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Jager MJ. Personalized ocular oncology care: how far have we come? CANADIAN JOURNAL OF OPHTHALMOLOGY 2024:S0008-4182(24)00152-2. [PMID: 38810956 DOI: 10.1016/j.jcjo.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
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Stålhammar G, Coupland SE, Ewens KG, Ganguly A, Heimann H, Shields CL, Damato B. Improved Staging of Ciliary Body and Choroidal Melanomas Based on Estimation of Tumor Volume and Competing Risk Analyses. Ophthalmology 2024; 131:478-491. [PMID: 38071620 DOI: 10.1016/j.ophtha.2023.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 12/19/2023] Open
Abstract
PURPOSE The current, 8th edition of the American Joint Committee on Cancer (AJCC) anatomic classification and staging model for uveal melanoma does not fully separate survival estimates for patients with advanced stages of the disease (e.g., IIIB and IIIC). Furthermore, some tumors in higher size categories have a smaller volume than tumors in lower categories. Therefore, we developed a novel model for prognostication of metastatic mortality based on estimations of tumor volume. DESIGN Retrospective, multicenter case series of patients with uveal melanoma involving the choroid, ciliary body, or both. PARTICIPANTS Six thousand five hundred twenty-eight consecutively registered patients treated at 3 tertiary ocular oncology centers on 2 continents between 1981 and 2022. METHODS Data on survival, tumor size, and extent were collected for all 6528 patients. Tumor volume was estimated using a simple equation based on largest basal diameter and thickness. Volume-based size categories and stages were developed and validated in independent patient cohorts using competing risk analyses, and correlations with cytogenetic and cytomorphologic features were examined. MAIN OUTCOME MEASURE Cumulative incidence of metastatic death. RESULTS The 6528 patients were distributed over 7 stages based on estimated tumor volume and anatomic extent (V stages IA, IB, IIA, IIB, IIIA, IIIB, and IIIC), with a 15-year incidence of metastatic death ranging from 7% to 77%. A new category, V1min, and corresponding stage IA, were introduced, indicating an excellent prognosis. Metastatic mortality in V stage IIIC was significantly higher than that in V stage IIIB (P = 0.03), whereas incidence curves crossed for patients in AJCC stages IIIC vs. IIIB (P = 0.53). Univariable and multivariable competing risk regressions demonstrated higher Wald statistics for V stages compared with AJCC stages (1152 vs. 1038 and 71 vs. 17, respectively). The frequency of monosomy 3, gain of chromosome 8q, and epithelioid cytomorphologic features increased with tumor volume (R2 = 0.70, R2 = 0.50, and R2 = 0.71, respectively; P < 0.001) and showed similar correlations with both AJCC and V stages. CONCLUSIONS Anatomic classification and staging of ciliary body and choroidal melanomas based on estimation of tumor volume improves prognostication of metastatic mortality. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Gustav Stålhammar
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden; Ocular Oncology Service and St. Erik Ophthalmic Pathology Laboratory, St. Erik Eye Hospital, Stockholm, Sweden.
| | - Sarah E Coupland
- Liverpool Ocular Oncology Research Group (LOORG), Institute of Systems, Molecular and Integrative Biology, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Kathryn G Ewens
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arupa Ganguly
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heinrich Heimann
- Liverpool Ocular Oncology Research Group (LOORG), Institute of Systems, Molecular and Integrative Biology, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom; Liverpool Ocular Oncology Centre, Liverpool University Hospitals Trust, Liverpool, United Kingdom
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Bertil Damato
- Ocular Oncology Service and St. Erik Ophthalmic Pathology Laboratory, St. Erik Eye Hospital, Stockholm, Sweden; Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom; Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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Gelmi MC, Jager MJ. Uveal melanoma: Current evidence on prognosis, treatment and potential developments. Asia Pac J Ophthalmol (Phila) 2024; 13:100060. [PMID: 38641203 DOI: 10.1016/j.apjo.2024.100060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024] Open
Abstract
Uveal Melanoma (UM) is a rare disease, yet it is the most common primary intraocular malignancy in adult patients. Despite continuous advancements and research, the risk of metastasis remains high. It is possible to stratify patients according to their risk of metastases using a variety of known risk factors. Even though there is no gold standard for the prognostication of patients with uveal melanoma, it is becoming increasingly clear that combining histo-pathological, patient-related and molecular prognostic markers allows a more accurate prediction of the metastatic risk than by using one parameter. Primary UM in the eye are treated very effectively with eye-sparing radiation-based techniques or enucleation. However, it is not yet possible to prevent or treat metastases with the current therapeutic options. Nonetheless, the efforts to find new therapeutic targets continue and progress is being made, especially in the field of targeted therapy, as exemplified by the anti-gp100 bispecific molecule Tebentafusp. This review delves into the history of uveal melanoma, its incidence, presentation and diagnosis, the known prognostic factors and the treatment options, both for the primary tumour and for metastases. We show that different populations may have different risks for developing UM, and that each country should evaluate their own patients.
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Affiliation(s)
- Maria Chiara Gelmi
- Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martine J Jager
- Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands.
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Kennedy S, Owens S, Ivers L, Hegarty C, O'Neill V, Berenguer-Pina JJ, Horgan N, Crown J, Walsh N. Prognostic Value of BAP1 Protein Expression in Uveal Melanoma. Am J Surg Pathol 2024; 48:329-336. [PMID: 38238977 PMCID: PMC10876168 DOI: 10.1097/pas.0000000000002176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
The prognostic value of the traditional pathologic parameters that form part of the American Joint Committee on Cancer staging system and genetic classifications using monosomy chromosome 3 and structural alterations in chromosome 8 are well established and are part of the diagnostic workup of uveal melanoma (UM). However, it has not been fully clarified whether nuclear protein expression of the tumor suppressor gene BAP1 (nBAP1) by immunohistochemistry alone is as powerful a predictor of overall survival (OS) and/or disease-specific survival (DSS) as chromosome analysis. The protein expression of nBAP1 was evaluated in a retrospective cohort study of 308 consecutive patients treated by primary enucleation between January 1974 and December 2022. We correlated clinical, pathologic, and cytogenetic characteristics to identify the best prognostic indicators for OS and DSS. Loss of nBAP1 was detected in 144/308 (47%) of patients. Loss of nBAP1 expression was significantly associated with poor survival. In patients with disomy chromosome 3, nBAP1 negative is significantly associated with poorer OS but not DSS. We observed that older age (>63 years), presence of metastasis, and nBAP1 negative remained independent prognostic factors in multivariate analysis. nBAP1 protein expression proved to be a more reliable prognostic indicator for OS than the American Joint Committee on Cancer staging, M3 status, or The Cancer Genome Atlas classification in this cohort. This study provides support for accurate prognostication of UM patients in routine histology laboratories by immunohistochemistry for nBAP1 alone.
