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Anguita R, Chou HD, Raval VR, Bajpai V, Ferro Desideri L, Bernardi E, Hussain RN, Kim M, Fung AT, Williams BK, Di Nicola M, Sagoo MS, da Cruz L, Damato B, Kiilgaard JF. Managing vitreoretinal complications in uveal melanoma: Surgical treatment and practical considerations. Semin Ophthalmol 2024:1-10. [PMID: 39194361 DOI: 10.1080/08820538.2024.2381774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND In the past few decades, the primary management for uveal melanoma has evolved from enucleation to eye-preserving treatments. However, despite achieving a high rate of local tumour control, complications following eye-preserving treatments still occur and are partly responsible for functional loss and secondary enucleation. METHODS A literature review by a broad international panel. RESULTS We summarised the current literature on utilizing vitreoretinal (VR) surgery for managing the complications of uveal melanoma. We also provided insights from the authors' personal experience and practical recommendations for clinical care. CONCLUSIONS With the advancement of VR instruments and surgical techniques and the combination of VR and ocular oncology knowledge ("Onco-VR"), it is now possible to manage or even prevent complications such as vitreous haemorrhage, retinal detachment, and toxic tumour syndrome.
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Affiliation(s)
- Rodrigo Anguita
- Department of Ophthalmology, Inselspital, University Hospital of Bern, Bern, Switzerland
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Hung-Da Chou
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
- Chang Gung Memorial Hospital, Linkou Main Branch, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Vishal R Raval
- Vitreoretina and ocular oncology, Anant Bajaj Retina Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Vidhi Bajpai
- Vitreoretina and ocular oncology, Anant Bajaj Retina Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Lorenzo Ferro Desideri
- Department of Ophthalmology, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Enrico Bernardi
- Department of Ophthalmology, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Rumana N Hussain
- Liverpool Ocular Oncology Service, St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Min Kim
- Department of Ophthalmology, Institute of Vision Research, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Adrian T Fung
- Westmead and Central (Save Sight Institute) Clinical Schools, Specialty of Clinical Ophthalmology and Eye Health, University of Sydney, Sydney, Australia
- Department of Ophthalmology, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Basil K Williams
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Maura Di Nicola
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mandeep S Sagoo
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Lyndon da Cruz
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Bertil Damato
- NIHR Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Jens Folke Kiilgaard
- Department of Ophthalmology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Anguita R, Makuloluwa A, Bhalla M, Katta M, Sagoo MS, Charteris DG. Rhegmatogenous retinal detachment in choroidal melanoma: clinical features and surgical outcomes. Eye (Lond) 2024; 38:494-498. [PMID: 37596400 PMCID: PMC10858248 DOI: 10.1038/s41433-023-02709-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/20/2023] Open
Abstract
PURPOSE To describe the clinical features, prognostic factors, safety and rate of success of surgery and visual outcomes in patients with rhegmatogenous retinal detachment (RRD) and choroidal melanoma (CM). METHODS A retrospective, observational case-series of 21 patients with rhegmatogenous retinal detachment or combined tractional-rhegmatogenous retinal detachment in patients with choroidal melanoma over a period of 20 years. RESULTS Nineteen patients were included in the final analysis. The mean elevation of CM was 4.0 mm and the mean largest diameter was 11.0 mm. RRD occurred after the CM treatment in 14 eyes at a mean interval of 44.2 months. The RRD was macula-on RRD in 6 eyes, there was posterior vitreous detachment (PVD) in 15 and PVR in 7 eyes. BCVA at presentation was 0.71 logMAR and final was 1.5 logMAR (p = 0.01). The primary surgical success rate was 59%. No intraocular or extraocular tumour dissemination occurred. Mean follow-up was 66 months. CONCLUSION RRD in patients with CM is uncommon but requires multidisciplinary management. Anatomical results are favourable but visual outcomes are poor due to a combination of factors related to melanoma treatment, macular retinal detachment and PVR. Vitrectomy as a surgical intervention for RRD in treated CM appears to be safe in terms tumour dissemination.
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Affiliation(s)
- Rodrigo Anguita
- Vitreoretinal Unit, Moorfields Eye Hospital NHS Foundation Trust, City Road, London, EC1V 2PD, UK.
- Ocular Oncology Service, Moorfields Eye Hospital NHS Foundation Trust, City Road, London, EC1V 2PD, UK.
- Department of Ophthalmology, Inselspital, University Hospital of Bern, Bern, Switzerland.
