pathogenesis of these ocular tumors and outlines the various pharmacological activators of p53 that are currently under investigation for the treatment of ocular malignancies.
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Affiliation(s)
- Fabio Casciano
- Department of Translational Medicine and LTTA Centre, University of Ferrara, 44121 Ferrara, Italy
| | - Enrico Zauli
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
| | - Massimo Busin
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
| | - Lorenzo Caruso
- Department of Environmental and Prevention Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Saleh AlMesfer
- Research Department, King Khaled Eye Specialistic Hospital, Riyadh 12329, Saudi Arabia
| | - Samar Al-Swailem
- Research Department, King Khaled Eye Specialistic Hospital, Riyadh 12329, Saudi Arabia
| | - Giorgio Zauli
- Research Department, King Khaled Eye Specialistic Hospital, Riyadh 12329, Saudi Arabia
| | - Angeli Christy Yu
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Department of Ophthalmology, Ospedali Privati Forlì "Villa Igea", 47122 Forlì, Italy
- Istituto Internazionale per la Ricerca e Formazione in Oftalmologia (IRFO), 47122 Forlì, Italy
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7
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Banou L, Tsani Z, Arvanitogiannis K, Pavlaki M, Dastiridou A, Androudi S. Radiotherapy in Uveal Melanoma: A Review of Ocular Complications. Curr Oncol 2023; 30:6374-6396. [PMID: 37504330 PMCID: PMC10378371 DOI: 10.3390/curroncol30070470] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/20/2023] [Accepted: 07/01/2023] [Indexed: 07/29/2023] Open
Abstract
Uveal melanoma represents the most prevalent form of primary malignant intraocular tumor in adults. Historically, enucleation was considered the gold-standard approach in the treatment of uveal melanoma. Currently, radiotherapy is the most commonly used therapy, aiming at a better quality of life. However, radiotherapy can result in several ocular complications, some of which may be vision-threatening. Radiation-induced dry eye, scleral necrosis, cataract, rubeosis iridis, neovascular glaucoma, radiation retinopathy, maculopathy, and optic neuropathy are the most common complications. This article aims to summarize the current literature regarding the ocular complications after radiotherapy, as well as their clinical features, risk factors, and management strategies. A thorough understanding of these issues is crucial for ophthalmologists and oncologists to provide optimal patient care, improve visual outcomes, and minimize long-term complications.
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Affiliation(s)
- Lamprini Banou
- Department of Ophthalmology, University of Thessaly, 41110 Larissa, Greece
| | - Zoi Tsani
- Department of Ophthalmology, University of Thessaly, 41110 Larissa, Greece
| | | | - Maria Pavlaki
- Department of Ophthalmology, University of Thessaly, 41110 Larissa, Greece
| | - Anna Dastiridou
- Department of Ophthalmology, University of Thessaly, 41110 Larissa, Greece
| | - Sofia Androudi
- Department of Ophthalmology, University of Thessaly, 41110 Larissa, Greece
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8
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Bai H, Bosch JJ, Heindl LM. Current management of uveal melanoma: A review. Clin Exp Ophthalmol 2023. [PMID: 37076276 DOI: 10.1111/ceo.14214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 04/21/2023]
Abstract
Uveal melanoma is the most frequent primary intraocular cancer in adulthood and is mostly localised to the choroid. It can be treated using radiation therapy, laser therapy, local resection and enucleation, with the best results achieved by combining these procedures. However, up to half of patients develop metastatic disease. There are no efficacious treatment methods for patients in advanced stage or with metastasis. In recent years, several novel treatment modalities aimed at improving tumour control and reducing adverse events have emerged. This review summarises current clinical treatment methods and new therapeutic perspectives for uveal melanoma.
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Affiliation(s)
- Haixia Bai
- Eye Center, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jacobus J Bosch
- Centre for Human Drug Research, Leiden, Netherlands
- Leiden University Medical Center, Leiden, Netherlands
| | - Ludwig M Heindl
- Department of Ophthalmology, University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
- Center for Integrated Oncology (CIO) Aachen-Bonn-Cologne-Duesseldorf, Cologne, Germany
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9
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Vega Escobar K, Armijos PO, Milman T, Shields CL, Eagle RC. Intratumoral bacteria in uveal melanoma: A case report. Am J Ophthalmol Case Rep 2023; 30:101833. [PMID: 37139176 PMCID: PMC10149332 DOI: 10.1016/j.ajoc.2023.101833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 02/07/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023] Open
Abstract
Purpose Intratumoral bacteria and their potential application to cancer immunotherapy have been a topic of interest in recent studies. To our knowledge, bacteria in uveal melanoma have not been previously reported. Observations We describe a patient with a large choroidal melanoma, measuring 18 × 16 mm in basal dimension and 15 mm in ultrasonographic thickness, managed by plaque brachytherapy. At the time of plaque removal, a prophylactic scleral patch graft was placed to protect from anticipated scleral necrosis. Progressive ocular ischemia led to a blind and painful eye. The enucleated eye demonstrated an extensively necrotic and heavily pigmented mushroom-shaped regressed cilichoroidal mass deep to the scleral patch graft. Numerous Gram-positive cocci were noted within the regressed uveal melanoma and the adjacent sclera. Conclusions and Importance This case highlights the fact that regressed uveal melanomas can contain intra-tumoral bacteria.
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Fionda B, Pagliara MM, Chyrek AJ, Guix B, O'Day RFJ, Fog LS, Martínez-Monge R, Tagliaferri L. Ocular Brachytherapy (Interventional Radiotherapy): Preserving the Vision. Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00043-2. [PMID: 36792447 DOI: 10.1016/j.clon.2023.01.021] [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: 11/10/2022] [Revised: 01/16/2023] [Accepted: 01/27/2023] [Indexed: 02/09/2023]
Abstract
Uveal melanoma represents the most common intraocular neoplasia among adults. Brachytherapy (interventional radiotherapy; IRT) has a great advantage, when compared with enucleation, both in terms of organ and function sparing. The Collaborative Ocular Melanoma Study introduced into clinical practice a standardised procedure that allowed the equivalence of IRT with enucleation in terms of overall survival to be demonstrated. IRT is carried out by placing a plaque in direct contact with the sclera under the uveal melanoma. Several radioactive sources may be used, including 106-ruthenium, 125-iodine, 103-palladium and 90-strontium. It is a multidisciplinary procedure requiring the collaboration of interventional radiation oncologists and ophthalmologists in the operating theatre and medical physicists for an accurate treatment time calculation. It also relies on ultrasound imaging to identify the lesion and verifiy the correct plaque placement. An emerging tool of paramount importance could be the use of artificial intelligence and predictive models to identify those patients at higher risk of developing late side-effects and therefore who may deserve preventive and supportive therapies.