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Affiliation(s)
- Susan Kennedy
- National Ophthalmic Pathology Laboratory & Research Foundation, Royal Victoria Eye and Ear Hospital
- School of Biotechnology, Dublin City University
| | - Sally Owens
- National Ophthalmic Pathology Laboratory & Research Foundation, Royal Victoria Eye and Ear Hospital
- School of Biotechnology, Dublin City University
| | - Laura Ivers
- School of Biotechnology, Dublin City University
| | - Ciara Hegarty
- National Ophthalmic Pathology Laboratory & Research Foundation, Royal Victoria Eye and Ear Hospital
- School of Biotechnology, Dublin City University
| | - Valerie O'Neill
- National Ophthalmic Pathology Laboratory & Research Foundation, Royal Victoria Eye and Ear Hospital
| | | | - Noel Horgan
- Ocular Oncology Service, Department of Ophthalmology, Research Foundation Royal Victoria Eye & Ear Hospital, Dublin, Ireland
| | - John Crown
- School of Biotechnology, Dublin City University
- Department of Medical Oncology, St Vincent's University Hospital
| | - Naomi Walsh
- School of Biotechnology, Dublin City University
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Negretti GS, Bayasi F, Goldstein S, Omega M, Taylor O, Ni R, Chiang L, Kim R, Lien E, Barke M, Dockery PW, Shields CL. Association of Fitzpatrick Skin Type with metastatic risk from uveal melanoma in 854 consecutive patients at a single center. Eye (Lond) 2024; 38:565-571. [PMID: 37770529 PMCID: PMC10858041 DOI: 10.1038/s41433-023-02735-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/08/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE To assess the association of skin color using Fitzpatrick Skin Type (FST) with metastatic risk of uveal melanoma. SUBJECTS 854 consecutive patients with uveal melanoma and documented FST. METHODS Retrospective detailed review of patient charts was performed for FST (type I- white, II-fair, III-average, IV-light brown, V-brown, VI-black), clinical details of the patient and the uveal melanoma, tumor cytogenetic classification according to The Cancer Genome Atlas (TCGA), and outcome of melanoma-related metastasis and death. RESULTS The FST classification was type I (n = 97 patients), type II (n = 665), type III (n = 79), type IV (n = 11), type V (n = 2), type VI (n = 0). A comparison of patient FST (type I vs. II vs. III-V) revealed significant differences in mean age at presentation (64.1 vs. 58.5 vs. 49.8 years, p < 0.001), race white (100% vs. 98% vs. 75%, p < 0.001), presence of ocular melanocytosis (3% vs. 3% vs. 10%, p = 0.01), visual acuity <20/200 at presentation (6% vs. 7% vs. 13%, p = 0.03), genetic results showing TCGA group B tumors (11% vs. 14% vs. 26%, p = 0.01) or TCGA group D tumors (22% vs. 11% vs. 9%, p = 0.01), 10-year incidence of melanoma-related metastasis (25% vs. 15% vs. 14%, p = 0.02) and 10-year incidence of melanoma-related death (9% vs. 3% vs. 4%, p = 0.04). FST was a significant predictor of melanoma-related metastasis (p = 0.02, Hazard ratio 2.3). CONCLUSIONS Fitzpatrick skin type may be a predictor of melanoma-related metastasis, with metastasis and TCGA Group D tumors being more common in patients with FST I.
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Affiliation(s)
- Guy S Negretti
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Ferris Bayasi
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Samuel Goldstein
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Michelle Omega
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Olivia Taylor
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Roselind Ni
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Lawrence Chiang
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Rachel Kim
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Eric Lien
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Matthew Barke
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Philip W Dockery
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA
| | - Carol L Shields
- From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut Street, 14th Floor, Philadelphia, PA, 19107, USA.
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Bas Z, Grant-Kels JM, Shields CL. The Cancer Genome Atlas for uveal melanoma is predictive of patient outcomes. Clin Dermatol 2024; 42:56-61. [PMID: 37890680 DOI: 10.1016/j.clindermatol.2023.10.005] [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: 10/29/2023]
Abstract
Uveal melanoma (UM) is the most common primary eye malignancy. Despite excellent local tumor rates, UM is a life-threatening disease with moderate systemic metastatic rates. In the past, certain clinical features were shown to be predictive of patient prognosis, including tumor thickness, tumor diameter, ciliary body involvement, and histopathologic factors. Genetic markers have lately been used to predict patient outcomes. The Cancer Genome Atlas (TCGA) is a worldwide effort developed by the National Cancer Institute and the National Human Genome Research Institute to study numerous mutations in various cancer types. TCGA has explored chromosome copy number alterations in UM, messenger RNA, micro-RNA, and long noncoding RNA expression levels and established four prognostic classes: group A (chromosome 3 and 8 disomy), group B (chromosome 3 disomy and 8q gain), group C (chromosome 3 monosomy and/or 8q gain), and group D (chromosome 3 monosomy and multiple 8q gains). Multiple studies have validated TCGA classification and have reported that it has been highly predictive of UM metastasis and patient survival.
