Histopathological findings in human choroidal melanomas after transpupillary thermotherapy

Oncolytic Viruses and Immunotherapy for the Treatment of Uveal Melanoma and Retinoblastoma: The Current Landscape and Novel Advances

Intraocular malignant tumors are rare; however, they can cause serious life-threatening complications. Uveal melanoma (UM) and retinoblastoma (RB) are the most common intraocular tumors in adults and children, respectively, and come with a great disease burden. For many years, several different treatment modalities for UM and RB have been proposed, with chemotherapy for RB cases and plaque radiation therapy for localized UM as first-line treatment options. Extraocular extension, recurrence, and metastasis constitute the major challenges of conventional treatments. To overcome these obstacles, immunotherapy, which encompasses different treatment options such as oncolytic viruses, antibody-mediated immune modulations, and targeted immunotherapy, has shown great potential as a novel therapeutic tool for cancer therapy. These anti-cancer treatment options provide numerous advantages such as selective cancer cell death and the promotion of an anti-tumor immune response, and they prove useful in preventing vision impairment due to macular and/or optic disc involvement. Numerous factors such as the vector choice, route of administration, dosing, and patient characteristics must be considered when engineering an oncolytic virus or other forms of immunotherapy vectors. This manuscript provides an in-depth review of the molecular design of oncolytic viruses (e.g., virus capsid proteins and encapsulation technologies, vectors for delivery, cell targeting) and immunotherapy. The most recent advances in preclinical- and clinical-phase studies are further summarized. The recent developments in virus-like drug conjugates (i.e., AU011), oncolytic viruses for metastatic UM, and targeted immunotherapies have shown great results in clinical trials for the future clinical application of these novel technologies in the treatment algorithm of certain intraocular tumors.

Incisional choroidal surgery

The choroid is a thin layer of highly vascular uveal tissue enclosed externally by sclera and internally by neurosensory retinal tissue. The choroid is a "middle layer" ocular tissue with anatomically challenging surgical access. The primary functional role of the choroid is to provide rapid, oxygenated, and nutrient-rich blood flow to both the highly metabolic retinal pigment epithelium and outer retina (i.e. photoreceptors) while simultaneously removing waste products. Historically, incisional choroidal surgery (ICS) has involved tumor biopsy or excision, removal of choroidal neovascular complex or autologous choroidal translocations; however, ICS also holds unique potential for novel and innovative approaches to address macular pathology. Using large-animal surgical studies, researchers have explored ICS with the objective of finding safer and more effective techniques to reduce surgical risks such as bleeding, tissue contraction, and scar tissue formation. We explore the relevant anatomy and embryology, existing surgical techniques, discuss the implications for retinal drug delivery, define ICS guiding principles, and offer a rationale for implementation of ICS into a vitreoretinal surgical practice. We also identify other future challenges and anticipate future innovations that will advance ICS.

Swept-source optical coherence tomography and swept-source optical coherence tomography angiography findings in circumscribed choroidal hemangioma before and after transpupillary thermotherapy

PURPOSE

To investigate the swept-source optical coherence tomography (SS-OCT) and SS-OCT angiography (SS-OCTA) findings in circumscribed choroidal hemangioma (CCH) before and after treatment with transpupillary thermotherapy (TTT).

METHODS

The clinical records of 21 eyes having CCH imaged with SS-OCT/SS-OCTA between September 2018 and December 2022 were evaluated.

RESULTS

SS-OCT examination in CCH showed dome-shaped appearance (100%), choroidal shadowing (100%), expansion of choroidal structures (100%), subretinal fluid (66.7%), intraretinal edema/schisis (33.3%), retinal pigment epithelium (RPE) atrophy (19.0%), hyperreflective dots (19.0%), and epiretinal membrane (4.8%). Internal arborizing tumor vessels showing hyperreflectivity were observed in the choriocapillaris slab on SS-OCTA in all eyes. In the deep capillary plexus (DCP), flow void changes were seen in 7 eyes with intraretinal schisis/cystoid macular edema. Four CCHs > 2 mm in thickness showed outer retinal involvement due to unmasking of flow in intratumoral vessels related to RPE atrophy. Following TTT/indocyanine green-enhanced TTT (ICG-TTT) of CCH, SS-OCT findings included total/partial resolution of subretinal fluid (57.1%), complete/partial regression of the tumor (52.4%), and RPE atrophy (33.3%). After treatment; loss of choriocapillaris, decrease in tumor vascularity together with increase in the fibrous component and flow void areas were detected on SS-OCTA.

CONCLUSIONS

SS-OCT/SS-OCTA are useful non-invasive tools for imaging the structural/vascular changes in CCHs managed with TTT or ICG-TTT. On SS-OCTA, hyporeflective spaces localizing to edema/schisis in the DCP and arborizing tumor vessels within a hyporeflective stromal background in the choriocapillaris slab were observed. After TTT/ICG-TTT, a decrease in tumor vessels and an increase in the fibrous component and flow-void areas inside the CCH were detected on SS-OCTA.

The State-of-the-Art and Perspectives of Laser Ablation for Tumor Treatment

Tumors significantly impact individuals' physical well-being and quality of life. With the ongoing advancements in optical technology, information technology, robotic technology, etc., laser technology is being increasingly utilized in the field of tumor treatment, and laser ablation (LA) of tumors remains a prominent area of research interest. This paper presents an overview of the recent progress in tumor LA therapy, with a focus on the mechanisms and biological effects of LA, commonly used ablation lasers, image-guided LA, and robotic-assisted LA. Further insights and future prospects are discussed in relation to these aspects, and the paper proposed potential future directions for the development of tumor LA techniques.

Laser treatment for choroidal melanoma: Current concepts

Laser treatment has offered a relatively nonsurgical alternative for eye, life, and vision-sparing treatment of malignant melanoma of the choroid. Historically, the most commonly used forms of lasers were xenon-arc, argon laser, krypton laser, and the more recent transpupillary thermotherapy (TTT) and photodynamic therapy (PDT). Melanomas selected for laser treatment tend to be smaller and visibly accessible, which means these tumors are usually located in the posterior choroid. Laser treatments have been associated with both local tumor destruction and side effects. Unlike radiation therapy, laser treatment has been commonly associated with retinal traction, hemorrhage, chorioretinal neovascularization, and extra scleral tumor extension, as well as higher rates of local treatment failure. In addition, however, laser-treatment has been successfully used to treat tumor-related retinal detachments, radiation retinopathy, and neovascular glaucoma. We review the world's experience of ophthalmic laser treatment for choroidal melanoma, offer safety and efficacy guidelines, as well as a comparison of laser treatment to radiation therapy outcomes.

