Survival from uveal melanoma in England and Wales 1986 to 2001

Gain of chromosome 8q and high expression of EZH2 may predict poor prognosis in Chinese patients with uveal melanoma

PURPOSE

To explore risk factors predicting poor prognosis of uveal melanoma in a Chinese population, with specific emphasis on monosomy 3, 8q gain, and EZH2 staining.

METHODS

Eighty-nine patients with uveal melanoma from 2012 to 2021 were reviewed. Clinical and pathological records were collected and analyzed. Immunohistochemical staining of EZH2, monosomy 3 and 8q gain were respectively conducted in 45, 54, and 57 cases. Survival was evaluated by Kaplan-Meier analysis and log-rank test. Cox proportional hazard regressions were employed to predict risk factors of distant metastasis.

RESULTS

The median follow-up was 44 months. Altogether, 16 % of patients developed distant metastases and died from disease-related causes. Disease-specific survival at one and three years was 96.6 % and 88.4 % while distant metastasis rates were 7.9 % and 12 %. Univariate Cox regression analysis revealed that age (HR: 1.04), tumor largest basal diameter (HR: 1.21), tumor thickness (HR: 1.21), ciliary body involvement (HR: 3.50), AJCC stage (HR: 5.68), epithelioid cell type (HR: 7.71), 8q gain (HR: 7.48), and high expression of EZH2 (HR: 6.09) were associated with distant metastasis. 8q gain was associated with epithelioid cell type and thicker tumor while EZH2 was correlated with epithelioid cell type. Monosomy 3 lacked a significant correlation with other factors.

CONCLUSION

EZH2 and 8q gain could be taken into consideration when calculating poor prognosis in Chinese patients with uveal melanoma. Monosomy 3 showed no significance in distant metastasis, but this may be due to a small sample size.

Hepatic and Overall Progression-Free Survival After Percutaneous Hepatic Perfusion (PHP) as First-Line or Second-Line Therapy for Metastatic Uveal Melanoma

BACKGROUND

Uveal melanoma often metastasizes to the liver, portending a poor prognosis. Melphalan/hepatic delivery system (HDS) via percutaneous hepatic perfusion (PHP) is a minimally invasive means of circulating high-dose chemotherapy through the affected liver. This study evaluated melphalan/HDS use as either first-line or second-line treatment to guide treatment sequencing.

PATIENTS AND METHODS

A retrospective review included patients with hepatic-dominant metastatic uveal melanoma who underwent melphalan/HDS treatment via PHP from 2008 to 2023.

RESULTS

A total of 30 patients were identified; 53.3% female, with a median age of 63.5 years (37-78 years). Median follow-up time was 14.5 months. First-line therapies included melphalan/HDS (n = 17), liver-directed (n = 7), and immunotherapy (n = 6). Second-line therapies included melphalan/HDS (n = 6), immunotherapy (n = 5), and liver-directed (n = 3). Median hepatic progression-free survival (hPFS) for first-line melphalan/HDS, immunotherapy, and liver-directed therapy was 17.6/8.8/9.2 months, respectively (P = 0.002). Median hPFS for second-line melphalan/HDS, immunotherapy, and liver-directed therapy was not reached/14.7/7.5 months, respectively (P < 0.001). Median overall PFS for first-line melphalan/HDS, immunotherapy, and liver-directed therapy was 15.4/8.8/9.2 months, respectively (P = 0.04). Median overall PFS for second-line melphalan/HDS, immunotherapy, and liver-directed therapy was 22.2/14.7/7.5 months, respectively (P = 0.001).

CONCLUSIONS

Melphalan/HDS via PHP for metastatic uveal melanoma to the liver was found to have significantly improved hPFS and overall PFS when used as first-line therapy compared with immunotherapy or liver-directed therapy. PHP continued to demonstrate improved hPFS and PFS when used as second-line therapy compared with second-line immunotherapy or liver-directed therapy.

Trends in the Clinical Presentation of Uveal Melanoma During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVE

The objective was to evaluate factors associated with clinical presentation of uveal melanoma (UM) during the initial two years of the coronavirus disease 2019 pandemic.

PATIENTS AND METHODS

This was a multi-site, retrospective cohort study of patients treated for uveal melanoma during the first (early) and second (late) year of the pandemic compared with the year prior (control).

RESULTS

A total of 48, 67, and 75 patients were in the control, early, and late cohorts, respectively. The early cohort had a higher frequency of large tumors (control: 29.2%, early: 40.3%, late: 29.3%; P < 0.001) at presentation. Both the early and late cohorts had higher rates of enucleation (control: 8.33%, early: 20.9%, late: 18.67%; P ≤ 0.0338) compared to the control cohort.

CONCLUSIONS

While there was an increase in large tumors along with a rise in enucleation during the first year of the pandemic, enucleation rates remained elevated even while tumor sizes normalized. [Ophthalmic Surg Lasers Imaging Retina 2024;55:278-284.].

Choroidal Melanoma: A Mini Review

Choroidal melanoma is a rare malignant tumour, yet it is the most common primary intra-ocular neoplasm and second on the list of top ten most malignant melanoma sites in the body. Clinical presentation can be non-specific and includes photopsia, floaters, progressive visual field loss, and blurry vision. The tumour is quite often diagnosed clinically during fundus examination; however, the most valued diagnostic tests are A- and B-scan ultrasonography (US). Several factors affect prognosis, including the patient's age, tumour size, histological features, and presence of metastases. Still, with primary treatment and tight surveillance, around 50% of choroidal melanoma patients metastasise.

