Mortality after deferral of treatment or no treatment for choroidal melanoma

Delays between Uveal Melanoma Diagnosis and Treatment Increase the Risk of Metastatic Death

PURPOSE

To investigate if the interval between diagnosis and treatment of posterior uveal melanoma (UM) is associated with metastatic death.

DESIGN

Retrospective, single-center cohort study.

PARTICIPANTS

A total of 1145 patients consecutively diagnosed with posterior UM at St. Erik Eye Hospital, Stockholm, Sweden, from 2012 to 2022, with recorded dates of diagnosis and primary treatment. This cohort represents 81% of all diagnosed patients in Sweden during this period.

METHODS

Data on the interval between diagnosis and treatment were collected for all patients. Its prognostic importance was examined with univariate and multivariate competing risks regressions, and cumulative incidence analyses.

MAIN OUTCOME MEASURES

Incidence of metastatic death (UM mortality) for patients with prompt (< 1 month from diagnosis) versus delayed treatment (≥ 1 month) and subdistribution hazard ratios (exp(βj)) for every additional 10-day delay in treatment.

RESULTS

The mean interval between diagnosis and treatment was 34 days (SD, 56, range, 0-932). Patients treated promptly had larger tumors at diagnosis, but there were no differences in patient age, tumor distance to the optic disc, rates of ciliary body involvement (CBI) or extraocular extension (EXE), or symptom duration before diagnosis. Those who were treated more than 1 month after diagnosis had greater UM mortality in American Joint Committee on Cancer (AJCC) stage II and III. In stage I, UM mortality for delayed treatment was lower for the first 10 years, followed by a marked spike in the 11th year. In multivariate competing risks regressions of all 1145 patients with tumor diameter, thickness, CBI, and EXE as covariates, the risk for UM mortality increased with 1% for every additional 10-day delay in treatment (exp(βj) 1.01). Among 355 patients treated with enucleation, this delay was associated with UM mortality, independent of AJCC stage, cytomorphology, and level of immunohistochemical BAP-1 expression.

CONCLUSIONS

Increasing time between diagnosis and treatment of UM is associated with a higher risk of metastatic death. These results challenge a central concept in the understanding of metastatic progression and may indicate the existence of late metastatic seeding. They also underscore the importance of prompt treatment. Validation in independent cohorts is recommended.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The Effects of Oncological Treatment on Redox Balance in Patients with Uveal Melanoma

(1) Background: Uveal malignant melanoma is the most common adult eye cancer and presents metabolic reprogramming that affects the tumoral microenvironment by altering the redox balance and producing oncometabolites. (2) Methods: The study prospectively evaluated patients undergoing enucleation surgery or stereotactic radiotherapy for uveal melanoma by following systemic oxidative-stress redox markers serum lipid peroxides, total albumin groups and total antioxidant levels (3) Results: Serum antioxidants and lipid peroxides were elevated from pre-treatment to longer-term follow-up. Antioxidants inversely correlated to lipid peroxides: higher in stereotactic radiosurgery patients pre/6/12/18 months post-treatment (p = 0.001-0.049) versus higher lipid peroxides in enucleation surgery patients pre/after/6 months post-treatment (p = 0.004-0.010). An increased variance in serum antioxidants was observed for enucleation surgery patients (p < 0.001), however enucleation did not increase mean serum antioxidants or albumin thiols; only lipid peroxides were increased post-enucleation (p < 0.001) and at 6-month follow-up (p = 0.029). Mean albumin thiols were increased for 18- and 24-month follow-ups (p = 0.017-0.022). Males who had enucleation surgery presented higher variance in serum determinations and overall higher lipid peroxides values pre/post-treatment and at the 18-month follow-up. (4) Conclusions: Initial oxidative stress-inducing events of surgical enucleation or stereotactic radiotherapy for uveal melanoma are followed by a longer-term inflammatory cascade gradually subsiding at later follow-ups.

Choroidal melanoma tumor profile and treatment pattern for newly diagnosed patients at a reference public hospital in Sao Paulo, Brazil

BACKGROUND

Choroid, ciliary body, and iris melanomas are often grouped as uveal melanoma, the most common intraocular primary malignancy. The purpose of the current study was to analyze the tumor profile of newly diagnosed cases of choroidal melanoma at a reference center in Sao Paulo, Brazil, and to investigate the frequency of eyes treated by enucleation that could have been treated with brachytherapy if available in the service.