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Affiliation(s)
- Zeynep Bas
- 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
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Gelmi MC, Gezgin G, van der Velden PA, Luyten GPM, Luk SJ, Heemskerk MHM, Jager MJ. PRAME Expression: A Target for Cancer Immunotherapy and a Prognostic Factor in Uveal Melanoma. Invest Ophthalmol Vis Sci 2023; 64:36. [PMID: 38149971 PMCID: PMC10755595 DOI: 10.1167/iovs.64.15.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/15/2023] [Indexed: 12/28/2023] Open
Abstract
Purpose Uveal melanoma (UM) is a rare disease with a high mortality, and new therapeutic options are being investigated. Preferentially Expressed Antigen in Melanoma (PRAME) is a cancer testis antigen, expressed in the testis, but also in cancers, including uveal melanoma. PRAME is considered a target for immune therapy in several cancers, and PRAME-specific T cell clones have been shown to kill UM cells. Methods We studied the literature on PRAME expression in hematological and solid malignancies, including UM, and its role as a target for immunotherapy. The distribution of tumor features was compared between PRAME-high and PRAME-low UM in a 64-patient cohort from the Leiden University Medical Center (LUMC) and in the Cancer Genome Atlas (TCGA) cohort of 80 cases and differential gene expression analysis was performed in the LUMC cohort. Results PRAME is expressed in many malignancies, it is frequently associated with a negative prognosis, and can be the target of T cell receptor (TCR)-transduced T cells, a promising treatment option with high avidity and safety. In UM, PRAME is expressed in 26% to 45% of cases and is correlated with a worse prognosis. In the LUMC and the TCGA cohorts, high PRAME expression was associated with larger diameter, higher Tumor-Node-Metastasis (TNM) stage, more frequent gain of chromosome 8q, and an inflammatory phenotype. Conclusions We confirm that PRAME is associated with poor prognosis in UM and has a strong connection with extra copies of 8q. We show that PRAME-specific immunotherapy in an adjuvant setting is promising in treatment of malignancies, including UM.
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Affiliation(s)
- Maria Chiara Gelmi
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gulçin Gezgin
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Sietse J. Luk
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Martine J. Jager
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
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Dockery PW, DeSimone JD, Liu CK, Achuck K, Hamburger J, Bas Z, Shields CL. Effectiveness of treatment for iris melanoma: surgical versus radiotherapeutic approaches. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023:S0008-4182(23)00341-1. [PMID: 38040029 DOI: 10.1016/j.jcjo.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/08/2023] [Accepted: 10/28/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of preventing metastasis for each major treatment modality for iris melanoma. DESIGN Retrospective case series. PARTICIPANTS Three hundred consecutive eyes with iris melanoma at a single tertiary referral centre for ocular oncology. METHODS Retrospective analysis of eyes with iris melanoma, both with (n = 69 eyes) and without (n = 231 eyes) ciliary body extension, was undertaken for metastasis-free survival at 5, 10, and 20 years based on type of treatment, including globe-sparing surgical resection (n = 169 eyes), plaque radiotherapy (n = 74 eyes), or enucleation (n = 57 eyes). RESULTS For the total population, 5-, 10-, and 20-year metastasis-free survival rates were 95%, 93%, and 87%, respectively, and there was no difference in metastatic rates for tumours with versus without ciliary body extension (p = 0.95). Noninferiority was demonstrated for surgical resection and plaque radiotherapy, with metastasis-free survival rates of 98%, 97%, and 94% for surgical resection and 94%, 94%, and 89% for plaque radiotherapy (p = 0.002). The rates for globe salvage were 94%, 92%, and 90% for surgical resection and 94%, 86%, and 86% for plaque radiotherapy (p = 0.003). However, metastasis-free survival was worse in patients who underwent enucleation (86%, 67%, and NA; p < 0.001). CONCLUSIONS Metastasis-free survival and globe salvage following plaque radiotherapy and surgical resection are not inferior to either, but eyes undergoing enucleation demonstrated a lower metastasis-free survival, likely because enucleation is performed for larger, more extensive melanomas, often with secondary glaucoma. In this analysis, iris melanoma with ciliary body involvement did not increase the risk of metastasis.
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Affiliation(s)
- Philip W Dockery
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pa
| | - Joseph D DeSimone
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pa
| | - Catherine K Liu
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pa
| | - Kathryn Achuck
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pa
| | - Jordan Hamburger
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pa
| | - Zeynep Bas
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pa
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pa.
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Tong TML, Bastiaannet E, Speetjens FM, Blank CU, Luyten GPM, Jager MJ, Marinkovic M, Vu THK, Rasch CRN, Creutzberg CL, Beenakker JWM, Hartgrink HH, Bosch JJJ, Kiliç E, Naus NC, Yavuzyigitoglu S, van Rij CM, Burgmans MC, Kapiteijn EHW. Time Trends in the Treatment and Survival of 5036 Uveal Melanoma Patients in The Netherlands over a 30-Year Period. Cancers (Basel) 2023; 15:5419. [PMID: 38001679 PMCID: PMC10670516 DOI: 10.3390/cancers15225419] [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: 10/19/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Uveal melanoma (UM) is a rare intraocular tumor with a dismal prognosis once metastasized. This study provides a nationwide overview and time trends of patients diagnosed with primary UM in the Netherlands between 1989 and 2019. METHODS A retrospective population-based cohort study based on patients with primary UM from the database of the Netherlands Cancer Registry (NCR), linked with the national population registry Statistics Netherlands on inhabitants' cause of death. Two time periods (1989-2004, 2005-2019) were compared with descriptive statistics. Kaplan-Meier and (multivariate) Cox proportional hazard models were used to assess changes over time for overall survival (OS) and cancer-specific survival (CSS). RESULTS In total, 5036 patients were analyzed with a median age of 64.0 years at the time of diagnosis. The number of patients increased over time. In the first (1989-2004) and second (2005-2019) period, 32% versus 54% of the patients received radiotherapy (p < 0.001). The median FU time was 13.4 years. The median OS of the first and second periods was 9.5 (95% CI 8.7-10.3) versus 11.3 years (95% CI 10.3-12.3; p < 0.001). The median CSS was 30.0 years (95% CI NA) in the first period and not reached in the second period (p = 0.008). In multivariate analysis (MVA), female gender (HR 0.85; 95% CI 0.79-0.92, p < 0.001) and radiotherapy treatment (HR 0.73; 95% CI 0.64-0.83, p < 0.001) were associated with better OS. Radiotherapy treatment (HR 0.74; 95% CI 0.61-0.90, p = 0.002) was also associated with better CSS. The period of diagnosis was not associated with OS or CSS. CONCLUSIONS In this study of patients with primary UM, there was a shift to the diagnosis of smaller tumors, possibly due to stage migration. There was also an increase in eye-preserving treatments over time. OS and CSS were modestly improved in the second time period; however, the time period was not associated with OS or CSS in multivariate analyses.