A Retrospective Analysis of 10 Years of Liver Surveillance Undertaken in Uveal Melanoma Patients Treated at the Supraregional "Liverpool Ocular Oncology Centre", UK

Simple Summary

Around 45% of patients with uveal melanoma (UM) develop liver metastases on average 3 years after diagnosis of the primary tumour. After clinical detection of metastases, median patient survival is approximately one year. Early identification of metastases through liver surveillance is important so that targeted treatment can benefit affected patients, aiming to prolong their survival. The aim of our retrospective study was to investigate and correlate the characteristics of UM patients diagnosed and treated at a UK supraregional referral center, the Liverpool Ocular Oncology Centre (LOOC), and who were included in the Centre’s liver screening programs for screening for liver metastases. “Real-world” data on the frequency of liver screening in patients after diagnosis and treatment of primary UM are lacking. Through the liver screening program, we found that metastases were detected in 37% of the 615 UM patients studied. A new output based on the prognostic indices of the Liverpool Uveal Melanoma Prognosticator Online version 3 (LUMPO3) model was fitted to the dataset of these patients and accurately estimated the time of onset of metastases.

Abstract

Purpose: To determine liver screening frequency and modality in UM patients following primary treatment, and the characteristics of detected metastases. Methods: A 10-year retrospective study of 615 UM patients undergoing liver surveillance in Liverpool. Information was collected from liver scan reports of these patients. Results: Of 615 UM patients analyzed, there were 337 men (55%) and 278 women (45%). Median age at primary treatment was 61 years (range, 22–94). At study end, median follow-up was 5.1 years, with 375 patients (61%) alive and 240 deceased (39%). Of the deceased patients, 187 (78%) died due to metastatic UM; 24 (10%) deaths were due to other causes; and 29 (12%) patients died of unknown conditions. In total, 3854 liver scans were performed in the 615 UM patients, with a median of 6.2 scans per patient (range, 1–40). Liver MRI was most frequently performed (62.8%). In total, 229 (37%) UM patients developed metastases during the study period: 150 were detected via liver surveillance and 79 were observed post-mortem. Conclusions: Metastatic UM onset is related to the size and genetic profiles of the primary UM, and can be predicted using the model LUMPO3. Regular liver surveillance allowed for timely detection of metastases, and through metastasectomy can lead to prolongation of life in some patients.

Long-term relative survival in uveal melanoma: a systematic review and meta-analysis

Background

A large proportion of patients with uveal melanoma develop metastases and succumb to their disease. Reports on the size of this proportion vary considerably.

Methods

PubMed, Web of Science and Embase were searched for articles published after 1980. Studies with ≥100 patients reporting ≥five-year relative survival rates were included. Studies solely reporting Kaplan-Meier estimates and cumulative incidences were not considered, due to risk for competing risk bias and classification errors. A meta-analysis was performed using random-effects and weighted averages models, as well as a combined estimate based on curve fitting.

Results

Nine studies and a total of 18 495 patients are included. Overall, the risk of selective reporting bias is low. Relative survival rates vary across the population of studies (I2 48 to 97% and Qp < 0.00001 to 0.15), likely due to differences in baseline characteristics and the large number of patients included (τ2 < 0.02). The 30-year relative survival rates follow a cubic curve that is well fitted to data from the random-effects inverse-variance and weighted average models (R2 = 0.95, p = 7.19E−7). The estimated five, ten, 15, 20, 25 and 30-year relative survival rates are 79, 66, 60, 60, 62 and 67%, respectively.

Conclusions

The findings suggest that about two in five of all patients with uveal melanoma ultimately succumb to their disease. This indicates a slightly better prognosis than what is often assumed, and that patients surviving 20 years or longer may have a survival advantage to individuals of the same sex and age from the general population.

The MOLES system to guide the management of melanocytic choroidal tumours: can optometrists apply it?

CLINICAL RELEVANCE

Although melanocytic choroidal tumours of the choroid are a common eye pathology, no standardised protocol exists for their management in the community.

BACKGROUND

Choroidal naevi are found in approximately 6% of the adult White population, whereas choroidal melanomas are rare, with an annual incidence of 5-10/million/year. Multimodal imaging has advanced the understanding of malignancy imaging biomarkers, but distinguishing between a small melanoma and naevus remains difficult and an algorithm for their management by community practitioners has not been uniformly adopted. One of the authors (BD) devised the MOLES scoring system, which indicates malignancy likelihood according to mushroom shape, orange pigment, large size, enlargement, and subretinal fluid. When applied by ocular oncologists, the system accurately distinguishes choroidal naevi from melanomas. The aim of this study was to evaluate whether community optometrists can appropriately manage patients with melanocytic choroidal tumours using this system.

METHODS

Clinical images of 25 melanocytic choroidal tumours were presented in an online survey, including colour fundus photographs, fundus autofluorescence, optical coherence tomography, and B-scan ultrasound images. Using the MOLES system, 39 optometrists diagnosed tumours as naevus or probable melanoma and decided between community monitoring and ophthalmologist referral. Responses were compared to MOLES grading of the same clinical images by ocular oncologists.

RESULTS

Using MOLES, optometrists correctly identified 389/406 probable melanomas (95.8% sensitivity) and 331/516 choroidal naevi (64.1% specificity); correctly referred 773/778 tumours to an ophthalmologist (99.4% sensitivity); and correctly managed 80/144 lesions (55.6% specificity) in the community.

CONCLUSION

Optometrists safely applied the MOLES scoring system in this survey. Further measures are indicated to reduce choroidal naevi over-referral and evaluate MOLES system usage in clinical optometric practice, where some imaging modalities may not be readily available.

Development and validation of a nomogram to predict cancer-specific survival of uveal melanoma

BACKGROUND

Uveal melanoma (UM) is a rare but aggressive cancer, which is the most common primary intraocular malignancy in adults. We aimed to develop and validate a competing risk nomogram to predict cancer-specific survival (CSS) of patients with UM, as well as compare its prognostic value with that of the American Joint Committee on Cancer (AJCC) staging system.

METHODS

Data of patients diagnosed with UM from 2010 to 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. We extracted and integrated significant prognostic factors based on competing risk regression to build a nomogram. The nomogram with an online prediction version was also created. The performance of the nomogram was evaluated using Harrell's concordance index (C-index) and calibration plots. Receiver operating characteristic (ROC) curve was carried out to estimate clinical applicability of the model. Improvements in the predictive accuracy of our new model compared with AJCC staging system were estimated by calculating the relative integrated discrimination improvement (IDI) and the net reclassification improvement (NRI).