Postoperative Echography for Optimization of Radiation Dosimetry in Patients with Uveal Melanoma Treated with Plaque Brachytherapy

PURPOSE

(1) To describe the technique of postoperative echography to confirm the intended treatment dose to the tumor apex in patients with uveal melanoma treated with plaque brachytherapy. (2) To describe the local tumor control rate and visual outcomes with the brachytherapy strategies used at our institution.

DESIGN

Retrospective review.

SUBJECTS

Three hundred and seventy-two consecutive patients with uveal melanoma (small, medium, and large) treated with plaque brachytherapy at the University of Iowa from August 2008 to February 2019.

METHODS

Patient demographics and tumor characteristics were recorded for each patient. Patients with posterior tumors treated with plaque brachytherapy (n = 355) underwent intraoperative ultrasound to confirm plaque placement, and additional postoperative ultrasound on day 1 to 3 postplaque insertion. In cases where intratumor/episcleral plaque edema or hemorrhage shifted the dose to the prescription point to < 85 Gray (Gy), the duration of plaque brachytherapy was increased to compensate. Statistical analysis was performed to compare variables associated with the need for plaque adjustment.

MAIN OUTCOMES MEASURES

Variables associated with plaque dose needing to be recalculated, local tumor control, and visual acuity outcomes.

RESULTS

In 31 (8.3%) cases, postoperative echography showed that the tumor apex had shifted outside the 85 Gy isodose curve, requiring adjustment of the duration of brachytherapy (28 cases) or repositioning of the plaque (3 cases). Collaborative Ocular Melanoma Study tumor size was significantly associated with need to adjust the plaque prescription dose (P = 0.03), with large tumors having the highest rate of adjustment. Tumor thickness was larger in cases requiring plaque adjustment compared with those that were not adjusted (median 4.9 mm vs. 3.0 mm, P < 0.01). Local tumor control was 99% (95% confidence interval, 97%-100%) at 5 years and 99% (95% confidence interval, 97%-100%) at 10 years. The percentage of patients who had experienced a visual acuity decline of ≥ 3 lines of vision or had < 20/200 acuity was 14.9% at 1 year after brachytherapy, 35.3% at 3 years, and 51.6% at 5 years.

CONCLUSIONS

Postoperative ultrasound performed on postoperative day 1 to 3 after plaque insertion for patients undergoing brachytherapy for uveal melanoma may result in improved local tumor control, particularly in the setting of thicker or larger tumors.

Circumscribed choroidal hemangioma: Comparative efficacy of transpupillary thermotherapy, indocyanine green-enhanced transpupillary thermotherapy, and photodynamic therapy and analysis of baseline clinical features effecting treatment outcomes

PURPOSE

To compare the efficacy of transpupillary thermotherapy (TTT), indocyanine green-enhanced TTT (ICG-TTT), and photodynamic therapy (PDT) in the management of circumscribed choroidal hemangioma (CCH) and to investigate the baseline clinical features effecting treatment outcomes METHODS: Retrospective review of clinical records of 60 eyes with CCH which underwent TTT (25), ICG-TTT (22), or PDT (13). Main study outcomes were 1) final visual acuity (VA) ≤20/200, 2) <2 Snellen lines VA increase, 3) persistent subretinal fluid (SRF), and 4) <20% decrease in tumor thickness.

RESULTS

Multivariable factors associated with final VA ≤20/200 included longer duration of symptoms (p = 0.015), lower initial VA (p = 0.030), and presence of retinoschisis overlying the tumor (p = 0.047). Multivariable factors for <2 Snellen lines VA increase were longer duration of symptoms (p = 0.018) and previous failed treatment (p = 0.003). By multivariable analysis, the only significant factor for persistent SRF was the presence of retinoschisis (p = 0.001). Multivariable factors associated with a decrease in tumor thickness by <20% were smaller initial tumor thickness (p = 0.045) and presence of retinoschisis (p = 0.014). By Pearson Chi-Square/Fisher Exact Test, final VA ≤20/200 rates (48.0%, 13.6%, 30.8% respectively, p = 0.041) and VA improvement by <2 lines rates (64.0%, 27.3%, 38.5% respectively, p = 0.036) were significantly different between TTT, ICG-TTT, and PDT groups. However, by post hoc analysis, ICG-TTT yielded statistically better outcomes compared to TTT with respect to final visual acuity (VA) ≤20/200 (p = 0.012) and <2 Snellen lines VA increase (p = 0.012).

CONCLUSIONS

Longer symptom duration, previous failed treatment, lower initial VA, and presence of retinoschisis were risk factors for worse visual outcomes. Eyes with retinoschisis displayed more SRF persistence after treatment. Smaller initial tumor thickness and presence of retinoschisis were risk factors for <20% decrease in tumor thickness.

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’.

Circumscribed choroidal hemangioma: An overview of clinical manifestation, diagnosis and management

Circumscribed choroidal hemangioma is a benign vascular tumor which presents in middle-aged adults with progressive diminution of vision, metamorphopsia, floaters, and visual field defects. Diagnosis is based on the characteristic clinical features. It is an orange-red, usually solitary, tumor situated in the posterior pole. The visual symptoms are because of the associated subretinal fluid, cystoid macular edema, and, in long-standing cases, retinal pigment epithelium changes, subretinal fibrosis and retinoschisis. It must be distinguished from the more ominous amelanotic melanoma and choroidal metastasis. Diagnostic tools such as ultrasound, fundus fluorescein angiography, indocyanine green angiography, and optical coherence tomography are helpful in cases with diagnostic dilemma. Treatment is indicated in symptomatic cases. The management of choroidal hemangioma has evolved over the years beginning with laser photocoagulation to transpupillary thermotherapy, photodynamic therapy, plaque brachytherapy and external beam radiotherapy. No one therapeutic option holds superiority over the other. In this article, we review the epidemiology, clinical manifestations and treatment of the circumscribed variant of choroidal hemangioma.

Which Choroidal Melanoma Should be Treated with Primary Transpupillary Thermotherapy? Our Experience from 78 Patients

Purpose

To report the outcomes of primary transpupillary thermotherapy (TTT) for choroidal melanomas.

Methods

A total of 78 patients were treated with TTT. Tumor thickness was up to 3.6 mm (mean 2.05 mm), follow-up 2.5–108 months (mean, 32.8 months). The main outcome measures were local control, enucleations, tumor recurrences, complications, and visual acuity. The predictors of treatment failures were analyzed.

