Prognostic parameters in uveal melanoma: a review

Comparative Study of Ultrasonography and Ultra-Widefield Fundus Photographs for Measurements of the Diameter of Choroidal and Retinal Tumors

INTRODUCTION

Measurement of the largest basal dimension (LBD) of intraocular tumors is important as a prognostic parameter. To evaluate the potential value of true color ultra-widefield fundus photography for measuring tumors, we compared LBD measurements of choroidal and retinal tumors using a color ultra-widefield fundus camera with clinical estimation based on indirect ophthalmoscopy and standardized ophthalmic ultrasound.

METHODS

The LBD of 148 choroidal and retinal tumors in 148 patients seen at Tongren Hospital were measured using ultra-widefield fundus photography and compared with measurements obtained using B-scan ultrasonography and clinical estimates based on indirect ophthalmoscopy.

RESULTS

Paired t-tests and Bland-Altman plots reveal that measurements from ultra-widefield fundus photographic images are not statistically different from clinical estimates and ultrasound measurements. The results also showed that, although not statistically significant, when the tumor boundary was clear, the height was < 3 mm, or the tumor was pigmented, measurement from ultra-widefield fundus photography tended to be greater than those obtained by ultrasound.

CONCLUSIONS

The LBD measurement using ultra-widefield fundus photography correlated well with ultrasonography and clinical estimation and could be used as a reliable tool for measuring the LBD of choroidal and retinal tumors.

Single-Masked Randomized Phase 2 Study Assessing 2 Forms of Hypofractionated Proton Therapy in Patients With Large Choroidal Melanomas

PURPOSE

Patients with large uveal melanomas are at major risk of liver metastases. Some patients are reluctant to undergo the standard treatment (ie, immediate enucleation). Proton therapy yields 5-year local control rates and eyeball retention of >85% and ≈20% in large uveal melanomas. Patients with T3/T4 uveal melanomas refusing enucleation were randomized between standard 4 to 13 Gy-fraction or moderately hypofractionated 8 to 6.5 Gy-fraction proton therapy. The main endpoint was the 2-year local recurrence-free survival without enucleation.

METHODS AND MATERIALS

A single-masked 1:2 randomized phase 2 trial was conducted between 2015 and 2017 with planned endoresection and distance to the posterior pole as strata. Local events were defined as local relapse, or enucleation due to complications or relapse.

RESULTS

The 32 patients, with a mean age of 64 years, had T3/4 (N = 17/15), M1 (N = 2) uveal melanomas, of mean tumor diameter and thickness of 16.5 mm and 9.1 mm, and of posterior location in 56.5%. Median follow-up was 56.7 months. The 2-year local recurrence-free survival rate without enucleation was 79% (95% confidence interval, 65%-96%), similar in both arms. There were 9 enucleations, 3 at relapse and 6 for toxicities. Twelve patients had distant metastases. The 2-year-overall survival was 72% (95% confidence interval, 58%-89%). At baseline, visual acuity by average logarithm value of the minimum angle of resolution was 0.68 and 0.70 in the standard and experimental arms, and at last follow-up 2 and 1.7, with mean differences of 1.44 and 1.01, respectively (P = .39).

CONCLUSION

An 8-times 6.5 Gy scheme is feasible without deteriorating local control and with similar toxicity rates in patients with large uveal melanomas. Larger studies incorporating adjuvant treatments are warranted.

Microphthalmia-Associated Transcription Factor: A Differentiation Marker in Uveal Melanoma

Microphthalmia-associated transcription factor (MITF) is an important regulator of melanogenesis and melanocyte development. In cutaneous melanoma, MITF loss has been linked to an increased expression of stem cell markers, a shift in epithelial-to-mesenchymal transition (EMT)-related factors, and increased inflammation. We explored the role of MITF in Uveal Melanoma (UM) using a cohort of 64 patients enucleated at the Leiden University Medical Center. We analysed the relation between MITF expression and clinical, histopathological and genetic features of UM, as well as survival. We performed differential gene expression and gene set enrichment analysis using mRNA microarray data, comparing MITF-low with MITF-high UM. MITF expression was lower in heavily pigmented UM than in lightly pigmented UM (p = 0.003), which we confirmed by immunohistochemistry. Furthermore, MITF was significantly lower in UM with monosomy 3/BAP1 loss than in those with disomy 3/no BAP1 loss (p < 0.001) and with 8q gain/amplification 8q (p = 0.02). Spearman correlation analysis showed that a low MITF expression was associated with an increase in inflammatory markers, hallmark pathways involved in inflammation, and epithelial-mesenchymal transition. Similar to the situation in cutaneous melanoma, we propose that MITF loss in UM is related to de-differentiation to a less favourable EMT profile and inflammation.

Identification and validation of a CCL18-related signature for prediction of overall survival in patients with uveal melanoma

Uveal melanoma (UM), the most frequent primary intraocular tumor in adults, has poor prognosis. High C-C motif chemokine ligand 18 (CCL18) has been detected in various tumors and is closely correlated with patients' clinicopathological characteristics. However, the essential role of CCL18 in UM remains unclear. Therefore, this study aimed to explore the prognostic value of CCL18 in UM. Uveal melanoma cells (M17) were transfected with pcDNA3.1-CCL18 si-RNA using Lipofectamine™ 2000. Cell growth and invasion abilities were measured through Cell Counting Kit-8 assay and invasion assay. RNA expression data and clinical and histopathological details were downloaded from the UM in The Cancer Genome Atlas (TCGA-UM) and GSE22138 datasets, which were defined as the training and validation cohorts, respectively. Univariate and multivariate Cox regression analyses were performed to identify significant prognostic biomarkers. The coefficients of these significant biomarkers generated by multivariate Cox proportional hazard regression analysis were used to establish a risk score formula. Functional enrichment analyses were also carried out. We found that downregulated CCL18 inhibits M17 cell growth and invasion in vitro. CCL18 may affect UM progression by altering C-C motif receptor 8 related pathways. Higher CCL18 expression was associated with worse clinical outcomes and tumor-specific death in the TCGA-UM dataset. Based on the coefficients obtained from the Cox proportional hazard regression analysis, a CCL18-related prognostic signature formula was constructed as follows: risk score = 0.05590 × age +2.43437 × chromosome 3 status +0.39496 × Expression^CCL18. Notably, in this formula, the normal chromosome 3 was coded as 0, whereas the chromosome 3 loss was coded as 1. Each patient was assigned to either low-risk or high-risk groups using the median cut-off in the training cohort. High-risk patients survived for a shorter time than low-risk patients. The time-dependent and multivariate receiver operating characteristic curves showed promising diagnostic efficacy. Multivariate Cox regression analysis demonstrated the potential of this CCL18-related signature as an independent prognostic indicator. These results were validated using the GSE22138 dataset. In addition, in both TCGA-UM and GSE22138 datasets, stratification of clinical correlations and survival analyses based on this signature indicated the involvement of clinical progression and survival outcome in UM. In the high-risk group, Gene Ontology analyses mainly indicated the enrichment of immune response pathways, such as the T cell activation, response to interferon-gamma, antigen processing and presentation, interferon-gamma-mediated signaling pathway, MHC protein complex, MHC class II protein complex, antigen binding, and cytokine binding. Meanwhile, Kyoto Encyclopedia of Genes and Genomes analyses showed enrichments of pathways in cancer, cell adhesion, cytokine-cytokine receptor interaction, chemokine signaling pathway, Th1 and Th2 cell differentiation, and chemokine signaling pathway. Moreover, single-sample gene set enrichment analysis demonstrated the enrichment of almost all immune cells and immune functions in the high-risk group. In summary, a new prognostic CCL18-related signature was successfully established using the TCGA-UM dataset and validated using the GSE22138 dataset with meaningful predictive and diagnostic efficacies. This signature could serve as an independent and promising prognostic biomarker for patients with UM.