| | - Achini Makuloluwa
- Vitreoretinal Unit, Moorfields Eye Hospital NHS Foundation Trust, City Road, London, EC1V 2PD, UK
| | - Minak Bhalla
- Vitreoretinal Unit, Moorfields Eye Hospital NHS Foundation Trust, City Road, London, EC1V 2PD, UK
| | - Mohamed Katta
- Vitreoretinal Unit, Moorfields Eye Hospital NHS Foundation Trust, City Road, London, EC1V 2PD, UK
| | - Mandeep S Sagoo
- Ocular Oncology Service, Moorfields Eye Hospital NHS Foundation Trust, City Road, London, EC1V 2PD, UK
- NIHR Biomedical Research Centre for Ophthalmology at UCL Institute of Ophthalmology and Moorfields Eye Hospital, London, EC1V 2PD, UK
| | - David G Charteris
- Vitreoretinal Unit, Moorfields Eye Hospital NHS Foundation Trust, City Road, London, EC1V 2PD, UK
- NIHR Biomedical Research Centre for Ophthalmology at UCL Institute of Ophthalmology and Moorfields Eye Hospital, London, EC1V 2PD, UK
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Caminal JM, Lorenzo D, Gutierrez C, Slocker A, Piulats JM, Cobos E, Garcia-Bru P, Morwani R, Santamaria JF, Arias L. Local Resection in Choroidal Melanoma: A Review. J Clin Med 2022; 11:jcm11237156. [PMID: 36498730 PMCID: PMC9735844 DOI: 10.3390/jcm11237156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
Surgical resection is widely used to treat small tumours located in the iris and the ciliary body, due to the accessibility of these sites. By contrast, surgical removal of choroidal tumours is substantially more challenging, which is why this procedure is performed only at specialised centres. In the present article, we review the literature on surgical resection of choroidal tumours, which can be performed as endoresection (ab interno) or transscleral resection (ab externo). An important aim of this review is to describe and compare the two approaches in terms of visual outcomes, survival rates, and complications. Both approaches are indicated for the removal of large tumours (thickness > 8 mm) with small base diameters. Surgical resection of the tumour allows clinicians to obtain valuable histopathologic and cytogenetic data from the specimen and eliminates the risks associated with radiotherapy. However, both of these surgical approaches are technically challenging procedures involving the risk of severe early and late postoperative complications.
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Affiliation(s)
- Josep Maria Caminal
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
- Correspondence:
| | - Daniel Lorenzo
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Cristina Gutierrez
- Department of Brachytherapy, Catalan Institute of Oncology, Avinguda de la Gran Vía de l’Hospitalet, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Andrea Slocker
- Department of Brachytherapy, Catalan Institute of Oncology, Avinguda de la Gran Vía de l’Hospitalet, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Josep Maria Piulats
- Department of Oncology, Catalan Institute of Oncology, Avinguda de la Gran Vía de l’Hospitalet, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Estefania Cobos
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Pere Garcia-Bru
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Rahul Morwani
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Juan Francisco Santamaria
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Luis Arias
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
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Zhou X, Ishikawa H, Gomi F. Macular hole and vitreous hemorrhage subsequent to stereotactic hypofractionated radiotherapy for choroidal melanoma: A case report and review of the literature. Front Oncol 2022; 12:1060307. [PMID: 36483031 PMCID: PMC9723233 DOI: 10.3389/fonc.2022.1060307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
Choroidal melanoma is the leading primary intraocular tumor with potentially fatal outcomes in adults. The coexistence of choroidal melanoma and a macular hole is extremely rare, and treatment strategies and information on the prognosis of associated complications are currently lacking. We report the first case of choroidal melanoma complicated with a macular hole and vitreous hemorrhage after stereotactic hypofractionated radiotherapy in Japan, and review the relevant literature in relation to the possible mechanisms, treatment strategies, and outcomes. An 83-year-old male with choroidal melanoma was treated with stereotactic hypofractionated radiotherapy in January 2021. Five months later, a full-thickness macular hole developed, followed by an acute massive vitreous hemorrhage about 2 weeks later. Following confirmation of tumor regression, the patient underwent a pars plana vitrectomy and internal limiting membrane peeling. The macular hole was closed postoperatively and the patient’s best-corrected visual acuity improved to 20/125. There was no evidence of intraocular tumor dissemination or distant metastases during follow-up. A systematic literature search only identified 10 previous cases of choroidal melanoma with a macular hole in eight reports worldwide, mainly in females. Macular edema may be the primary cause of macular hole formation in these cases. Most patients who underwent vitrectomy for complications after tumor regression achieved a good prognosis. The development of a macular hole is a rare complication associated with choroidal melanoma. Anterior-posterior traction of posterior vitreous detachment and secondary macular edema may have contributed to the formation of the macular hole in the current case.
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Affiliation(s)
- Xiaoyin Zhou
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroto Ishikawa
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
- Department of Ophthalmology, Mirai Eye & Skin Clinic, Osaka, Japan
- *Correspondence: Hiroto Ishikawa,
| | - Fumi Gomi
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
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Gündüz AK, Mirzayev I. Surgical Approach in Intraocular Tumors. Turk J Ophthalmol 2022; 52:125-138. [PMID: 35481734 PMCID: PMC9069084 DOI: 10.4274/tjo.galenos.2021.24376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Surgery in intraocular tumors is done for excision/biopsy and the management of complications secondary to the treatment of these tumors. Excision/biopsy of intraocular tumors can be done via fine-needle aspiration biopsy (FNAB), transretinal biopsy (TRB), partial lamellar sclerouvectomy (PLSU), and endoresection. FNAB, TRB, and PLSU can be used in tumors that cannot be diagnosed by clinical examination and other ancillary testing methods. PLSU is employed in tumors involving the iridociliary region and choroid anterior to the equator. Excisional PLSU is performed for iridociliary and ciliary body tumors with less than 3 clock hours of iris and ciliary body involvement and choroidal tumors with a base diameter less than 15 mm. However, for biopsy, PLSU can be employed with any size tumor. Endoresection is a procedure whereby the intraocular tumor is excised using vitrectomy techniques. The rationale for performing endoresection is based on the fact that irradiated uveal melanomas may cause complications such as exudation, neovascular glaucoma, and intraocular pigment and tumor dissemination (toxic tumor syndrome), and removing the dead tumor tissue may contribute to better visual outcome. Endoresection is recommended 1-2 weeks after external radiotherapy. Pars plana vitrectomy is also used in the management of complications including vitreous hemorrhage, retinal detachment, and epiretinal membrane that can occur after treatment of posterior segment tumors using radiotherapy and transpupillary thermotherapy. It is important to make sure the intraocular tumor has been eradicated before embarking on such treatment.