Results

A total of 51 tumors regressed completely, and 20 incompletely. Out of 7 patients without response, 2 had enucleation, and 5 had Ru-106 irradiation. Recurrences after primary response were observed in 10 patients in 7–54 months (mean 23.4), 8 of them after incomplete regression. Six recurrences were successfully treated with additional TTT, and 4 with brachytherapy There were no metastases or deaths. Logistic regression showed the main predictive factors for TTT failure to be tumor height (OR=6.85; 95% 01=1.2–38.1; p=0.02), basal diameter (OR=22.85; 95% 01=3.6–144.7; p=0.0003), amelanotic pigmentation (for primary failure, OR=9.18; 95% Cl=1.7–49.2; p=0.008), high maximum systolic velocity (for primary failure, OR=13.6; 95% 01=2.3–81.7; p=0.003), subretinal fluid (OR=11.04; 95% 01=1.2–100.4; p=0.03), and incomplete regression (OR=30.62; 95% 01=6.0–156.4; p=0.00001). Receiver operating characteristic analysis showed the following cutoff levels: for tumor height 3.0 mm, for basal diameter 10.2 mm, for maximum systolic velocity 11.7 cm/s. Kaplan-Meier analysis of negative results was fulfilled in all treated patients and in patients without negative predictors. Mean visual acuity before TTT was 0.65, and after treatment 0.58. A total of 23% of patients had increased visual acuity, 42% had decreased acuity, and there was no change in 35%.

Conclusions

TTT is an investigative treatment for choroidal melanomas. TTT needs careful selection of patients, based on consideration of predictive factors and functional perspectives.

Patterns of care and survival outcomes after treatment for uveal melanoma in the post-coms era (2004-2013): a surveillance, epidemiology, and end results analysis

PURPOSE

The Collaborative Ocular Melanoma Study (COMS) established modern treatment recommendations for uveal melanoma. We aim to evaluate patterns of care and survival outcomes in the time after COMS.

MATERIAL AND METHODS

The retrospective study population includes 2,611 patients in the SEER database treated for uveal melanoma between 2004-2013. Patients stage were T1-4N0M0. Data analyzed included age, clinical stage, tumor size, race, and treatment. Treatments included enucleation (EN) and globe preserving therapy (GPT), which consisted of limited surgical resection or ablation (LSRA), external beam radiation (EBRT), or brachytherapy (BT). Patients treated with radiation may receive radiation therapy alone (RTA) or radiation therapy and supplemental laser therapy (RT+SLT). We evaluated disease specific survival (DSS) and overall survival (OS) using log-rank statistics, and Cox univariate and multivariate analysis.

RESULTS

The median follow-up was 44 months. Treatment strategy was EN in 538 (20.6%) patients, LSRA in 80 (3.1%), EBRT in 609 (23.3%), and BT in 1,384 (53.0%). 1,876 patients received RTA and 117 received RT+SLT. Enucleation was associated with inferior DSS and OS compared to GPT in multivariate analysis (MVA) (p < 0.01). Limited surgical resection or ablation and radiation had similar DSS and OS. Brachytherapy and EBRT had similar DSS and OS. Radiation therapy and supplemental laser therapy was associated with improved DSS compared to RTA in UVA (p = 0.03), but not MVA. The 5-year DSS for enucleation, RTA, and RT+SLT were 66.7%, 87.0%, and 94.7% (p < 0.01), respectively.

CONCLUSIONS

Globe preserving treatments such as limited surgery or radiation are commonly utilized alternatives to enucleation, and resulted in favorable survival outcomes. Additional research is required to compare the outcomes of the various globe preserving treatment strategies.

Die Geschichte der Ophthalmoonkologie an der Univ.-Augenklinik Graz

Einleitung

Der Beginn der organerhaltenden Therapie an der Univ.-Augenklinik datiert auf das Jahr 1985 mit der Einführung der Ruthenium 106 Applikatoren (Lommatzsch, Vormun) zurück.

Der Autor skizziert in zeitlicher Abfolge die Einführung und gemeinsame Entwicklung verschiedener Arten von organerhaltender Therapien und endet mit neuen Therapieansätzen des Retinoblastoms und des metastasierenden Aderhautmelanoms.

Methodik

Die Vorstände der Univ.-Augenklinik beginnend mit Hofmann (1964–1987) unterstützten den Paradigmenwechsel von einem radikalchirurgischen Konzept (Enukleation) bei intraokularen Tumoren zu einem organerhaltenden Konzept trotz Fehlens von großen Studien mit hoher Evidenz. Zuweisende FachärztInnen waren zu Recht im Zweifel über die Sinnhaftigkeit dieser neuen Therapiekonzepte, unterstützen jedoch mit ihren PatientInnen Zuweisungen den neuen Arbeitsschwerpunkt bzw. den organerhaltenden Therapieansatz bis zum heutigen Tag.

Ergebnisse

Aderhautmelanom: 1985 wurde die organerhaltende Therapie mittels Ruthenium 106 Applikatoren in Graz für kleine und mittelgroße Aderhautmelanome mit aequatorialler und anteriorer Lokalisation eingeführt, ab 1992 war die Gamma Knife Radiochirurgie alternativ zur Protonen- und Photonentherapie an der Univ. Klinik für Neurochirurgie in Graz verfügbar und wurde mit Beiträgen anderer Tumorzentren für die Behandlung von großen Aderhautmelanomen oder solchen mit posteriorer Lokalisation entwickelt.

Die transpupillare Thermotherapie (TTT) wurde 1995 in Leiden von Osterhuis und Journée-de Korver für die Behandlung von flachen posterior lokalisierten Melanomen im Tiermodell entwickelt. Die Therapie geriet auf Grund einer erhöhten Rate von Rezidiven in einzelnen Tumorzentren in Mißkredit und Vergessenheit, sollte jedoch auf Grund guter eigener Erfahrungen und der Einführung der TTT bei der Behandlung von Retinoblastomen in Hinblick auf Technik und Indikationen neuerlich evaluiert werden.

Endoresektion: Aderhautmelanome werden nach Vorbestrahlung wegen des großen Tumorvolumens bzw. einer persistierenden Amotio mittels Vitrektomie Techniken reserziert, als Bestrahlungstechnik wurde in Graz und in Essen das Gamma Knife verwendet.

Biopsien werden seit einigen Jahren für genetische und mikrobiologische Untersuchungen durchgeführt, neue mikrobiologische Erkenntnisse werden zur Entwicklung neuer systemischer Therapiekonzepte führen.