Cytogenetic Abnormalities for Predicting the Risk of Metastases in Choroidal and Ciliary Body Melanoma

Purpose

Choroidal melanoma (CM) and ciliary body melanoma (CBM) are the two most common subtypes of uveal melanoma. Starting from the observation that CBM tends to have a higher metastatic potential than CM, we hypothesized that specific cytogenetic abnormalities could be associated with tumor location - reflecting distinct genetic signatures that would drive the risk of distant spread.

Methods

Chromosomal alterations were investigated by molecular cytogenetic techniques in 217 and 97 patients with CM and CBM, respectively. Cox proportional hazards regression analysis was used to identify the independent predictors of distant metastasis.

Results

Patients with CBM had larger tumor sizes (P < 0.001), higher disease stages (P < 0.001), and more frequently showed distant metastasis (P = 0.002) than those with CM. On analyzing the entire study cohort, we found that specific chromosomal alterations - including chromosome 8p loss (P < 0.001), 1p loss (P < 0.001), and monosomy 3 (P < 0.005) - were independent predictors of distant metastasis. Based on a decision-tree learning algorithm, we identified three specific subgroups of patients with uveal melanoma at high risk of distant spread. Monosomy 3 occurred significantly more frequently in patients with T3 CBM tumors.

Conclusions

Specific cytogenetic abnormalities - including chromosome 8p loss, 1p loss, and monosomy 3 - are independent risk factors for distant metastasis in uveal melanoma. Larger tumor size at presentation and monosomy 3 contribute to a higher metastatic risk in patients with CBM.

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.

Detection of Uveal Melanoma by Multiplex Immunoassays of Serum Biomarkers

Multiplex immunoassays simultaneously measure multiple analytes in a single sample providing quantitative data via parallel analyses, which is especially suitable for serum biomarker verification and validation. Multiplex immunoassays demonstrate several advantages over traditional enzyme-linked immunosorbent assays such as increasing productivity, conserving critical reagents and samples, and delivering results quickly. Here we describe the detection of uveal melanoma by magnetic bead-based multiplex immunoassays of serum biomarkers. The biomarker panels evaluated by multiplex immunoassays with high analytical performance demonstrated potential complementary values in detection of uveal melanoma.

PD-1 expression on uveal melanoma induces tumor proliferation and predicts poor patient survival

INTRODUCTION

Uveal melanoma is one of the most common primary intraocular malignant tumors with poor prognosis and limited treatments. Programmed cell death receptor-1 (PD-1) blockade represents the primary treatment strategy of immune checkpoint inhibition; however, there is a lack of studies on whether PD-1 expression in primary (ocular) uveal melanoma affects tumor progression.

METHODS

PD-1 expression in 82 cases of primary (ocular) uveal melanoma was detected by immunohistochemistry. The clinical significance of PD-1 expression was evaluated using univariate and multivariate analysis. PD-1 overexpression and knockdown studies were conducted in C918 and Mum-2B cell lines to analyze the effect of PD-1 expression on tumor cell proliferation and intracellular cell signaling transduction. real-time qPCR (RT-qPCR) and western blot analysis were performed to investigate the gene expression level. CCK8 assays were performed to examine the cell proliferation ability.

RESULTS

High expression of primary (ocular) intratumor PD-1 was associated with poor patient survival. Moreover, PD-1 expression was correlated with the largest tumor diameter. PD-1 expression and optic nerve invasion were independent prognostic risk factors. PD-1 overexpression in uveal melanoma cell lines promoted tumor cell proliferation, while knockdown of PD-1 inhibited cell proliferation capacity.

CONCLUSION

Our study established the role of PD-1 in the progression of uveal melanoma and provided a new potential treatment selection for uveal melanoma.

The Role of Mutation Rates of GNAQ or GNA11 in Cases of Uveal Melanoma in Japan

GNAQ and GNA11 mutations are thought to be important for the tumorigenesis of uveal melanoma. Although previous studies have reported on mutation rates in cases of uveal melanoma, presently, no such report for the Japanese population exists. In this study, we examined the frequency of GNAQ and GNA11 somatic mutations in cases of uveal melanoma in Japan and their relationship with clinicopathologic features or Ki-67-positive cell rates (Ki-67 labeling index: Ki-67 LI) using immunofluorescence methods. The study involved 19 cases of uveal melanoma. We extracted the template DNA from formalin-fixed, paraffin-embedded specimens using a DNA extraction kit. We amplified the DNA sequences of GNAQ and GNA11 using polymerase chain reaction and analyzed mutations by direct sequencing. We evaluated Ki-67 LI using immunofluorescence methods. The frequencies of GNAQ and GNA11 somatic mutations were 26.3% (5/19) and 31.6% (6/19), respectively. The GNAQ and GNA11 mutations were mutually exclusive, as indicated in previous reports. The frequency of GNA11 mutations was significantly higher in epithelioid cells; however, no significant association between GNAQ mutations and cell type was evident, and there was no significant difference in Ki-67 LI between the mutation-positive and mutation-negative tumors. GNAQ and GNA11 mutations were identified in cases of uveal melanoma in Japan, although at lower frequencies than in white counterparts. The mutation frequency of GNA11 was significantly higher in epithelioid cells.

A multiplex immunoassay of serum biomarkers for the detection of uveal melanoma

Background

Approximately 50% of uveal melanoma (UM) patients develop metastases preferentially in the liver leading to death within 15 months. Currently, there is no effective treatment for metastatic UM, in part because the tumor burden is typically high when liver metastases are detected through abnormal liver function tests (LFTs) or imaging studies. The use of LFTs results followed by diagnostic tests has high specificity and predictive values but low sensitivity, and better tests are needed for early diagnosis of the primary tumor as well as its metastatic spread. To evaluate serum biomarkers for the early detection of UM, multiplex immunoassays were developed.

Methods

Magnetic bead-based multiplex immunoassays were developed for the selected serum biomarkers using a Bio-Plex 200 system. The dynamic ranges, lower limits of detection and quantification, cross-reactivity, and intra- and inter-assay precision were assessed. All proteins were analyzed in sera of 48 patients diagnosed with UM (14 metastatic, 9 disease–free (DF) ≥ 5 years, 25 unknown) and 36 healthy controls. The performance of the biomarkers was evaluated individually and in combination for their ability to detect UM.