RESULTS

A total of 839 eligible patients with primary UM were randomly assigned to a training cohort (588, 70%) and a validation cohort (251, 30%). Age, histological type, T stage and M stage were independent prognostic factors to predict CSS of UM and were incorporated in the nomogram. The calibration plots indicated that the 3- and 5-year CSS probabilities were consistent between the nomogram prediction and the actual observation. The C-index for this model was 0.778 (95% CI:0.756-0.800) and 0.786 (95% CI: 0.749-0.816) in the training cohort and validation cohort. Areas under the curve (AUCs) were 0.814, 0.771, and 0.792 in the training cohort, 0.788, 0.781 and 0.804 in the validation cohort, respectively. The NRI value in AJCC staging system was - 0.153 (95% CI -0.29 - - 0.041) for 3 years of follow-up and - 0.276 (95% CI -0.415 - - 0.132) for 5 years of follow-up. The IDI values for 3 and 5 years of follow-up in the AJCC staging system were - 0.021 (P = 0.076) and - 0.045 (P = 0.004), respectively.

CONCLUSIONS

We have developed and validated a competing risk nomogram to reliably predict cancer-specific survival of patients with UM. This convenient tool may be useful for evaluating cancer-specific prognosis.

Small High-Risk Uveal Melanomas Have a Lower Mortality Rate

Simple Summary

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

Abstract

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

Impact of COVID-19 pandemic on eye cancer care in United Kingdom

The COVID-19 pandemic has had an unprecedented impact on the National Health Service in United Kingdom. The UK Ocular Oncology Services evaluated the impact on the adult eye cancer care in the UK. All four adult Ocular Oncology centres participated in a multicentre retrospective review comparing uveal melanoma referral patterns and treatments in a 4-month period during the national lockdown and first wave of the COVID-19 pandemic in 2020 with corresponding periods in previous 2 years. During the national lockdown, referral numbers and confirmed uveal melanoma cases reduced considerably, equalling to ~120 fewer diagnosed uveal melanoma cases compared to previous 2 years. Contrary to the recent trend, increased caseloads of enucleation and stereotactic radiosurgery (p > 0.05), in comparison to fewer proton beam therapy (p < 0.05), were performed. In the 4-month period following lockdown, there was a surge in clinical activities with more advanced diseases (p < 0.05) presenting to the services. As the COVID-19 pandemic continues to mount pressure and reveal its hidden impact on the eye cancer care, it is imperative for the Ocular Oncology Services to plan recovery strategies and innovative ways of working.

Evaluation of Racial, Ethnic, and Socioeconomic Associations With Treatment and Survival in Uveal Melanoma, 2004-2014

Importance

Identifying disparities in uveal melanoma (UM) treatment patterns and survival across racial, ethnic, and socioeconomic (SES) groups reveals possible inequities in ophthalmologic health care.

Objective

To examine the association of race, ethnicity, and SES with UM treatment and survival.

Design, Setting, and Participants

A retrospective cohort analysis of 28% of the US population using the Surveillance, Epidemiology, and End Results (SEER) 18 registries from January 1, 2004, to December 31, 2014, was conducted. Data analysis was performed from April to July 2018. SEER identified 4475 individuals using International Classification of Diseases for Oncology, Third Edition site and morphology codes.

Exposures

Race, ethnicity, and SES estimated by tertile using Yost Index composite scores.

Main Outcomes and Measures

Treatment odds ratios (ORs), 1-year and 5-year survival estimates, mortality hazard ratios (HRs), and Kaplan-Meier survival curves. Hypothesis was formulated before data collection.

Results

Multivariate analyses of 4475 individuals (2315 [51.7%] men; non-Hispanic white, 4130 [92.3%]; nonwhite, 345 [7.7%]) showed that patients who were nonwhite (OR, 1.45; 95% CI, 1.12-1.88) and socioeconomically disadvantaged (lower SES: OR, 2.21; 95% CI, 1.82-2.68; middle SES: OR, 1.86; 95% CI, 1.56-2.21) were more likely to receive primary enucleation. No interactions were observed between race/ethnicity, SES, and stage at diagnosis. From 2004 to 2014, rates of primary enucleation decreased across all racial/ethnic and SES groups, but disparities persisted. Socioeconomically disadvantaged patients had lower 5-year all-cause survival rates (lower SES: 69.2%; middle SES: 68.1%; and upper SES: 73.8%), although disease-specific survival did not vary significantly by racial/ethnic or SES strata. Mortality risk was associated with older age at diagnosis (56-68 years: HR, 1.70; 95% CI, 1.44-2.01; ≥69 years: HR, 3.32; 95% CI, 2.85-3.86), advanced stage of UM (stage 2: HR, 1.40; 95% CI, 1.19-1.65; stage 3: HR, 2.26; 95% CI, 1.87-2.73; and stage 4: HR, 10.09; 95% CI, 7.39-13.77), and treatment with primary enucleation (HR, 2.14; 95% CI, 1.88-2.44) with no racial/ethnic or SES variation.

Conclusions and Relevance

In this study, SEER data from 2004 to 2014 suggest that nonwhite and socioeconomically disadvantaged patients with UM are more likely to be treated with primary enucleation, although no such variation appears to exist in disease-specific survival. These differences reveal opportunities to address issues regarding treatment choice in UM.

Five Decades of Enucleations for Uveal Melanoma in One Center: More Tumors with High Risk Factors, No Improvement in Survival over Time

Background

In order to improve medical care for uveal melanoma (UM) patients, we need to monitor disease and survival to guide our research efforts. We analyzed the data of UM patients who underwent an enucleation at the Leiden University Medical Center over the last five decades and investigated trends in patient and tumor characteristics and survival.

Methods

Data were collected from charts and pathology reports from all patients who underwent an enucleation for UM between 1973 and 2019 (n = 1,212), of which 1,066 were primary enucleations; data were analyzed according to five time periods: 1973-1979 (n = 209), 1980-1989 (n = 148), 1990-1999 (n = 174), 2000-2009 (n = 280), and 2010-2019 (n = 401).