Retinoblastom: Im Gegensatz zum Aderhautmelanom erwies sich die adjuvante Chemotherapie beim Retinoblastom als hoch wirksam v. a. in der Volumsreduktion der Tumoren.

Die Brachytherapie mit Ruthenium 106 Schalen, die 3‑fach Kryotherapie bzw. die Lasertherapie werden bereits seit Jahrzehnten an der Univ.-Augenklinik als organerhaltende Lokaltherapien durchgeführt, seit kurzem komplettiert die TTT (mit oder ohne simultane Chemotherapie) das Spektrum der fokalen Therapien. Neue Therapiekonzepte wie die intrabulbäre Chemotherapie (bereits in Anwendung) sowie die intraarterielle Chemotherapie (steht kurz vor der Implementierung) sind bereits in Routine.

Seit 2003 werden erstmals Retinoblastome in einer Therapie Optimierungsstudie RBA2003 (die das Department für Hämato‑/Onkologie der Univ. Kinderklinik Graz zusammen mit der Univ.-Augenklinik entwickelt hat) in Graz behandelt. Das Univ. Klinikum Graz etabliert sich als Referenzzentrum für Retinoblastome und Pseudoretinoblastome in Österreich und dem umgebenden Ausland und erhielt Anfragen und PatientInnen Zuweisungen aus den Alpe Adria Ländern sowie Schweiz, Bulgarien, Tschechien, Rumänien, Ukraine und Rußland. Wedrich, derzeitiger Vorstand der Univ.-Augenklinik Graz, förderte die Entwicklung des Retinoblastom Kompetenz Zentrums in personeller, instrumenteller und logistischer Hinsicht.

2015 entwickelte das Klinikum Essen ein auf das Protokoll RBA2003 aufbauendes, erweitertes internationales Protokoll, nach dem nun PatientInnen aus Essen und Graz gemeinsam behandelt, evaluiert und nachkontrolliert werden. Dieses wiederum wird in einem EU-Antrag, initiert von Chandada (Buenos Aires, Barcelona) für eine einheitliche Behandlung des Retinoblastoms in Europa berücksichtigt.

2005 engagierte sich die Arbeitsgruppe erstmals in Mosambique, Afrika folgend einer Bitte der NGO, Licht für die Welt, die Rahmenbedingungen für die Etablierung eines Retinoblastomzentrums zu prüfen.

2008 wurde am LKH Univ. Klinikum Graz ein Forschungsfeld Onkologie etabliert, in weiterer Folge das Comprehensive Cancer Center (CCC) der MUG gegründet, in das die Ophthalmoonkologie thematisch eingegliedert ist.

Schlussfolgerung

Das vor 32 Jahren am LKH Univ.-Klinikum Graz etablierte Konzept der organerhaltenden Therapie erfuhr 13 Jahre später die Bestätigung durch die bislang größte multizentrische Studie (COMS Studie) in den USA, wonach kein Unterschied in Hinblick auf Überleben zwischen Enukleation und bulbuserhaltender Therapie mit Jod 125 Schalen bei kleinen und mittelgroßen Aderhautmelanomen gefunden wurde. Die seit über 30 Jahren unveränderte (z. T. sehr schlechte) Prognose kann möglicherweise in absehbarer Zeit durch neue Medika verbessert werden. Basis für diese erfreulichen Entwicklungen sind neue bahnbrechende Erkenntnisse aus der zytogenetischen und molekularbiologischen Forschung.

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.

Association Between Choroidal Thickness and Metabolic Activity on Positron Emission Tomography in Eyes With Choroidal Melanoma

PURPOSE

To investigate the relationship between subfoveal choroidal thickness and metabolic activity in eyes with choroidal melanoma.

DESIGN

Retrospective, interventional case series.

METHODS

The medical records of 16 patients with unilateral choroidal melanoma who underwent ruthenium (Ru) 106 brachytherapy with adjuvant transpupillary thermotherapy and who had available pretreatment positron emission tomography-computed tomography (PET-CT) images were retrospectively reviewed. Subfoveal choroidal thickness was measured in tumor eyes and in unaffected fellow eyes using enhanced-depth imaging spectral-domain optical coherence tomography (EDI OCT). Tumor eyes were divided into 2 groups (metabolically active and inactive) based on PET-CT findings and subfoveal choroidal thickness was compared between groups. Additionally, choroidal thickness measurements were compared before and after treatment.

RESULTS

Before treatment, mean choroidal thickness was 293.31 ± 46.80 μm in tumor eyes and 242.44 ± 65.37 μm in fellow eyes, a difference that was statistically significant (P = .003). Eyes with metabolically active tumors had a significantly thicker choroid (348.00 ± 17.32 μm) than eyes with metabolically inactive tumors (280.69 ± 42.04 μm, P = .019). In tumor eyes, mean choroidal thickness significantly decreased from pretreatment values to 253.56 ± 61.27 μm 6 months after treatment (P = .018).

CONCLUSION

Eyes with choroidal melanoma had thicker choroids than unaffected fellow eyes. Increased choroidal thickness was more prominent in metabolically active tumors. Choroidal thickness significantly decreased in tumor eyes 6 months after treatment.

Management of posterior uveal melanoma: past, present, and future: the 2014 Charles L. Schepens lecture

PURPOSE

To review the management of ciliary body and choroidal melanoma (posterior uveal melanoma [PUM]) over the last century with an emphasis on changing concepts.

DESIGN

Retrospective review.

PARTICIPANTS

Review of personal experience over 40 years and pertinent literature on management of PUM.

METHODS

Diagnosis and therapy for PUM.

MAIN OUTCOME MEASURES

Patient survival.

RESULTS

In the early 1900s, most patients presented with a large symptomatic melanoma that necessitated enucleation, and the systemic prognosis was poor. In the 1970s, controversy erupted regarding the role of enucleation for PUM. Some authorities advocated prompt enucleation, and others proposed that enucleation promoted metastasis, known as the "Zimmerman hypothesis." Others recommended observation, withholding treatment until tumor growth was documented. During the 1970s, there was a trend toward eye-saving procedures, including laser photocoagulation, surgical removal of tumor, and techniques of radiotherapy. Despite local treatment success, systemic prognosis remained guarded with approximately 40% mortality overall. However, there was convincing evidence that smaller tumors offered a significantly better prognosis. Currently, there is a movement toward earlier identification and treatment of small melanomas using clinical factors predictive of malignant potential, in keeping with similar philosophy regarding other cancers. Further understanding of melanoma cytogenetics and molecular pathways have helped to recognize patients at risk for metastasis. At-risk patients are offered systemic therapeutic trials to prevent metastasis. We anticipate that the future management of PUM will focus on detection of clinical and imaging clues for earliest diagnosis, prompt local tumor treatment, and systemic targeted therapies for microscopic metastasis or prevention of metastasis. Personalized evaluation of patient-specific melanoma molecular pathway signature could allow for therapeutic intervention at a site specific to the pathway abnormality that leads to the development of melanoma.