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Affiliation(s)
- Ahmet Kaan Gündüz
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
| | - Ibadulla Mirzayev
- Ankara University Faculty of Medicine, Department of Ophthalmology, Ankara, Turkey
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Böker A, Pilger D, Cordini D, Seibel I, Riechardt AI, Joussen AM, Bechrakis NE. Neoadjuvant proton beam irradiation vs. adjuvant ruthenium brachytherapy in transscleral resection of uveal melanoma. Graefes Arch Clin Exp Ophthalmol 2018; 256:1767-1775. [PMID: 29907945 DOI: 10.1007/s00417-018-4032-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/26/2018] [Accepted: 05/31/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alexander Böker
- Department of Ophthalmology, Campus Benjamin Franklin and Virchow Klinikum, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Daniel Pilger
- Department of Ophthalmology, Campus Benjamin Franklin and Virchow Klinikum, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Dino Cordini
- Department of Ophthalmology, Campus Benjamin Franklin and Virchow Klinikum, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
- Lise-Meitner-Campus, Berlinprotonen at the Helmholtz-Zentrum Berlin, Berlin, Germany
| | - Ira Seibel
- Department of Ophthalmology, Campus Benjamin Franklin and Virchow Klinikum, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Aline I Riechardt
- Department of Ophthalmology, Campus Benjamin Franklin and Virchow Klinikum, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Antonia M Joussen
- Department of Ophthalmology, Campus Benjamin Franklin and Virchow Klinikum, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
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Abstract
Uveal melanoma is the most common intraocular malignant tumor, with the choroid being the most common site. Management of choroidal melanoma has evolved greatly over the past years. In the past, the conventional method of treatment was enucleation of the affected eye with a debate regarding the effect of enucleation to promote or prevent metastasis. However, nowadays, there are many therapeutic options available including plaque radiotherapy, proton beam radiotherapy, argon laser photocoagulation, transpupillary thermotherapy, stereotactic radiotherapy using gamma knife, enucleation, and surgical resection of the tumor whether through transscleral approach "Exoresection" or less commonly through internal resection approach "Endoresection." The indications and complications of each technique are reviewed. Although radiotherapy is the primary treatment of choroidal melanoma in most ocular oncology centers, it is used as an adjuvant therapy in combination with surgical resection. Preoperative stereotactic radiotherapy before endoresection and brachytherapy to the surgical bed in both exo and endoresection can effectively decrease the recurrence rate. In this article, we will focus on surgical resection of choroidal melanoma whether endoresection or exoresection. We collected data published in indexed journals and related books.
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Affiliation(s)
- Hany S. Hamza
- Department of Ophthalmology, Kasr Al-Ainy Medical School, Cairo University, Giza, Egypt
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Rospond-Kubiak I, Groenewald C, Coupland SE, Damato B. Core Endoresection as Neoadjuvant Treatment of Uveal Melanoma. Ocul Oncol Pathol 2016; 2:91-3. [PMID: 27171344 DOI: 10.1159/000439134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 07/29/2015] [Indexed: 11/19/2022] Open
Abstract
AIM To present a case of neoadjuvant treatment of uveal melanoma with a limited core endoresection, which enabled ruthenium plaque radiotherapy to be administered. MATERIAL AND METHODS A 77-year-old woman presented in 2005 with a ciliochoroidal uveal melanoma measuring 7.2 by 6.5 mm basally with a thickness of 6.2 mm. The vision in the affected eye was 6/9. Because of diagnostic uncertainty, we performed a biopsy, which produced a copious sample. The biopsy serendipitously reduced the tumour thickness to 4.4 mm, making ruthenium plaque brachytherapy possible. RESULTS Histopathological examination showed the tumour to be a melanoma predominantly of spindle cell type. Postoperative complications included a dense vitreous haemorrhage, which cleared spontaneously, and raised intraocular pressure, controlled with latanoprost. Seven years after brachytherapy, the vision was 6/5 and the thickness of the residual tumour was 2.5 mm. Nine years after treatment, there was no evidence of any intra- or extraocular seeding or distant metastases. CONCLUSIONS Core endoresection of a ciliochoroidal melanoma may reduce tumour thickness enough to allow subsequent ruthenium plaque radiotherapy.