Results

Over time, mean patient age at the time of enucleation for UM increased from 54.9 to 64.7 years (p < 0.001), more tumors showed histopathological involvement of the ciliary body (p < 0.001), and were classified in a high TNM/AJCC class (p < 0.001). Overall, the 5- and 10-year UM-related survival rates were 0.68 and 0.59, respectively. Over time, survival showed no change in patients with tumors in AJCC stages I or III, with recently a slightly worse survival in stage II UM (p = 0.02).

Conclusion

Between 1973 and 2019, we found similar rates of UM-related survival following enucleation, although we noticed a strong increase in more unfavorable patient and tumor characteristics over time, such as an older age and larger tumor size. The lack of improvement indicates that more research should take place to develop adjuvant treatments to prevent metastases and efficient treatments once metastases develop.

A 45-year experience of uveal melanoma in Taiwan: Verification of American Joint Committee on Cancer staging system and prognostic factors

BACKGROUND/PURPOSE

To verify the staging system of the American Joint Committee on Cancer (AJCC) 8th edition for uveal melanoma, and to propose the prognostic factors of uveal melanoma by a 45-year cohort study.

METHODS

We collected patients who underwent operation with pathological proof from 1973 to 2017. The demographic data including gender, age, laterality, metastatic pattern, and histopathology type were recorded. The predictability for survival and monotonicity of gradients of the AJCC 8th edition were evaluated. The prognostic factors for survival were analyzed by univariate and multivariate analysis.

RESULTS

A total of 72 patients were collected. The median age was 55 year-old (range 24-100). No specific gender predilection was revealed in our study. About 75.9% of metastases events happened in the first five-year of follow-up, and hepatic involvement was the most common. By the AJCC 8th edition, the distribution for stage I: II: III was 8 (11.1%), 37 (51.4%), and 27 (37.5%). The prognostic staging groups manifested fair predictability and monotonicity of gradients for survival outcome. The tumors with epithelioid cell type and ciliary body involvements had higher tumor-related mortality.

CONCLUSION

The AJCC 8th edition prognostic staging groups for outcome prediction was validated. Periodic screening for metastases should be more frequent in the first five-year follow-up. The tumors with epithelioid cell pattern and ciliary body involvements were at risk of higher tumor-related mortality in Taiwanese patients.

Molecular Insights and Emerging Strategies for Treatment of Metastatic Uveal Melanoma

Uveal melanoma (UM) is the most common intraocular cancer. In recent decades, major advances have been achieved in the diagnosis and prognosis of UM allowing for tailored treatments. However, nearly 50% of patients still develop metastatic disease with survival rates of less than 1 year. There is currently no standard of adjuvant and metastatic treatment in UM, and available therapies are ineffective resulting from cutaneous melanoma protocols. Advances and novel treatment options including liver-directed therapies, immunotherapy, and targeted-therapy have been investigated in UM-dedicated clinical trials on single compounds or combinational therapies, with promising results. Therapies aimed at prolonging or targeting metastatic tumor dormancy provided encouraging results in other cancers, and need to be explored in UM. In this review, the latest progress in the diagnosis, prognosis, and treatment of UM in adjuvant and metastatic settings are discussed. In addition, novel insights into tumor genetics, biology and immunology, and the mechanisms underlying metastatic dormancy are discussed. As evident from the numerous studies discussed in this review, the increasing knowledge of this disease and the promising results from testing of novel individualized therapies could offer future perspectives for translating in clinical use.

Epidemiological Study of Uveal Melanoma from US Surveillance, Epidemiology, and End Results Program (2010-2015)

Purpose

Uveal melanoma is the most common intraocular malignancy, and the American Joint Committee on Cancer (AJCC) changed its staging methodology from 2010, incorporating notable changes into the T-staging. There were few literatures evaluating the epidemiological trend and risk factors of survival in multicenter longitudinal studies regarding the new staging system.

Methods

We performed population-based cohort analyses using the Surveillance, Epidemiology, and End Results (SEER) database to identify patients with primary uveal melanoma from 2010 to 2015. Patients and potential prognosis indicators were extracted from SEER 18. Incidence rates, incidence rates ratios (IRR), annual percent changes (APC) in rate, hazard ratios (HR), 5-year accumulative overall survival (OS), and disease-specific survival (DSS) were calculated.

Results

A total of 2631 patients for incidence analysis and 1142 patients for survival analysis were retrieved. The overall incidence of uveal melanoma was 4.637 per million (95% confidence interval (CI), 4.458–4.821), which was significantly elevated by average APC of 4.215% (p = 0.03). Females had significantly lower incidence (4.076 per million, IRR, 0.768, 95% CI, 0.710–0.832) with noticeable differences among age, race, origin, and laterality in sex-stratified analyses as well. Survival analyses revealed 5-year accumulative OS and DSS for patients with uveal melanoma of 61.8% and 66.5%, respectively. Age, AJCC stage, and radiation therapy were found to be consistent predictors in both univariate and multivariate analysis models.

Conclusion

Incidence of uveal melanoma increased by significant APC and varied between genders. Determinants of survival included age at diagnosis, AJCC stage, and radiation therapy.

GDF11 upregulation independently predicts shorter overall-survival of uveal melanoma

Growth differentiation factor 11 (GDF11), is a member of the transforming growth factor-beta (TGF-β) superfamily and bone morphogenetic protein (BMP) subfamily. In this study, we aimed to assess the expression profile of GDF11, its prognostic value in terms of OS, as well as the potential mechanisms leading to its dysregulation in uveal melanoma. A retrospective study was conducted using our primary data and genetic, clinicopathological and overall survival (OS) data from the Cancer Genome Atlas-Uveal Melanoma (TCGA-UVM). Results showed that GDF11 expression was significantly higher in tumor tissues compared with that in adjacent normal tissues. High GDF11 expression was associated with uveal melanoma in advanced stages (IV), epithelioid cell dominant subtype, as well as extrascleral extension. Univariate analysis showed that older age, epithelioid cell dominant, with extrascleral extension and increased GDF11 expression were associated with unfavorable OS. Multivariate analysis confirmed that GDF11 expression was an independent prognostic indicator of unfavorable OS (HR: 1.704, 95%CI: 1.143–2.540, p = 0.009), after adjustment of age, histological subtypes and extrascleral extension. Among the 80 cases of uveal melanoma, only 3 cases had low-level copy gain (+1) and 2 cases had heterozygous loss (-1). No somatic mutations, including SNPs and small INDELs were observed in GDF11 DNA. The methylation of these four CpG sites had weakly (cg22950598 and cg23689080), moderately (cg09890930), or strongly (cg05511733) negative correlation with GDF11 expression. In addition, the patients with high methylation of these four sites had significantly better OS compared to the group with low methylation. Based on these findings, we infer that methylation modulated GDF11 expression might be a valuable prognostic biomarker regarding OS in uveal melanoma.