Results

A 7-plex immunoassay of OPN, MIA, CEACAM-1, MIC-1, SPON1, POSTN and HSP27 was developed with negligible cross-reactivity, recovery of 84–105%, and intra-assay and inter-assay precision of 2.3–7.5% or 2.8–20.8%, respectively. Logistic regression identified a two-marker panel of HSP27 and OPN that significantly improved the individual biomarker performance in discriminating UM from healthy controls. The improved discrimination of a two-marker panel of MIA and MIC-1 was also observed between metastatic UM and DF, however not statistically significant due to the small sample size.

Conclusions

The multiplex immunoassay provides sufficient analytical performance to evaluate serum biomarkers that complement each other in detection of UM, and warrants further validation with a larger number of patient samples.

Electronic supplementary material

The online version of this article (10.1186/s12014-019-9230-8) contains supplementary material, which is available to authorized users.

Somatostatin Receptors as Molecular Targets in Human Uveal Melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults, with an incidence of 4–5 cases per million. The prognosis of UM is very poor. In the present study, our aim was to investigate the expression of mRNA and protein for somatostatin receptor types-1, -2, -3, -4, -5 (SSTR-1–5) in human UM tissue samples and in OCM-1 and OCM-3 human UM cell lines by qRT-PCR, western blot and ligand competition assay. The mRNA for SSTR-2 showed markedly higher expression in UM tissues than SSTR-5. The presence of SSTRs was demonstrated in 70% of UM specimens using ligand competition assay and both human UM models displayed specific high affinity SSTRs. Among the five SSTRs, the mRNA investigated for SSTR-2 and SSTR-5 receptors was strongly expressed in both human UM cell lines, SSTR-5 showing the highest expression. The presence of the SSTR-2 and SSTR-5 receptor proteins was confirmed in both cell lines by western blot. In summary, the expression of somatostatin receptors in human UM specimens and in OCM-1 and OCM-3 human UM cell lines suggests that they could serve as a potential molecular target for therapy of UM using modern powerful cytotoxic SST analogs targeting SSTR-2 and SSTR-5 receptors.

Brachytherapy for patients with uveal melanoma: historical perspectives and future treatment directions

Surgical management with enucleation was the primary treatment for uveal melanoma (UM) for over 100 years. The Collaborative Ocular Melanoma Study confirmed in 2001 that globe-preserving episcleral brachytherapy for UM was safe and effective, demonstrating no survival difference with enucleation. Today, brachytherapy is the most common form of radiotherapy for UM. We review the history of brachytherapy in the treatment of UM and the evolution of the procedure to incorporate fine-needle-aspiration biopsy techniques with DNA-and RNA-based genetic prognostic testing.

Long-term Outcomes After Proton Beam Irradiation in Patients With Large Choroidal Melanomas

Importance

Although radiotherapy has been used more frequently in past decades for the management of large melanomas, long-term efficacy of proton beam irradiation (PBI) of large choroidal melanomas has not been reported.

Objective

To evaluate long-term outcomes in patients who underwent PBI for the treatment of large choroidal melanomas.

Design, Setting, and Participants

Data were obtained at a single Boston, Massachusetts, academic tertiary referral practice for this retrospective cohort study. In total, 336 patients with large tumors treated over a 13-year period from January 1, 1985, to December 31, 1997, and followed up until the end points were reached or until December 31, 2008, were included. Data analyses were initially completed in February 2017 and finalized in July 2017. Large tumors were those with a height 10 mm or greater or a longest linear diameter greater than 16 mm or a height greater than 8 mm when the optic nerve was involved.

Intervention

Proton beam irradiation (total 70 Gy) delivered in 5 equal fractions.

Main Outcomes and Measures

The primary outcomes of rates of visual acuity retention, eye retention, tumor recurrence, and melanoma-related mortality were calculated using Kaplan-Meier estimates, and Cox proportional hazards regression analyses were completed to evaluate risk factors for tumor recurrence and melanoma-related mortality.

Results

In this cohort of 336 patients with large tumors, 150 were women and 329 were white; mean (SD) age was 60.0 (14.0) years. Of 178 patients without optic nerve involvement (tumor >1 disc diameter from optic nerve), the mean (SD) largest basal diameter was 18.1 (1.9) mm and mean height was 8.2 (2.7) mm. Optic nerve involvement and tumors greater than 8 mm were observed in 109 patients (32.4% of the cohort). Baseline visual acuity of 20/200 or better was observed in 244 patients (72.6%), and worse than 20/800 in 52 (15.5%). Ten-year rates of visual acuity retention were 8.7% (95% CI, 4.1%-15.6%) for at least 20/200 and 22.4% (95% CI, 15.4%-30.4%) for at least counting fingers. Ten years after PBI therapy, the eye was retained (70.4%; 95% CI, 61.5%-77.6%) and tumor controlled (87.5%; 95% CI, 76.8%-93.5%) in most patients. The 10-year all-cause mortality rate was 60.7% (95% CI, 55.5%-65.9%). Approximately half of the patients died of metastatic uveal melanoma (10-year rate, 48.5%; 95% CI, 43.0%-54.4%).

Conclusions and Relevance

This study demonstrates that eye conservation is possible in most cases, with ambulatory vision retained in a small proportion of patients 10 years after PBI. Tumor recurrence rates were low and mortality rates were comparable to those observed after enucleation.

Overexpression of the anti-apoptotic protein BAG3 in human choroidal melanoma: A case report

Bcl-2-associated athanogene 3 (BAG3), a co-chaperone of heat shock protein 70 (HSP70), exerts anti-apoptotic effects in various malignant tumors. However, relationships between choroidal melanoma and BAG3 are poorly studied. This study investigated the expression of BAG3 in a case of human choroidal melanoma. Funduscopy, computed tomography, and single-photon emission computed tomography with the intravenous injection of N-isopropyl-p-[¹²³I] iodoamphetamine strongly indicated choroidal melanoma in a 68-year-old woman. Accordingly, we carried out an enucleation and pathological diagnosis. Proteins and total RNA were extracted from normal retinochoroidal and tumor tissues. Proteins were also extracted from ocular nevus tissues of other patients. We examined the expression of BAG3 protein and mRNA using Western blotting and the real-time quantitative polymerase chain reaction, respectively. Immunohistochemical stains were positive for melan-A, HMB-45, and S-100. Histopathology confirmed a choroidal melanoma. The expression of BAG3 protein and mRNA in the choroidal melanoma tissue was upregulated with respect to both normal retinochoroidal tissue and ocular nevus tissues from other patients. Because BAG3 may inhibit apoptosis of choroidal melanoma and facilitate its survival, overexpression of this gene product may be a prognostic marker and therapeutic target.