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Affiliation(s)
- Thaïs M. L. Tong
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Esther Bastiaannet
- Department of Epidemiology, Biostatistics and Prevention, University of Zurich, Rämistrasse 71, 8006 Zürich, Switzerland
| | - Frank M. Speetjens
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Christian U. Blank
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Gregorius P. M. Luyten
- Department of Ophthalmology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Martine J. Jager
- Department of Ophthalmology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Marina Marinkovic
- Department of Ophthalmology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - T. H. Khanh Vu
- Department of Ophthalmology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Coen R. N. Rasch
- Department of Radiation Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Carien L. Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jan-Willem M. Beenakker
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Ophthalmology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Henk H. Hartgrink
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jacobus J. J. Bosch
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Centre for Human Drug Research, Zernikedreef 8, 2333 CL Leiden, The Netherlands
| | - Emine Kiliç
- Department of Ophthalmology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Nicole C. Naus
- Department of Ophthalmology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Serdar Yavuzyigitoglu
- Department of Ophthalmology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Caroline M. van Rij
- Department of Radiation Oncology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Mark C. Burgmans
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Ellen H. W. Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Gerard C, Shum B, Nathan P, Turajlic S. Immuno-oncology approaches in uveal melanoma: tebentafusp and beyond. IMMUNO-ONCOLOGY TECHNOLOGY 2023; 19:100386. [PMID: 37483658 PMCID: PMC10362360 DOI: 10.1016/j.iotech.2023.100386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Uveal melanoma (UM) is the most common ocular malignancy in adults, associated with the poorest prognosis, with metastatic disease occurring in up to 50% of patients. In contrast to metastatic cutaneous melanoma, the use of immune checkpoint inhibitors is associated with poor outcomes in metastatic uveal melanoma (mUM). Tebentafusp, a bispecific molecule, has recently become the first treatment in decades to improve overall survival for mUM. This review summarises the existing and emerging immuno-oncology approaches for the treatment of mUM, and biomarkers of response and resistance to the same. Finally, we propose future research directions that could maximise treatment benefit to a wider pool of patients with UM.
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Affiliation(s)
- C. Gerard
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
- Precision Oncology Center, Oncology Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - B. Shum
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
- Skin and Renal Unit, The Royal Marsden NHS Foundation Trust, London
| | - P. Nathan
- Mount Vernon Cancer Centre, East and North Herts NHS Trust, Northwood, UK
| | - S. Turajlic
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, UK
- Skin and Renal Unit, The Royal Marsden NHS Foundation Trust, London
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Demirci H, Tang L, Demirci FY, Ozgonul C, Weber S, Sundstrom J. Investigating Vitreous Cytokines in Choroidal Melanoma. Cancers (Basel) 2023; 15:3701. [PMID: 37509362 PMCID: PMC10378009 DOI: 10.3390/cancers15143701] [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: 05/25/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Due to the close relationship between the vitreous and posterior eye layers, the microenvironment of these layers can affect the composition of the vitreous. Molecular analysis of the vitreous may therefore provide important insights into the pathogenesis of chorioretinal diseases. In this study, vitreous cytokines (n = 41) were evaluated to gain further insights into the tumor microenvironment in uveal melanoma (UM) arising from the choroid (CM). Cytokine levels were measured using a bead-based multiplex immunoassay panel in vitreous samples obtained from 32 eyes, including 18 with CM and 14 controls. Median fluorescence intensity values were extracted and used as relative quantification of the cytokine abundance. Vitreous cytokine levels were compared between the CM and non-CM groups and between different prognostic categories within the CM group (classified as having low or high metastatic risk using tumor biopsy-based gene expression profiling). Correlations between vitreous cytokine levels and tumor dimensions were also evaluated. Our analysis revealed twenty-six vitreous cytokines significantly upregulated in CM-affected eyes compared to the control eyes. Within the CM group, six vitreous cytokines showed altered levels (five upregulated and one downregulated) in eyes with high- vs. low-risk tumors. Levels of these six plus several other cytokines showed correlations with the tumor dimensions. In conclusion, our study has uncovered several UM-relevant vitreous cytokines, worthy of follow-up in larger studies as potential candidates for liquid biopsy-based biomarker development and/or new therapeutic targeting.
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Affiliation(s)
- Hakan Demirci
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
| | - Lu Tang
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - F Yesim Demirci
- Department of Human Genetics, School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Cem Ozgonul
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
| | - Sarah Weber
- Department of Ophthalmology and Visual Sciences, Penn State University, Hershey, PA 17033, USA
| | - Jeffrey Sundstrom
- Department of Ophthalmology and Visual Sciences, Penn State University, Hershey, PA 17033, USA
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12
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Ge Y, Zhang J, Jin K, Ye Z, Wang W, Zhou Z, Ye J. Multifunctional Nanoparticles Precisely Reprogram the Tumor Microenvironment and Potentiate Antitumor Immunotherapy after Near-Infrared-II Light-Mediated Photothermal Therapy. Acta Biomater 2023:S1742-7061(23)00316-1. [PMID: 37302731 DOI: 10.1016/j.actbio.2023.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/18/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023]
Abstract
Mild-temperature photothermal therapy (mild PTT) is a safe and efficient antitumor therapy. However, mild PTT alone usually fails to activate the immune response and prevent tumor metastasis. Herein, a photothermal agent, copper sulfide@ovalbumin (CuS@OVA), with an effective PTT effect in the second near-infrared (NIR-II) window, is developed. CuS@OVA can optimize the tumor microenvironment (TME) and evoke an adaptive immune response. Copper ions are released in the acidic TME to promote the M1 polarization of tumor-associated macrophages. The model antigen OVA not only acts as a scaffold for nanoparticle growth but also promotes the maturation of dendritic cells, which primes naive T cells to stimulate adaptive immunity. CuS@OVA augments the antitumor efficiency of the immune checkpoint blockade (ICB) in vivo, which suppresses tumor growth and metastasis in a mouse melanoma model. The proposed therapeutic platform, CuS@OVA nanoparticles, may be a potential adjuvant for optimizing the TME and improving the efficiency of ICB as well as other antitumor immunotherapies. STATEMENT OF SIGNIFICANCE: Mild-temperature photothermal therapy (mild PTT) is a safe and efficient antitumor therapy, but usually fails to activate the immune response and prevent tumor metastasis. Herein, we develop a photothermal agent, copper sulfide@ovalbumin (CuS@OVA), with an excellent PTT effect in the second near-infrared (NIR-II) window. CuS@OVA can optimize the tumor microenvironment (TME) and evoke an adaptive immune response by promoting the M1 polarization of tumor-associated macrophages and the maturation of dendritic cells. CuS@OVA augments the antitumor efficiency of the immune checkpoint blockade (ICB) in vivo, suppressing tumor growth and metastasis. The platform may be a potential adjuvant for optimizing the TME and improving the efficiency of ICB as well as other antitumor immunotherapies.