Cytokines concentrations in aqueous humor of eyes with uveal melanoma

Uveal melanoma (UM) is the major intraocular malignancy in adults, of which the molecular biology is still unknown. Therefore, this study was designed to determine the aqueous concentrations of angiogenic, inflammatory, and chemotactic cytokines in eyes with UM.Aqueous humor samples were collected from 38 patients with UM and 22 patients undergoing cataract surgery. Interleukin 6, 8 (IL-6, IL-8, respectively), interferon-inducible protein-10 (IP-10), placental growth factor1 (PIGF1), regulated on activation, normal T Cell expressed and secreted (RANTES), monocyte chemoattractant protein-1 (MCP-1), nerve growth factor-beta (NGF-β), epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), and vascular endothelia growth factor A (VEGF-A) were assessed by multiplex bead assay.In the study group, significantly higher concentrations of IL-6 (P = .006), IL-8 (P = .018), IP-10 (P = .004), RANTES (P = .008), MCP-1 (P = .02), NGF-β (P = .013), EGF (P < .001), PIGF1 (P = .01), bFGF (P = .016), and VEGF (P = .017) were measured, when compared with the control group.Several angiogenic, inflammatory, and chemotactic cytokines are highly expressed in the aqueous humor of the UM eyes, which provides new insights into the pathophysiology of UM and could be potential targets for treatment.

Linear accelerator-based stereotactic fractionated photon radiotherapy as an eye-conserving treatment for uveal melanoma

Background

The purpose of this retrospective analysis is to analyze clinical outcome, visual acuity and enucleation rates after linear accelerator-based stereotactic fractionated photon radiotherapy for primary uveal melanoma.

Methods

Twenty-four patients with primary uveal melanoma treated at the Department of Radiation and Oncology of the University Hospital Heidelberg between 1991 and 2015 were analyzed regarding survival and treatment-related toxicity including eye- and sight-preservation.

Results

Photon radiotherapy (RT) offered good overall local control rates with a local progression-free survival (LPFS) of 82% after 5 years and a median LPFS of 5.5 years at a median follow-up time of 5.2 years. Gender had a significant impact on LPFS yielding a mean LPFS of 8.1 years for women and 8.7 years for men (p = 0.04). Of all local progressions, 80% occurred within the first 5 years after RT. In one case, enucleation as final therapy option was necessary. Enucleation-free survival (EFS) was related to the radiotherapy dose (p < 0.0001). Thus, higher prescribed doses led to a significantly higher enucleation rate. T-stage had no significant impact on EFS, but affected the enucleation rate (p = 0.01). The overall survival (OS) rate was 100% after 2 years and 70% after 5 years with a median OS of 5.75 years. Age (p = 0.046), T stage (p = 0.019), local control rate (p = 0.041) and the time between diagnosis and the first radiation session (p = 0.01) had a significant effect on OS. Applied biologically effective dose (BED) did not significantly influence OS or PFS. A 2-year sight preservation rate of 75% could be achieved. In all patients, irradiation could be applied safely without any interruptions due to side effects. Six significant late toxicities with consequential blindness could be observed, making a secondary enucleation necessary in four patients. An impairment of visual acuity due to chronic optic nerve atrophy was identified in five patients within 2 years after treatment.

Conclusions

Linear accelerator-based stereotactic fractionated photon radiotherapy is an effective method in the treatment of uveal melanoma with excellent local control rates and a 2-year vision retention rate comparable to brachytherapy (BRT) or proton beam radiotherapy, even available in small centers and easy to implement. Interdisciplinary decision making is necessary to guarantee best treatment for every patient.

Percutaneous Isolated Hepatic Perfusion as a Treatment for Isolated Hepatic Metastases of Uveal Melanoma: Patient Outcome and Safety in a Multi-centre Study

PURPOSE

Percutaneous isolated hepatic perfusion (PIHP) with Melphalan has been developed as a treatment for patients with isolated hepatic metastases of uveal melanoma. We discuss patient outcome and safety in a retrospective multi-centre study.

MATERIALS AND METHODS

Between 2012 and 2016 18 patients with un-resectable isolated hepatic metastases of uveal melanoma received single or repeated PIHP with Melphalan (n = 35) at seven sites. Progression-free time, overall survival time (OS) and tumour response by means of RECIST 1.1 criteria were evaluated. Peri- and post-procedural adverse events (AE) were registered. Patients' life quality was assessed using four-point scale questionnaires.

RESULTS

Of 18 patients, initial PIHP treatment resulted in partial response (PR) in eight, stable disease (SD) in seven and progressive disease (PD) in three cases. Nine patients underwent second PIHP with PR in eight cases and PD in one case. Six patients were evaluated after third PIHP with PR in five patients and SD in one patient. Two patients received fourth PIHP with PD in both cases. Median OS was 9.6 months (range 1.6-41.0 months). Median progression-free survival time was 12.4 months (range 0.9-41.0 months) with 1-year survival of 44%. Most common post-procedural AE grade 3 and 4 were temporary leukopenia (n = 11) and thrombocytopenia (n = 8). Patients' self-assessments showed good ratings for overall health and quality of life with only slight changes after PIHP, and a high degree of satisfaction with PIHP treatment.

