Risk factors associated with secondary enucleation after fractionated stereotactic radiotherapy in uveal melanoma

Anatomical and Functional Outcomes after Endoresection and Adjuvant Ruthenium Brachytherapy for Uveal Melanoma: A Single-Center Experience

PURPOSE

To evaluate the anatomical and functional outcomes of endoresection and adjuvant ruthenium (Ru)-106 brachytherapy for uveal melanoma (UM).

METHODS

Retrospective case series of 15 UM patients (15 eyes) treated at our center (Careggi University Hospital, Florence).

RESULTS

Six patients (40%) were male and nine were female (60%). The mean age of patients at the time of treatment was 61.6 years (±19.41). The mean BCVA at baseline was 20/50. In all cases UM originated from the choroid. The mean tumor thickness at baseline was 7.14 mm (±2.05), and the mean largest basal diameter was 11.2 mm (±1.92). A concurrent retinal detachment was diagnosed in 11 patients (73.3%). Two patients (13.3%) showed vitreous seeding at baseline. Eleven patients (73.3%) were treated with primary endoresection, while four patients (26.7%) were treated with a "salvage endoresection" after primary treatment failure (previous radiation treatment). The mean follow-up time was 28.9 months (±10.6). Thirteen out of fifteen patients were alive and showed no evidence of local recurrence or distance metastasis at the last follow-up visit. The treatment achieved local control of the disease in 14 out of 15 cases (93.3%). In one case, the patient underwent enucleation for disease recurrence. The overall survival rate at the end of the follow-up was 93.3%. The mean BCVA at last follow-up visit was 20/40. Treatment was well tolerated, without significant complications.

CONCLUSIONS

Endoresection and adjuvant Ru-106 brachytherapy is a valuable conservative option for selected UM patients and can be used both as a primary treatment and as a salvage therapy. It can control melanoma and avoid enucleation, reduce radiation-related complications, and provide tumor tissue for chromosomal analysis and prognostic testing.

Every other day stereotactic radiation therapy for the treatment of uveal melanoma decreases toxicity

BACKGROUND AND PURPOSE

To report the long-term results of stereotactic radiosurgery and fractionated stereotactic radiation therapy (SRS/FSRT) in patients with uveal melanoma (UM).

MATERIALS AND METHODS

We retrospectively evaluated the results of patients treated between 2007 and 2019. The primary endpoints were local control (LC), local recurrence-free survival (LRFS), enucleation-free survival (EFS) and treatment toxicity.

RESULTS

443 patients with 445 UMs were treated via CyberKnife®. According to the COMS classification, 70% of the tumors were small/medium and 30% were large. Median total RT dose was 54 Gy, median BED10 was 151 Gy. After a median 74-months follow-up, SRS/FSRT yielded an 83% overall LC rate. The 5- and 10-year LRFS rate was 74% and 56%, respectively. Patient age and the COMS size were prognostic for all survival endpoints. An increased SRS/FSRT dose was associated with higher LRFS and EFS rates. SRS/FSRT-related toxicity was observed in 49% of the eyes. Median visual acuity (VA) significantly deteriorated after SRS/FSRT in 76% of the treated eyes. The overall eye preservation rate was 62%, and the 5- and 10-year EFS rate was 64% and 36%, respectively. The delivery of FSRT every other day resulted in a significantly lower rate of toxicity and enucleation compared to FSRT on consecutive days.

CONCLUSION

A total dose of ≥45 Gy and BED_10Gy ≥ 112.5 SRS/FSRT is associated with a higher LC rate in patients with UM. Despite the favorable outcomes, treatment toxicity is the major limitation of this treatment. Toxicity and enucleation can be minimized by treating the eye every other day.

Fractionated stereotactic radiotherapy for uveal melanoma: Long-term outcome and control rates

Purpose

The aim of our study is to evaluate local tumour control rates, radiation side‐effects, visual preservation and disease‐free survival (DFS) of uveal melanoma (UM) patients treated with fractionated stereotactic radiotherapy (fSRT).