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Affiliation(s)
- B Fionda
- U.O.C. Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - M M Pagliara
- U.O.C. Oncologia Oculare, Dipartimento di Scienze dell'Invecchiamento, Neurologiche Ortopediche e Della Testa Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A J Chyrek
- Brachytherapy Department, Greater Poland Cancer Centre, Poznań, Poland
| | - B Guix
- Department of Radiation Oncology, Foundation IMOR, Barcelona, Spain
| | - R F J O'Day
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - L S Fog
- The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - R Martínez-Monge
- Department of Oncology, Clínica Universitaria de Navarra, CCUN, Pamplona, Spain
| | - L Tagliaferri
- U.O.C. Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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11
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The Impact of Robotic Fractionated Radiotherapy for Benign Tumors of Parasellar Region on the Eye Structure and Function. J Clin Med 2023; 12:jcm12020404. [PMID: 36675334 PMCID: PMC9864507 DOI: 10.3390/jcm12020404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To evaluate the radiation effect of fractionated robotic radiotherapy of benign tumors located in the parasellar region on the anterior and posterior segments of the eye. METHODS A prospective observational study based on the expanded ophthalmological examination. The pre-treatment baseline was used as a control for the post-radiotherapy follow-up examinations. The study group consists of 34 patients (68 eyes) irradiated using the CyberKnife system. There were ten patients with cavernous sinus meningioma, nine with pituitary adenoma, five with meningioma of the anterior and middle cranial fossa, five with meningioma in the region close to optic chiasm, three with craniopharyngioma, and two with meningioma of the orbit. All patients were treated using three fractions of 600-800 cGy. We assessed the impact of radiation on the eye based on changes in anatomical and functional features. The condition of the eye surface, central corneal thickness (CCT), endothelial cell density (ECD), lens densitometry, central macular thickness (CMT), and retinal nerve fiber layer (RNFL) were the anatomical features assessed. The functional tests were best-corrected visual acuity (BCVA), intraocular pressure (IOP), visual field (VF) and visual-evoked potentials (VEP). An ophthalmologic examination was performed before and 6, 12, 18, and 24 months after radiotherapy. RESULTS We did not observe any significant changes in BCVA, IOP, CCT, CMT, VF, and VEP, nor in the slit-lamp examination during the two-years observation. We found a significant decrease in ECD at all follow-up measurements. The drop in ECD exceeded approximated age-related physiological loss. The reduction in ECD was not large enough to disrupt corneal function and thus affect vision. We also observed a statistically significant reduction of RNFL in all observation time points. However, there was no correlation between the dose delivered to the optic pathway and the decrease in RNFL thickness. The thinning of the RNFL was not significant enough to impair visual function. CONCLUSION Fractionated robotic radiotherapy of the tumors located close to the optical pathway is safe and does not impair patient's vision. Minor changes found in optic nerve anatomy (RNFL thinning) might be related to radiation effect or tumor compression. The causal relation between low doses of radiation delivered to the cornea and the observed significant but slight decrease in ECD is uncertain. The observed changes did not cause visual disturbances perceivable by the patients.
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12
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Zemba M, Dumitrescu OM, Gheorghe AG, Radu M, Ionescu MA, Vatafu A, Dinu V. Ocular Complications of Radiotherapy in Uveal Melanoma. Cancers (Basel) 2023; 15:cancers15020333. [PMID: 36672282 PMCID: PMC9856287 DOI: 10.3390/cancers15020333] [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: 11/22/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Uveal melanoma is the most common primary malignant intraocular tumor in adults. Radiation therapy has replaced enucleation and is now the preferred treatment in most cases. Nonetheless, around 70% of patients develop radiation-related complications, some of which are vision-threatening. The objective of this review is to present the most important complications associated with radiotherapy in the treatment of uveal melanoma and their pathogenesis, incidence, risk factors, and available preventive and therapeutic measures. The most common complications are cataracts, with a reported incidence ranging from 4% to 69%, and radiation retinopathy, reported in 5-68% of cases. Radiation-related complications are responsible for approximately half of secondary enucleations, the leading cause being neovascular glaucoma. A poor visual outcome is mainly associated with the presence of radiation retinopathy and radiation optic neuropathy. Therapeutic options are available for the majority of complications with the notable exception of optic neuropathy. However, many studies report a final visual acuity of less than 20/200 in more than 60% of treated eyes. Reducing complication rates can be achieved by lowering the dose of radiation, with the use of eccentric, customized plaques and careful planning of the irradiation delivery in order to protect structures vital to vision and by associating radiation therapy with other methods with the aim of reducing tumor volume.
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Affiliation(s)
- Mihail Zemba
- Department of Ophthalmology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Otilia-Maria Dumitrescu
- Department of Ophthalmology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010825 Bucharest, Romania
- Correspondence:
| | - Alina Gabriela Gheorghe
- Department of Ophthalmology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | - Madalina Radu
- Department of Ophthalmology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Mihai Alexandru Ionescu
- Department of Ophthalmology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Andrei Vatafu
- Department of Ophthalmology, ‘Dr. Carol Davila’ Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Valentin Dinu
- Department of Ophthalmology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
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Klassen AM, Zimbelmann M, Lüken S, Cremers F, Rades D, Chronopoulos A, Rommel F, Ranjbar M, Grisanti S, Kakkassery V. [Clinical aspects and care of radiogenic treatment side effects on the eye]. DIE OPHTHALMOLOGIE 2022; 119:1085-1096. [PMID: 36175772 DOI: 10.1007/s00347-022-01730-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 06/16/2023]
Abstract
Malignant tumors of the eye can be successfully treated with radiotherapy, which, however, can lead to radiogenic side effects in the surrounding healthy tissues. A distinction can be made between two forms of irradiation, external radiotherapy (teletherapy) and brachytherapy with a radiation source close to the tumor. The radiation dose is important for the occurrence of side effects. Acute damage usually results from inflammatory processes initiated at the cellular level. In contrast, late side effects are rather due to the reaction of the tissue with repair and remodeling processes . Acute side effects often resolve completely, especially under corresponding treatment, whereas late side effects tend to be irreversible. The aim of this article is to present risk factors as well as the clinical signs of periocular and ocular radiogenic side effects for the relevant tissue structures of the eye in a narrative review to facilitate ophthalmologic follow-up and, if necessary, treatment measures for these patients during everyday practice.
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Affiliation(s)
- Andrea M Klassen
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - Michael Zimbelmann
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Sabine Lüken
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Florian Cremers
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - Dirk Rades
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - Argyrios Chronopoulos
- Augenklinik, Klinikum Ludwigshafen, Akademisches Lehrkrankenhaus der Johannes-Gutenberg-Universität Mainz und der Medizinischen Fakultät Mannheim der Universität Heidelberg, Ludwigshafen, Deutschland
| | - Felix Rommel
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Mahdy Ranjbar
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Salvatore Grisanti
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - Vinodh Kakkassery
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
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14
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Oare C, Sun S, Dusenbery K, Reynolds M, Koozekanani D, Gerbi B, Ferreira C. Analysis of dose to the macula, optic disc, and lens in relation to vision toxicities - A retrospective study using COMS eye plaques. Phys Med 2022; 101:71-78. [PMID: 35981450 DOI: 10.1016/j.ejmp.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/08/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The aim of this study was to relate common toxicity endpoints with dose to the macula, optic disc, and lens for uveal melanoma patients treated with Iodine-125 Collaborative Ocular Melanoma Study (COMS) eye plaque brachytherapy. METHODS A cohort of 52 patients treated at a single institution between 2005 and 2019 were retrospectively reviewed. Demographics, dosimetry, and clinical outcomes were recorded. Univariate, relative risk, and Kaplan-Meier analyses were performed to relate dose to toxicity endpoints including retinopathy, vision decline, and cataracts. RESULTS By the end of follow up (Median = 3.6 years, Range = 0.4 - 13.5 years), 65 % of eyes sustained radiation retinopathy, 40 % demonstrated moderate vision decline (>5 Snellen lines lost), and 56 % developed cataracts. Significant (p < 0.05) risk estimates exist for retinopathy and VA decline for doses >52 Gy to the macula and >42 Gy to the optic disc. Moreover, dose to the lens > 16 Gy showed a significant risk for cataract formation. Kaplan-Meier analysis demonstrated significantly different incidence of radiation retinopathy for > 52 Gy to the macula and > 42 Gy to the optic disc. In addition, the Kaplan-Meier analysis showed significantly different incidence of cataract formation for patients with lens dose > 16 Gy. CONCLUSIONS Dose-effect relationships exist for the macula and optic disc with respect to the loss of visual acuity and the development of retinopathy. To better preserve vision after treatment, further research is needed to reduce macula, optic disc, and lens doses while maintaining tumor control.