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Affiliation(s)
- Iwona Rospond-Kubiak
- Liverpool Ocular Oncology Centre, Royal Liverpool University Hospital, Liverpool, UK; Department of Ophthalmology, Poznań University of Medical Sciences, Poznań, Poland
| | - Carl Groenewald
- Liverpool Ocular Oncology Centre, Royal Liverpool University Hospital, Liverpool, UK
| | - Sarah E Coupland
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Bertil Damato
- Ocular Oncology Service, Department of Ophthalmology, San Francisco, Calif., USA; Department of Radiation Oncology, University of California, San Francisco, San Francisco, Calif., USA
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Caminal JM, Padrón-Pérez N, Arias L, Masuet-Aumatell C, Gutiérrez C, Piulats JM, Pera J, Català J, Rubio MJ, Arruga J. Transscleral resection without hypotensive anaesthesia vs iodine-125 plaque brachytherapy in the treatment of choroidal melanoma. Eye (Lond) 2016; 30:833-42. [PMID: 27034202 DOI: 10.1038/eye.2016.49] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 01/23/2016] [Indexed: 11/09/2022] Open
Abstract
AimsThe aim of this study was to compare transscleral resection technique performed without hypotensive anaesthesia (TSRWH) with iodine-125 brachytherapy (IBT) in the treatment of choroidal melanoma.Patients and methodsThis was a retrospective surgical cohort study. Nineteen eyes treated with TSRWH were matched with 53 eyes treated with IBT according to: tumour size, distance to fovea, distance to optic nerve, and follow-up time. Best-corrected visual acuity (BCVA), local recurrence, secondary enucleation, metastasis, overall and specific survival, and complications were evaluated.ResultsPatients treated with TSRWH had significantly better BCVA than those treated with IBT. The local recurrence risk was significantly higher when ciliary body was involved (HR=11.4, 95% CI 2.24-49.7, P=0.04). Metastatic disease was observed in 14 of 53 patients (26.4%) in the IBT group vs 3 patients (15.8%) in the TSRWH group (P=0.531). Multivariate analysis showed that iris involvement (HR=16.0, 95% CI 4.2-170.2, P=0.033) and large tumour (HR=2.3, 95% CI 1.2-4.8, P=0.04) increased the probability of metastasis. During follow-up, six patients (11.3%) in IBT group died vs two (10.5%) in the TSRWH group (P≥0.999). Nine patients required secondary enucleation: 5 (9.4%) in the IBT group vs 4 (21.1%) in the TSRWH group (P=0.231). The most common complications in IBT group were radiation-induced retinopathy (45.3%), neovascular glaucoma (28.3%), and macular oedema (24.5%), whereas rhegmatogenous retinal detachment (21.1%), ocular hypertension (21.1%), and submacular haemorrhage (15.8%) were the most frequent complications after TSRWH.ConclusionTSRWH is a technically challenging procedure. However, when performed successfully, this technique achieves better preservation of visual acuity than IBT and without the limitations inherent in hypotensive anaesthesia.
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Affiliation(s)
- J M Caminal
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, Feixa Llarga s/n. L'Hospitalet de Llobregat, Barcelona, Spain
| | - N Padrón-Pérez
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, Feixa Llarga s/n. L'Hospitalet de Llobregat, Barcelona, Spain
| | - L Arias
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, Feixa Llarga s/n. L'Hospitalet de Llobregat, Barcelona, Spain
| | - C Masuet-Aumatell
- Department of Preventive Medicine, Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, Feixa Llarga s/n. L'Hospitalet de Llobregat, Barcelona, Spain
| | - C Gutiérrez
- Department of Brachytherapy, Catalan Institute of Oncology, Avinguda de la Gran Vía de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J M Piulats
- Department of Oncology, Catalan Institute of Oncology, Avinguda de la Gran Vía de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J Pera
- Department of Brachytherapy, Catalan Institute of Oncology, Avinguda de la Gran Vía de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J Català
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, Feixa Llarga s/n. L'Hospitalet de Llobregat, Barcelona, Spain
| | - M J Rubio
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, Feixa Llarga s/n. L'Hospitalet de Llobregat, Barcelona, Spain
| | - J Arruga
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, Feixa Llarga s/n. L'Hospitalet de Llobregat, Barcelona, Spain
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11
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Chia SN, Smith HB, Hammer HM, Kemp EG. Incidence and indications for pars plana vitrectomy following the treatment of posterior uveal melanomas in Scotland. Eye (Lond) 2015; 29:748-56. [PMID: 25853443 DOI: 10.1038/eye.2015.20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 01/19/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Globe-sparing treatments such as plaque brachytherapy, local or endoresection, and proton beam therapy (PBT) are the treatments of choice for posterior uveal melanoma. However, both early and late complications can arise from these techniques, including vitreous haemorrhage (VH) and retinal detachment (RD). Choroidal melanomas in Scotland are managed by a single unit, the Scottish Ocular Oncology Service (SOOS). METHODS Indications and outcomes from surgery were analysed for patients undergoing vitrectomy following treatment for uveal melanoma in the SOOS between 1998 and 2013. RESULTS Seventeen from 715 cases (2.4%) required vitrectomy, of which 8/445 (1.8%) followed plaque brachytherapy, 7/43 (16.3%) combined local resection and brachytherapy, and 2/227 (0.9%) PBT. Case notes were reviewed for 16/17 cases, with surgery indicated for VH in 10 (63%), RD in 5 (31%), and combined VH/RD in 1 (6%). The median interval from initial tumour treatment to vitrectomy was 5.8 months (range 10 days to 8.8 years). Ten (63%) required early vitrectomy (within 6 months), of which the majority (70%) followed combined resection/brachytherapy. Six (37%) required late vitrectomy (after 6 months), of which all were non-clearing VH following plaque brachytherapy, with proliferative retinopathy in 4/6 (67%), and tumour recurrence in 2/6 (33%). Overall vision improved in 8 eyes (50%), remained the same in 2 (12.5%), and deteriorated in 6 (37.5%). CONCLUSIONS Early vitrectomy was most commonly indicated for RD following local resection, and late vitrectomy for VH due to radiation retinopathy. The majority of patients undergoing vitrectomy gained or maintained vision.