Methods

A retrospective study of UM patients, who were treated with fSRT (N = 189), was performed by the Rotterdam Ocular Melanoma Study group (ROMS), the Netherlands, between 1999 and 2014 with a follow‐up of at least 5 years.

Results

The 1‐, 3‐, 5‐, 10‐ and 15‐year local tumour control rates were as follows: 99.4%, 92.8%, 92.2%, 89.3% and 89.3%, respectively. Cataract (67.8%) was the most common side‐effect of fSRT followed by retinopathy (35.1%), maculopathy (23.8%), vitreous haemorrhage (20.1%), neovascular glaucoma (NVG) (20.0%) and optic neuropathy (12.4%). Patients with anterior located UMs developed cataract more frequently (p = 0.047, multivariable analysis). By multivariable analysis, significant factors for secondary enucleation were tumour recurrence (p < 0.001) and NVG (p < 0.001). In multivariable analysis, risk factors for a worse DFS were larger UM (p = 0.024) and tumours with subretinal fluid (SRF) at baseline (p = 0.038). The 5‐year DFS was 77.0% and the best corrected visual acuity decreased significantly after treatment. After 5 years, 22.0% of patients and after 10 years 17.6% of patients had a visual acuity of ≤0.3 logMAR.

Conclusion

Fractionated stereotactic radiotherapy is a good treatment option for small‐, medium‐ and large‐sized tumours with 5‐year local tumour control of 92.2%. After 5 years, 22.0% of the patients had a good vision. Independently of tumour location, the visual acuity decreased significantly after treatment. Overall, the 5‐year DFS was 77.0%.

Clinical outcomes and secondary glaucoma after gamma-knife radiosurgery and Ruthenium-106 brachytherapy for uveal melanoma: a single institution experience

We retrospectively analyzed data from records of 48 patients (48 eyes) treated with gamma-knife (n = 18) or Ruthenium-106 brachytherapy (n = 30) for uveal melanoma, in our Ocular Oncology Unit between December 2013 and September 2019, with the aim to evaluate treatment outcomes, and incidence and risk factors for secondary glaucoma. Patients demographics and tumor characteristics at diagnosis were recorded. Follow-up data were collected regarding local tumor control, treatment complications, enucleation need, metastases occurrence and survival status. The median follow-up period was 33.7 months in the gamma-knife group and 26.2 months in the brachytherapy group. The mean tumor thickness, the largest basal diameter and the tumor volume were significantly higher in the gamma-knife group than in the brachytherapy group. The local tumor control rate was 100% in the brachytherapy group and 77.8% in the gamma-knife group. In the gamma-knife group, six patients were enucleated, no patient treated with brachytherapy underwent enucleation. The overall survival rate was 96.7% in the brachytherapy group and 94.44% in the gamma-knife group. Secondary glaucoma occurred in 10 patients after gamma-knife and in one patient after brachytherapy: it should be emphasized that larger lesions were treated with gamma-knife, whereas smaller tumors were selected for brachytherapy. We found a significative correlation of tumor thickness (P value = 0.043) and volume (P value = 0.040) with secondary glaucoma occurrence after gamma-knife treatment. Moreover, secondary glaucoma significantly correlated with radiation retinopathy in the gamma-knife group (P value = 0.009). This study shows preliminary clinical results that could be useful for further studies with more patients and longer follow-up.

[Local treatment of choroidal melanoma: possibilities and limitations]

Local treatment of choroidal melanoma (CM) attracts the attention of many ophthalmology specialists, especially in recent years as the capabilities to target irradiation at small objects and possibilities of surgical interventions on the eyeball have expanded. The article discusses the medical indications for local treatment of CM. Review of literature of the last 16 years and author's own observations on CM patients who underwent almost all kinds of conventional methods of local treatment allowed thorough analysis of indications and counter-indications for their usage. Among the authors who favor local destruction and removal of large CM, the main indication is the possibility to preserve vision and anatomical structures of the eye. This led to unreasonably wide spread of local destruction (removal) of large CM, primarily the endovitreal resection method. However, such metastasis risk factors as CM size and its localization are being overlooked. Literature analysis and author's own observations helped validate the unsafety of the local treatment of large CM. The article features long-term results of contact and distant radiation therapy, and presents CM metrics for best therapeutic effect.