METHODS

Medical records of patients referred to our service with initial diagnostic hypothesis of choroidal melanoma from July 2014 to June 2020 were analysed on demographics, diagnosis confirmation, tumor measurement by ultrasonography and established treatment. Data were evaluated on clinical and demographic characteristics as age, sex, affected eye, ultrasound parameters, and treatment management of patients with clinically diagnosed choroidal melanoma. Among the patients submitted to enucleation, we investigated how many could have been selected to receive brachytherapy.

RESULTS

From the 102 patients referred with the choroidal melanoma diagnosis hypothesis, 70 (68.62%) were confirmed. Mean measurements from the tumors in millimetres were: 9.19 ± 3.69 at height and 12.97 ± 3.09 by 13.30 ± 3.30 at basal. A total of 48 cases (68.57%) were enucleated, 8 (11.43%) were treated by brachytherapy in a different service, and 14 patients (20.00%) returned for enucleation at their original referral center. Out of the 48 patients enucleated, 26 (54.17%) could have been selected to brachytherapy treatment.

CONCLUSIONS

The results indicate a late diagnosis of choroidal melanoma cases referred to our service. Most enucleated cases could have been treated with brachytherapy if it was broadly available at the national public health insurance. Further public health political efforts should focus on early diagnosis and better quality of life post-treatment for oncologic patients.

The long-term prognosis of patients with untreated primary uveal melanoma: A systematic review and meta-analysis

PURPOSE

To examine patient survival in untreated primary uveal melanoma.

METHODS

Systematic review and meta-analysis.

RESULTS

Seven studies with a total of 19 patients were included. Fifteen patients died from metastases during a median follow-up of > 20 years. When excluding two patients with iris melanoma, fifteen of 17 patients with choroidal or ciliary body melanoma developed metastases. The cumulative disease-specific survival for these 17 patients was 71% at five years, 29% at 10 years, 18% at 15 years and 11% at 30 years. This was significantly worse than the survival in comparison cohorts of both medium-sized and large treated tumors (p < 0.001).

CONCLUSIONS

Among the exceedingly rare published patients with untreated primary uveal melanoma, 80-90% have developed metastases and their disease-specific survival seems to be shorter than treated patients. This could indicate that some metastases might be prevented by primary tumor treatment.

No differences in the long-term prognosis of iris and choroidal melanomas when adjusting for tumor thickness and diameter

Objective

To assess the long-term prognosis for patients with iris melanomas and compare it with the prognosis for small choroidal melanomas.

Design

Retrospective observational case series.

Methods

All patients treated for iris melanomas at a single referral institution between January 1st 1986 and January 1st 2016 were included. Patients treated for small choroidal melanomas during the same period were included for comparison. The cumulative incidence of melanoma-related mortality was calculated. Patient and tumor characteristics and size-adjusted hazard ratio (HR) for melanoma-related mortality were compared between iris and small choroidal melanomas.

Results

Forty-five iris melanomas and 268 small choroidal melanomas were included. Twenty-four iris melanomas (53%) had been treated with local resection, 12 (27%) with Ruthenium-106 brachytherapy, 7 (16%) with enucleation and 2 (4%) with proton beam irradiation. Twenty-one (68%), 7 (16%) and 2 (4%) of the iris melanomas were of the spindle, mixed and epithelioid cell types, respectively. Twenty-three patients had deceased before the end of follow-up. Median follow-up for the 22 survivors was 13.3 years (SD 9.4). Patients with iris melanomas were more often asymptomatic at presentation and had a trend towards significantly lower age (59 versus 63 years, Student’s T-tests p = 0.057). Further, iris melanomas had significantly smaller basal diameter (5.8 versus 8.0 mm, p < 0.0001) and tumor volume (79 mm³ versus 93 mm mm³, p < 0.0001) but greater thickness (3.0 versus 2.5 mm, p < 0.0001). The cumulative incidence of iris melanoma-related mortality was 5% at 5 years after diagnosis, and 8% at 10, 15 and 20 years. The incidence was not significantly different to small choroidal melanomas (Wilcoxon p = 0.46). In multivariate Cox regression with tumor diameter and thickness as covariates, patients with choroidal melanomas did not have increased HR for melanoma-related mortality (HR 2.2, 95% CI 0.5–9.6, p = 0.29). Similarly, there were no significant survival differences in matched subgroups (Wilcoxon p = 0.82).