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Affiliation(s)
- S N Chia
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, UK
| | - H B Smith
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, UK
| | - H M Hammer
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, UK
| | - E G Kemp
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, UK
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Lee CS, Rim THT, Kwon HJ, Yi JH, Lee SC. Partial lamellar sclerouvectomy of ciliary body tumors in a Korean population. Am J Ophthalmol 2013; 156:36-42.e1. [PMID: 23540709 DOI: 10.1016/j.ajo.2013.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 01/11/2013] [Accepted: 01/16/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE To describe the clinical characteristics of ciliary body tumors, surgical outcomes, and factors associated with poor visual outcome and metastasis. DESIGN Retrospective case series. METHODS Medical records of 27 patients with ciliary body tumors who underwent partial lamellar sclerouvectomy in a single-center setting (Seoul, South Korea) were reviewed. Surgical outcomes were reviewed, and clinical characteristics were analyzed with respect to visual prognosis and globe retention rate. RESULTS Tumors were diagnosed histopathologically as benign in 8 (30%) cases and as melanoma in 19 (70%) cases. Patients had a median age of 48 years. The median follow-up was 3.5 years (range, 0.5 to 6 years). The tumors had a median diameter of 11 mm and a median thickness of 9 mm. The globe was retained in 20 (74%) eyes, with visual acuity of 20/400 or better in 13 (48%) eyes and 20/40 or better in 6 (22%) eyes. Choroidal involvement of tumor (P = .003), larger diameter of tumor (P < .001), and thicker tumor (P < .001) were associated with poor visual outcome. Local recurrence (P = .003) and presence of epithelioid cells (P = .040) were predictive factors for metastasis in melanoma patients. Kaplan-Meier estimates of metastasis-free survival at 3 and 5 years for melanoma patients were 82% and 55%, respectively. CONCLUSIONS Partial lamellar sclerouvectomy is a reasonable primary therapeutic option in ciliary body tumors, and good visual prognosis is expected in selected cases.
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Laser Treatment of Choroidal Melanoma. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00148-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Damato B. Progress in the management of patients with uveal melanoma. The 2012 Ashton Lecture. Eye (Lond) 2012; 26:1157-72. [PMID: 22744385 PMCID: PMC3443832 DOI: 10.1038/eye.2012.126] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 05/24/2012] [Indexed: 01/06/2023] Open
Abstract
Uveal melanomas are diverse in their clinical features and behaviour. More than 90% involve the choroid, the remainder being confined to the ciliary body and iris. Most patients experience visual loss and more than a third require enucleation, in some cases because of pain. Diagnosis is based on slit-lamp biomicroscopy and/or ophthalmoscopy, with ultrasonography, autofluorescence photography, and/or biopsy in selected cases. Conservation of the eye with useful vision has improved with advances in brachytherapy, proton beam radiotherapy, endoresection, exoresection, transpupillary thermotherapy, and photodynamic therapy. Despite ocular treatment, almost 50% of patients develop metastatic disease, which occurs almost exclusively in patients whose tumour shows chromosome 3 loss and/or class 2 gene expression profile. When the tumour shows such lethal genetic changes, the survival time depends on the anatomical stage and the histological grade of malignancy. Prognostication has improved as a result of progress in multivariate analysis including all the major risk factors. Screening for metastases is more sensitive as a consequence of advances in liver scanning with magnetic resonance imaging and other methods. More patients with metastases are living longer, benefiting from therapies such as: partial hepatectomy; radiofrequency ablation; ipilumumab immunotherapy; selective internal radiotherapy; intra-hepatic chemotherapy, possibly with isolated liver perfusion; and systemic chemotherapy. There is scope for improvement in the detection of uveal melanoma so as to maximise any opportunities for conserving the eye and vision, as well as preventing metastatic spread. Patient management has been enhanced by the formation of multidisciplinary teams in specialised ocular oncology centres.
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Affiliation(s)
- B Damato
- Department of Molecular and Clinical Cancer Medicine, Ocular Oncology Service, Royal Liverpool University Hospital, Prescot St, Liverpool, UK.
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Russo A, Laguardia M, Damato B. Eccentric ruthenium plaque radiotherapy of posterior choroidal melanoma. Graefes Arch Clin Exp Ophthalmol 2012; 250:1533-40. [PMID: 22354369 DOI: 10.1007/s00417-012-1962-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Revised: 01/16/2012] [Accepted: 02/01/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim of this work is to report on conservation of visual acuity after eccentric ruthenium(106) (Ru-106) brachytherapy of posterior choroidal melanoma. METHODS Fifty-four patients with choroidal melanoma extending to within 5 mm of the optic disc or fovea were treated at a single institution during the 3 years up to July 31, 2007. The plaque was positioned eccentrically with its posterior edge aligned with the posterior tumor margin to reduce the radiation dose to the optic disc and fovea. The main outcome measures were local tumor control and conservation of vision of 6/12 or better, according to baseline variables. RESULTS The tumors had a mean longest basal diameter of 12.0 mm and a mean thickness of 3.1 mm. The posterior tumor margin extended to within 3 mm of the fovea in 30 patients (56%). In the 24 eyes with the posterior tumor margin located 3.1-5.0 mm from the fovea, 74.9% retained visual acuity of 6/12 or better 4 years after treatment (95% confidence interval [CI], 55.5-94.3%). In the 30 eyes with tumor extension to within 3.0 mm of the fovea, then 3 years after treatment only 25.3% retained such vision (95% CI, 5.3-45.3%). Recurrence at the posterior tumor margin occurred in two patients. CONCLUSIONS Eccentric ruthenium(106) plaque radiotherapy of posterior choroidal melanoma achieves good rates of local tumor control and conservation of vision if special measures are taken to ensure that the plaque is positioned correctly.
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Affiliation(s)
- Andrea Russo
- St. Paul's Eye Unit, Oncology Service, Royal Liverpool University Hospital, Prescot Street, L7 8XP, Liverpool, UK.