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.

Incidence of secondary glaucoma after treatment of uveal melanoma with robotic radiosurgery versus brachytherapy

PURPOSE

Different modalities of radiation therapy nowadays allow for effective treatment of uveal melanoma combined with the advantage of eye preservation. However, this advantage can secondarily be impaired by radiation-related side effects. After local recurrence, secondary glaucoma (SG) has been described as second most frequent complication leading to need of enucleation. This study compares the incidence of SG after conventional Ruthenium (Ru)-106 brachytherapy (BT) versus CyberKnife robotic radiosurgery (RRS) which has been gaining importance lately as an efficient treatment option offering improved patient comfort.

METHODS

Medical records of all patients diagnosed with uveal melanoma in the Eye Clinic of the Ludwig-Maximilians-University Munich between 2007 and 2013 were reviewed. A total of 268 eyes of 268 patients treated with Ru-106 BT or CyberKnife-RRS as monotherapy were entered in this retrospective cohort study. Incidence of SG was correlated with treatment modality and baseline tumour characteristics.

RESULTS

Fifty-three patients (19.8%) developed SG. At 5 years, SG was significantly more frequent after RRS (46.7%) than BT (11.1%); however, tumour thickness (maximum apical height) as a marker of tumour progress was more pronounced in the RRS group. Subgroup analysis of 178 patients for tumours amenable to both BT and RRS (thickness ≤6 mm) revealed comparable results at 3 years (RRS: 13.8 versus BT: 11.2%), but a trend towards increased incidence after RRS beyond year three. However, this difference was not significant at 5 years (28.2% versus 11.2%, p = 0.138). Tumour thickness was significantly associated with incidence of SG.

CONCLUSION

In tumours ≤6 mm thickness, RRS and BT seem to offer a comparable safety profile in terms of SG. Beyond year three, SG was tendentially, but not significantly more frequent after RRS. Increasing tumour thickness is associated with risk of SG.

Ruthenium-106 brachytherapy for choroidal melanoma without transpupillary thermotherapy: Similar efficacy with improved visual outcome

PURPOSE

To evaluate efficacy and toxicity of two different protocols for eye-conserving treatment of patients with small to intermediate-sized choroidal melanomas; the current ruthenium-106 (Ru106) brachytherapy protocol and the preceding protocol of Ru106-brachytherapy with transpupillary thermotherapy (Ru106/TTT).

METHODS AND MATERIALS

Long-term outcomes of 449 consecutive patients, of whom 196 (43.6%) treated using Ru106/TTT and 253 (56.3%) treated using Ru106, were compared in terms of local control, survival, eye preservation and visual outcome.

RESULTS

Median follow-up was 82.8 months. Patients in the Ru106-group had smaller, less centrally located tumours and better pre-treatment visual acuity (VA). Five-year cumulative incidence of local failure was 11.2% for Ru106/TTT and 5.2% for Ru106, which was not statistically significant after correction for differences in baseline characteristics (hazard ratio for Ru106 = 0.57, p = 0.14). Cumulative incidence of distant metastases was 11.2 versus 6.2%, and cumulative incidence of cause-specific death was 22.4 versus 5.5% for Ru106/TTT and Ru106 respectively. Enucleation was performed in 9.2 versus 4.0% for Ru106/TTT versus Ru106; 5.1 versus 3.2% for local failure and 2.6 versus 0.8% for complications. At one year of follow-up, significantly more patients had lost useful vision (VA < 0.33) in the Ru106/TTT-group than in the Ru106-group (50.0 versus 24.5%). After two and three years, the differences decreased (54.6 versus 34.0% and 61.7 versus 45.8%, respectively) and lost statistical significance.