Concurrence of chromosome 3 and 4 aberrations in human uveal melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy with a very poor prognosis. The most frequent chromosome aberration in UM is the monosomy of chromosome 3. Previously, we demonstrated that ~50% of UMs express type-I receptor for luteinizing hormone‑releasing hormone (LH-RH-R). The gene encoding LH-RH-R is located in chromosome 4 (location: 4q21.2); however, the occurrence of numerical aberrations of chromosome 4 have never been studied in UM. In the present study, we investigated the abnormalities of chromosome 3 and 4, and the possible correlation between them, as well as with LH-RH-R expression. Forty-six specimens of UM were obtained after enucleation. Numerical aberrations of chromosome 3 and 4 were studied by fluorescence in situ hybridization (FISH). Chromosome 4 was detected in normal biparental disomy only in 14 (30%) samples; however, 32 cases (70%) showed more than 2 signals/nucleus. Monosomy of chromosome 3 could be found in 16 (35%) samples. In 6 specimens (13%), more than 2 copies of chromosome 3 were found, while normal biparental disomy was detected in 24 (52%) samples. Statistical analysis indicated a statistically significant (p<0.05) correlation between the copy number of chromosome 3 and 4. Moreover, moderate difference was revealed in the survival rate of the UM patients with various pathological profiles. No correlation was found between chromosome aberrations and LH-RH-R expression. Our results clearly demonstrate abnormalities in chromosome 3 and 4 and the incidence of the monosomy of chromosome 3 in human UM. In summary, our results provide new incite concerning the genetic background of this tumor. Our findings could contribute to a more precise determination of the prognosis of human UM and to the development of new therapeutic approaches to this malignancy.

Outcomes After Proton Beam Therapy for Large Choroidal Melanomas in 492 Patients

PURPOSE

To evaluate proton beam therapy (PBT) as a means to preserve the eye and spare some vision while not deteriorating survival in patients with large choroidal melanomas.

DESIGN

This is a retrospective, consecutive cohort study of patients with T3-4 choroidal melanomas according to the 7th edition of the American Joint Cancer Classification treated with PBT over a 24-year period.

RESULTS

A total of 492 patients were included. Mean (range) tumor thickness and diameter were 8.77 (2-15) mm and 14.91 (7-24.1) mm, respectively. Mean macular and optic disc distance were 4.56 (0-19.9) mm and 4.59 (0-22.1) mm, respectively. Mean follow-up was 61.9 months. Rates of neovascular glaucoma (NVG) and enucleation (mainly for local recurrence or NVG) were 27.0% and 19.5%, respectively. Enucleation rates decreased over time. The 5-year local control was 94%. Mean baseline visual acuity was 20/63, and visual acuity ≥20/200 was preserved in 20% of patients. At 5 years, 25% of T3 patients presented with metastasis; overall and specific survival rates were 65% and 75%, respectively.

CONCLUSION

Local control after PBT remained good with increasingly manageable complications and fewer secondary enucleations over time for these large melanomas. As PBT does not seem to deteriorate survival in these patients having a high risk of metastasis, PBT may be considered as a safe and efficient alternative to enucleation in patients with large choroidal melanoma, and may help to spare some vision.

Uveal melanoma

Uveal melanoma is the most common primary intraocular malignancy in adults. It is associated with a high rate of distant tumor spread and consequent mortality. Unlike retinoblastoma, for which treatment advances over the last few decades have resulted in a dramatic improvement in survival, outcomes for patients with uveal melanoma remain unchanged. Despite improvement in local control of this tumor, roughly 50% of patients develop metastatic disease within 15 years. Delays in diagnosis and marked vascularity of this tumor may underlie that situation. Tumor size, location, histopathologic appearance, cytogenetic abnormalities, and molecular profiling are used in prognostication. The revised 7th edition of the American Joint Committee on Cancer (AJCC) manual has presented new information that may improve that process as well. Herein, we review current knowledge on uveal melanoma.

Survival from uveal melanoma in Western Australia 1981-2005

BACKGROUND

The survival rates for patients diagnosed with uveal melanoma in Australia are unknown. Few long-term studies of uveal melanoma are available, and it is unclear whether their results are applicable to the Australian population.

DESIGN

Retrospective population-based study.

PARTICIPANTS

Patients diagnosed with uveal melanoma between 1981 and 2005 in Western Australia.

METHODS

Three hundred eight cases were included. Relative survival and Cox regression were performed. Variables tested for their predictive ability included patient age and sex, tumour-specific variables, and treatment modality.

MAIN OUTCOME MEASURES

All-cause survival rates and relative survival rates of patients with diagnosed uveal melanoma.

RESULTS

Relative survival rates for the entire cohort were 88.2%, 81.4% and 71.4% at 3, 5 and 10 years, respectively. Predictors of worse survival included mixed-cell tumour morphology (hazard ratio [HR] = 2.1; P-value = 0.002), tumour location at the ciliary body (HR = 1.7; P-value = 0.029) and tumour apical height more than 5 mm (HR 1.9, P-value = 0.026). Of all patients who underwent enucleation, those diagnosed in 1998-2005 died twice as fast (HR = 2.3; P-value = 0.004). In the 17 patients with metastasis, the median survival time from date of diagnosis of metastasis was 3.1 months.

CONCLUSIONS

These survival estimates are comparable to those reported for the USA, and more optimistic than those reported for most European-based studies. Tumour apical height, tumour site, tumour morphology and having an enucleation in certain calendar periods of diagnosis were independent predictors of survival. Survival prognosis for patients with diagnosed metastatic uveal melanoma is very poor.

Long overall survival after dendritic cell vaccination in metastatic uveal melanoma patients

PURPOSE

To assess the safety and efficacy of dendritic cell vaccination in metastatic uveal melanoma.

DESIGN

Interventional case series.

METHODS

We analyzed 14 patients with metastatic uveal melanoma treated with dendritic cell vaccination. Patients with metastatic uveal melanoma received at least 3 vaccinations with autologous dendritic cells, professional antigen-presenting cells loaded with melanoma antigens gp100 and tyrosinase. The main outcome measures were safety, immunologic response, and overall survival.

RESULTS

Tumor-specific immune responses were induced with dendritic cell vaccination in 4 (29%) of 14 patients. Dendritic cell-vaccinated patients showed a median overall survival with metastatic disease of 19.2 months, relatively long compared with that reported in the literature. No severe treatment-related toxicities (common toxicity criteria grade 3 or 4) were observed.

CONCLUSIONS

Dendritic cell vaccination is feasible and safe in metastatic uveal melanoma. Dendritic cell-based immunotherapy is potent to enhance the host's antitumor immunity against uveal melanoma in approximately one third of patients. Compared with other prospective studies with similar inclusion criteria, dendritic cell vaccination may be associated with longer than average overall survival in patients with metastatic uveal melanoma.

Prognostic parameters in uveal melanoma and their association with BAP1 expression

AIM

To determine whether BAP1 gene and protein expression associates with different prognostic parameters in uveal melanoma and whether BAP1 expression correctly identifies patients as being at risk for metastases, following enucleation of the primary tumour.

METHODS

Thirty cases of uveal melanoma obtained by enucleation between 1999 and 2004 were analysed for a variety of prognostic markers, including histological characteristics, chromosome aberrations obtained by fluorescence in situ hybridisation (FISH) and single nucleotide polymorphism (SNP) analysis and gene expression profiling. These parameters were compared with BAP1 gene expression and BAP1 immunostaining.