Conclusions

There are no survival differences between iris and choroidal melanomas when adjusting for tumor size. The reason for the relatively favorable prognosis of iris melanomas compared to melanomas of the choroid and ciliary body is likely that they are diagnosed at a smaller size.

Uveal Melanoma: Refusal of Treatment

Purpose

This study aimed to explore factors for refusing treatment in patients diagnosed with uveal melanoma and their subsequent clinical course.

Methods

This study included patients with uveal melanoma who refused standard of care treatment. Patient-reported reasons and pre-existing mental health diagnoses were assessed. The sociodemographic profile was compared with the controls. Ocular survival, metastasis-free survival (MFS), and overall survival (OS) were calculated.

Results

Nine patients with uveal melanoma declined ocular treatment (plaque brachytherapy, n = 7 [78%]; enucleation, n = 2 [22%]). The choroidal melanomas were small (n = 1 [11%]), medium (n = 5 [56%]), and large (n = 3 [33%]) in size (COMS criteria). The sociodemographic profile of the study patients was not different from those that accepted treatment. One patient (11%) had pre-existing mental health diagnosis. Five patients (56%) eventually accepted treatment following an average delay of 19 months (range: 4-55 months) due to neovascular glaucoma or severe vision loss. MFS could not be ascertained, and OS was 67% (6/9) at 4.2 years of follow-up (mean).

Conclusions

Refusal of initial recommended treatment is associated with poor ocular survival. The small sample size did not allow for an evaluation of the impact on survival.

Uveal melanoma diagnosis and current treatment options (Review)

Uveal melanoma is a rare condition accounting for only 5% of all primary melanoma cases. Still, it is the most frequently diagnosed primary intraocular malignant tumor in adults. Almost 90% of the tumors involve the choroid and only a small percentage affects the ciliary body or the iris. There is a consistent difference in incidence between different regions with individuals of northern European descent having a significantly higher risk as compared to Hispanics, Asians, and Blacks. Among the many risk factors, mutations in the G protein subunit alpha Q (GNAQ) or G protein subunit alpha 11 (GNA11) genes and different receptors are highly suggestive. While iris melanoma can easily be noticed by the patient itself or diagnosed at a routine slit-lamp evaluation, a consistent percentage of posterior uveal tumors are incidentally diagnosed at funduscopic evaluation as they can evolve silently for years, especially if located in the periphery. Uveal melanoma classifications rely on the tumor size (thickness and basal diameter) and also on intraocular and extraocular extension. The differential diagnosis with pseudomelanomas is carried out according to the tumor aspect and position. Iris melanoma has a better prognosis and a lower mortality rate as compared to choroidal melanoma that has a much higher rate of metastasis (50% of the patients) and a subsequent limited life expectancy from 6 to 12 months. While conservative therapeutic options for the primary tumor, relying on different surgical excision techniques and/or irradiation therapies, offer good local tumor control, the treatment options for metastatic disease, although numerous, are still inadequate in preventing a fatal outcome.

Five-Year Follow-up of Microincisional Vitrectomy Surgery, Endolaser Tumor Ablation, and Gene-Expression Profiling in Small Uveal Melanoma

Purpose:

This work evaluates a microincisional vitrectomy surgical (MIVS) approach to endolaser ablation of small uveal malignant melanoma by incorporating genetic tumor classification as a means to avoid radiotherapy while maintaining local tumor control without compromising visual acuity (VA).

Methods:

An institutional review board–approved, single-surgeon, retrospective analysis was conducted of a consecutive case series of all patients with tumors less than 2.5 mm in apical thickness who underwent MIVS, endolaser tumor ablation, fine-needle aspiration biopsy (FNAB), and intravitreal triamcinolone acetonide for small uveal melanoma between 2012 and 2015.