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Affiliation(s)
- Courtney Oare
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States.
| | - Susan Sun
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Kathryn Dusenbery
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Margaret Reynolds
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Dara Koozekanani
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Bruce Gerbi
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Clara Ferreira
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
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15
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Mirshahi R, Sedaghat A, Jaberi R, Azma Z, Mazloumi M, Naseripour M. Ruthenium-106 plaque radiotherapy for uveal melanoma: analysis of tumor dimension and location on anatomical and functional results. BMC Ophthalmol 2022; 22:309. [PMID: 35842619 PMCID: PMC9288719 DOI: 10.1186/s12886-022-02521-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background To report the long-term outcomes of Ru-106 plaque radiotherapy in eyes with uveal melanoma (UM) and to assess the effect of tumor thickness and location on final outcomes. Methods Medical records of 234 patients undergoing Ru-106 plaque radiotherapy for UM were reviewed, and the visual outcome, globe preservation, and patient survival were evaluated. The results of 2 groups were compared: 1. between thin (small and medium-sized, thickness < 7 mm, 148 eyes [63.2%]) and thick (thickness ≥ 7 mm, 86 eyes [36.8%]) tumors, and 2. between large (largest basal diameter [LBD] > 12 mm, 109 eyes [46.6%]) and medium/small (LBD ≤ 12 mm, 125 eyes [53.4%]). In addition, a comparison of the juxtapapillary location in 46 eyes (19.7%) versus tumors arising elsewhere and between tumors with and without ciliary involvement in 48 eyes (21.5%) were done. Results The patients were followed for a median of 54.2 months (range: 6–194.5 months). After adjusting for baseline visual acuity (VA), there was no significant association between final VA and different dimension and tumor location groups. Final globe preservation was 91.9%, and there was no significant difference between different dimension- and ciliary body involvement groups regarding anatomical success rate. The juxtapapillary tumors had lower globe preservation (80.4% vs .94.7%, p = 0.002). The hazard ratio (HR) for enucleation in juxtapapillary tumors was HR = 6.58 (95-CI: 3.84 to 11.21). The overall metastasis rate was 6.8%, with no significant difference in juxtapapillary tumors (4.3% vs.7.4%, p = 0.455). Conclusions Ru-106 plaque radiotherapy is an effective treatment for thick and large UM. With this type of treatment, the globe preservation rate is lower in juxtapapillary tumors, but there is no significant difference in the metastasis rate.
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Affiliation(s)
- Reza Mirshahi
- Eye Research Center, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ahad Sedaghat
- Eye Research Center, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ramin Jaberi
- Cancer Institute, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Azma
- Radiation Medicine Department, Shahid Beheshti University, Tehran, Iran
| | - Mehdi Mazloumi
- Eye Research Center, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Masood Naseripour
- Eye Research Center, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. .,Stem Cell and Regenerative Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran.
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16
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Stael Apolo JA, Conde I, Fernández D, Fernández S, Bande M, Pardo M, Ruiz-Oliva F, Blanco MJ, Piñeiro A. Identification of extraocular extension in uveal melanoma by ophthalmological ultrasound. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2022; 97:70-76. [PMID: 35152951 DOI: 10.1016/j.oftale.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 02/03/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND PURPOSE Uveal melanoma is the most common primary malignant intraocular tumour in the adult population, with a survival rate of 50% despite advances in treatment and knowledge of this disease. The presence of extraocular extension (EE) worsens the prognosis of these patients, so its proper identification can ensure its management and early intervention. Ophthalmological ultrasound is the technique of choice for the diagnosis and follow-up of these patients, both of the anterior EE using ultrasonic biomicroscopy (UBM), and the posterior EE using A and B ultrasound. The aim of this study is to describe the ultrasound characteristics of the BMU and the A and B ultrasound. MATERIAL AND METHODS A descriptive and retrospective study is carried out on patients diagnosed with uveal melanoma (UM) and EE from 2003 to 2019. The ultrasound characteristics of the local disease and the follow-up after treatment were recorded completely and at each visit. In the case of anterior EE, photographs of the anterior segment and UBM were taken, while those involving the posterior segment were explored under A and B mode ultrasound. All enucleated eyes were sent for anatomopathological study. RESULTS Ten patients with an average age of 72.3 years were included. The largest proportion of them were medium-sized tumours, followed by large and small ones. The most frequent morphology of the primary tumour was cupuliform. All the EE presented lower internal reflectivity compared to the primary tumour. No trans-scleral connection bridges were found between the primary tumour and the EE in the ultrasound studies. 50% of patients underwent primary enucleation at the time of diagnosis of intraocular MU due to the presence of the EE, and the remaining 50% presented the EE after initial treatment of the primary tumour with I125 brachytherapy. Sixty percent of the patients presented with posterior EE, and were therefore diagnosed with ultrasound A and B. The most frequent histopathological pattern with 87.5% of patients was the epithelioid pattern. DISCUSSION Ultrasound scanning in patients with MU is mandatory for diagnosis and follow-up of EE. BMU and A and B ultrasound are the test of choice for anterior and posterior EE, respectively. EE have particular ultrasound characteristics such as low internal reflectivity, regularity of their contour and their location usually adjacent to the base of the primary intraocular tumor.