RESULTS

The presence of monosomy of chromosome 3 as identified by the different chromosome 3 tests showed significantly increased HRs (FISH on isolated nuclei cut-off 30%: HR 11.6, p=0.002; SNP analysis: HR 20.3, p=0.004) for death due to metastasis. The gene expression profile class 2, based on the 15-gene expression profile, similarly provided a significantly increased HR for a poor outcome (HR 8.5, p=0.005). Lower BAP1 gene expression and negative BAP1 immunostaining (50% of 28 tumours were immunonegative) were both associated with these markers for prognostication: FISH cut-off 30% monosomy 3 (BAP1 gene expression: p=0.037; BAP1 immunostaining: p=0.001), SNP-monosomy 3 (BAP1 gene expression: p=0.008; BAP1 immunostaining: p=0.002) and class 2 profile (BAP1 gene expression: p<0.001; BAP1 immunostaining: p=0.001) and were themselves associated with an increased risk of death due to metastasis (BAP1 gene expression dichotomised: HR 8.7, p=0.006; BAP1 immunostaining: HR 4.0, p=0.010).

CONCLUSIONS

Loss of BAP1 expression associated well with all of the methods currently used for prognostication and was itself predictive of death due to metastasis in uveal melanoma after enucleation, thereby emphasising the importance of further research on the role of BAP1 in uveal melanoma.

The first case of omental metastasis from primary choroidal melanoma

Choroidal melanoma is the most common intraocular malignancy and can be fatal in half of the patients because of metastatic disease. Metastasis of choroidal melanoma to the omentum is extremely rare and, to our knowledge, no such case has ever been described in the literature. Here we present a 41-year-old Chinese man with an omental metastasis, 5 years after he was diagnosed with a spindle-cell-type malignant melanoma of the choroid and had his left eye enucleated. The patient demonstrated some uncommon symptoms, but the diagnosis was confirmed histopathologically. The cells were positive for S-100, HMB-45 and Melan-A proteins. He underwent a complete tumor resection and concomitantly received chemotherapy, biological treatment and traditional Chinese medicine. At 2-year follow-up, this patient continues to do well.

Clinical spectrum and prognosis of uveal melanoma based on age at presentation in 8,033 cases

PURPOSE

To evaluate clinical features and life prognosis of uveal melanoma based on age at presentation.

DESIGN

Retrospective, nonrandomized, interventional case series.

RESULTS

Of 8,033 eyes with uveal melanoma, 106 (1%) were in young patients (≤20 years), 4,287 (53%) in mid adults (21-60 years), and 3,640 (45%) in older adults (>60 years). Based on age (young, mid adults, and older adults) at presentation, tumor epicenter was located in iris (21, 4, 2%; P < 0.0001), ciliary body (8, 5, and 7%; P = 0.0225), or choroid (71, 91, and 90%; P < 0.0001). Mean tumor diameter (10.2, 10.8, 11.5 mm; P < 0.0001), mean tumor thickness (5.0, 5.3, 5.7 mm; P < 0.0001), and extraocular extension (1, 2, and 4%; P = 0.0004) increased with age. Kaplan-Meier estimates of tumor-related metastasis at 3, 5, 10, and 20 years were 2%, 9%, 9%, and 20% in young patients (P < 0.011); 6%, 12%, 23%, and 34% in mid adults (P < 0.0001); and 11%, 19%, 28%, and 39% in older adults. Kaplan-Meier estimate of tumor-related death at 3, 5, 10, and 20 years were 0%, 2%, 5%, and 17% in young patients (P = 0.08); 3%, 6%, 11%, and 17% in mid adults (P < 0.001); and 7%, 11%, 16%, and 20% in older adults.

CONCLUSION

Compared with mid adults and older adults, young patients manifested a higher proportion of iris melanoma. Compared with older adults, young and mid adults showed smaller melanoma basal dimension and lower tumor-related metastasis and death.

Uveal melanoma: molecular pattern, clinical features, and radiation response

PURPOSE

To characterize the clinical spectrum of class 1 and class 2 uveal melanomas and their relationship with intraocular proton radiation response.

DESIGN

Masked retrospective case series of uveal melanoma patients with fine needle biopsy-based molecular profiles.

METHODS

A total of 197 uveal melanoma patients from a single institution were analyzed for pathology, clinical characteristics, and response to radiation therapy.

RESULTS

A total of 126 patients (64%) had class 1 tumors and 71 (36%) had class 2 tumors. Patients with class 2 tumors had more advanced age (mean: 64 years vs 57 years; P = .001), had thicker initial mean ultrasound measurements (7.4 mm vs 5.9 mm; P = .0007), and were more likely to have epithelioid or mixed cells on cytopathology (66% vs 38%; P = .0004). Although mean pretreatment and posttreatment ultrasound thicknesses were significantly different between class 1 and class 2 tumors, there was no difference in the mean change in thickness 24 months after radiation therapy (mean difference: class 1 = -1.64 mm, class 2 = -1.47; P = .47) or in the overall rate of thickness change (slope: P = .64). Class 2 tumors were more likely to metastasize and cause death than class 1 tumors (DSS: P < .0001).

CONCLUSIONS

At the time of radiation therapy, thicker tumors, epithelioid pathology, and older patient age are significantly related to class 2 tumors, and class 2 tumors result in higher tumor-related mortality. We found no definitive clinical marker for differentiating class 1 and class 2 tumors.

Liver function testing is not helpful for early diagnosis of metastatic uveal melanoma

OBJECTIVE

To study the relevance of liver function test (LFT) results for early detection of liver metastasis of uveal melanoma.

DESIGN

Evaluation of diagnostic test.

PARTICIPANTS

Eighty-eight patients were included in whom metastasis developed while undergoing semiannual follow-up with LFTs, including aspartate-aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyltransferase (γGT), lactate dehydrogenase (LDH), and phosphatase alkaline (PA). As controls, 174 patients with uveal melanoma without metastasis were included.

METHODS

The diagnostic attributes of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for each test were estimated from cross-tabulation tables of test results according to the diagnosis of metastasis. The proportions of false-positive results between groups of patients with and without metastasis were compared in log-binomial regression models.

MAIN OUTCOME MEASURES

Sensitivity, specificity, PPV, NPV, and cost evaluation.

RESULTS

Metastases were detected after LFT abnormality (at least 1 abnormal test result) in 40 (45%) patients. The overall sensitivity of LFTs ranged from 12.5% to 58.0%, and the PPV ranged from 9.4% to 38.6%. The overall specificity and NPV were 90% or greater. The proportions of false-positive results between groups of patients with and without metastasis did not differ significantly (all P≥0.38). Using a cost evaluation, semi-annual screening by LFTs was calculated to cost $35.5/year per patient, including liver imaging induced by true and false-positive results.

CONCLUSIONS

Isolated or combined LFTs for AST, ALT, γGT, LDH, and PA are not helpful for detection of early metastasis. However, the high NPVs suggest that LFT screening can allow clinicians to reassure the patient when the LFT results are negative.

Insights into melanoma: targeting the mTOR pathway for therapeutics

INTRODUCTION

Cutaneous melanoma represents < 5% of all skin cancers, but is responsible for the majority of skin cancer-related deaths. Ocular melanoma is the most common primary eye tumor in adults, and accounts for approximately 5% of all melanomas. Despite new diagnostic and therapeutic tools, the overall survival of patients treated for melanoma has not improved and most patients die of metastatic disease. Therefore, clarification of the molecular mechanisms underlying the etiopathogenesis of cutaneous and ocular melanomas may help determining the prognosis and tailoring therapy of patients harboring melanomas.