Results:

A total of 226 patients underwent FNAB from January 2012 to January 2015 for uveal melanoma. All 58 patients treated for a small uveal melanoma were included. This group of patients had a minimum follow-up of 60 months (range, 60-93 months). At initial diagnosis, subretinal fluid was present in 52 eyes (89.1%), macular edema was present in 24 eyes (41.4%), and epiretinal membrane was present in 11 eyes (20.1%). Fifty-six specimens (96.5%) received a molecular classification of either class 2 (4 of 56, 7.1%) or class 1 (52 of 56, 92.8%). Initial VA was 20/40 or better in 26 eyes (44.8%), and final VA was 20/40 or better in 48 of 58 eyes (82.8%).

Conclusions:

Endolaser tumor ablation delivered at MIVS surgery enables excellent tumor control (98.3%) and improves VA to better than 20/40 in more than 80% of treated eyes. FNAB achieves molecular classification in 96.5% of all patients undergoing treatment for small choroidal melanoma independent of tumor size.

Small High-Risk Uveal Melanomas Have a Lower Mortality Rate

Simple Summary

The current paradigm concerning metastatic spread in uveal melanoma is that the critical point for dissemination occurs prior to presentation and that treatment of the primary tumor does not change outcome. However, we show that patients with small uveal melanomas with genetic characteristics typical for high risk for metastatic disease have a lower mortality rate from metastatic disease, if treated earlier. Our data demonstrate that such small melanomas are potentially lethal (like larger tumors), but that there is a window of opportunity to prevent life-threatening metastatic spread if actively treated, rather than being monitored, as is often done currently.

Abstract

Our aim was to determine whether size impacts on the difference in metastatic mortality of genetically high-risk (monosomy 3) uveal melanomas (UM). We undertook a retrospective analysis of data from a patient cohort with genetically characterized UM. All patients treated for UM in the Liverpool Ocular Oncology Centre between 2007 and 2014, who had a prognostic genetic tumor analysis. Patients were subdivided into those with small (≤2.5 mm thickness) and large (>2.5 mm thickness) tumors. Survival analyses were performed using Gray rank statistics to calculate absolute probabilities of dying as a result of metastatic UM. The 5-year absolute risk of metastatic mortality of those with small monosomy 3 UM was significantly lower (23%) compared to the larger tumor group (50%) (p = 0.003). Small disomy 3 UM also had a lower absolute risk of metastatic mortality (0.8%) than large disomy 3 UM (6.4%) (p = 0.007). Hazard rates showed similar differences even with lead time bias correction estimates. We therefore conclude that earlier treatment of all small UM, particularly monosomy 3 UM, reduces the risk of metastatic disease and death. Our results would support molecular studies of even small UM, rather than ‘watch-and-wait strategies’.

Practice Considerations for Proton Beam Radiation Therapy of Uveal Melanoma During the Coronavirus Disease Pandemic: Particle Therapy Co-Operative Group Ocular Experience

Uveal melanoma (UM) is a rare but life-threatening cancer of the eye. In light of the coronavirus disease (COVID-19) pandemic, hospitals and proton eye therapy facilities must analyze several factors to ensure appropriate treatment protocols for patients and provider teams. Practice considerations to limit COVID-19 transmission in the proton ocular treatment setting for UM are necessary. The Particle Therapy Co-Operative Group is the largest international community of particle/proton therapy providers. Participating experts have current or former affiliation with the member institutions of the Particle Therapy Co-Operative Group Ocular subcommittee with long-standing high-volume proton ocular programs. The practices reviewed in this document must be taken in conjunction with local hospital procedures, multidisciplinary recommendations, and regional/national guidelines, as each community may have its unique needs, supplies, and protocols. Importantly, as the pandemic evolves, so will the strategies and recommendations. Given the unique circumstances for UM patients, along with indications of potential ophthalmologic transmission as a result of health care providers working in close proximity to patients and intrinsic infectious risk from eyelashes, tears, and hair, practice strategies may be adapted to reduce the risk of viral transmission. Certainly, providers and health care systems will continue to examine and provide as safe and effective care as possible for patients in the current environment.

