Contralateral orbital melanoma 28 years following enucleation for choroidal melanoma

Comparison of primary and secondary enucleation for uveal melanoma

We investigated operative course and post-operative findings of patients undergoing primary enucleation for uveal melanoma versus those requiring secondary enucleation after brachytherapy. A retrospective chart review was performed with IRB approval on patients receiving treatment for uveal melanoma. Patients with enucleation as initial treatment and patients enucleated after plaque brachytherapy were analyzed for demographic data, operative course, and post-enucleation outcome. Further cause analysis for secondary enucleations was investigated. No significant difference was seen in age, laterality, or gender between the primarily enucleated (n = 54) and secondarily enucleated (n = 34) groups. Greater difficulty with surgery was noted in 28/32 (87.5%) of secondary enucleations compared to 1/54 (1.8%) of primary enucleations (p < 0.0001). Operative time was >2 hours in 3/51 (6%) of primary enucleations (vs. 8 of 32, 25%, p = 0.02). Average implant size was similar in the 2 groups (20.6 mm), however 2/34 (6%) of secondary enucleations required dermis fat grafting. Post-enucleation anophthalmic ptosis occurred after 8/49 (16%) of primary cases (vs. 13/30, 43%, p = 0.02) and prosthetic enophthalmos after none (0%) of primary cases (vs. 5/30, 17%, p = 0.006). Class 2 gene expression profile was found in 6/8 (60%) of eyes enucleated for treatment failure. Secondary enucleation performed after plaque brachytherapy was technically more difficult, and had more anophthalmic socket and eyelid complications compared to primary enucleation for uveal melanoma. Primary enucleation may avoid additional surgery and morbidity in a subset of patients with contraindications to plaque brachytherapy.

Presentation, Treatment, and Prognosis of Secondary Melanoma within the Orbit

BACKGROUND

Ocular melanoma is a rare but often deadly malignancy that arises in the uvea, conjunctiva, or orbit. Uveal melanoma is the most common type, with conjunctival melanoma being the second most frequently observed. Melanoma accounts for 5-10% of metastatic or secondary orbital malignancies, but only a minute proportion of primary orbital neoplasia. The aim of this study was to characterize the clinical presentation, treatment, and prognosis in patients presenting with melanoma metastatic to, or secondary within, the orbit.

METHODS

A retrospective cohort study of patients presenting to a tertiary referral orbital unit from 1982 to 2016 was performed. Eighty-nine patients with biopsy-proven diagnosis of melanoma within the orbit were included in the study. The clinical notes, radiological imaging, histology, surgical notes, and outcome data for the patients were reviewed. The main outcome measures of interest were the interval between primary malignant melanoma and orbital presentation, survival after orbital presentation, and clinical parameters (such as gender, age at presentation, and treatment approach).

RESULTS

The commonest primary source of tumor was choroidal melanoma, with conjunctival and cutaneous melanomas being relatively common; eyelid and naso-sinus tumors occurred in a few cases. The mean age at presentation with orbital disease was 65 years (31-97 years). The interval between primary malignancy and orbital disease (either local spread/recurrence or true metastatic disease) showed wide variability, with almost one-third of patients having orbital disease at the time of primary diagnosis, but others presenting many years later; indeed, the longest orbital disease-free interval was over 34 years. Twenty-three patients were considered to have had late orbital metastases-that is, at more than 36 months after primary tumor. The median survival following presentation with orbital involvement was 24 months. Patients with tumors of cutaneous origin had worst survival, whereas those with conjunctival tumors had the best prognosis.

CONCLUSION

A high index of suspicion for orbital recurrence should be maintained in any patient with prior history of melanoma, however distant the primary tumor is in site or time. Furthermore, giving a prognosis for orbital melanoma remains problematic due to highly variable survival, and further investigation will be necessary to understand the likely genetic basis of this phenomenon.

Effectiveness of treatments for metastatic uveal melanoma

PURPOSE

To evaluate and comment on published peer-reviewed literature for evidence of effectiveness of treatments for metastatic uveal melanoma.

DESIGN

Analytical nonexperimental study of published peer-reviewed data.

METHODS

Literature search and analysis of pertinent articles published between January 1, 1980 and June 30, 2008.

RESULTS

Of 80 identified publications, 12 (15.0%) were review articles without original information, 2 (2.5%) were review articles combined with case reports, 22 (27.5%) were case reports, 16 (20.0%) were retrospective descriptive case series reports, 3 (3.75%) were pilot studies of a novel intervention, 2 (2.5%) were prospective phase I clinical trials, 8 (10.0%) were prospective phase I/II clinical trials, and 15 (18.75%) were prospective phase II clinical trials. None of the articles reported a prospective, randomized phase III clinical trial. The largest reported unselected patient groups had a median survival of 3 to 4 months after detection of metastasis, whereas the largest selected patient groups showed substantially longer median survival times.

CONCLUSIONS

Although median survival time after diagnosis of metastatic uveal melanoma tends to be substantially longer in selected patient subgroups subjected to aggressive invasive interventions than it is in unselected groups, much if not most of this apparent difference in survival is likely to be attributable to selection bias, surveillance bias, and publication bias rather than treatment-induced alteration of expected outcome. Published peer-reviewed articles do not provide compelling scientific evidence of any survival benefit of any method of treatment for any subgroup of patients with metastatic uveal melanoma.