CONCLUSIONS

Management of PUM has made major strides over the past century from the days of enucleation for massive, fatal tumor to early detection of smallest tumors with a more favorable prognosis. Current and future targeted specific tumor pathway interruption using systemic agents could improve survival.

Primary transpupillary thermotherapy for choroidal melanoma in 391 cases: importance of risk factors in tumor control

PURPOSE

To report the long-term outcome of primary transpupillary thermotherapy (TTT) for choroidal melanoma.

DESIGN

Retrospective review of medical records.

PARTICIPANTS

We included 391 patients with choroidal melanoma treated between 1995 and 2012 at the Oncology Service, Wills Eye Hospital, Philadelphia.

METHODS

We delivered TTT with an infrared diode laser.

MAIN OUTCOME MEASURES

Local tumor recurrence, Snellen visual acuity after TTT, and distant metastasis.

RESULTS

Of 391 patients, 311 (80%) were treated from 1995 to 2000 and 80 (20%) from 2001 to 2012. Tumors in the 2001 to 2012 group were ultrasonographically thinner (2.2 vs. 2.7 mm), more distant from the optic disc (3.2 vs. 2.5 mm) and foveola (4.0 vs. 2.0 mm), were less often located in the macular area (14% vs. 40%), and had lower rates of acoustic hollowness on B-scan ultrasonography (63% vs. 84%), subretinal fluid (58% vs. 90%), and orange pigment (50% vs. 70%). Kaplan-Meier estimates for tumor recurrence in the 1995 to 2000 group were 29% at 5 years and 42% at 10 years, whereas estimates for tumor recurrence in the 2001-2012 group were 11% at 5 years and 15% at 10 years. Of 108 recurrent tumors 20 were controlled with additional TTT and 62 required plaque radiation (n=60) or proton beam radiation (n=2), with enucleation necessary in 26 patients. Tumor recurrence correlated with the number of high-risk tumor features: 10-year recurrence was 18% in those with 1 or 2 risk factors, 35% in those with 3 to 5 factors, and 55% in those with 6 or 7 factors. On multivariate analysis, features predictive of tumor recurrence were presence of symptoms (P<0.001), shorter distance between the tumor and the optic disc (P=0.026), subretinal fluid (P=0.035), thickness of residual tumor scar (P<0.001), and elevation of residual tumor scar (P<0.001). The only factor predictive of extraocular tumor extension was intraocular tumor recurrence after TTT treated with additional TTT (P=0.007). Presence of orange pigment before TTT (P=0.019), tumor recurrence (P=0.002), and extraocular tumor extension (P=0.017) were predictive of distant metastasis.

CONCLUSION

This study shows a direct correlation between a larger number of high-risk tumor features and higher rates of tumor recurrence after primary TTT of (small) choroidal melanoma. We advise that, when possible, small choroidal melanomas with multiple risk factors be treated with methods other than TTT.

Transscleral delivery of Nd: YLF laser at 1,047 nm causes vascular occlusion in experimental pigmented choroidal melanoma

PURPOSE

The aims of this study were to determine the scleral attenuation of focused neodymium: yttrium-lanthanum-fluoride laser at 1,047 nm applied transsclerally and whether transscleral delivery can close the vascular supply at the base of experimental choroidal melanoma in rabbits.

METHODS

Fifty-two New Zealand albino rabbits were included. Scleral laser attenuation was measured across fresh sclera. B16F10 melanomas were established in the subchoroidal space of 49 rabbits. Twenty-one animals were killed immediately after transscleral treatment, 14 were followed for 2 weeks to 4 weeks, and 14 were followed without treatment. Ophthalmoscopy, fundus photographs, and fluorescein angiography were performed before treatment, immediately after, and weekly during the follow-up. Eyes were examined by light microscopy.

RESULTS

Sclera attenuated laser energy by 31% ± 7%. Immediately after treatment, angiography showed diffuse hypofluorescence in 71% (15 of 21 rabbits). Light microscopy showed vascular occlusion extending at least two thirds of the tumor thickness from the base. Seven of the 14 tumors followed for 15 days ± 8 days were eradicated. There was no correlation between tumor height and eradication.

CONCLUSION

Rabbit sclera attenuated 31% ± 7% of laser energy. A single transscleral treatment causes tumor vascular closure at the base and may serve as an adjuvant therapy to ensure destruction of deep and intrascleral tumor cells.

Regression of uveal melanoma after ru-106 brachytherapy and thermotherapy based on metabolic activity measured by positron emission tomography/computed tomography

PURPOSE

To evaluate regression rates of uveal melanoma after combined Ru-106 plaque radiotherapy and thermotherapy according to metabolic activity measured by positron emission tomography/computed tomography imaging.

METHODS

A retrospective medical chart review was conducted on 26 patients with uveal melanoma who underwent pretreatment whole-body positron emission tomography/computed tomography and received combined plaque radiotherapy and thermotherapy between 2006 and 2011. Tumors were classified as metabolically active and inactive based on the positron emission tomography/computed tomography imaging and compared with tumor height regression rates after treatment.

RESULTS

Before treatment, the median tumor thickness was 8.8 mm for metabolically active tumors (7 eyes) and 5.0 mm for metabolically inactive tumors (19 eyes). The median tumor thicknesses with respect to the original thickness at 3, 6, and 12 months after treatment were 88%, 78%, and 64% for metabolically active tumors and 95%, 89%, and 81% for metabolically inactive tumors, respectively. The monthly tumor regression rates during the first 3 months (4.2% vs. 1.7%, P = 0.022) and the overall monthly tumor regression rates (3.0% vs. 1.5%, P = 0.041) were significantly higher for metabolically active tumors versus inactive tumors. Two patients with positive metabolic activity developed metastatic diseases 2 years after treatment, whereas no patient with negative metabolic activity developed metastatic disease during the study period.

CONCLUSION

Positive metabolic activity of uveal melanoma based on the positron emission tomography/computed tomography was significantly associated with rapid initial tumor regression after combined plaque radiotherapy and thermotherapy, suggesting a prognostic value for this diagnostic approach.