Outcome Analysis of Visual Acuity and Side Effect after Ruthenium-106 Plaque Brachytherapy for Medium-sized Choroidal Melanoma

PURPOSE:

The purpose of this study is to report on treatment outcomes for medium-sized choroidal melanoma treated with Ruthenium-106 (Ru-106) plaque brachytherapy.

METHODS:

A retrospective case series of 28 patients received Ru-106 brachytherapy treatment for choroidal melanoma. The prescribed tumor dose was 85 Gy to a depth of 5 mm.

RESULTS:

Median follow-up was 31.2 months. At 12 and 24-month postirradiation, the best corrected visual acuity ≥20/70 (LogMar ≥−0.54) was 53.8% and 64.2%, respectively. Median time to tumor regression was estimated to be 10 months (95% CI = 9–18 months), with 100% of response rate by 32 months. Radiation-induced side effects were limited, and there were no postradiation enucleations.

CONCLUSIONS:

The majority of patients maintained good visual acuity, with no enucleations and minimal side effects. In this cohort, the Ru-106 plaque brachytherapy proved to be an efficacious and safe treatment option for patients with medium-sized choroidal melanomas with a maximal tumor height of 5 mm.

The Collaborative Ocular Melanoma Study: An Overview

BACKGROUND

The Collaborative Ocular Melanoma Study (COMS) is a 3-arm study that includes two multicenter randomized clinical trials designed to compare the effectiveness of brachytherapy to enucleation for treatment of medium-size choroidal melanomas, and the effectiveness of enucleation with and without preoperative external-beam radiotherapy for large choroidal melanomas. The third arm is an observational study of small choroidal melanomas. Patient accrual ran from 1987 to 1998.

METHODS

A review of COMS published reports was conducted.

RESULTS

There is no difference in 5-year all-cause mortality for large- and medium-size choroidal melanomas with COMS-designated treatments. Preoperative radiation for large choroidal melanomas does not improve survival. The accuracy of the clinical diagnosis of choroidal melanoma is excellent.

CONCLUSIONS

Data from the trials are still being collected and analyzed, but primary outcomes will unlikely change significantly in the future. Similar rates of mortality after treatment with enucleation and brachytherapy shift the emphasis of selection of therapy to secondary outcomes such as preservation of vision. The findings highlight the need to better understand the biological mechanisms and timing of hematogenous dissemination to achieve an appreciable impact on choroidal melanoma survival.

Prognostic factors of choroidal melanoma in Slovenia, 1986-2008

Introduction

Choroidal melanoma is the most common primary malignancy of the eye, which frequently metastasizes. The Cancer Registry of Slovenia reported the incidence of choroid melanoma from 1983 to 2009 as stable, at 7.8 cases/million for men and 7.4/million for women. The aim of the retrospective study was to determinate the prognostic factors of survival for choroidal melanoma patients in Slovenia.

Patients and methods

From January 1986 to December 2008 we treated 288 patients with malignant choroidal melanoma; 127 patients were treated by brachytherapy with beta rays emitting ruthenium-106 applicators; 161 patients were treated by enucleation.

Results

Patients with tumours thickness < 7.2 mm and base diameter < 16 mm were treated by brachytherapy and had 5- and 10-year overall mortality 13% and 32%, respectively. In enucleated patients, 5- and 10-year mortality was higher, 46% and 69%, respectively, because their tumours were larger. Thirty patients treated by brachytherapy developed local recurrence. Twenty five of 127 patients treated by brachytherapy and 86 of 161 enucleated patients developed distant metastases. Patients of age ≥ 60 years had significantly lower survival in both treatment modalities. For patients treated by brachytherapy the diameter of the tumour base and treatment time were independent prognostic factors for overall survival, for patients treated by enucleation age and histological type of tumour were independent prognosticators. In first few years after either of treatments, the melanoma specific annual mortality rate increased, especially in older patients, and then slowly decreased.

Conclusions

It seems that particularly younger patients with early tumours can be cured, whereby preference should be given to eyesight preserving brachytherapy over enucleation.