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Affiliation(s)
- J A Stael Apolo
- Unidad de Retina Quirúrgica y Tumores Intraoculares del Adulto (URQTIA), Área Sanitaria de Santiago de Compostela y Barbanza, Complejo Hospitalario Universitario de Santiago de Compostela. Servicio Gallego de Salud (SERGAS), Santigo de Compostela, Spain; Servicio de oftalmología, Hospital de Palamós, Servicio de Salud Integral del Bajo Empordá, Palamós, Spain.
| | - I Conde
- Unidad de Retina Quirúrgica y Tumores Intraoculares del Adulto (URQTIA), Área Sanitaria de Santiago de Compostela y Barbanza, Complejo Hospitalario Universitario de Santiago de Compostela. Servicio Gallego de Salud (SERGAS), Santigo de Compostela, Spain
| | - D Fernández
- Unidad de Retina Quirúrgica y Tumores Intraoculares del Adulto (URQTIA), Área Sanitaria de Santiago de Compostela y Barbanza, Complejo Hospitalario Universitario de Santiago de Compostela. Servicio Gallego de Salud (SERGAS), Santigo de Compostela, Spain
| | - S Fernández
- Unidad de Retina Quirúrgica y Tumores Intraoculares del Adulto (URQTIA), Área Sanitaria de Santiago de Compostela y Barbanza, Complejo Hospitalario Universitario de Santiago de Compostela. Servicio Gallego de Salud (SERGAS), Santigo de Compostela, Spain
| | - M Bande
- Unidad de Retina Quirúrgica y Tumores Intraoculares del Adulto (URQTIA), Área Sanitaria de Santiago de Compostela y Barbanza, Complejo Hospitalario Universitario de Santiago de Compostela. Servicio Gallego de Salud (SERGAS), Santigo de Compostela, Spain; Departamento de Cirugía y Especialidades Médico Quirúrgicas, Área de Oftalmología, Universidad de Santiago de Compostela, Santigo de Compostela, Spain; Laboratorio de Tumores Intraoculares del Adulto, IDIS, Santiago de Compostela, Spain
| | - M Pardo
- Laboratorio de Tumores Intraoculares del Adulto, IDIS, Santiago de Compostela, Spain
| | - F Ruiz-Oliva
- Unidad de Retina Quirúrgica y Tumores Intraoculares del Adulto (URQTIA), Área Sanitaria de Santiago de Compostela y Barbanza, Complejo Hospitalario Universitario de Santiago de Compostela. Servicio Gallego de Salud (SERGAS), Santigo de Compostela, Spain
| | - M J Blanco
- Unidad de Retina Quirúrgica y Tumores Intraoculares del Adulto (URQTIA), Área Sanitaria de Santiago de Compostela y Barbanza, Complejo Hospitalario Universitario de Santiago de Compostela. Servicio Gallego de Salud (SERGAS), Santigo de Compostela, Spain; Departamento de Cirugía y Especialidades Médico Quirúrgicas, Área de Oftalmología, Universidad de Santiago de Compostela, Santigo de Compostela, Spain; Laboratorio de Tumores Intraoculares del Adulto, IDIS, Santiago de Compostela, Spain
| | - A Piñeiro
- Unidad de Retina Quirúrgica y Tumores Intraoculares del Adulto (URQTIA), Área Sanitaria de Santiago de Compostela y Barbanza, Complejo Hospitalario Universitario de Santiago de Compostela. Servicio Gallego de Salud (SERGAS), Santigo de Compostela, Spain; Departamento de Cirugía y Especialidades Médico Quirúrgicas, Área de Oftalmología, Universidad de Santiago de Compostela, Santigo de Compostela, Spain; Laboratorio de Tumores Intraoculares del Adulto, IDIS, Santiago de Compostela, Spain
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17
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Oare CC, Deufel CL, McCauley Cutsinger J, De La Fuente Herman T, Ferreira C. On the importance of quality assurance (QA) for COMS eye plaque Silastic inserts: A guide to measurement methods, typical variations, and an example of how QA intercepted a manufacturing aberration. J Appl Clin Med Phys 2021; 22:72-82. [PMID: 34231949 PMCID: PMC8364280 DOI: 10.1002/acm2.13325] [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: 03/22/2021] [Revised: 04/22/2021] [Accepted: 05/26/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Eye plaques are widely used for ocular melanoma and provide an effective alternative to enucleation with adequate tumor control. A COMS plaque utilizes a Silastic insert for precise positioning of the radioactive seeds with respect to the scleral surface of the eye; however, due to manufacturing variability, the insert may unintentionally increase or decrease the distance between the sources and tumor. The purpose of this work is to provide guidance in measuring and identifying outliers in Silastic inserts. The importance of regular quality assurance (QA) is illustrated in an experience where a systematic problem was detected and the manufacturer's 22-mm mold was corrected. METHODS A detailed description of the molds and manufacturing process used to produce Silastic inserts is provided, including photographs of the process steps. The variability in Silastic insert production was evaluated by measuring the thickness of 124 Silastic inserts. An estimate of how the observed Silastic thickness discrepancies impact the dose to the tumor and critical eye structures was performed using homogeneous dose calculations. A standard QA protocol was developed to guide the clinical user. RESULTS Thickness of the measured Silastic inserts ranged from 1.22 to 2.67 mm, demonstrating variation from the 2.25 mm standard. Six of the 22-mm inserts were outliers (Δthickness >3 standard deviations) and were excluded from the statistics. The outliers were investigated with the help of the manufacturer, who discovered that a systematic error was accidentally introduced into the 22-mm mold. CONCLUSIONS Due to manufacturing errors or variability, the Silastic inserts used in COMS eye plaques may be thicker or thinner than the design standard. Such variations may impact tumor control or increase the risk of normal tissue side effects. A standardized QA program is recommended to detect variations and communicate unusual findings to the manufacturer.
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Affiliation(s)
- Courtney C Oare
- Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | | | | | - Tania De La Fuente Herman
- Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Clara Ferreira
- Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
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18
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Jabbarli L, Guberina M, Biewald E, Flühs D, Guberina N, Le Guin CHD, Sauerwein W, Bornfeld N, Stuschke M, Bechrakis NE. Scleral necrosis after brachytherapy for uveal melanoma: Analysis of risk factors. Clin Exp Ophthalmol 2021; 49:357-367. [PMID: 33866652 DOI: 10.1111/ceo.13928] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radiation-induced scleral necrosis (RISN) is a rare, but a serious complication of brachytherapy for uveal melanoma. We aimed at analysing the incidence, timing and risk factors associated with development of RISN in a large institutional series. METHODS All consecutive cases with brachytherapy for uveal melanoma treated by the Departments of Ophthalmology and Radiotherapy at University Hospital Essen between 1999 and 2016 were eligible. Development of RISN during the post-treatment follow-up was recorded. A 1:2 propensity score matched case-control study was performed for the evaluation of the prognostic value of different tumour- and treatment-associated parameters. RESULTS RISN was documented in 115 (2.9%) of 3960 patients with uveal melanoma included in the final analysis, and occurred at the mean 30.3 months (range: 1.26-226 months) after brachytherapy. In the whole cohort, younger age (p = 0.042), plaque type (p = 0.001) and ciliary body involvement (p < 0.0001) were independently associated with the RISN occurrence. In the case-control study, multivariable weighted proportional hazard analysis discovered the association of the following additional tumour- and treatment-associated characteristics with RISN: posterior tumour margin anterior to equatorial region (p = 0.0003), extraocular tumour extension (p = <0.0001), scleral contact dose (p = <0.0001), conjunctival dehiscence after therapy (p = 0.0001), disinsertion of the superior rectus muscle (p = 0.001) and the glaucoma medication (p = 0.014). CONCLUSIONS Our study confirms RISN as a rare complication, which might occur even years later after the brachytherapy for uveal melanoma. Alongside with scleral dose five other tumour and therapy related factors predict the risk of RISN after brachytherapy for uveal melanoma were established.