CONCLUSION

PIHP with Melphalan proved to be a relatively safe, minimal-invasive and repeatable treatment for patients with non-resectable hepatic metastases of uveal melanoma.

Ocular oncology: advances in retinoblastoma, uveal melanoma and conjunctival melanoma

BACKGROUND

Retinoblastoma, uveal and conjunctival melanomas are important malignancies within the remit of ocular oncology. Outlined are the diagnostic features and management principles, as well as advancements in the field and current challenges.

SOURCES OF DATA

Original papers, reviews and guidelines.

AREAS OF AGREEMENT

Most eyes with retinoblastoma (International Intraocular Retinoblastoma Classification (IIRC) Group A-D) are salvaged, whereas advanced cases (Group E) remain a challenge. Despite a high rate of local tumour control in uveal melanoma, metastatic spread commonly occurs. Conjunctival melanoma is treated by complete resection, but high rates of local recurrence occur, with the possibility of systemic relapse and death.

AREAS OF CONTROVERSY

Use of the IIRC in retinoblastoma, and systemic screening in melanomas.

GROWING POINTS

Utilization of novel treatment modalities in retinoblastoma and an increasing understanding of the genetic basis of melanomas.

AREAS TIMELY FOR DEVELOPING RESEARCH

Improvements in chemotherapy delivery in retinoblastoma and prognostic tests in melanomas.

Uveal melanoma as a target for immune-therapy

Uveal melanoma (UM) is a rare disease that can be deadly in spite of adequate local treatment. Systemic therapy with chemotherapy is usually ineffective and new-targeted therapies have not improved results considerably. The eye creates an immunosuppressive environment in order to protect eyesight. UM cells use similar processes to escape immune surveillance. Regarding innate immunity the production of macrophage inhibiting factor (MIF) and TGF-β, added to MHC class I upregulation, inhibits the action of natural killer (NK) cells. UM cells produce cytokines such as IL-6 and IL-10 that favor macrophage differentiation to the M2 subtype, which promote tumor growth instead of an effective immune response. UM cells also impair the adaptive immune response through production of indoleamine 2,3-dioxygenase (IDO), overexpression of programmed death ligand-1 (PD-L1), alteration of FasL expression, and resistance to perforin. This biological background suggests that immunotherapy could be effective in fighting UM. A Phase II clinical trial with Ipilimumab has shown promising results with mean Overall Survival rate of ten months, and close to 50% of the patients alive at one year. Clinical trials with anti-PD1 antibodies in monotherapy and in combination with anti-CTLA4 are currently recruiting patients worldwide.

Disparities in Uveal Melanoma: Patient Characteristics

Uveal melanoma is the most common intraocular malignancy in adults. Despite excellent rates of local control, half of all patients with uveal melanoma ultimately go on to develop fatal metastatic disease. This review focuses on disparities and differences in the underlying characteristics of the patients, and how these patient characteristics impact the development of metastasis and subsequent patient survival. Specifically, we detail disparities in epidemiology and risk factors as they relate to the development of primary uveal melanoma, to the development of metastasis, and to patient survival following metastasis.

Tumor Characteristics, Genetics, Management, and the Risk of Metastasis in Uveal Melanoma

Uveal melanoma is the most common intraocular malignancy in adults. Although rates of local control for uveal melanoma exceed 95% with radiotherapy or enucleation, as many as 50% of patients develop hematogenous metastases, which manifest in the decades following initial diagnosis and are uniformly and rapidly fatal. Recent compelling evidence suggests that not all uveal melanomas are themselves equivalent with respect to metastatic potential and patient survival. This review focuses on the mounting evidence of survival disparities based on intrinsic tumor clinical and histopathologic characteristics and based on tumor genetics and gene expression profiles.

Clinical Characteristics of 582 Patients with Uveal Melanoma in China

OBJECTIVE

To assess clinical characteristics, treatment and survival of patients with uveal melanoma in China.

METHODS

The retrospective study included all patients with malignant uveal melanoma who were consecutively examined in the study period from January 2005 and June 2015 in the Beijing Tongren hospital.

RESULTS

The mean age of the 582 patients (295(50.7%) women) was 44.6±12.6 years (range: 5-77 years). The tumors were located most often in the superior temporal region (in 117(21.5%) patients) and least common in the inferior region (in 31(5.7%) patients). In 548(94.2%) patients, the tumors were located in the choroid, in 33(5.7%) patients in the ciliary body, and in one (0.2%) patient in the iris. Treatment included episcleral brachytherapy (415(71.3%) patients), local tumor resection (48(8.2%) patients) and primary enucleation (119(20.4%) patients). In 53 individuals out of the 415 patients with primary brachytherapy, episcleral brachytherapy was followed by enucleation, due to an increasing tumor size or due to uncontrolled neovascular glaucoma. Median follow-up time was of 30 months (range: 1-124 months; mean: 34.8 ± 24.4 months). Overall survival rate at 5 and 10 years was of 92.7% and 85.1%. Younger age (P = 0.017), tumor location in the nasal meridian(P = 0.004), smaller tumor size (P<0.001), hemispheric tumor shape (P = 0.025), histological tumor cell type (spindle-cell type versus epitheloid cell type;P = 0.014), and type of treatment (episcleral brachytherapy versus local tumor resection and versus primary enucleation; P<0.001) were significantly associated with the overall survival in univariate analysis, while in multivariate analysis only smaller tumor size was significantly (P<0.001; RR: 4.75; 95% confidence interval: 2.11,10.7) associated with better overall survival.

CONCLUSIONS

In this study on clinical characteristics of uveal melanoma of a larger group of patients from China, the onset age was considerably younger and survival rate better than in studies from Western countries. Tumor size was the most significant factor for survival.

What's more general than a whole population?

Statistical inference is commonly said to be inapplicable to complete population studies, such as censuses, due to the absence of sampling variability. Nevertheless, in recent years, studies of whole populations, e.g., all cases of a certain cancer in a given country, have become more common, and often report p values and confidence intervals regardless of such concerns. With reference to the social science literature, the current paper explores the circumstances under which statistical inference can be meaningful for such studies. It concludes that its use implicitly requires a target population which is wider than the whole population studied - for example future cases, or a supranational geographic region - and that the validity of such statistical analysis depends on the generalizability of the whole to the target population.