The comparison of ruthenium brachytherapy and simultaneous transpupillary thermotherapy of choroidal melanoma with brachytherapy alone

PURPOSE

To compare the outcomes of combined treatment of choroidal melanoma with ruthenium brachytherapy (BT) simultaneously with transpupillary thermotherapy (TTT) and treatment with BT alone.

METHODS AND MATERIALS

Two matched groups of patients, one treated with BT and simultaneous TTT (Group BT+TTT, n=63), the other treated with BT alone (Group BT, n=70) were analyzed retrospectively. The main outcome measures were rate of tumor regression, recurrences, enucleations, metastases, recurrence-free and overall survival rate, and visual acuity, assessed by Kaplan-Meier analysis.

RESULTS

Patients were matched according to mean age (p=0.22), mean tumor thickness (6.4 vs. 6.25mm, range 2.5-10.8mm, p=0.59), and mean length of followup (42 vs. 34.4 months, range 3-109, p=0.052). Tumor largest basal diameter (13.0 vs. 12.9mm), tumor location, and mean radiation dose (apical 135 vs. 136Gy and scleral 1294 vs. 1438Gy) were also similar in both groups (p>0.1). Treatment with BT+TTT resulted in higher rate of tumor regression (63% vs. 49%, respectively, p=0.036), lower 5-year tumor recurrence rate (96% vs. 83%, p<0.034), and higher eye-globe preservation (98% vs. 87%, p<0.024) and recurrence-free survival rates (89% vs. 67%, p<0.017) than treatment with BT alone. There was no difference in complications (p>0.5), metastasis-free (93% vs. 81%, p>0.22) and overall survival rates (91% vs. 81%, p>0.39), or in visual outcomes.

CONCLUSION

Combined treatment of choroidal melanoma with ruthenium BT and simultaneous TTT seems to provide higher local control, eye-globe preservation, and recurrence-free survival rates than treatment with BT alone and results in similar rates of metastases and overall survival.

Primary transpupillary thermotherapy of choroidal melanocytic lesions

Purpose:

To evaluate the role of primary transpupillary thermotherapy (TTT) in the treatment of choroidal melanocytic lesions.

Materials and Methods:

Retrospective chart review of 24 patients (24 eyes) with choroidal melanocytic lesions, including 20 choroidal melanoma and four choroidal nevus treated with primary TTT. Choroidal nevus cases treated with primary TTT either demonstrated risk factors for growth into an early melanoma or had overlying choroidal neovascularization.

Results:

The mean initial tumor basal diameter was 6.6 (3.0-10.0) mm and the mean initial tumor thickness was 3.0 (1.0-5.0) mm. The mean number of TTT sessions was 2.5 (1-6). The mean decrease in tumor thickness was 1.2 mm (from 3.0 to 1.8 mm) at a mean follow-up of 22.7 (range 3-90) months. On the LogMar scale, visual acuity was stable at 1.0. Complications occurred in 50% of eyes. The most frequent complications were vitreous hemorrhage [5 patients (20.8%)], focal cataract [5 patients (20.8%)], iris atrophy [4 patients (16.6%)] and posterior synechia [4 patients (16.6%)]. There was no significant difference in the complication rate with respect to tumor thickness >3 mm versus tumor thickness ≤3 mm and juxtapapillary versus nonjuxtapapillary location (Fisher’s exact test, P>0.05). Kaplan-Meier curves showed that 9% of eyes develop recurrence by 1 year and 27% develop recurrence by 5 years after primary TTT. Two eyes (8.3%) were enucleated because of neovascular glaucoma and one eye (4.1%) was exenterated because of extraocular tumor recurrence. Globe salvage was achieved in 21 patients (87.5%). One patient (4.1%) with extraocular tumor recurrence developed liver metastasis and expired.

Conclusions:

Although TTT may be useful in the treatment of small choroidal melanocytic lesions, the high complication and recurrence rates warrant close monitoring of patients after primary TTT even when a flat chorioretinal scar has been achieved.

Sturge-Weber syndrome: decrease in intraocular pressure after transpupillary thermotherapy for diffuse choroidal haemangioma

PURPOSE

To report intraocular pressure (IOP) reduction after selective and partial destruction of diffuse choroidal haemangioma (DCH) by transpupillary thermotherapy (TTT) using an 810 nm infrared diode laser in two patients with Sturge-Weber syndrome (SWS) having late-onset juvenile glaucoma (LOJG).

METHODS

An interventional small case series. Laser spots (diameter, 1 mm) were applied to the tumour surface located outside the posterior pole. Energy level (600-1700 mW) and exposure time (1-4 seconds) were increased stepwise until the tumour exhibited a greyish discoloration. The treatment was split into 2-4 sessions.

RESULTS

Before TTT, both patients had uncontrolled LOJG with an IOP of 23 mmHg (Case 1) and 45 mmHg (Case 2) in spite of topical medications. In both cases, TTT led to normalization of IOP to 15 mmHg and 24 mmHg, respectively, and stopped the progression of LOJG during a follow-up period of 6 years (Case 1) and 1 year (Case 2). Visual loss or other complications were not observed.

CONCLUSIONS

Our study highlights the close link that exists between LOJG and DCH in SWS. A single treatment modality such as TTT may both reduce IOP in LOJG and help to prevent exudative retinal detachment in DCH. We believe that TTT is a good therapeutic option for SWS patients who have both DCH and LOJG.

Long-term choroidal vascular changes after iodine brachytherapy versus transpupillary thermotherapy for choroidal melanoma

PURPOSE

To compare long-term choroidal vascular changes after iodine-125 brachytherapy (IBT) versus transpupillary thermotherapy (TTT) used as primary treatment of small choroidal melanoma.

METHODS

Ninety-five small choroidal melanomas were randomized: 49 eyes with TTT and 46 eyes with IBT alone. Fluorescein and indocyanine green angiography (ICGA) were performed at 3-month intervals during the first year, and every 6 months thereafter.