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Affiliation(s)
- Leyla Jabbarli
- Department of Ophthalmology, University Hospital of Essen, Essen, Germany
| | - Maja Guberina
- Department of Radiotherapy, University Hospital of Essen, Essen, Germany
| | - Eva Biewald
- Department of Ophthalmology, University Hospital of Essen, Essen, Germany
| | - Dirk Flühs
- Department of Radiotherapy, University Hospital of Essen, Essen, Germany
| | - Nika Guberina
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - Wolfgang Sauerwein
- Department of Radiotherapy, University Hospital of Essen, Essen, Germany
| | - Norbert Bornfeld
- Department of Ophthalmology, University Hospital of Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, University Hospital of Essen, Essen, Germany.,German Cancer Consortium (DKTK), Heidelberg, Partner Site University Hospital Essen, Essen, Germany
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19
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Quhill H, Gosling D, Sears K, Rundle P. Primary photodynamic therapy for small amelanotic choroidal melanomas: consecutive case series of 69 patients with at least 24-month follow-up. Br J Ophthalmol 2020; 105:794-799. [PMID: 32675064 DOI: 10.1136/bjophthalmol-2020-316616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 02/03/2023]
Abstract
AIMS To investigate the success and recurrence rates and visual outcomes in a large case series of amelanotic posterior choroidal melanomas treated by means of primary photodynamic therapy (PDT) with verteporfin. METHODS Retrospective case series from a single specialist ocular oncology centre. All patients had a clinical diagnosis of choroidal melanoma and were selected for PDT based on tumour characteristics. Included patients had at least 24 months of follow-up from initiation of treatment and all but one had not received treatment prior to PDT. RESULTS 69 patients were included. Mean tumour thickness was 1.9 mm (range 0.5-4.4), while the mean basal diameter was 6.9 mm (range 2.4-11.0). Included lesions were stage cT1a (n=66) or cT2a (n=3). The mean duration of follow-up from treatment initiation was 57 months (range 24-116 months). Seven lesions (10%) failed to respond to PDT. 10 patients (16%) experienced recurrence during follow-up. Overall success rate in this series was 75% (n=52). 83% of successfully treated patients (n=43) maintained or gained vision by final follow-up. Visual outcomes were significantly better in those patients who received PDT therapy alone in comparison to those who needed other treatments for their melanoma (Fisher's exact test, p=0.004). Unfortunately, one patient (1.4%) in the series developed systemic metastases and died. CONCLUSION Selected amelanotic posterior uveal melanomas may be successfully treated with PDT with retention of good vision in the majority of cases, maintained with a mean of 57 months (minimum of 24 months) of follow-up.
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Affiliation(s)
- Hibba Quhill
- Department of Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Daniel Gosling
- Department of Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Katharine Sears
- Department of Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul Rundle
- Department of Ophthalmology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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20
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Filì M, Trocme E, Herrspiegel C, Seregard S, Stålhammar G. Effect of plaque brachytherapy dose and dose rate on risk for disease-related mortality in 1238 patients with choroidal melanoma. Br J Ophthalmol 2020; 105:57-62. [PMID: 32430342 DOI: 10.1136/bjophthalmol-2019-315722] [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: 12/18/2019] [Revised: 02/17/2020] [Accepted: 03/11/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Episcleral brachytherapy is the most common treatment for medium-sized choroidal melanomas. Although controversial, inadequate brachytherapy dose and dose rates have at least a hypothetical implication on patient survival. METHODS All patients who received ruthenium-106 or iodine-125 brachytherapy for choroidal melanoma at St. Erik Eye Hospital 1996 to 2016 were included (n=1238). Cox regression hazard ratios for melanoma-related mortality across deciles, quartiles and individual integers of apex radiation doses (Gy) and dose rates (Gy/hour) were calculated, adjusted for tumour size and location. RESULTS The average radiation dose at the tumour apex ranged from 73.0 Gy in the first decile to 108.6 Gy in the tenth. Decreasing apex dose by 1 Gy increments or by decile or quartile group was not associated with melanoma-related mortality (p>0.2) The average radiation dose rate at the tumour apex ranged from 0.5 Gy/hour in the first decile to 2.8 Gy/hour in the tenth. Similarly, decreasing apex dose rate by 1 Gy/hour increments or by decile or quartile groups was not associated with melanoma-related mortality (p>0.5). CONCLUSION There are no increased hazards for choroidal melanoma-related mortality after brachytherapy with decreasing doses between 108.6 and 73.0 Gy, or with decreasing dose rates between 2.8 and 0.5 Gy/hour.
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Affiliation(s)
- Maria Filì
- St. Erik Eye Hospital, Stockholm, Sweden .,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eric Trocme
- St. Erik Eye Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Christina Herrspiegel
- St. Erik Eye Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Seregard
- St. Erik Eye Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gustav Stålhammar
- St. Erik Eye Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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21
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Kim TH, Kim BR, Ko JS, Yoon JS. Leptomeningeal Seeding in Choroidal Melanoma after Enucleation Surgery. KOREAN JOURNAL OF OPHTHALMOLOGY 2020; 34:176-177. [PMID: 32233155 PMCID: PMC7105793 DOI: 10.3341/kjo.2019.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/16/2019] [Accepted: 11/24/2019] [Indexed: 11/23/2022] Open
Affiliation(s)
- Tae Hwan Kim
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Bo Ram Kim
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Sang Ko
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sook Yoon
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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22
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Complications and adverse events of plaque brachytherapy for ocular melanoma. J Contemp Brachytherapy 2019; 11:392-397. [PMID: 31523242 PMCID: PMC6737573 DOI: 10.5114/jcb.2019.87407] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/19/2019] [Indexed: 12/21/2022] Open
Abstract
Plaque brachytherapy is a well-accepted modality to manage selected cases of ocular melanoma. Although this modality provides validated oncologic and quality of life benefits, severe complications and adverse events can occur. This article reviews complications and adverse events of plaque brachytherapy, including scleral necrosis, strabismus, cataract, glaucoma, and retinopathies as well as management of these conditions. For practicing oncologists and ophthalmologists, these complications are important to understand, identify, and treat. Additionally, an understanding of common complications of brachytherapy should influence the decision of pursuing it as a treatment option.