AREAS COVERED

In this review the authors aim to survey relevant research in the molecular mechanisms underlying melanomagenesis, and therapies under evaluation with emphasis in the mTOR pathway.

EXPERT OPINION

Despite an increasingly understanding of the genetics and biochemistry of melanoma, the mechanisms underlying their complex interactions are still poorly understood. Their clarification will lead to more successful therapeutic strategies and evidence-based management of patients with melanoma. More active drug combinations together with appropriate melanoma patient stratification based on molecular biomarkers will be essential for new advances in melanoma therapy.

Iris melanoma: features and prognosis in 317 children and adults

PURPOSE

To evaluate iris melanoma in children versus adults.

METHODS

Retrospective, nonrandomized clinical case series including all patients with a clinical diagnosis of iris melanoma managed at the Ocular Oncology Service at Wills Eye Institute over 40 years. Patients were divided into three age categories based on age at presentation: children (≤ 20 years), mid-adults (21-60 years), and older adults (>60 years). The clinical features, treatments, and outcomes were statistically analyzed based on patient age at presentation. The main outcome measures were melanoma features and related metastasis and death.

RESULTS

Of 8,101 eyes with uveal melanoma, there were 317 (4%) with iris melanoma, including 24 (8%) children (≤ 20 years), 187 (59%) mid-adults (21-60 years), and 106 (33%) older adults (>60 years). There was no age-related difference in race, sex, tumor quadrant, thickness, pigmentation, associated corectopia, ectropion uveae, hyphema, or extraocular extension. Significant age-related differences were found with mean tumor basal diameter, tapioca appearance, mean intraocular pressure, secondary glaucoma, tumor seeding in angle, and mean number of clock hours of angle seeding. Multivariate analysis of factors predictive of metastasis included extraocular extension and high intraocular pressure. Factors predictive of death included increased tumor thickness and high intraocular pressure. There was no difference in metastasis or death by age group.

CONCLUSIONS

Iris melanoma shows significant clinical differences in children versus adults, with smaller tumor size, less tumor seeding in angle, and lower incidence of secondary glaucoma. There was no significant difference in metastasis or death by age group.

Effect of heterogeneous distribution of monosomy 3 on prognosis in uveal melanoma

CONTEXT

Fluorescence in situ hybridization (FISH) analyses on tumor sections and on isolated nuclei showed that even low numbers of cells with monosomy of chromosome 3 adversely affected survival.

OBJECTIVE

To determine what percentage of uveal melanoma cells with monosomy of chromosome 3 influences patient mortality.

DESIGN

To determine the presence of monosomy 3, karyotyping and FISH on cultured cells and FISH on isolated nuclei were performed on 50 primary uveal melanomas. Clinical and pathologic prognostic factors were assessed and compared with 5-year survival data. Analyses were performed using Cox proportional hazards test, log-rank analysis, sensitivity, specificity, and positive and negative likelihood ratios.

RESULTS

Combined karyotyping and FISH on cultured cells showed monosomy 3 in 19 of 50 cases (38%), whereas determination of the monosomy 3 status by FISH on isolated nuclei with a threshold of 5% assigned 31 of 50 cases (62%) to the monosomy-3 category. When monosomy 3 on isolated nuclei with a cutoff value of 5% was used, a significant difference in 5-year survival was present (hazard ratio, 15.5; P = .007), indicating that monosomy 3 in greater than 5% of tumor cells is related to death due to metastases.

CONCLUSION

In uveal melanoma, the presence of greater than 5% of cells with monosomy 3, as determined by FISH on isolated nuclei, is associated with the development of metastases within 5 years after enucleation.

GDF-15: a novel serum marker for metastases in uveal melanoma patients

BACKGROUND

About 50% of patients with uveal melanoma (UM) develop metastases during the course of their disease. We analyzed serum levels of Growth Differentiation Factor-15 (GDF-15), with the aim of identifying patients with early metastases.

METHODS

GDF-15 concentration was measured using an enzyme-linked immunosorbent assay (ELISA) in serum samples from 188 UM patients (170 patients without metastases; 18 patients with clinically detectable metastases) and 18 healthy control individuals. Data were analyzed with respect to differences between patients with and without clinically detectable UM metastases. GDF-15 serum levels were further analyzed with regard to significant patient and tumor characteristics as revealed by histology and multiplex ligation-dependent probe amplification (MLPA) to determine chromosome 3 copy number. GDF-15 expression in UM was investigated by immunohistochemistry.

RESULTS

Patients with clinically detectable metastases had significantly higher GDF-15 serum levels compared to those without clinically detectable metastases as well as to healthy individuals (ANOVA; p < 0.001). GDF-15 concentrations in UM patients with overt clinically detectable metastases were significantly higher than those in UM patients with a second malignancy in remission but without clinically detected UM metastases (ANOVA; p < 0.001). No association between serum concentration of GDF-15 and clinical, pathological, and genetic features was observed. GDF-15 protein was only expressed in a minority of UM cells in most tumors.

CONCLUSIONS

Our data suggest that GDF-15 can be used as a serum marker for the diagnosis of metastases in UM patients. Further data collection and analysis are necessary to evaluate a possible prognostic role of GDF-15 in predicting early metastases.

DNA methylation or histone modification status in metastasis and angiogenesis-related genes: a new hypothesis on usage of DNMT inhibitors and S-adenosylmethionine for genome stability

Metastasis is a leading cause of mortality and morbidity in cancer. This process needs angiogenesis. The biology underlying cancer, metastasis, and angiogenesis has been investigated so as to determine the therapeutic targets. Invasive and metastatic cancer cells have undergone numerous genetic and epigenetic changes, manifested by cytoskeletal changes, loss of adhesion, and expression of proteolytic enzymes that degrade the basement membrane. Additionally, in endothelial cells, some epigenetic modifications occur during the formation of angiogenesis. Researchers have used some methylation inhibitors, histone deacetylase inhibitors, or methylating agents (such as S-adenosylmethionine, SAM) against cancer and angiogenesis. Although they are effective to beat these diseases, each one results in differentiation or changes in genome structure. We review epigenetically modified genes related with angiogenesis and metastasis in cancer and endothelial cells, and suggest a new proposal. This hypothesis has discussed the importance of the usage of DNA methylation inhibitors together with SAM to prevent tumor progression and genome instability or changes resulting in additional diseases.

A comparative transcriptomic analysis of uveal melanoma and normal uveal melanocyte

Background

Uveal melanoma is the most common primary intraocular tumor in adults in western countries. It is associated with very severe visual morbidity and may lead to distant metastases even after successful treatment of the primary tumor. In order to gain better insight into molecular mechanisms related to tumorigenesis and metastasis of uveal melanoma, we used next-generation sequencing technology (SOLiD, Life Technologies) to acquire global transcriptome alteration between posterior uveal melanoma cells and normal uveal melanocyte.

Results

From mRNAs of the cultured uveal melanoma cells and normal uveal melanocytes, we annotated more than 3.7×10⁷ and 2.7×10⁷ sequencing tags based on human Ensembl databases, respectively. For detailed analysis, we chose 5155 well-annotated genes mainly involved in the MAPK signaling pathway, cell cycle, cell adhesion junction, apoptosis, and P53 signaling pathways as well as melanogenesis. In an effort to confirm the authenticity of our sequencing results, we validated twenty-one identically differentially expressed genes by using quantitative real time PCR from cultured cell lines of other posterior uveal melanoma cells and normal uveal melanocytes.