RESULTS

Mean follow-up was 56.2 months (range, 24-118 months; SD, 22.6). Tumor regressed in 45 (92%) TTT-treated vs 45 (98%) IBT-treated eyes (p=0.397). Four TTT-treated and one IBT-treated tumor recurred. Occlusion of choriocapillaris was present in all TTT and IBT cases. Closure of medium and large choroidal vessels was observed in 17 (35%) TTT-treated vs 44 (96%) IBT-treated eyes (p<0.001). Choroidal vascular remodeling was detected in 20 (41%) TTT-treated and 16 (35%) IBT-treated eyes (p=0.693). Retinochoroidal anastomosis was present in 4 of the 37 (11%) TTT-treated eyes with patency of medium and large choroidal vessels, but never observed in the IBT-treated eyes, and was associated with tumor recurrence. Among IBT-treated eyes, segments of choroidal vascular wall ICG staining and choroidal aneurysmal changes were detected in 30 (65%) and 7 (15%), respectively. These changes were never detected in TTT-treated cases (p<0.0001 and p=0.015, respectively).

CONCLUSIONS

The pattern of tumor choroidal vascular changes following IBT and TTT differs. TTT is less effective in closing all tumor vasculature. The role of long-term choroidal vascular remodeling observed after these two treatments needs longer follow-up.

Long-term outcome of transpupillary thermotherapy as primary treatment of selected choroidal melanoma

PURPOSE

To evaluate prospectively, on a long-term range, the clinical outcomes of transpupillary thermotherapy (TTT) as primary treatment of selected choroidal melanoma.

METHODS

Seventy-seven eyes of 77 patients affected by small posterior choroidal melanoma were treated with TTT as a sole treatment, using an infrared diode laser at 810 nm according to a standard procedure. Follow-up was longer than 36 months.

RESULTS

Seventeen tumours (22%) were parapapillary (PP) and 60 tumours (78%) were non-parapapillary (NPP) in location. Mean follow-up was 55.2 ± 17.9 months in PP tumours and 44.3 ± 23.7 months in NPP tumours. Thirteen (76%) PP tumours and 55 (92%) NPP tumours regressed (P > 0.05). Nine tumours recurred: seven were retreated using Iodine-125 brachytherapy and two were enucleated (both parapapillary). Four patients (5%) developed liver metastasis and died during follow-up. Tumour thickness was found to be predictive of recurrence (odds ratio: 4.3). Complications were found in 20 eyes (26%): macular pucker in 11 (14%), macular oedema in three (4%), retinal vein occlusion in six (8%), vitreous and subretinal haemorrhage in two (3%) and neovascular glaucoma in three (4%). PP tumours had more local complications (but this was not statistically significant; P > 0.05). Complications appeared more frequently in tumours treated with more than one TTT session (P = 0.01), and time-risk to develop intraocular complications seems longer in the PP group, without reaching statistical significance (P = 0.07).

CONCLUSION

TTT may be a clinically effective method for conservative treatment of selected, non-parapapillary, small posterior choroidal melanoma.

Fluorescein and indocyanine green angiography after transpupillary thermotherapy of choroidal neovascularization. Early vascular changes

Transpupillary thermotherapy (TTT) is currently being evaluated in clinical trials for the treatment of choroidal neovascularization (CNV). Preliminary results show that TTT achieves closure of CNV and reduction in subretinal exudation while preserving visual acuity. Fluorescein and indocyanine green angiography reveal increased leakage activity from CNV and collateral choroid within 1 hour after TTT and absence of dye leakage from CNV at 1 week after treatment. Optical coherence tomography confirms the angiographic findings. The early vascular changes after TTT of CNV are similar to those observed after PDT of CNV. Transpupillary thermotherapy and PDT might share common mechanisms of action. A placebo-controlled, multi-center trial (TTT4CNV) evaluating the long-term efficacy and visual implications of TTT in occult CNV is underway.

Efficacy of transpupillary thermotherapy (TTT) in the treatment of occult subfoveal choroidal neovascularization in age-related macular degeneration

PURPOSE

To determine the efficacy of transpupillary thermotherapy (TTT) in the treatment of occult subfoveal choroidal neovascularization in patients with age-related macular degeneration (ARMD).

METHODS

We conducted a retrospective review of patients with ARMD treated with TTT from June, 1999 through July, 2000 at a retina referral practice. TTT was delivered through a slit-lamp using a modified diode laser at 810 nm wavelength and a spot size of 3 mm delivered at one location for a minimum of 60 seconds duration. Re-treatment was performed at 2-month intervals if indicated.

RESULTS

81 eyes of 77 patients were included in the study. Vision improved greater than one line Snellen in 18 eyes (22%), vision was stable within one line Snellen in 38 (47%), and worsened greater than one line Snellen in 25 (31%). Patients had a mean follow-up of 9 months. The average number of treatments was 1.37 (range 1 to 4). Pretreatment vision was less than or equal to 20/200 in 54% of eyes.

CONCLUSIONS

Transpupillary thermotherapy may stabilize visual acuity in a majority of patients with occult subfoveal choroidal neovascularization secondary to ARMD. Proof of therapeutic benefit is best determined by a randomized clinical trial that is currently underway (TTT4CNV).

Two differing presentations, treatments, and outcomes of malignant choroidal melanoma

BACKGROUND

Choroidal melanomas represent the most common primary malignancy of the eye. As primary eye care providers, optometrists must be able to identify suspicious lesions to facilitate proper referrals and timely treatment. Metastasis occurs in approximately 75% of cases. Ongoing studies such as the Collaborative Ocular Melanoma Study are bringing new information on how to best manage choroidal melanoma. Current treatments include enucleation, plaque brachytherapy, and transpupillary thermotherapy.

CASE REPORT

Two patients presented to the Veterans Affairs (VA) Illiana Health Care System optometry clinic for routine visits and had malignant melanomas diagnosed. The first patient was in for a 6-month routine glaucoma follow-up, noting that the right eye seemed to be worse. The second patient was new, complaining of a painful, red eye. Both were referred to a retinal specialist and later treated by an ocular oncologist with enucleation and plaque brachytherapy, respectively. Their differing chief complaints and cases are discussed.

CONCLUSION

Patients with malignant choroidal melanomas present with a wide variety of complaints, and optometrists need to be diligent in properly assessing the cause of seemingly common conditions, such as anterior uveitis, as well as performing routine dilated fundus examinations. Given the relationship between size and prognosis, early detection is important.

Peripheral subretinal pigment accumulation following transpupillary thermotherapy for choroidal melanoma

Transpupillary thermotherapy (TTT) used as either an adjunct to plaque brachytherapy or a primary treatment for choroidal melanoma can cause several intraocular complications, particularly in the retina. A 61-year-old woman had a macular choroidal melanoma measuring 8 x 7.5 X 3.6 mm and received TTT in three sessions, each 6 months apart. After the second treatment, pigmented material began to accumulate on the peripheral retina with an increasing pace. The tumor gradually regressed for 16 months, followed by a sudden regrowth. Enucleation of the eye revealed that the peripheral subretinal pigmented deposits consisted of pigment-laden macrophages and retinal pigment epithelial cells without viable tumor cells. The rare complication of peripheral subretinal pigment dispersion following TTT should not be alarming, but close monitoring is recommended.