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23
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Kim JT, Kim KW, Mun SK, Chun YS, Kim JC. Transplantation of autologous perichondrium with amniotic membrane for progressive scleral necrosis. Ocul Surf 2019; 17:571-577. [PMID: 31112741 DOI: 10.1016/j.jtos.2019.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/10/2019] [Accepted: 05/16/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Scleral necrosis with severe ischemia is refractory to conventional treatment because of avascular progressive necrosis. We assessed the therapeutic efficacy and safety of autologous perichondrium transplantation in patients with progressive scleral necrosis (PSN) and analyzed the clinical effects. METHODS This study was a prospective, interventional, and noncomparative case series. Reconstructive surgery using autologous perichondrium and amniotic membrane (AM) was performed in patients with PSN who showed progressive ischemic scleral melting with impending perforation state and/or broad avascular area larger than 10 mm in diameter. The primary outcome was restoration of scleral integrity with healthy vascularized epithelium over the graft at six months after surgery. The secondary outcome was complication rate associated with autologous perichondrium graft use. RESULTS Eighteen eyes of 14 patients underwent reconstructive surgery using autologous perichondrium patch and AM grafts. Observations indicated the graft provided the eyeball with successful structural integrity in 17 out of the 18 cases (94.4%) at six months after surgery. One eye showed a small scleral defect due to wound dehiscence at four month after the surgery. Additional surgery using perichondrium and AM stabilized the eye. The scleral necrosis healed completely after perichondrium and AM transplantation, even in cases with full-thickness scleral defect. The scleral integrity was maintained until the last follow-up session. There were no serious complications of endophthalmitis or graft infection. CONCLUSIONS Reconstructive surgery using autologous perichondrium and AM is an effective method for restoration of scleral integrity and vascularization of the episclera and conjunctiva in eyes with PSN. Therefore, autologous perichondrium can be considered as an appropriate new biologic tissue for PSN.
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Affiliation(s)
- Jee Taek Kim
- Department of Ophthalmology, College of Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Kyoung Woo Kim
- Department of Ophthalmology, College of Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Seog-Kyun Mun
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Yeoun Sook Chun
- Department of Ophthalmology, College of Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Jae Chan Kim
- Department of Ophthalmology, Cheil Eye Research Institute, Cheil Eye Hospital, Daegu, Republic of Korea.
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24
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Hankins M, Margo CE. Histopathological evaluation of scleritis. J Clin Pathol 2019; 72:386-390. [PMID: 30723093 DOI: 10.1136/jclinpath-2018-205360] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 01/06/2019] [Accepted: 01/14/2019] [Indexed: 12/22/2022]
Abstract
The sclera is an uncommon site of primary inflammation. Biopsy is infrequently employed in the evaluation of scleritis, but familiarity with its differential diagnosis is instrumental in ensuring efficient histological evaluation. This review provides a clinical overview of scleritis and describes the context in which scleral biopsy might arise. Most cases are associated with systemic autoimmune disease, but a sizeable proportion occur as an isolated disorder. Conditions mimicking autoimmune scleritis include infection and neoplasm. Histological patterns of inflammation in eyes removed surgically or at autopsy have been placed into three groups: (1) autoimmune scleritis characterised by varying mixtures of palisading granulomas, necrosis and vasculitis; (2) infectious scleritis, characterised by acute inflammation and necrosis; and (3) idiopathic scleritis, characterised by chronic non-specific inflammation with follicles and varying amounts of fibrosis. This traditional system of classification may be oversimplified. Aetiological or categorical classification is not always possible on small biopsies given the histopathological overlap of infectious and non-infectious scleritis.
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Affiliation(s)
- Mark Hankins
- Department of Ophthalmology, USF Health Morsani College of Medicine, Tampa, Florida, USA
| | - Curtis Edward Margo
- Department of Ophthalmology, USF Health Morsani College of Medicine, Tampa, Florida, USA .,Department of Dermatopathology, USF Health Morsani College of Medicine, Tampa, Florida, USA
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25
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Siegel DT, Szalai E, Wells JR, Grossniklaus HE. Scleral Thinning after Transscleral Biopsy for Uveal Melanoma Using Lamellar Scleral Flap. Ocul Oncol Pathol 2018; 4:381-387. [PMID: 30574491 DOI: 10.1159/000487007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 01/17/2018] [Indexed: 11/19/2022] Open
Abstract
Purpose The purpose of the study is to describe the clinical history and histopathologic findings of three cases of scleral thinning after lamellar scleral flap, including one case with confirmed extraocular tumor extension. Methods The medical records and pathology specimens of three patients with scleral thinning after biopsy and plaque brachytherapy and lamellar scleral flap performed during a transscleral biopsy were reviewed. Results The first two patients developed scleral thinning and visible pigmentation, but had tumors that were regressing in size on ultrasound. The two patients were followed by serial observation. The third patient exhibited scleral thinning and evidence of tumor growth on ultrasound, raising the suspicion for extraocular tumor extension. Histopathologic examination of the enucleated eye confirmed extrascleral tumor extension and showed necrotic and intact melanoma with associated pigmented macrophages. Conclusions Patients with scleral flaps created for biopsy of uveal melanoma are at risk for scleral thinning and extrascleral extension of tumor recurrence through the flap.
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Affiliation(s)
- Diane T Siegel
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eszter Szalai
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jill R Wells
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hans E Grossniklaus
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
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26
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Yang YM, Chow PE, McCannel TA, Lamb JM. A comparison of the shielding effectiveness of silicone oil vitreous substitutes when used with Palladium-103 and Iodine-125 eye plaques. Med Phys 2018; 46:1006-1011. [PMID: 30554429 DOI: 10.1002/mp.13341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/11/2018] [Accepted: 12/06/2018] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Episcleral eye plaques provide excellent local control of ocular melanoma, but vision sparing remains a significant problem with 30% or more of patients experiencing significant visual acuity degradation. The use of silicone oil shielding with Iodine-125 plaques has previously been reported to improve critical structure sparing. We hypothesized that the use of Palladium-103 would improve the shielding effectiveness of silicone oil due to the strong energy dependence of the photoelectric effect. This Monte Carlo simulation study reports a comparison of the shielding effects of silicone oil when used in conjunction with Pd-103 and with I-125 plaques. MATERIALS AND METHODS GEANT4 was used to simulate eye plaque treatments to an eye with either water-equivalent vitreous humor, or silicone oil in place of the vitreous humor. Two solid gold plaques, 15 and 23 mm, were simulated loaded with I-125 and with Pd-103 source seeds. Seed activity was normalized such that 85 Gy was delivered to the tumor apex in the water-equivalent cases. Tumor apex dose, central axis dose, and inner sclera dose reductions with silicone oil were evaluated. RESULTS Silicone oil resulted in an underdosing to the tumor apex of 6.1% and 7.5% in the 15 mm plaque for I-125 and Pd-103, respectively, and 3.4% and 4.3% in the 23 mm plaque for I-125 and Pd-103, respectively. When renormalized to 85 Gy to the tumor apex in all scenarios, silicone oil reduced the dose to the inner sclera 90° from the plaque by 19-32% for the 15 and 23 mm plaques using I-125, and by 33-65% for the 15 and 23 mm plaques using Pd-103. CONCLUSIONS The combination of silicone oil and Pd-103 eye plaques offers the potential for greatly improved sparing to normal structures compared to Pd-103 plaques alone or I-125 plaques with or without silicone oil.