Conclusion

We have identified a large number of potentially interesting genes for biological investigation of uveal melanoma. The expression profiling also provides useful resources for other functional genomic and transcriptome studies. These 21 potential genes could discriminate between uveal melanoma cells and normal uveal melanocyte, which may be indicative of tumorigenesis process. Our results further suggest that high-throughput sequencing technology provides a powerful tool to study mechanisms of tumogenesis in the molecular level.

Ocular melanoma

CONTEXT

Intraocular melanoma of the ciliary body and choroid is the most common primary ocular malignant tumor in adults and the most common noncutaneous melanoma.

OBJECTIVE

To describe the most salient clinical features, histopathologic findings, and treatment modalities of intraocular melanoma, as well as the novel therapies currently being tested.

DATA SOURCES

Clinically, it is important to determine which lesions carry a worse prognosis so as to offer patients the best treatment modalities available. Tumor location, size, histopathology, cytogenetic abnormalities, and tumor profiling are all used in determining the risk of death from metastatic disease of uveal melanocytic lesions. Despite successful local tumor control, up to 50% of patients have metastatic disease within 15 years of diagnosis; there is no effective treatment for metastatic disease.

CONCLUSIONS

Pathologists should be aware of the importance of tumor gross description, cellular histopathology classification, the use of fine-needle aspiration biopsy coupled with cytogenetics, and the new classification of uveal malignant melanomas that is based on chromosome 3 status.

Inflammatory cytokines in eyes with uveal melanoma and relation with macrophage infiltration

PURPOSE

The presence of an inflammatory phenotype, characterized by an increased expression of HLA antigens and an immunologic infiltrate, carries a bad prognosis in uveal melanoma. This study was conducted to determine whether the aqueous humor (AqH) from eyes with uveal melanoma contains inflammatory cytokines and whether their presence is associated with inflammation.

METHODS

Immediately after enucleation, AqH was obtained from 37 eyes containing uveal melanoma. Samples were stored at -80°C until use. Fifteen different cytokines were measured with a multiplex bead array. Intratumoral macrophages were analyzed by immunohistochemistry and immunofluorescence staining. The presence of specific cytokines was compared with histopathologic, genetic, and clinical tumor characteristics, as well as patient survival.

RESULTS

Several cytokines showed significantly higher expression in the AqH of uveal melanoma-containing eyes than in the AqH of eyes undergoing cataract surgery. MCP-3 was associated with the presence of CD68(+) macrophages. Correlations were found between some cytokine levels and a few known prognostic factors of uveal melanoma, but cytokine levels were not of predictive value for survival.

CONCLUSIONS

Uveal melanoma-containing eyes often carry increased levels of inflammation-related cytokines in their AqH. However, the presence of most specific cytokines was not related to the presence of macrophages, clinical or histopathologic parameters, or prognosis.

Uveal melanoma in the Saudi Arabian population: Two decades of management at the King Khaled Eye Specialist Hospital

OBJECTIVE

To present the experience of King Khaled Eye Specialist Hospital (KKESH) with uveal melanoma over the last two decades in a fashion similar to the result of the Collaborative Ocular Melanoma Study (COMS).

DESIGN

Retrospective, non-comparative, interventional, case series.

PARTICIPANTS

All patients were diagnosed with uveal melanoma at the King Khaled Eye Specialist Hospital (KKESH), Riyadh, Saudi Arabia from June 1983 to July 2005 and met the inclusion criteria of the COMS.

METHODS

A medical record review of clinical history, imaging studies, surgical procedures and treatment outcome was performed.

RESULTS

Forty patients (24 males and 16 females) with uveal melanoma (average age 50 years; range 24-77 years) were included in the study; 28 (70%) were of Saudi Arabian descent and the remaining 12 (30%) patients were from neighboring Arab countries. Decreased vision was the main presenting complaint of 29 (72.5%) patients; the duration of this symptom was 3 months or more in 27 (67.5%) patients. The apical height of the tumor was 10 mm or more in nine (22.5%) of the affected eyes and the largest basal dimension was more than 16 mm in nine (22.5%) of the affected eyes. The posterior border of the tumor was 1-2 mm from the optic disc in three (7.5%) affected eyes. Primary enucleation was performed for 33 (82.5%) eyes, episcleral radiation plaque therapy for six (15%) of the eyes and endo resection of the uveal melanoma in one (2.5%) eye. Adjunct external beam radiation therapy was performed in two (5%) orbits for extrascleral extension. The histopathological diagnosis was available for 34 (84%) eyes in which surgery had been performed (33 patients underwent primary enucleation and one patient underwent endo resection of the uveal melanoma); 24 (70.6%) eyes had spindle cell and the remaining 10 (29.4%) had epithelioid or mixed cell types. Evidence of extraocular tumor extension was found in three eyes. The average follow-up was 33.7 months with a median of 19 months (range 0.5 months to 10 years). Two (5%) patients developed metastasis after 2 years and 5 years from the initial treatment of large and medium-sized uveal melanomas, respectively.

CONCLUSION

Individuals of Saudi Arabian ancestry appear to have a low incidence of uveal melanoma. Further studies are required to estimate the true incidence of uveal melanoma in the larger Arab population. Early detection is essential for improving the patient outcomes. Regular communication between the tertiary care eye centers and the local ophthalmic care providers is required to enhance the understanding about uveal melanoma behavior in Arab population.

Genomic Investigations of Posterior Uveal Melanoma

The specific genetic mechanisms responsible for the malignant behavior of uveal melanoma are not known. Unlike cutaneous melanoma, epidemiologic studies have not demonstrated a definitive germline form of uveal melanoma, though familial melanoma and racial predilections occur. Molecular cytogenetic characterization of uveal melanoma suggests that somatic deletions of chromosome 3 are associated with a worse prognosis. Microarray technology has been used to characterize uveal melanoma gene expression and may provide tests useful for determining prognosis. As an improved understanding of the cellular mechanisms used by uveal melanoma is gained, new opportunities to adapt or design therapeutic approaches may emerge.

Uveal melanoma cell-based vaccines express MHC II molecules that traffic via the endocytic and secretory pathways and activate CD8+ cytotoxic, tumor-specific T cells

We are exploring cell-based vaccines as a treatment for the 50% of patients with large primary uveal melanomas who develop lethal metastatic disease. MHC II uveal melanoma vaccines are MHC class I(+) uveal melanoma cells transduced with CD80 genes and MHC II genes syngeneic to the recipient. Previous studies demonstrated that the vaccines activate tumor-specific CD4(+) T cells from patients with metastatic uveal melanoma. We have hypothesized that vaccine potency is due to the absence of the MHC II-associated invariant chain (Ii). In the absence of Ii, newly synthesized MHC II molecules traffic intracellularly via a non-traditional pathway where they encounter and bind novel tumor peptides. Using confocal microscopy, we now confirm this hypothesis and demonstrate that MHC II molecules are present in both the endosomal and secretory pathways in vaccine cells. We also demonstrate that uveal melanoma MHC II vaccines activate uveal melanoma-specific, cytolytic CD8(+) T cells that do not lyse normal fibroblasts or other tumor cells. Surprisingly, the CD8(+) T cells are cytolytic for HLA-A syngeneic and MHC I-mismatched uveal melanomas. Collectively, these studies demonstrate that MHC II uveal melanoma vaccines are potent activators of tumor-specific CD4(+) and CD8(+) T cells and suggest that the non-conventional intracellular trafficking pattern of MHC II may contribute to their enhanced immunogenicity. Since MHC I compatibility is unnecessary for the activation of cytolytic CD8(+) T cells, the vaccines could be used in uveal melanoma patients without regard to MHC I genotype.