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Affiliation(s)
- Yanni Ge
- Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Provincial Key Laboratory of Ophthalmology, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Hangzhou, Zhejiang, China
| | - Jiaojiao Zhang
- MOE Key Laboratory of Macromolecular Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou 310027, P. R. China
| | - Kai Jin
- Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Provincial Key Laboratory of Ophthalmology, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Hangzhou, Zhejiang, China
| | - Ziqiang Ye
- MOE Key Laboratory of Macromolecular Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou 310027, P. R. China
| | - Wei Wang
- Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Provincial Key Laboratory of Ophthalmology, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Hangzhou, Zhejiang, China; Zhejiang Key Laboratory of Smart Biomaterials, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou 310027, China.
| | - Zhuxian Zhou
- Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Provincial Key Laboratory of Ophthalmology, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Hangzhou, Zhejiang, China; Zhejiang Key Laboratory of Smart Biomaterials, College of Chemical and Biological Engineering, Zhejiang University, Hangzhou 310027, China.
| | - Juan Ye
- Eye Center, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Provincial Key Laboratory of Ophthalmology, Zhejiang Provincial Clinical Research Center for Eye Diseases, Zhejiang Provincial Engineering Institute on Eye Diseases, Hangzhou, Zhejiang, China.
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13
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Miguez S, Lee RY, Chan AX, Demkowicz PC, Jones BSCL, Long CP, Abramson DH, Bosenberg M, Sznol M, Kluger H, Goldbaum MH, Francis JH, Pointdujour-Lim R, Bakhoum MF. Validation of the Prognostic Usefulness of the Gene Expression Profiling Test in Patients with Uveal Melanoma. Ophthalmology 2023; 130:598-607. [PMID: 36739981 PMCID: PMC10619207 DOI: 10.1016/j.ophtha.2023.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/11/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To validate the prognostic usefulness of gene expression profile (GEP) testing in patients with uveal melanoma. To determine whether combining tumor size with the GEP classification provides additional prognostic value. DESIGN Retrospective analysis. PARTICIPANTS Patients with a diagnosis of choroidal melanoma examined at Yale New Haven Hospital; University of California, San Diego; and Memorial Sloan Kettering Cancer Center. METHODS Patients' demographic and clinical data and tumor characteristics were collected. Univariate and multivariate Cox hazard regression analysis were used to assess the association between tumor characteristics and GEP classification with metastasis as an outcome. MAIN OUTCOME MEASURES Metastasis-free survival (MFS). RESULTS Of the 337 individuals included in the study, 87 demonstrated metastases. The mean follow-up time was 37.2 (standard deviation [SD], 40.2) months for patients with metastases and 55.0 (SD, 49.3) months for those without metastases. Tumors of larger thickness and GEP class 2 (vs. class 1) were associated significantly with increased risk of metastasis. Tumor thickness showed better prognostic usefulness than GEP classification (Wald statistic, 40.7 and 24.2, respectively). Class 2 tumors with a thickness of 7.0 mm or more were associated with increased risk of metastasis than tumors with a thickness of < 7.0 mm (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.61-6.51), whereas class 1 tumors with a thickness of 9.0 mm or more were associated with increased risk of metastasis than tumors with a thickness of < 9.0 mm (HR, 2.07; 95% CI, 0.86-4.99). No difference in MFS was found between patients with class 1A tumors compared with those with class 1B tumors (P = 0.8). Patients with class 2 tumors showed an observed 5-year MFS of 47.5% (95% CI, 36.0%-62.8%). CONCLUSIONS Tumor size was the most significant predictor of metastasis and provided additional prognostic value independent of GEP classification. In addition, rates of metastasis for class 2 tumors were lower than estimates reported by Castle Bioscience, and no difference in rates of metastasis were found between class 1A and 1B tumors. This indicates that tumor size should be accounted for when relying on GEP for prognostication and that patients with GEP class 1A or 1B tumors may benefit from the same metastatic surveillance protocols. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Sofia Miguez
- Yale University School of Medicine, New Haven, Connecticut
| | - Ryan Y Lee
- Yale University School of Medicine, New Haven, Connecticut
| | - Alison X Chan
- The Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California
| | | | - Bailey S C L Jones
- Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher P Long
- Department of Ophthalmology, University of Southern California, Los Angeles, California
| | - David H Abramson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcus Bosenberg
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut; Yale Cancer Center, Yale University, New Haven, Connecticut
| | - Mario Sznol
- Yale Cancer Center, Yale University, New Haven, Connecticut; Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Harriet Kluger
- Yale Cancer Center, Yale University, New Haven, Connecticut; Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michael H Goldbaum
- The Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, California
| | - Jasmine H Francis
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Renelle Pointdujour-Lim
- Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut; Yale Cancer Center, Yale University, New Haven, Connecticut
| | - Mathieu F Bakhoum
- Department of Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut; Department of Pathology, Yale University School of Medicine, New Haven, Connecticut; Yale Cancer Center, Yale University, New Haven, Connecticut.