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Affiliation(s)
- You M Yang
- University of California, Los Angeles, 200 Medical Plaza Ste B265, Los Angeles, CA, 90095, USA
| | - Phillip E Chow
- University of California, Los Angeles, 200 Medical Plaza Ste B265, Los Angeles, CA, 90095, USA
| | - Tara A McCannel
- Department of Ophthalmology, Stein Eye and Doheny Eye Institutes, University of California, 100 Stein PLZ, Los Angeles, CA, 90095, USA
| | - James M Lamb
- University of California, Los Angeles, 200 Medical Plaza Ste B265, Los Angeles, CA, 90095, USA
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27
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Berry DE, Grewal DS, Mruthyunjaya P. Conjunctival Dehiscence and Scleral Necrosis following Iodine-125 Plaque Brachytherapy for Uveal Melanoma: A Report of 3 Cases. Ocul Oncol Pathol 2018; 4:291-296. [PMID: 30320099 DOI: 10.1159/000481858] [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: 07/26/2017] [Revised: 09/26/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Plaque brachytherapy is currently the most common treatment for uveal melanoma and has many known potential complications. Here we present 3 cases of early conjunctival and scleral necrosis following iodine-125 plaque. METHODS This study was conducted as a retrospective case series. RESULTS We identified 3 cases of early conjunctival and scleral necrosis following iodine-125 plaque. All patients were managed conservatively with resolution of the necrosis. CONCLUSIONS While delayed corneoscleral necrosis following plaque brachytherapy has been previously reported, occurring many months to years after treatment, the 3 cases in this series presented within 2-6 weeks in the postoperative period. While we were unable to identify a specific etiology, we believe this represents a distinct clinical entity of post-brachytherapy cornea-scleral necrosis that is important to recognize. Possible causes include acute radiation toxicity, mechanical trauma, and/or conjunctival microinfection.
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Affiliation(s)
- Duncan E Berry
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, USA
| | - Dilraj S Grewal
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, USA
| | - Prithvi Mruthyunjaya
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, California, USA
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28
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Pham CM, Couch SM, Harocopos GJ. Extrascleral Tumor Extension Associated with Localized Scleral Melt following Plaque Brachytherapy for Uveal Melanoma: Clinical and Histologic Findings. Ocul Oncol Pathol 2018; 4:93-99. [PMID: 30320088 PMCID: PMC6167664 DOI: 10.1159/000477302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 05/03/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND/AIMS Our study aims to better characterize the clinical and histopathologic features of eyes with extrascleral uveal melanoma associated with scleral melt following brachytherapy. METHODS A retrospective review was performed on patients who had undergone 125I (iodine-125) brachytherapy for uveal melanoma at our institution between 1992 and 2015. Patients with postradiation scleral necrosis who required enucleation were identified, and an analysis including a review of histopathology results was performed on those cases. RESULTS A total of 301 patients underwent plaque brachytherapy for uveal melanoma, of whom 31 required eventual enucleation. The histologic analysis showed extraocular extension through full-thickness scleral discontinuities in 6 cases. All but 1 (5 of 6) of these eyes exhibited either mitotic figures or Ki-67 positivity. Mitotic figures were noted in 4 specimens, including 3 eyes exhibiting mitoses within or adjacent to the extrascleral portion of the tumor. Two eyes exhibiting mitoses, as well as the case with Ki-67 positivity, also had clinical evidence of tumor regrowth. CONCLUSION We found evidence of mitotic activity at the area of scleral discontinuity in some eyes with and in some without clinical evidence of tumor regrowth. Protruding pigmented material in areas of scleral necrosis after plaque brachytherapy may represent actively proliferating tumors even without internal evidence of tumor regrowth.
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Affiliation(s)
- Chau M. Pham
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven M. Couch
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - George J. Harocopos
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
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29
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Kuzmanović Elabjer B, Bušić M, Miletić D, Bjeloš M, Vukojević N, Bosnar D. Scleral Thinning Documented by Ultrasound Biomicroscopy after Plaque Therapy for Anterior Ciliary Melanoma. Semin Ophthalmol 2017; 33:571-575. [PMID: 28704130 DOI: 10.1080/08820538.2017.1346131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate, by ultrasound biomicroscopy (UBM), changes in scleral thickness after ruthenium-106 CCB and CCC plaque (Eckert & Ziegler BE-BIG GmbH, Berlin, Germany) therapy for anterior ciliary melanoma. METHODS Eleven patients with anterior ciliary melanoma underwent ruthenium-106 CCB and CCC plaque radiation with a radiation dose at the tumor apex of 80-100 Gy. UBM measurements performed prior to and after treatment were as follows: the largest prominence of the tumor perpendicular to the sclera and scleral thickness at scleral spur, 1.0 mm, and 2.0 mm posteriorly. RESULTS The article presents one year follow-up results for each of the 11 patients. The mean regression of the tumor of 24.3±9.31% was observed. The thinning of the sclera was statistically significant at the scleral spur (t=1.80, p ≤ 0.05) and at maximal tumor thickness (t=1.35, P=0.05). CONCLUSION UBM documented significant thinning of the sclera at the scleral spur and overlying the maximal tumor thickness after Ru-106 CCB and CCC plaque radiation. Taking into consideration the shortcomings of the study-small sample size, insufficient probe resolution, and subjectively determined anatomic landmarks-observed minimal thickness change of the sclera does not necessarily mean its necrosis. However, thinning of the sclera documented at one year follow-up associated with very slow regression of the tumor indicates the need for the introduction of the CIA plaque treatment in our patients with anterior ciliary melanoma.
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Affiliation(s)
- B Kuzmanović Elabjer
- a University Eye Clinic, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, University Hospital "Sveti Duh" , Zagreb , Croatia
| | - M Bušić
- a University Eye Clinic, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, University Hospital "Sveti Duh" , Zagreb , Croatia
| | - D Miletić
- a University Eye Clinic, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, University Hospital "Sveti Duh" , Zagreb , Croatia
| | - M Bjeloš
- a University Eye Clinic, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, University Hospital "Sveti Duh" , Zagreb , Croatia
| | - N Vukojević
- b University Eye Clinic, University Hospital Centre Zagreb , Zagreb , Croatia
| | - D Bosnar
- a University Eye Clinic, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, University Hospital "Sveti Duh" , Zagreb , Croatia
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30
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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: 358] [Impact Index Per Article: 44.8] [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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31
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Abstract
PURPOSE To evaluate the anatomical outcomes of corneal patch grafts in patients with progressive scleral necrosis secondary to plaque radiotherapy used for uveal malignant melanoma management. METHODS In this case series, 4 patients with progressive scleral necrosis after Ru-106 plaque radiotherapy underwent corneal patch grafts with the anterior corneal button from Descemet stripping automated endothelial keratoplasty donor tissue to strengthen the sclera and to improve appearance of the eye. RESULTS Ciliary body involvement was evident in all cases. All 4 patients had received radiation doses of 400 Gy or more to the tumor base. The mean time interval between plaque radiotherapy and scleral necrosis was 24.5 ± 7.5 months (range, 18-34 months). Successful results were achieved in all patients with tectonic graft. No patients experienced graft thinning, rejection, infection, or tumor recurrence in a mean follow-up of 28.5 ± 7.9 months (range, 20-39 months). CONCLUSIONS Corneal patch graft by anterior corneal button from Descemet stripping automated endothelial keratoplasty donor tissue results in successful restoration of globe integrity and satisfactory cosmetic appearance in patients with scleral necrosis secondary to plaque radiotherapy.