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Abstract
PURPOSE The purpose of this study is to compare uveal melanomas (UMs) in men and women. METHODS The Liverpool Ocular Oncology Centre (LOOC) database was reviewed. Patients treated for UM at the LOOC between 1993 and 2010 were selected. Differences between sexes were identified using the χ (2)-test for categorical variables and the Mann-Whitney test for continuous variables. RESULTS The 3380 patients comprised 1685 women and 1695 men. The tumours were considered clinically to have arisen in choroid in 89.5%, ciliary body in 5.3%, and iris in 5.2%. Tumours in women were less likely to originate in choroid (87.2 vs 91.7%; P<0.001) and showed more circumferential spread in ciliary body (P<0.001) and iris (P=0.003). Tumours in men were more likely to extend to within 3 mm of optic disc or fovea (46.3 vs 39.0%, P<0.001), showing more extensive optic-disc involvement (P<0.001). The median largest basal tumour diameter was 12.2 mm in men and 11.9 mm in women (P=0.001). The tumour thickness had a median of 4.4 mm and 3.8 mm in men and women, respectively (P=0.015). The 180 ciliary body tumours occurred in 112 women and 68 men. In these, the prevalence of extraocular spread was higher in women (19.6 vs 8.8%; P=0.052). The 175 iris melanomas were more common in women than men (103 vs 72, respectively). CONCLUSIONS In men, UMs tend to be larger and more posterior than in women.
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Zorlu F, Selek U, Kiratli H. Initial results of fractionated CyberKnife radiosurgery for uveal melanoma. J Neurooncol 2009; 94:111-7. [PMID: 19234813 DOI: 10.1007/s11060-009-9811-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 02/02/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate prospectively local tumor control and morbidity after fractionated CyberKnife radiosurgery for uveal melanoma unsuitable for ruthenium-106 brachytherapy or local resection. METHODS This study includes melanoma > or =7 mm in initial height, or juxtapapillary and/or juxtamacular tumors (height > or =3 mm; posterior tumor margin extending to within 3 mm of optic disk rim and/or fovea). Patients were excluded if they presented evidence of echographic extrascleral tumor extension, neovascular glaucoma, or any form of pretreatment or metastases at baseline. The eye was stabilized by the same ophthalmologist via peribulbar injection of 5 cc 2% lidocaine. CyberKnife radiosurgery was performed delivering a total dose of 60 Gy to the 80% or 85% isodose line in three fractions. The planning target volume (PTV) included the contrast-enhancing lesion on MRI plus a 1-mm margin (no margin on fovea site). RESULTS Five patients with uveal melanoma were treated by this procedure. All patients had serous retinal detachment associated with the tumor. No grade > or =2 acute toxicities were observed. Eight-month follow-up revealed a decrease in tumor thickness in three patients and reattachment of the retina in four. The tumors remained stable in two eyes and an increase in retinal detachment was noted in one eye. Vision improved minimally in two eyes and remained stable in three. CONCLUSION CyberKnife fractionated radiosurgery seems to be a viable alternative local treatment modality in uveal melanoma with no serious acute side effects. Further follow-up is indicated.
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Affiliation(s)
- Faruk Zorlu
- Department of Radiation Oncology, Hacettepe University, Oncology Hospital, Sihhiye, Ankara 06100, Turkey
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Bovine Pericardium for Scleral Closure in Transscleral Local Resection of Choroidal Melanoma. Retina 2008; 28:1530-2. [DOI: 10.1097/iae.0b013e3181835730] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Puusaari I, Damato B, Kivelä T. Transscleral local resection versus iodine brachytherapy for uveal melanomas that are large because of tumour height. Graefes Arch Clin Exp Ophthalmol 2006; 245:522-33. [PMID: 17111148 DOI: 10.1007/s00417-006-0461-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2006] [Revised: 09/07/2006] [Accepted: 09/16/2006] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND To compare visual outcome and ocular complications of transscleral local resection (TSR) with those of iodine-125 plaque brachytherapy (IBT) for uveal melanomas categorised as large because of tumour height. METHODS Retrospective study of 87 patients with a uveal melanoma <or=16 mm by largest basal diameter (median, 12.6 vs 14.0 mm for TSR and IBT, respectively) and large by height (median, 11.0 vs 10.6 mm) by the Collaborative Ocular Melanoma Study (COMS) criteria. Thirty-three patients underwent TSR in the United Kingdom and 54 underwent IBT in Finland. Loss of 20/65 and 20/400 vision, local tumour recurrence, cataract, iris neovascularization, glaucoma, maculopathy, optic neuropathy, persistent retinal detachment, and vitreous haemorrhage were analysed using competing risks and logistic regression to control for confounders. RESULTS All patients save one managed with TSR lost 20/70 vision within 3 years. The 2-year cumulative incidence of losing 20/400 vision was 60% (95% CI, 35-75) for TSR and 75% (95% CI, 59-86) for IBT. The 5-year incidence of local tumour recurrence was 41% (95% CI, 17-63) after TSR and 7% (95% CI, 2-17) after IBT. Glaucoma and optic neuropathy were rare after TSR. Cataract, maculopathy, retinal detachment, and vitreous haemorrhage were common after either treatment. The number of patients needed to treat with TSR instead of IBT was four for one additional patient to benefit by avoiding loss of visual acuity 20/400 for at least 2 years, and the corresponding number was three for one additional patient to experience a local recurrence from TSR. CONCLUSIONS If TSR is further evaluated as an alternative to IBT in avoiding blindness of an eye with a ciliochoroidal melanoma categorised as large by COMS criteria because of its height, special emphasis must be given to increased risk of local tumour recurrence.