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14
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Guo X, Yu X, Zhang Y, Luo H, Huang R, Zeng Y, Duan C, Chen C. A Novel Glycolysis-Related Signature for Predicting the Prognosis and Immune Infiltration of Uveal Melanoma. Ophthalmic Res 2023; 66:692-705. [PMID: 36858025 DOI: 10.1159/000529818] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/14/2023] [Indexed: 03/03/2023]
Abstract
INTRODUCTION As the most common aggressive intraocular cancer in adults, uveal melanoma (UVM) threatens the survival and vision of many people. Glycolysis is a novel hallmark of cancer, but the role of glycolysis-related genes in UVM prognosis remains unknown. The purpose of the study was to establish a glycolysis-related gene signature (GRGS) to predict UVM prognosis. METHODS Raw data were obtained from TCGA-UVM and GSE22138 datasets. The GRGS was established by univariate, LASSO, and multivariate Cox regression analyses. Kaplan-Meier survival and time-dependent receiver operating characteristic curves were used to evaluate the predictive ability of the GRGS. The relationships of the GRGS with infiltrating immune cell levels and mutations were analyzed with CIBERSORT and maftools. RESULTS A novel GRGS (risk score = 0.690861*ISG20 + 0.070991*MET - 0.227520*SDC2 + 0.690223*FBP1 + 0.048008*CLN6 - 0.128520*SDC3) was developed for predicting UVM prognosis. The GRGS had robust predictive stability in UVM. Enrichment annotation suggested that the high-risk group had stronger adaptive immune responses and that the low-risk group had more innate immune cell infiltration. Moreover, BAP1 mutation was related to high risk, and SF3B1 mutation was related to low risk. CONCLUSIONS This study developed and validated a novel GRGS to predict UVM prognosis and immune infiltration. The signature revealed an association between glycolysis-related genes and the tumor microenvironment, providing new insights into the role of glycolysis in UVM.
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Affiliation(s)
- Xiaoyu Guo
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, China,
| | - Xin Yu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuying Zhang
- Oral Histopathology Department, School and Hospital of Stomatology, Wuhan University, Wuhan, China
- The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei_MOST) and Key Laboratory of Oral Biomedicine Ministry of Education, School and Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Huijuan Luo
- Department of Ophthalmology, The People's Hospital of Yidu, Yichang, China
| | - Rong Huang
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuyang Zeng
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chaoye Duan
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Changzheng Chen
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, China
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15
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Carvajal RD, Sacco JJ, Jager MJ, Eschelman DJ, Olofsson Bagge R, Harbour JW, Chieng ND, Patel SP, Joshua AM, Piperno-Neumann S. Advances in the clinical management of uveal melanoma. Nat Rev Clin Oncol 2023; 20:99-115. [PMID: 36600005 DOI: 10.1038/s41571-022-00714-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 01/05/2023]
Abstract
Melanomas arising in the uveal tract of the eye are a rare form of the disease with a biology and clinical phenotype distinct from their more common cutaneous counterparts. Treatment of primary uveal melanoma with radiotherapy, enucleation or other modalities achieves local control in more than 90% of patients, although 40% or more ultimately develop distant metastases, most commonly in the liver. Until January 2022, no systemic therapy had received regulatory approval for patients with metastatic uveal melanoma, and these patients have historically had a dismal prognosis owing to the limited efficacy of the available treatments. A series of seminal studies over the past two decades have identified highly prevalent early, tumour-initiating oncogenic genomic aberrations, later recurring prognostic alterations and immunological features that characterize uveal melanoma. These advances have driven the development of a number of novel emerging treatments, including tebentafusp, the first systemic therapy to achieve regulatory approval for this disease. In this Review, our multidisciplinary and international group of authors summarize the biology of uveal melanoma, management of primary disease and surveillance strategies to detect recurrent disease, and then focus on the current standard and emerging regional and systemic treatment approaches for metastatic uveal melanoma.
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Affiliation(s)
- Richard D Carvajal
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.
| | - Joseph J Sacco
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Martine J Jager
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | - David J Eschelman
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - J William Harbour
- Department of Ophthalmology and Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nicholas D Chieng
- Medical Imaging Services, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Sapna P Patel
- Department of Melanoma Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony M Joshua
- Department of Medical Oncology, Kinghorn Cancer Centre, St Vincent's Hospital Sydney and Garvan Institute of Medical Research, Sydney, New South Wales, Australia.,School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW, Sydney, New South Wales, Australia
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16
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Gill VT, Sabazade S, Herrspiegel C, Ewens KG, Opalko A, Dan N, Christersdottir T, Berg Rendahl A, Shields CL, Seregard S, Ganguly A, Stålhammar G. A prognostic classification system for uveal melanoma based on a combination of patient age and sex, the American Joint Committee on Cancer and the Cancer Genome Atlas models. Acta Ophthalmol 2023; 101:34-48. [PMID: 35801361 PMCID: PMC10083913 DOI: 10.1111/aos.15210] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/12/2022] [Accepted: 06/21/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To revisit the independent importance of ciliary body involvement (CBI), monosomy 3 (M3), tumour size, histological and clinical factors in uveal melanoma (UM) and to devise a new prognostic classification based on a combination of the American Joint Committee on Cancer (AJCC) and the Cancer Genome Atlas (TCGA) models. METHODS Two cohorts with a total of 1796 patients were included. Clinicopathological factors were compared between patients with and without CBI and M3. Development of the prognostic classification was performed in a training cohort and was then tested in two independent validation cohorts. RESULTS Tumours with CBI were more common in women, had greater apical thickness, greater basal tumour diameter, greater rates of vasculogenic mimicry and greater rates of M3, were more often asymptomatic at diagnosis and had poorer 5- and 10-year globe conservation rates (p < 0.023). In multivariate logistic regression, patient age at diagnosis, tumour diameter and CBI were independent predictors of M3 (p < 0.001). In multivariate Cox regression, male sex, age at diagnosis, tumour diameter, M3 and CBI were independent predictors of metastasis. The proposed prognostic classification combined patient age, sex, CBI, extraocular extension, M3, 8q (optional) and tumour size, and demonstrated greater prognostic acumen than both AJCC 4 T categories and TCGA groups A to D in validation cohorts. CONCLUSIONS Tumour size does not confound the prognostic implication of CBI, M3, male sex and age at diagnosis in UM. These factors were included in a new prognostic classification that outperforms AJCC T category and TCGA groups.