Emerging insights into the molecular pathogenesis of uveal melanoma

Uveal melanoma is the most common primary cancer of the eye, and often results not only in vision loss, but also in metastatic death in up to half of patients. For many years, the details of the molecular pathogenesis of uveal melanoma remained elusive. In the past decade, however, many of these details have emerged to reveal a fascinating and complex story of how the primary tumor evolves and progresses. Early events that disrupt cell cycle and apoptotic control lead to malignant transformation and proliferation of uveal melanocytes. Later, the growing tumor encounters a critical bifurcation point, where it progresses along one of two genetic pathways with very distinct genetic signatures (monosomy 3 vs 6p gain) and metastatic propensity. Late genetic events are characterized by increasing aneuploidy, most of which is nonspecific. However, specific chromosomal alterations, such as loss of chromosome 8p, can hasten the onset of metastasis in susceptible tumors. Taken together, this pathogenetic scheme can be used to construct a molecularly based and prognostically relevant classification of uveal melanomas that can be used clinically for personalized patient management.

Expression of the SST receptor 2 in uveal melanoma is not a prognostic marker

INTRODUCTION

Uveal melanoma (UM) cells and neurohormone-producing cells both originate from the neural crest. Somatostatin receptors subtype 2 (SSTR2) are over-expressed in several tumors, often from neuroendocrine origin, and synthetic antagonists like octreotide and octreotate are being used as diagnostic or therapeutic agents. We investigated the SSTR2 expression in UM, and determined whether this expression was related to prognosis of the disease.

MATERIALS AND METHODS

UM cell lines and fresh primary UM samples were tested for SSTR2 expression by autoradiography (AR) using 125I-Tyr3-octreotate. Furthermore, UM cell lines were analyzed for SSTR2 mRNA expression with quantitative real-time RT-PCR.

RESULTS

Using AR, cell-surface SSTR2 expression was demonstrated in two UM metastatic cell lines, but no expression was detected in three cell lines derived from primary UM. However, all primary and metastatic UM cell lines showed mRNA expression levels for SSTR2 using quantitative real-time RT-PCR. Only three of 14 primary UM demonstrated moderate SSTR2 expression, and this expression was not significantly associated with tumor-free survival or any tested prognostic factor.

CONCLUSIONS

Based on the rare and low expression of SSTR2 found in primary UM specimens and in UM cell lines, we conclude that SSTR2 is not widely expressed in UM. Furthermore, SSTR2 expression was not associated with tumor-free survival and prognostic factors. Therefore SSTR2 is not suited as prognostic marker or therapeutic target in UM.

Transscleral fine-needle aspiration biopsy of macular choroidal melanoma

PURPOSE

To report transscleral 30-gauge fine-needle aspiration biopsy (FNAB) for cytology and cytogenetics in eyes with macular choroidal melanoma.

DESIGN

Prospective, interventional case series.

METHODS

Twenty-five patients (25 eyes) who underwent transscleral 30-gauge FNAB of macular choroidal melanoma immediately prior to iodine-125 plaque placement were included in this study, conducted at a tertiary care university hospital. The main outcome measures were FNAB feasibility, cytology, cytogenetic analysis for monosomy 3, and surgical complications.

RESULTS

Transscleral 30-gauge FNAB of choroidal melanoma in the macula was performed in 24 of 25 (96%) eyes and was not feasible owing to insufficient exposure in one eye (4%). Biopsy was diagnostic of choroidal melanoma in 17 of 24 (71%) eyes. Fluorescent in situ hybridization (FISH) and/or GeneChip 500k NspI Mapping array (Affymetrix, Santa Clara, California, USA) analysis for monosomy 3 was completed in 16 of 24 (67%) revealing monosomy 3 in five eyes and disomy 3 in 11 eyes. Retinal perforation (four eyes) did not require treatment or result in retinal detachment; submacular hemorrhage (nine eyes) and vitreous hemorrhage (five eyes) cleared spontaneously within one month.

CONCLUSION

Transscleral FNAB of macular choroidal melanoma is feasible in most eyes and frequently yields cytogenetic information relevant to prognosis.

Choroidal melanoma: natural history and management options

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

MHC class II-transduced tumor cells originating in the immune-privileged eye prime and boost CD4(+) T lymphocytes that cross-react with primary and metastatic uveal melanoma cells

Uveal melanoma, the most common malignancy of the eye, has a 50% rate of liver metastases among patients with large primary tumors. Several therapies prolong survival of metastatic patients; however, none are curative and no patients survive. Therefore, we are exploring immunotherapy as an alternative or adjunctive treatment. Uveal melanoma may be particularly appropriate for immunotherapy because primary tumors arise in an immune-privileged site and may express antigens to which the host is not tolerized. We are developing MHC class II (MHC II)-matched allogeneic, cell-based uveal melanoma vaccines that activate CD4(+) T lymphocytes, which are key cells for optimizing CD8(+) T-cell immunity, facilitating immune memory, and preventing tolerance. Our previous studies showed that tumor cells genetically modified to express costimulatory and MHC II molecules syngeneic to the recipient are potent inducers of antitumor immunity. Because the MHC II-matched allogeneic vaccines do not express the accessory molecule, Invariant chain, they present MHC II-restricted peptides derived from endogenously encoded tumor antigens. We now report that MHC II-matched allogeneic vaccines, prepared from primary uveal melanomas that arise in the immune-privileged eye, prime and boost IFNgamma-secreting CD4(+) T cells from the peripheral blood of either healthy donors or uveal melanoma patients that cross-react with primary uveal melanomas from other patients and metastatic tumors. In contrast, vaccines prepared from metastatic cells in the liver are less effective at activating CD4(+) T cells, suggesting that tumor cells originating in immune-privileged sites may have enhanced capacity for inducing antitumor immunity and for serving as immunotherapeutic agents.

Proteomics in uveal melanoma research: opportunities and challenges in biomarker discovery

Uveal melanoma (UM) is the most frequent primary intraocular tumor in adult humans. Despite the significant advances in diagnosis and treatment of UM in the last decades, the prognosis of UM sufferers is still poor. Metastatic liver disease is the leading cause of death in UM and can develop after a long disease-free interval, suggesting the presence of occult micrometastasis. Proteomics technology has opened new opportunities for elucidating the molecular mechanism of complex diseases, such as cancer. This article will review the recent developments in biomarker discovery for UM research by proteomics. In the last few years, the first UM proteomics-based analyses have been launched, yielding promising results. An update on recent developments on this field is presented.

Survival from uveal melanoma in England and Wales 1986 to 2001

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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