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Affiliation(s)
- Ilkka Puusaari
- Department of Ophthalmology, Helsinki University Central Hospital, PL 220, Haartmaninkatu 4 C, FI-00029 HUS, Helsinki, Finland.
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Affiliation(s)
- Bertil Damato
- FRCOphth, St Paul's Eye Unit, Royal Liverpool University Hospital, UK
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Surgical Resection of Choroidal Melanoma. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Bornfeld N, Anastassiou G. Laser Treatment of Choroidal Melanoma. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50048-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Damato B, Patel I, Campbell IR, Mayles HM, Errington RD. Local tumor control after 106Ru brachytherapy of choroidal melanoma. Int J Radiat Oncol Biol Phys 2005; 63:385-91. [PMID: 15913907 DOI: 10.1016/j.ijrobp.2005.02.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Revised: 02/14/2005] [Accepted: 02/15/2005] [Indexed: 11/16/2022]
Abstract
PURPOSE To report on local tumor control after (106)Ru brachytherapy for choroidal melanoma. METHODS AND MATERIALS A total of 458 patients with choroidal melanoma were treated at a single institution between January 1993 and December 2001. The tumors had a median longest basal dimension of 10.6 mm and a median height of 3.2 mm. The brachytherapy was administered using a 15- or 20-mm plaque. For posterior tumors, the plaque was positioned eccentrically with its posterior edge aligned with the posterior tumor margin to reduce the radiation dose to the optic disk and fovea. A minimal scleral dose sufficient to cause visible choroidal atrophy provided a permanent ophthalmoscopic record of the distribution of choroidal irradiation. If radiotherapy to the posterior tumor was uncertain, adjunctive transpupillary thermotherapy was administered 6 months postoperatively. RESULTS The actuarial rates of tumor recurrence were 1%, 2%, and 3% at 2, 5, and 7 years, respectively. Local tumor recurrence correlated with the longest basal tumor dimension (Cox univariate analysis, p = 0.02, risk ratio 1.41, 95% confidence interval 1.06-1.88). Seven of the nine eyes with recurrent tumor were salvaged with additional conservative therapy. CONCLUSION The low rate of local tumor recurrence suggests that ruthenium plaque radiotherapy is effective with good case selection and if special measures are taken to ensure that the plaque is positioned correctly.
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Affiliation(s)
- Bertil Damato
- Ocular Oncology Service, St. Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom.
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Damato B, Patel I, Campbell IR, Mayles HM, Errington RD. Visual acuity after Ruthenium106 brachytherapy of choroidal melanomas. Int J Radiat Oncol Biol Phys 2005; 63:392-400. [PMID: 15990248 DOI: 10.1016/j.ijrobp.2005.02.059] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Accepted: 02/01/2005] [Indexed: 11/18/2022]
Abstract
PURPOSE To report on conservation of visual acuity after Ruthenium(106) (Ru-106) brachytherapy of choroidal melanoma. METHODS AND MATERIALS This study was a noncomparative interventional case series of 458 patients with choroidal melanoma treated at a single center between January 1993 and December 2001. The intervention consisted of Ru-106 brachytherapy delivering minimum scleral and apex doses of 300 Gy and 80 Gy, respectively, using a 15-mm or 20-mm plaque. For discrete, posterior tumors, the plaque was positioned eccentrically with its posterior edge aligned with the posterior tumor margin. To ensure correct plaque positioning, any overlying extraocular muscles were dis-inserted, and the locations of both tumor and plaque edges were confirmed by transillumination and indentation. The main outcome measures were conservation of vision of 20/40 or better, 20/200 or better, and Counting Fingers or better, according to baseline variables. RESULTS The actuarial rate of conservation of 20/40 or better was 55% at 9 years, loss of such vision correlating with posterior tumor extension (p < 0.001), temporal tumor location (p = 0.001), increased tumor height (p = 0.01), and older age (p < 0.01) (Cox multivariate analysis). Similar analyses showed conservation of 20/200 or better in 57% of eyes at 9 years, loss correlating with reduced initial visual acuity (p < 0.001), posterior tumor extension (p < 0.001), and temporal tumor location (p = 0.006). Counting Fingers or better vision was conserved in 83% of patients at 9 years, loss correlating with increased tumor height (p < 0.0001). Local tumor recurrence occurred in 9 patients (actuarial rate, 3% at 9 years). CONCLUSION Ruthenium(106) brachytherapy of posterior choroidal melanoma achieves good conservation of vision if the tumor does not extend close to the optic nerve or fovea.
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Affiliation(s)
- Bertil Damato
- Ocular Oncology Service, St. Paul's Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom.
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Abstract
Uveal melanomas threaten visual loss, enucleation, and death from metastatic disease. Most patients present because of symptoms, but failures of detection and diagnosis still occur commonly. Treatments aimed at avoiding enucleation include: plaque, proton beam or stereotactic radiotherapy; trans-scleral or trans-retinal local resection; and transpupillary thermotherapy. Increasingly, different modalities are being used in combination. The ocular outcomes are related to tumour size, location, spread and cell type. Metastatic disease occurs in many patients and is related to factors such as tumour dimensions, ciliary body involvement, cell type, extravascular matrix patterns and cytogenetics. Abnormalities related to chromosomes 3, 6 and 8 are strongly related to tumour behaviour, for the first time enabling survival probability to be estimated with a high degree of reliability in an individual patient. This enables high-risk individuals to be targeted for screening while providing reassurance to those with a minimal chance of developing metastatic disease. Such targeting would allow selection of patients for adjuvant systemic therapy, should a suitable treatment become available, and would also facilitate the evaluation of such treatment by increasing the statistical power of any randomized prospective study. The high mortality in patients with monosomy 3 melanoma suggests that in these patients ocular treatment is only palliative. Cytogenetic studies suggest that some melanomas may never develop any metastatic potential and if these impressions are confirmed by further studies, then in these patients the main priority of treatment would be to conserve vision.