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Affiliation(s)
- Viktor T Gill
- Department of Pathology, Västmanland Hospital Västerås, Västerås, Sweden.,Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden
| | - Shiva Sabazade
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Christina Herrspiegel
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Kathryn G Ewens
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Nicole Dan
- St. Erik Eye Hospital, Stockholm, Sweden
| | - Tinna Christersdottir
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Alexander Berg Rendahl
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stefan Seregard
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Arupa Ganguly
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustav Stålhammar
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
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17
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Cherkas E, Negretti GS, Zeiger JS, Shields CL. Iris melanoma outcomes based on the Cancer Genome Atlas (TCGA) classification in 78 consecutive patients. Ophthalmic Genet 2022; 43:736-741. [PMID: 36326016 DOI: 10.1080/13816810.2022.2141798] [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: 11/06/2022]
Abstract
BACKGROUND The Cancer Genome Atlas (TCGA) classification of genetic alterations in uveal melanoma is widely used for prognostication. We present novel observations on the impact of TCGA Group specifically for iris melanoma. METHODS This was a retrospective cohort study at a tertiary referral ocular oncology center. All patients with a diagnosis of iris melanoma who underwent genetic evaluation and assessment for TCGA classification between 20 November 1995 and 5 April 2021 were included. The main outcome measures were visual acuity, secondary glaucoma, tumor recurrence, melanoma-related metastasis and death per TCGA group. RESULTS There were a total of 78 patients included. The mean patient age was 49.6 years (median 53.0, range 3.0-85.0), mean tumor basal diameter was 6.7 mm (median 6.0, range 1.5-22.0), and mean tumor thickness was 2.6 mm (median 2.5, range 0.5-8.5). Cytology results confirmed iris melanoma (93%) or were inconclusive (7%). The TCGA groups included Group A (n = 36, 46%), Group B (n = 7, 9%), Group C (n = 34, 44%), and Group D (n = 1, 1%). There was no statistically significant difference in outcomes of visual acuity, tumor thickness reduction, secondary glaucoma, tumor recurrence, melanoma-related metastasis or death per individual TCGA group (A vs. B vs. C vs. D) and per bimodal comparison (A/B vs. C/D). CONCLUSIONS In this analysis, iris melanoma was classified as TCGA group A or B in 55% and as C or D in 45%. The TCGA classification was not predictive of melanoma-related metastasis or death.
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Affiliation(s)
- Elliot Cherkas
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Guy S Negretti
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jennifer S Zeiger
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA
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18
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Zhang X, Zhang X, Liu T, Zhang Z, Piao C, Ning H. METTL14 promotes migration and invasion of choroidal melanoma by targeting RUNX2 mRNA via m6A modification. J Cell Mol Med 2022; 26:5602-5613. [PMID: 36264762 DOI: 10.1111/jcmm.17577] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/25/2022] Open
Abstract
The modification of N6-methyladenosine is involved in the progression of various cancers. This study aimed to clarify its regulatory mechanism in the pathogenesis of choroidal melanoma. Expression of methyltransferase-like 14 in choroidal melanoma or normal choroidal tissues was determined by Western blot and immunohistochemistry. The impacts of methyltransferase-like 14 on invasion and migration of choroidal melanoma cells were determined using functional and animal experiments. The interaction between methyltransferase-like 14 and its downstream target was identified by methylated RNA immunoprecipitation and a dual-luciferase reporter assay. Additionally, Wnt/β-catenin signalling pathway was evaluated by Western blot. Methyltransferase-like 14 was upregulated in choroidal melanoma compared to the normal choroidal tissues. Overexpression or knockdown of methyltransferase-like 14 enhanced or inhibited the invasion and migration of choroidal melanoma cells, respectively, both in vivo and in vitro. Methyltransferase-like 14 directly targeted downstream runt-related transcription factor 2 mRNA, depending on N6-methyladenosine. Additionally, the Wnt/β-catenin signalling pathway was activated by methyltransferase-like 14 in choroidal melanoma cells. Our study identified a novel RNA regulatory mechanism in which runt-related transcription factor 2 was upregulated by enhanced expression of methyltransferase-like 14 via N6-methyladenosine modification, thus facilitating migration and invasion of choroidal melanoma cells.
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Affiliation(s)
- Xi Zhang
- Department of Ophthalmology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xiaonan Zhang
- Department of Ophthalmology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Tengyue Liu
- Department of Ophthalmology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhe Zhang
- Department of Urology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Chiyuan Piao
- Department of Urology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Hong Ning
- Department of Ophthalmology, The First Hospital of China Medical University, Shenyang, Liaoning, China
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Singh AD, Binkley EM, Wrenn JM, Bena JF, Hinz C, Boldt HC. Predicted vs Observed Metastasis-Free Survival in Individuals With Uveal Melanoma. JAMA Ophthalmol 2022; 140:847-854. [PMID: 35862032 PMCID: PMC9305597 DOI: 10.1001/jamaophthalmol.2022.2623] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Accuracy of the predicted metastasis-free survival (MFS) by a commercially available gene expression profiling (GEP) test is not known. Objective To compare the predicted MFS with the observed MFS in patients in this cohort and with those in published studies (published MFS, meta-analysis). Design, Setting, and Participants This cohort study included consecutive patients from the University of Iowa and Cleveland Clinic who were diagnosed with uveal melanoma who underwent prognostic fine-needle aspiration biopsy at the time of primary treatment. Patients were recruited from December 2012 to December 2020. The predicted MFS for patients was extracted from the GEP report. The observed MFS was defined as time to metastasis. Cox proportional hazards models were fit to identify tumor variables impacting MFS in patients with class 2 tumors. The overall estimate of the published MFS was obtained by performing meta-analysis of data from published series. Analysis took place in August 2021. Main Outcomes and Measures MFS. Results There were 92 patients from the University of Iowa and 255 patients from the Cleveland Clinic. The mean (SD) age at diagnosis was 59.4 (13.0) years. The median (IQR) follow-up interval was 38.0 (19.0-57.0) months. The observed MFS for patients with class 2 tumor in this cohort (3 years: 67% [95% CI, 59%-77%]; 5 years: 47% [95% CI, 37%-61%]) and in published studies (3 years: 62% [95% CI, 57%-66%]; 5 years: 40% [95% CI, 34%-46%]) were better than those predicted (50% and 28% for 3 and 5 years, respectively). Within patients with class 2 tumor, those with metastasis had larger tumors compared with nonmetastatic tumors (mean largest basal diameter difference, 1.7 [95% CI, 0.5-3.0] mm; P = .01; mean thickness ratio, 1.3 [95% CI, 1.04-1.5]; P = .01, respectively). An increasing tumor size was significantly associated with increased hazard ratio (1.16 [95% CI, 1.06-1.27]; P < .001) of metastasis. Conclusions and Relevance These findings suggest the predicted MFS for metastatic tumors (class 2) appears to be worse than that observed here and reported by others. Incorporation of tumor size in the prediction model may enhance its accuracy. Adjuvant therapy trials may not be able to rely on predicted MFS to calculate efficacy with a high degree of confidence.