Clinicopathological correlation for the role of fluorodeoxyglucose positron emission tomography computed tomography in detection of choroidal malignant melanoma

BACKGROUND

The purpose of this study was to redefine the role of whole-body 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG) positron emission tomography fused with computed tomography (PET/CT) in the clinical diagnosis of choroidal malignant melanoma.

METHODS

The study design was a retrospective case series involving 7 consecutive patients with choroidal malignant melanoma who underwent enucleation to reach the final pathological diagnosis. FDG-PET/CT was performed together with magnetic resonance imaging and ophthalmological examinations before the surgery. The area, thickness, longest diameter, and circumference of the tumor mass were measured on pathological sections, and were correlated with maximum standardized uptake values (SUVmax) of the tumors on FDG-PET/CT.

RESULTS

Abnormally high uptake of FDG was noted in the affected eyes of 5 patients, but not in the eyes of 2 patients. The 5 patients with high uptake showed nodular tumors extruding into the vitreous cavity while the 2 patients with absence of uptake showed diffusely infiltrating tumors in the wide area of the choroid with or without a small mushroom-like protrusion. One patient with diffuse infiltration showed concurrent liver metastases with high uptake on PET/CT while another patient with a nodular tumor developed liver metastases a year later. The tumors with higher SUVmax had a tendency to have a wider area and greater thickness on pathological sections (ρ = 0.775, P = 0.0557, Spearman rank correlation test).

CONCLUSIONS

FDG-PET/CT showed correlation of the uptake with tumor sizes but was limited in detecting diffusely infiltrating tumors in the choroid without nodular formation.

Collaborative ocular melanoma study randomized trial of I-125 brachytherapy

BACKGROUND

Although findings from observational studies published in the 1970s and early 1980s suggested that length of remaining life after a diagnosis of uveal melanoma was similar following enucleation (removal of the eye) and local eye-conserving radiotherapy, the majority of ophthalmologists in the United States were not convinced that "saving the eye" would not compromise survival.

PURPOSE

The Collaborative Ocular Melanoma Study (COMS) was designed to compare enucleation and radiotherapy among similar patients with respect to survival outcomes.

METHODS

A multicenter randomized trial of primary treatment with iodine-125 brachytherapy versus enucleation (i.e., a comparative effectiveness trial) was conducted to provide the evidence required to answer the concerns of ophthalmologists and their patients. Eligibility criteria adopted for the trial were intended to apply to the majority of patients diagnosed with choroidal melanoma who would be suitable candidates for either form of primary treatment.

RESULTS

Accrual to this COMS trial began in 1986 and ended in 1998. Participating patients were followed for 5 to 15 years, depending upon date of enrollment, before all clinical follow-up ended in 2003. No difference in survival outcomes and little difference in quality-of-life outcomes were observed between patients in the brachytherapy arm and those in the enucleation arm. Five-year survival was substantially better than anticipated based on a review of the literature when the trial was designed.

LIMITATIONS

The choice of brachytherapy for delivery of radiation to the tumor had important advantages but also imposed restrictions regarding eligibility.

CONCLUSIONS

The multidisciplinary COMS Group not only successfully conducted a randomized trial that answered the primary study questions but also has contributed to clinical and epidemiologic knowledge of choroidal melanoma through numerous publications. As a consequence of the COMS, a standard approach to I-125 brachytherapy for treatment of choroidal melanoma became widely available to affected patients.

Does ocular treatment of uveal melanoma influence survival?

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

Frontal skull craniotomy combined with moderate-dose radiotherapy effectively ameliorate a rare case of non-secretory, multiple myeloma with orbital involvement

BACKGROUND

Orbital infiltration in patients with multiple myeloma is a rare condition, with less than 50 cases reported in the medical literature. Most patients undergo conservative treatment because multiple myeloma is a disseminated systemic disease.

CASE PRESENTATION

A 43-year-old male subject with multiple myeloma and long-term survival presented with orbital involvement. The subject lacked the typical features and poor prognostic factors associated with multiple myeloma, such as renal failure, hypercalcemia, and paraprotein in the serum and urine. The orbital computed tomographic scan revealed the tumor encasing the optic nerve, but without prominent bony destruction. Therefore, a frontal skull craniotomy with an epidural entrance to the orbital space was performed, to completely extirpate the orbital mass. The surgical procedure was followed by moderate-dose radiation therapy. After 32 months of follow-up care, the subject is doing well with excellent local control.