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Affiliation(s)
- Bertil Damato
- Liverpool Ocular Oncology Centre, Royal Liverpool University Hospital, Liverpool, UK.
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Damato B, Lecuona K. Conservation of eyes with choroidal melanoma by a multimodality approach to treatment. Ophthalmology 2004; 111:977-83. [PMID: 15121377 DOI: 10.1016/j.ophtha.2003.09.028] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2003] [Accepted: 09/05/2003] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To report on conservation of eyes with choroidal melanoma with a multimodality approach to treatment. DESIGN Prospective, noncomparative, interventional case series. PARTICIPANTS All 1632 patients with choroidal melanoma treated at a single center between 1993 and 2002. INTERVENTION Primary enucleation (35%), brachytherapy (31.3%), proton beam radiotherapy (16.7%), transscleral local resection (11.0%), endoresection (3.7%), transpupillary thermotherapy (2.5%), and photocoagulation (0.1%). MAIN OUTCOME MEASURES Primary and secondary enucleation. RESULTS Logistic regression showed the main predictive factors for primary enucleation to be: age more than 60 years (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.8%-3.2%); reduced visual acuity (OR, 2.5; 95% CI, 1.9%-3.2%); posterior extension close to or involving the optic disc and fovea (OR, 1.7; 95% CI, 1.2%-2.4%); circumferential spread around the ciliary body, iris, or angle (OR, 3.1; 95% CI, 1.8%-5.5%); basal tumor diameter (OR, 3.5; 95% CI, 2.4%-5.0%); and tumor height (OR, 6.3; 95% CI, 4.5%-8.9%). After conservative treatment, the actuarial rate of secondary enucleation was 11.1% at 5 years (95% CI, 8.6%-13.6%). Cox multivariate analysis indicated the factors independently predicting secondary enucleation as: nasal/midline tumor location (risk ratio [RR], 2.6; 95% CI, 1.6%-4.4%); disc involvement (RR, 2.2; 95% CI, 1.2%-4.1%); tumor diameter (RR, 1.2; 95% CI, 1.0%-1.5%); and tumor thickness (RR, 1.8; 95% CI, 1.5%-2.1%). CONCLUSIONS With a multimodality approach to treatment, 65% of patients underwent conservative treatment, and of them, 89% retained their eye at 5 years, with success depending on tumor diameter, tumor thickness, disc involvement, and coronal location.
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Affiliation(s)
- Bertil Damato
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.
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Kivelä T, Puusaari I, Damato B. Transscleral resection versus iodine brachytherapy for choroidal malignant melanomas 6 millimeters or more in thickness. Ophthalmology 2003; 110:2235-44. [PMID: 14597535 DOI: 10.1016/j.ophtha.2003.02.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess differences in treatment outcome after transscleral resection (TSR) and iodine brachytherapy (IBT) of choroidal melanomas too thick for ruthenium brachytherapy. DESIGN Matched case-control study. SETTING Two national ocular oncology services. PARTICIPANTS Forty-nine pairs of patients with choroidal melanoma 6 mm thick or more (range = 6-14), treated within 3 years of each other by either TSR or IBT, and retrospectively matched by age, visual acuity at diagnosis, largest basal tumor diameter, and posterior extension of the tumor. INTERVENTION Iodine brachytherapy in Finland or TSR in United Kingdom. Prospectively collected time-to-event data were compared with parametric Weibull regression, adjusting for matching. MAIN OUTCOME MEASURES Tumor control, complications, and visual acuity. RESULTS Risk of local recurrence after IBT was smaller than that after TSR (hazard ratio [HR] = 0.02, 95% confidence interval [CI] = 0.01-0.11, P<0.001, Weibull regression adjusted for matching), but the 8-year all-cause and melanoma-specific (HR = 0.81, 95% CI = 0.30-2.22, P = 0.69) survivals did not differ. The risks of cataract (HR = 2.05, 95% CI = 1.08-3.89, P = 0.029), maculopathy (HR = 2.28, 95% CI = 0.96-5.43, P = 0.062), and vitreous hemorrhage (HR = 2.30, 95% CI = 0.95-5.57, P = 0.064) were higher after IBT. Rubeosis, neovascular glaucoma, and optic neuropathy developed only after IBT. Risk of retinal detachment, exudative after IBT and rhegmatogenous after TSR (HR = 0.84, 95% CI = 0.40-1.75, P = 0.63), and risk of losing 20/60 vision (HR = 1.37, 95% CI 0.76-2.45, P = 0.29) were comparable between the groups, but risk of losing 20/200 vision was higher after IBT (HR = 2.38, 95% CI = 1.48-3.83, P<0.001). No overall difference in quality of life was found. CONCLUSIONS This study suggests that TSR preserves 20/200 vision better than IBT and avoids some of its major complications, but increases the risk of local recurrence. About 350 patients would need to be randomized to prove that TRS preserves 20/60 vision better than IBT.
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Affiliation(s)
- Tero Kivelä
- Oncology and Vitreoretinal Service, Department of Ophthalmology, Helsinki University Central Hospital, Helsinki, Finland
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