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.

Clinical, pathologic, and imaging features and biological markers of uveal melanoma

Uveal melanoma has unique clinical and pathologic features including virtually exclusive metastasis to the liver in high-risk cases. In this chapter, the clinical findings in uveal melanoma and diagnostic methods including imaging tests and serum markers are described. Additionally, the histopathologic features including the modified Callender classification and immunohistochemical findings of uveal melanoma are described.

[Uveal melanoma: clinical characteristics, treatment and survival in a series of 500 patients]

OBJECTIVE

To analyse the clinical features, treatment and survival of uveal melanoma patients diagnosed in a referral Intraocular Tumours Unit over a twenty-year period.

METHODOLOGY

A prospective study was performed including five hundred patients, diagnosed between January 1992 and December 2011. Clinical tumour characteristics and treatment were collected in a database in Microsoft@ Access@. The numeric variables were expressed as means of frequency and standard deviation, and the quantitative variables using frequency tables.

RESULTS

The mean age of the sample was 62.19 years, with 51.2% females, and 64.2% presented with symptoms. The tumours were small in 31.12% of cases, and large in 23.09%, according to COMS criteria. Hazel green was the iris colour in 42.2% of the cases. The initial treatment was episcleral brachytherapy in 42.4% of the total. The overall mortality rate was 17% and 31.3%, and melanoma-related mortality rate was 11.6% and 14.8%, at 5 and 10 years, respectively.

CONCLUSIONS

In the serie studied melanomas were more frequent in women, and a higher proportion of darker irides were observed than in other previous studies. Most of the tumours were diagnosed when they became symptomatic and in the early or medium stages, allowing conservative therapies to be used, with brachytherapy being the predominant treatment. The melanoma-related mortality appeared to be lower than previously data published. However, further studies are required on the factors influencing survival.

Progression of ocular melanoma metastasis to the liver: the 2012 Zimmerman lecture

IMPORTANCE

To the best of my knowledge, this study demonstrates for the first time small, apparently dormant micrometastasis in the liver of patients with uveal melanoma.

OBJECTIVE

To evaluate the histological and immunohistochemical findings in metastatic uveal melanoma to the liver.

DESIGN

Samples of liver were obtained at autopsy from patients who died of metastatic uveal melanoma to the liver.

SETTING

L. F. Montgomery Laboratory, Emory Eye Center, Atlanta, Georgia.

PARTICIPANTS

A total of 10 patients who died of metastatic uveal melanoma to the liver.

INTERVENTION

Sections of the liver were examined with hematoxylin-eosin, periodic acid-Schiff, Masson trichrome, or reticulin stains.

MAIN OUTCOME MEASURES

The tumors' morphology, growth pattern, mean vascular density, and mitotic index were determined with the aid of immunohistochemical stains for S100, HMB45, CD31, and Ki67.

RESULTS

Stage 1 metastases (defined as tumor clusters ≤50 μm in diameter) were identified in the sinusoidal spaces of 9 of 10 patients (90%). Stage 1 metastases were avascular and lacked mitotic activity. Stage 2 metastases (defined as tumors measuring 51-500 μm in diameter) and stage 3 metastases (defined as tumors measuring >500 μm in diameter) were found in all patients. Immunohistochemical stains were positive for S100 or HMB45 in all tumors. Overall, stage 1 metastases outnumbered stage 2 metastases (which outnumbered stage 3 metastases). The mean vascular density and mitotic index increased from stage 2 to stage 3 metastases (P < .05). The architecture of stage 2 metastases mimicked the surrounding hepatic parenchyma, whereas stage 3 metastases exhibited either lobular or portal growth patterns.

CONCLUSIONS

Uveal melanoma that spreads to the liver can be categorized as stage 1 (≤50 μm in diameter), stage 2 (51-500 μm in diameter), or stage 3 (>500 μm in diameter) metastases. The later stage exhibits a lobular or portal pattern of growth. During this progression, tumors become vascularized and mitotically active.

Relative survival of patients with uveal melanoma managed in a single center

To assess the 5-year relative survival of patients diagnosed with uveal melanoma (UM) in a single center. UM patients were recruited from 1995 to 2004 (N = 155) and were followed until December 2008. Relative survival (RS) methods were used to assess excess mortality. An RS regression model was fitted by sex, age, tumor origin, treatment, and tumor size to estimate the excess hazard rate (EHR) of death from UM. The overall 5-year RS was 90%, lower in women (84.6%) than in men (100%), lower in patients older than 60 years (88.8%) compared with those younger than or of 60 years of age (94.8%). Large tumors (80.8%) showed lower RS than medium (95.1%) and small ones (98.3%). Enucleated patients (80.5%) had lower RS compared with those who received brachytherapy (93.6%) and other treatments (94.7%). A significant EHR was found for women (EHR: 3.65), patients older than 60 years (EHR: 2.25), large-sized melanoma (EHR: 2.45), and during the third (EHR: 5.37) and fourth year (EHR: 3.01) of follow-up. This is the first Spanish study in a single center reporting RS among UM patients, taking into account clinical characteristics. Prognostic factors that explained RS among UM patients were sex, age, tumor size, and the year of follow-up. We also found a peak of excess mortality from the third until the fourth year after diagnosis, which warrants strict follow-up of these patients during this time interval.