CONCLUSIONS

Both the current Ru106 and the preceding Ru106/TTT-protocols provided excellent tumour control, cosmetic and functional eye preservation and vital prognosis. The Ru106-protocol yielded prolonged preservation of VA and should be regarded the current standard of treatment.

Choroidal melanoma treated with stereotactic fractionated radiotherapy and prophylactic intravitreal bevacizumab: The Dunedin Hospital experience

INTRODUCTION

Choroidal melanoma (CM) is the most common primary ocular malignancy in adults. This study reviewed the Dunedin Hospital (DH) experience in the treatment of CM with stereotactic fractionated radiotherapy (SRT) and the outcome of prophylactic use of intravitreal injection bevacizumab (PIB) in preventing radiation retinopathy (RR).

METHODS

A retrospective study was conducted of patients at DH who underwent SRT for CM with and without PIB from 1 January 2001 to 31 January 2012. In DH, some patients who had SRT following the introduction of intravitreal bevacizumab in December 2006 were also treated with PIB with the expectation that this might reduce the risk of developing RR, although the evidence of its effectiveness in this respect is not clear. The primary outcome measure was local progression as monitored with regular ultrasound. Secondary outcome measures were metastatic progression incidence, enucleation incidence, no functional vision incidence, overall survival, disease-specific mortality, incidence of RR, and radiotherapy to clinical diagnosis of RR time.

RESULTS

Twenty-seven patients who were followed up at DH were reviewed after a mean follow-up of 5.1 years (range 0.4-12.6). Fourteen patients received PIB. The local progression, metastatic progression and enucleation rate were 4%, 8% and 11%, respectively. The no functional vision (hand movements or less) rate was 62%. Overall survival was 63%, but only three (11%) deaths were due to metastatic choroidal melanoma. Incidence of RR was 57% and 54% for those that received PIB and those who did not, respectively. PIB did not reduce the rate of RR (P = 1.00).

CONCLUSION

This study reaffirmed that SRT achieves very good local control and eye retention rates. PIB did not appear to reduce the radiation retinopathy rate in this study, and more studies are required especially Phase II and III trials to determine PIB efficacy in preventing RR.

Uveal Melanomas with SF3B1 Mutations: A Distinct Subclass Associated with Late-Onset Metastases

PURPOSE

To investigate the prevalence and prognostic value of SF3B1 and EIF1AX mutations in uveal melanoma (UM) patients.

DESIGN

Case series.

PARTICIPANTS

Cohort of 151 patients diagnosed with and treated for UM.

METHODS

SF3B1 and EIF1AX mutations in primary tumors were investigated using whole-exome sequencing (n = 25) and Sanger sequencing (n = 151). For the detection of BAP1 mutations, a previously reported cohort of 90 patients was extended using BAP1 sequencing or immunohistochemistry.

MAIN OUTCOME MEASURES

The status of SF3B1, EIF1AX, and BAP1 in tumors of patients were correlated to clinical, histopathologic, and genetic parameters. Survival analyses were performed for patients whose tumors had SF3B1, EIF1AX, and BAP1 mutations.

RESULTS

Patients with tumors harboring EIF1AX mutations rarely demonstrated metastases (2 of 28 patients) and overall had a longer disease-free survival (DFS; 190.1 vs. 100.2 months; P < 0.001). Within the patient group with disomy 3, UM patients with an SF3B1 mutation had an increased metastatic risk compared with those without an SF3B1 mutation (DFS, 132.8 vs. 174.4 months; P = 0.008). Patients with such a mutation were more prone to demonstrate late metastases (median, 8.2 years; range, 23-145 months). Patients with UM and loss of BAP1 expression had a significantly decreased survival (DFS, 69.0 vs. 147.9 months; P < 0.001).

CONCLUSIONS

According to our data, patients with UM can be classified into 3 groups, of which EIF1AX-mutated tumors and tumors without BAP1, SF3B1, or EIF1AX mutations are associated with prolonged survival and low metastatic risk, SF3B1-mutated tumors are associated with late metastasis, and tumors with an aberrant BAP1 are associated with an early metastatic risk and rapid decline in patient DFS.