CONCLUSION

Although the effectiveness and applicability of this approach remains to be determined, this case report demonstrates that accurate and early detection combined with local surgical treatment and appropriate radio/chemotherapy, can be applied to effectively extend an orbital multiple myeloma patient's life.

Ocular melanoma: relatively rare but requiring respect

Primary ocular melanoma can involve the uveal tract, conjunctiva, eyelid, or orbit. Uveal melanoma is the most common ocular melanoma and carries a serious prognosis, especially if the tumor is medium or large in size. Conjunctival melanoma manifests on the surface of the eye and has been increasing in incidence. Eyelid and primary orbital melanoma are the least common variants. Early diagnosis from annual ocular examination by an experienced ophthalmologist and treatment strategies are reviewed.

Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not participate

BACKGROUND

Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up-to-date physicians and treatments. This is an updated version of the original Cochrane review published in Issue 1, 2005.

OBJECTIVES

To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not. We aimed to compare similar patients receiving similar treatment inside and outside of RCTs.

SEARCH STRATEGY

In March 2007, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded 7586 new references. In addition, we reviewed the reference lists of relevant articles.

SELECTION CRITERIA

Randomized studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies for inclusion, assessed study quality and extracted data.

MAIN RESULTS

We identified 30 new non-randomized cohort studies (45 comparisons): no new RCTs were found. This update now includes five RCTs (yielding 6 comparisons) and 80 non-randomized cohort studies (130 comparisons), with 86,640 patients treated in RCTs and 57,205 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. When the results of RCTs and non-randomized cohorts that reported dichotomous outcomes were combined, there were 98 comparisons; there was also heterogeneity (P < 0.00001, I(2) = 42.2%) between studies. No statistical significant differences were found for 85 of the 98 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. There was significant heterogeneity (P < 0.00001, I(2) = 58.2%) among the 38 continuous outcome comparisons. No statistically significant differences were found for 30 of the 38 comparisons. Three comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs.

AUTHORS' CONCLUSIONS

This review indicates that participation in RCTs is associated with similar outcomes to receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.

Small Choroidal Melanocytic Lesions

PURPOSE

To evaluate clinical features at presentation of small choroidal melanocytic lesions that were predictive of growth.

DESIGN

Retrospective observational case series.

PARTICIPANTS

A cohort of 240 patients with a presumptive diagnosis of small choroidal melanocytic lesions who were observed to document growth before treatment.

METHODS

Data regarding size, location, diagnostic features, and growth were collected. To evaluate the diagnostic features at presentation, Barnard and Fisher exact tests were performed for categorical variables, and the Wilcoxon rank sum test was used for continuous factors.

MAIN OUTCOME MEASURE

Documented growth.

RESULTS

Eleven patients with small choroidal melanocytic lesions (4.6%) demonstrated growth within 50 months of follow-up. Lesions that demonstrated growth were significantly thicker (> or =2.0 mm; P<0.001) and closer to the foveola (<3.0 mm; P = 0.002). Significant increases in the risk of growth also were observed for gender (male), presence of symptoms, and orange pigment.

CONCLUSIONS

Significant clinical features of small choroidal melanocytic lesions predictive of growth are greater thickness (> or =2.0 mm), location closer to the foveola (<3.0 mm), and presence of symptoms and orange pigment.

18 years' experience with high dose rate strontium-90 brachytherapy of small to medium sized posterior uveal melanoma

AIM

To analyse local tumour control, radiation related complications, visual acuity, enucleation rate, and survival after brachytherapy of small to medium sized choroidal melanoma (CM) with a high dose rate (HDR) strontium-90 (Sr-90) applicator.

METHODS

From 1983 until 2000, 98 eyes with CM were treated with Sr-90 brachytherapy. The main outcome measures were actuarial rates of the patients' survival, ocular conservation rate, tumour regression, complication rates, and preservation of visual acuity. End point rates were estimated using Kaplan-Meier analysis.