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32
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Hill JR, Corrêa ZM. Progressive Scleral Necrosis following I-125 Plaque Radiotherapy for Ciliochoroidal Melanoma with Protruding Extraocular Mass. Ocul Oncol Pathol 2016; 2:136-9. [PMID: 27239452 DOI: 10.1159/000441660] [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: 07/31/2015] [Revised: 10/05/2015] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The aim of this study was to describe the side effects of I-125 brachytherapy in the treatment of uveal melanoma. METHODS This study was conducted as a case report. RESULTS We report a case of scleral necrosis and protruding episcleral mass following the treatment of uveal melanoma with I-125 brachytherapy. CONCLUSIONS Scleral necrosis after plaque radiotherapy can clinically simulate tumor recurrence with extraocular extension. The management of uveal melanoma requires a careful clinical follow-up, weighing the implications of treatment morbidity and mortality.
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Affiliation(s)
- Jordan R Hill
- Department of Ophthalmology, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Zélia M Corrêa
- Department of Ophthalmology, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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33
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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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Francis JH, Abramson DH. Update on Ophthalmic Oncology 2013: Retinoblastoma and Uveal Melanoma. Asia Pac J Ophthalmol (Phila) 2014; 3:241-56. [PMID: 26107765 DOI: 10.1097/apo.0000000000000079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to discuss the clinical and translational content of the literature as well as advancement in our knowledge pertaining to retinoblastoma and uveal melanoma that were published from January to December 2013. DESIGN This study is a literature review. METHODS The search terms retinoblastoma and uveal melanoma were used in a MEDLINE literature search. Abstracts were studied, and the most relevant articles were selected for inclusion and further in-depth review. RESULTS In retinoblastoma, fewer eyes are lost because of the expanded use of ophthalmic artery chemosurgery and intravitreal melphalan, and the past year marks a deepening in our understanding of these modalities. Knowledge on the genetic underpinnings of uveal melanoma has broadened to include genes associated with a favorable prognosis. This is accompanied by promising results in the treatment of metastatic uveal melanoma. CONCLUSIONS This past year, there were important advancements in our knowledge of retinoblastoma and uveal melanoma.
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Affiliation(s)
- Jasmine H Francis
- From the Ophthalmic Oncology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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35
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36
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Wong JR, Nanji AA, Galor A, Karp CL. Management of conjunctival malignant melanoma: a review and update. EXPERT REVIEW OF OPHTHALMOLOGY 2014; 9:185-204. [PMID: 25580155 DOI: 10.1586/17469899.2014.921119] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Conjunctival malignant melanoma is a pigmented lesion of the ocular surface. It is an uncommon but potentially devastating tumor that may invade the local tissues of the eye, spread systemically through lymphatic drainage and hematogenous spread, and recur in spite of treatment. Despite its severity, the rarity of available cases has limited the evidence for diagnosis and management. This review will provide an overview of the epidemiology, presentation, diagnosis, management, and surveillance of conjunctival melanoma, with an emphasis on recent advances in biological therapies to treat this disease.
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Affiliation(s)
- James R Wong
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Afshan A Nanji
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anat Galor
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA ; Department of Ophthalmology, Miami Veterans Affairs Medical Center, Miami, FL, USA
| | - Carol L Karp
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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Perez BA, Mettu P, Vajzovic L, Rivera D, Alkaissi A, Steffey BA, Cai J, Stinnett S, Dutton JJ, Buckley EG, Halperin E, Marks LB, Mruthyunjaya P, Kirsch DG. Uveal melanoma treated with iodine-125 episcleral plaque: an analysis of dose on disease control and visual outcomes. Int J Radiat Oncol Biol Phys 2014; 89:127-36. [PMID: 24613808 DOI: 10.1016/j.ijrobp.2014.01.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 12/29/2013] [Accepted: 01/18/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate, in the treatment of uveal melanomas, how tumor control, radiation toxicity, and visual outcomes are affected by the radiation dose at the tumor apex. METHODS AND MATERIALS A retrospective review was performed to evaluate patients treated for uveal melanoma with (125)I plaques between 1988 and 2010. Radiation dose is reported as dose to tumor apex and dose to 5 mm. Primary endpoints included time to local failure, distant failure, and death. Secondary endpoints included eye preservation, visual acuity, and radiation-related complications. Univariate and multivariate analyses were performed to determine associations between radiation dose and the endpoint variables. RESULTS One hundred ninety patients with sufficient data to evaluate the endpoints were included. The 5-year local control rate was 91%. The 5-year distant metastases rate was 10%. The 5-year overall survival rate was 84%. There were no differences in outcome (local control, distant metastases, overall survival) when dose was stratified by apex dose quartile (<69 Gy, 69-81 Gy, 81-89 Gy, >89 Gy). However, increasing apex dose and dose to 5-mm depth were correlated with greater visual acuity loss (P=.02, P=.0006), worse final visual acuity (P=.02, P<.0001), and radiation complications (P<.0001, P=.0009). In addition, enucleation rates were worse with increasing quartiles of dose to 5 mm (P=.0001). CONCLUSIONS Doses at least as low as 69 Gy prescribed to the tumor apex achieve rates of local control, distant metastasis-free survival, and overall survival that are similar to radiation doses of 85 Gy to the tumor apex, but with improved visual outcomes.
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Affiliation(s)
- Bradford A Perez
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Pradeep Mettu
- Department of Ophthalmology, Duke University, Durham, North Carolina
| | - Lejla Vajzovic
- Department of Ophthalmology, Duke University, Durham, North Carolina
| | | | - Ali Alkaissi
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Beverly A Steffey
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Jing Cai
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Sandra Stinnett
- Department of Biostatistics and Informatics, Duke University, Durham, North Carolina
| | - Jonathan J Dutton
- Department of Ophthalmology, University of North Carolina, Chapel Hill, North Carolina
| | - Edward G Buckley
- Department of Ophthalmology, Duke University, Durham, North Carolina
| | - Edward Halperin
- Department of Radiation Oncology, New York Medical College, Valhalla, New York
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Prithvi Mruthyunjaya
- Department of Radiation Oncology, Duke University, Durham, North Carolina; Department of Ophthalmology, Duke University, Durham, North Carolina
| | - David G Kirsch
- Department of Radiation Oncology, Duke University, Durham, North Carolina; Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina.
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Abstract
AIMS To report on the use of multi-dose photodynamic therapy (PDT) in the treatment of posterior uveal melanoma. METHODS Prospective case series. 18 patients with posterior uveal melanoma were treated with a minimum of three sessions of PDT. Mean tumour thickness was 1.92 mm (median 1.75, range 0.5-4.4 mm) while the mean basal diameter was 7.1 mm (median 6.3, range 5.2-11 mm). Patients were assessed for visual acuity, complications, tumour status and systemic metastases. RESULTS In 16 cases, the tumour regressed with stable or improved vision in 15 patients (83%) over a mean follow-up period of 28 months (median 26.5, range 12-44 months). One patient developed an edge recurrence on two occasions ultimately requiring proton beam therapy while one patient showed no response to PDT before being successfully treated with proton beam therapy. Two patients developed scleritis requiring a short course of systemic steroids. No patient developed metastatic disease in the study period. CONCLUSIONS Posterior uveal melanomas may be successfully treated with high dose PDT with retention of good vision in the majority of cases, at least in the short-term. Longer follow-up is required to see if these encouraging results are maintained.
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