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Affiliation(s)
- Arun D Singh
- Department of Ophthalmology, University of Iowa, Iowa City
| | | | - Jacquelyn M Wrenn
- Department of Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - James F Bena
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Connie Hinz
- Department of Ophthalmology, University of Iowa, Iowa City
| | - H Culver Boldt
- Department of Ophthalmology, University of Iowa, Iowa City
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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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Im DH, Peng CC, Xu L, Kim ME, Ostrow D, Yellapantula V, Bootwalla M, Biegel JA, Gai X, Prabakar RK, Kuhn P, Hicks J, Berry JL. Potential of Aqueous Humor as a Liquid Biopsy for Uveal Melanoma. Int J Mol Sci 2022; 23:ijms23116226. [PMID: 35682905 PMCID: PMC9181140 DOI: 10.3390/ijms23116226] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 12/10/2022] Open
Abstract
Tumor biopsy can identify prognostic biomarkers for metastatic uveal melanoma (UM), however aqueous humor (AH) liquid biopsy may serve as an adjunct. This study investigated whether the AH of UM eyes has sufficient circulating tumor DNA (ctDNA) to perform genetic analysis. This is a case series of 37 AH samples, taken before or after radiation, and one tumor wash sample, from 12 choroidal and 8 ciliary body (CB) melanoma eyes. AH was analyzed for nucleic acid concentrations. AH DNA and one tumor wash sample underwent shallow whole-genome sequencing followed by Illumina sequencing to detect somatic copy number alterations (SCNAs). Four post-radiation AH underwent targeted sequencing of BAP1 and GNAQ genes. Post-radiation AH had significantly higher DNA and miRNA concentrations than paired pre-radiation samples. Highly recurrent UM SCNAs were identified in 0/11 post-radiation choroidal and 6/8 post-radiation CB AH. SCNAs were highly concordant in a CB post-radiation AH with its matched tumor (r = 0.978). BAP1 or GNAQ variants were detected in 3/4 post-radiation AH samples. AH is a source of ctDNA in UM eyes, particularly in post-radiation CB eyes. For the first time, UM SCNAs and mutations were identified in AH-derived ctDNA. Suggesting that AH can serve as a liquid biopsy for UM.
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Affiliation(s)
- Deborah H. Im
- The Vision Center at Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.H.I.); (C.-C.P.); (L.X.); (M.E.K.)
- USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Chen-Ching Peng
- The Vision Center at Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.H.I.); (C.-C.P.); (L.X.); (M.E.K.)
- USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Liya Xu
- The Vision Center at Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.H.I.); (C.-C.P.); (L.X.); (M.E.K.)
- USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Mary E. Kim
- The Vision Center at Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.H.I.); (C.-C.P.); (L.X.); (M.E.K.)
- USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Dejerianne Ostrow
- Center for Personalized Medicine, Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.O.); (V.Y.); (M.B.); (J.A.B.); (X.G.)
| | - Venkata Yellapantula
- Center for Personalized Medicine, Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.O.); (V.Y.); (M.B.); (J.A.B.); (X.G.)
- Department of Pathology and Laboratory Medicine, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Moiz Bootwalla
- Center for Personalized Medicine, Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.O.); (V.Y.); (M.B.); (J.A.B.); (X.G.)
- Department of Pathology and Laboratory Medicine, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Jaclyn A. Biegel
- Center for Personalized Medicine, Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.O.); (V.Y.); (M.B.); (J.A.B.); (X.G.)
- Department of Pathology and Laboratory Medicine, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Xiaowu Gai
- Center for Personalized Medicine, Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.O.); (V.Y.); (M.B.); (J.A.B.); (X.G.)
- Department of Pathology and Laboratory Medicine, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - Rishvanth K. Prabakar
- Department of Biological Sciences, Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA 90007, USA; (R.K.P.); (P.K.); (J.H.)
| | - Peter Kuhn
- Department of Biological Sciences, Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA 90007, USA; (R.K.P.); (P.K.); (J.H.)
- Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Department of Aerospace and Mechanical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90007, USA
- Department of Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90007, USA
| | - James Hicks
- Department of Biological Sciences, Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA 90007, USA; (R.K.P.); (P.K.); (J.H.)
- Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Department of Biochemistry and Molecular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Jesse L. Berry
- The Vision Center at Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (D.H.I.); (C.-C.P.); (L.X.); (M.E.K.)
- USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
- Correspondence:
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22
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Coupland S, Kalirai H, Taktak A, Eleuteri A, Damato B. Re: Gelmi et al.: Adding The Cancer Genome Atlas Chromosome Classes to American Joint Committee on Cancer System offers more precise prognostication in uveal melanoma (Ophthalmology. 2022:129:431-437). Ophthalmology 2022; 129:e78-e79. [DOI: 10.1016/j.ophtha.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022] Open
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