RESULTS

The median follow up time was 6.7 years (0.5-18.8 years). Actuarial melanoma free patient survival rate was 85% (SE 4.8%) after 18 years. Actuarial rate of ocular conservation and complete tumour regression was 90% (SE 3.8%) after 15 years. In 93% local tumour control was achieved, 88% showed a stable scar. Recurrence of the tumour on the border caused enucleation of six eyes (7%). In three cases (4%) retinal detachment was the end point. No cases of optic atrophy or of sight impairing retinopathy outside the treated area were found. Actuarial rate of preservation of visual acuity of 1/10 was 65% at 5 years and 45% at 15 years of follow up (SE 5.9% and 8.8%).

CONCLUSIONS

Sr-90 brachytherapy is as effective as iodine or ruthenium brachytherapy for small to medium sized CM but causes fewer complications. The preservation of vision is better than with all other described radioisotopes. HDR Sr-90 brachytherapy can therefore safely be recommended for small to medium sized CM.

Recent developments in the management of choroidal melanoma

PURPOSE OF REVIEW

To describe recent advances in the management of choroidal melanoma.

RECENT FINDINGS

During the past 10 years, there has been a trend in the management of choroidal melanoma from enucleation to conservative nonenucleation treatments such as thermotherapy, plaque radiotherapy, charged-particle radiotherapy, and local resection. Recently published information regarding conservative management has revealed that plaque radiotherapy combined with thermotherapy offers 97% tumor control, similar to charged-particle radiotherapy. Additionally, patient survival after treatment of medium-size melanoma is similar when comparing plaque radiotherapy versus enucleation. Risk factors identifying small choroidal melanoma include patient symptoms, tumor thickness more than 2 mm, presence of associated subretinal fluid, presence of orange pigment on the tumor surface, and location of the tumor margin at the optic disc. These factors assist in early detection of choroidal melanoma.

SUMMARY

The management of choroidal melanoma continues to improve with earlier detection of tumors and better treatment methods. Local tumor control is excellent with radiotherapeutic methods. Future studies should investigate control of subclinical metastasis.

Changing concepts in the management of choroidal melanoma

PURPOSE

To review emerging information related to changing concepts in the management of choroidal melanoma.

DESIGN AND METHODS

This perspective reviews and discusses selected studies from the past two decades that have influenced management strategies for large, medium, and small-size choroidal melanomas.

RESULTS

Large choroidal tumors continue to be managed primarily by enucleation. The large tumor trial of the Collaborative Ocular Melanoma Study (COMS) demonstrated neither a positive nor negative effect on 5- and 8-year mortality rates among more than 1000 patients whose eyes containing large choroidal melanomas were randomized to treatment between enucleation alone or enucleation preceded by external radiation. The medium-size tumor trial of the COMS randomized more than 1300 patients between iodine-125 brachytherapy and enucleation. Mortality rates following brachytherapy did not differ from mortality rates following enucleation for up to 12 years after treatment. Iodine-125 has become the most commonly used isotope for brachytherapy in North America. Ten-year follow-up of eyes treated with helium ion and 20 years of experience with proton beam confirm the relative safety and efficacy of these modalities for treatment of choroidal melanoma. Although there is a trend toward earlier treatment of small melanomas, controversy exists regarding the indications for treatment as well as the choice of specific therapy. Recurrences of melanoma after eye-sparing treatment appear to be associated with an increased rate of metastatic disease. Effective adjunctive therapy to prevent or treat melanoma metastasis is lacking.

CONCLUSIONS

Choroidal melanoma is a lethal tumor. Although evidence suggests that patients with untreated choroidal melanomas have a poorer prognosis than patients who receive treatment, our current treatments are unable to prevent tumor-related deaths for many patients. The use of preoperative external radiation as an adjunct to enucleation for large choroidal melanomas is unsupported by data from the COMS trial. The use of radiation with either brachytherapy or charged particles for the management of medium-size choroidal melanomas is well supported on the basis of long-term follow-up studies. There is a trend toward treatment of smaller choroidal melanomas. Treatment of melanomas should be directed toward minimizing the potential for recurrences as recurrent melanomas are associated with an increased rate of metastatic disease. Gains in our ability to manage choroidal melanoma will likely be modest at best until effective systemic therapies can be identified.