Melanoma associated spongiform scleropathy: characterization, biochemical and immunohistochemical studies

SUMMARY

Melanoma associated spongiform scleropathy (MASS) is a non-inflammatory scleral change with a spongiotic morphology seen in association with uveal melanoma. MASS is seen as whitish spindle shaped areas within the sclera that is adjacent to and in contact with a choroidal or ciliary body melanoma. This change can be seen as small scattered lesions in the inner scleral layers or as extensive areas along the whole extent of contact between the tumour and the sclera and involves most of the scleral thickness. MASS changes of different grades of severity were seen in 38% of 363 melanoma eyes investigated. The presence of MASS showed a statistical correlation with age. A significant high incidence of MASS was found in old age groups. This might due to the fact that MASS needs a longer period of contact between the tumour and the sclera to develop. It is also possible that age-related changes of the extracellular matrix might alter its response to melanoma produced factors leading to the development of MASS. The development of MASS and its severity are influenced by the extent of contact between the tumour and the sclera. This is supported by the significant statistical relation between the largest basal diameter of the tumours and the severity of MASS. Statistical correlation was found between MASS and scleral and extrascleral tumour extension. More than 90% of 82 specimens that showed tumour extension were associated with MASS. A biochemical analysis of scleral samples taken from areas with severe MASS showed a significant reduction of the main amino acids of collagen type I, which is the main scleral collagen. The amounts of total scleral proteins were significantly reduced. This scleral protein reduction is associated with an increase in glycosaminoglycans. These findings indicate a collagen degradation process. Immunohistochemical studies were performed to investigate the expression of matrix metalloproteinases (MMPs). In situ hybridization showed a significantly more frequent and more intense expression of MMP-2 by scleral fibroblasts in areas with MASS compared with areas without MASS. This was also seen by immunohistochemical staining. Similar high frequency and intense expression of MMP-2 were seen in tumour infiltrating macrophages. The results of biochemical and immunohistochemical studies indicate a collagen degradation process. This degradation may be the result of the proteolytic enzyme MMP-2 expressed by scleral fibroblasts under the effect of tumour humeral factors and/or tumour infiltrating macrophages. This scleral degradation results in fragmentation of the scleral collagen fibrils. This along with the accumulation of water in the sclera, as a result of the increase in the production of glycosaminoglycans, results in increase of scleral thickness in MASS areas and forms the histopathological picture of MASS. The scleral degradation may facilitate tumour invasion and may explain the statistical relation between MASS and scleral tumour invasion. MASS was found in a few of the eyes that had received pre-enucleation radiation. The possible explanation is that radiation might cause destruction of scleral fibroblasts reducing their ability to produce MMP-2, thus decreasing the development of MASS. No relation between MASS and survival was found. This is probably explained by the fact that the main cause of death due to uveal melanoma is distant metastasis. MASS changes are found to be associated with local tumour invasion but not statistically correlated to survival.

Superior survival of females among 10,538 Dutch melanoma patients is independent of Breslow thickness, histologic type and tumor site

BACKGROUND

Worldwide, female melanoma patients have superior survival compared with males, which is usually ascribed to earlier detection among women and/or a more favorable site distribution. We studied gender difference in melanoma survival in a large population-based setting after adjusting for tumor-related variables and offer clues for further research.

PATIENTS AND METHODS

A total of 10,538 patients diagnosed with melanoma from 1993 to 2004 in The Netherlands were included. Multivariate analyses were carried out to estimate adjusted relative excess risk (RER) of dying for men compared with women, adjusted for the patient and tumor characteristics.

RESULTS

Univariate relative survival analyses showed a RER of dying of 2.70 [95% confidence interval (CI) 2.38-3.06] for men compared with women. After adjusting for time period of diagnosis, region, age, Breslow thickness, histologic subtype, body site, nodal and metastatic status, a significant excess mortality risk was still present for males (RER 1.87, 95% CI 1.65-2.10). Among patients with advanced disease and in those < 45 or > or = 60, the adjusted risk estimates were similar.

CONCLUSIONS

The superior survival of women compared with men persisted after adjusting for multiple confounding variables indicating that factors other than stage at diagnosis and body site reduce mortality risk in female melanoma patients.

Meningitis registry of hospitalized cases in children: epidemiological patterns of acute bacterial meningitis throughout a 32-year period

Background

Bacterial meningitis remains a source of substantial morbidity and mortality in childhood. During the last decades gradual changes have been observed in the epidemiology of bacterial meningitis, related to the introduction of new polysaccharide and conjugate vaccines. The study presents an overview of the epidemiological patterns of acute bacterial meningitis in a tertiary children 's hospital during a 32-year period, using information from a disease registry. Moreover, it discusses the contribution of communicable disease registries in the study of acute infectious diseases.

Methods

In the early 1970s a Meningitis Registry (MR) was created for patients admitted with meningitis in Aghia Sofia Children's Hospital in Athens. The MR includes demographic, clinical and laboratory data as well as treatment, complications and outcome of the patients. In 2000 a database was created and the collected data were entered, analyzed and presented in three chronological periods: A (1974–1984), B (1985–1994) and C (1995–2005).

Results

Of the 2,477 cases of bacterial meningitis registered in total, 1,146 cases (46.3%) were classified as "probable" and 1,331 (53.7%) as "confirmed" bacterial meningitis. The estimated mean annual Incidence Rate (IR) was 16.9/100,000 for bacterial meningitis, 8.9/100,000 for Neisseria meningitidis, 1.3/100,000 for Streptococcus pneumoniae, 2.5/100,000 for Haemophilus influenzae type b (Hib) before vaccination and 0.4/100,000 for Hib after vaccination. Neisseria meningitis constituted the leading cause of childhood bacterial meningitis for all periods and in all age groups. Hib was the second most common cause of bacterial meningitis before the introduction of Hib conjugate vaccine, in periods A and B. The incidence of bacterial meningitis due to Streptococcus pneumoniae was stable. The long-term epidemiological pattern of Neisseria meningitidis appears in cycles of approximately 10 years, confirmed by a significant rise of IR in period C. The Case Fatality Rate (CFR) from all causes was 3.8%, while higher CFR were estimated for Streptococcus pneumoniae (7.5%, RR=2.1, 95% CI 1.2–3.7) and Neisseria meningitidis (4.8%, RR=1.7, 95% CI 1.1–2.5) compared to other pathogens. Moreover, overall CFR varied significantly among the three time periods (p = 0.0015), and was estimated to be higher in period C.

Conclusion

By using the MR we were able to delineate long-term changes in the epidemiology of bacterial meningitis. Thus the MR proved to be a useful tool in the study and the prevention of communicable diseases in correlation with prevention strategies, such as vaccinations.