Choroidal melanoma: natural history and management options

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Braquiterapia com rutênio-106 em melanomas uveais - resultados preliminares: experiência uni-institucional

OBJETIVO: Analisar os resultados preliminares da braquiterapia com rutênio-106 em pacientes portadores de melanomas uveais. MATERIAIS E MÉTODOS: No período de abril de 2002 a julho de 2003, 20 pacientes com diagnóstico de melanoma uveal foram tratados com braquiterapia com rutênio-106. A dose calculada no ápice tumoral variou de 55 Gy a 100 Gy. Pacientes com lesões com altura maior que 5 mm foram submetidos a termoterapia transpupilar concomitante à colocação da placa oftálmica. RESULTADOS: Quanto à localização da lesão, esta se encontrava na coróide em 75% dos casos, na íris em 15% e no corpo ciliar em 10% dos pacientes. Com seguimento mediano de 19 meses, a sobrevida livre de progressão para a braquiterapia e para a associação com a termoterapia transpupilar foi de 69% e 87%, respectivamente. Observou-se redução significante da altura tumoral após o tratamento. Nenhum dos pacientes foi submetido a enucleação. CONCLUSÃO: Nossos resultados preliminares mostram que a braquiterapia com rutênio-106 é uma opção adequada para o tratamento conservador de melanomas uveais em termos de controle local, manutenção do globo ocular e visão útil, com índice aceitável de complicações.

Combined brachytherapy and transpupillary thermotherapy for large choroidal melanoma: tumor regression and early complications

BACKGROUND

To determine the effectiveness and risk profile of combined ruthenium- (Ru)-106-brachytherapy and transpupillary thermotherapy (TTT) of the tumour apex for the treatment of large choroidal melanoma.

METHODS

A consecutive series of 31 large choroidal melanoma treated by Ru-106-brachytherapy and adjuvant TTT was studied. TTT was performed 1 day prior to plaque removal and up to 3 times (mean: 1.8) during follow-up. Evaluation comprised tumour regression, treatment-related adverse events, necessity of additional treatment and visual results.

RESULTS

Mean follow-up was 21.6+/-7.8 (10.8-38.3) months. Mean tumour thickness was 6.8+/-1.0 (5.0-8.9) mm prior to treatment. Mean residual tumour thickness at the end of follow-up was 2.5+/-1.0 mm. Relevant adverse treatment effects were exudative maculopathy or macula oedema (22.6%), vitreous haemorrhage (16.1%), optic neuropathy (16.1%) and retinal detachment (9.7%). One tumour recurrence occurred during follow-up, and was treated by enucleation.

CONCLUSIONS

The combination of Ru-106-brachytherapy with TTT allows for the treatment of large posterior choroidal melanoma. The rate of treatment-related adverse events appears to be acceptable.

Primary transpupillary thermotherapy for 18 small posterior pole uveal melanomas

PURPOSE

To evaluate transpupillary thermotherapy (TTT) for the treatment of small uveal melanomas of the posterior pole.

DESIGN

Prospective, nonrandomized interventional case series.

METHODS

Eighteen patients underwent TTT for small uveal melanomas located in the posterior pole of the eyes. Tumors were between 2.5 and 4 mm in thickness. TTT was performed with a diode laser at 810 nm. Patients had between one and three TTT sessions, with an intensity adapted to the coloration of the fundus impact. Biomicroscopic examination, ultrasonographic measurements, and angiography were performed before and two months, four months, and six months after treatment, then regularly during follow-up.

RESULTS

Eight of the 18 tumors regressed and 10 recurred. The one- and two-year metastasis-free survival rates calculated by the Kaplan-Meier method were, respectively, 61.11% to 44.44% (95% confidence interval). Recurrences were managed with enucleation (three patients), proton beam therapy (six), or additional thermotherapy (one). After treatment, visual acuity was maintained or improved for the eight patients with nonrecurrent tumors. Pathologic analysis of the three enucleated eyes revealed scleral invasion.

CONCLUSIONS

Despite encouraging initial short-term results obtained with TTT for the management of small choroidal melanomas, the occurrence of severe complications, especially recurrences and insufficient local tumor control, should raise concern about indications for primary TTT given as isolated treatment for small melanomas of the posterior pole.

Long term results after transpupillary thermotherapy in eyes with occult choroidal neovascularisation associated with age related macular degeneration: a prospective trial

AIM

To evaluate long term results after transpupillary thermotherapy (TTT) in eyes with exudative age related macular degeneration.

METHODS

In a prospective clinical study eyes with occult or predominantly occult choroidal neovascularisation and no pretreatment were scheduled to have a TTT with a power of 630 mW. Visual acuity for far and near distances as well as contrast sensitivity were evaluated 6, 12, and 24 months postoperatively and statistically analysed.

RESULTS

47 eyes fulfilled the inclusion criteria. Overall, 70% of the patients showed an improved (14%) or had unchanged (56%) ETDRS vision after 24 months. Reading vision was stabilised (51%) or better (5%) in 56% of the eyes at this time. However, the increasing number of eyes with severe deterioration resulted in a significant decrease of both parameters over time (p = 0.0002 and p = 0.0003, respectively). Contrast sensitivity could be maintained (70%) or improved (9%) in 79%. Statistical analyses indicated a trend but no significant decrease over time (p = 0.056).

CONCLUSION

Although in the majority of patients far and near distance acuity could be stabilised on average a significant decrease over time after TTT was observed. Statistical comparison of months 12 and 24 showed no further deterioration.

Subthreshold transpupillary thermotherapy of the retina and experimental choroidal neovascularization in a rat model

PURPOSE

To study the effect of subthreshold transpupillary thermotherapy (TTT) on the retina and experimental choroidal neovascularization (CNV) in the rat.

METHODS

Subthreshold TTT was performed on normal Brown Norway rats or those with krypton laser-induced CNV and appropriate controls with an 810-nm diode laser coupled to a slit lamp. At different intervals after TTT, fundus fluorescence angiography (FFA) and histopathological examinations were performed. Terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) was used to detect apoptosis. Immunohistochemistry was used to detect heat shock protein 70 (Hsp70) expression.

RESULTS

In normal retina, edema and whitening was found on day 1 after TTT. Different degrees of hyperfluorescence could be seen on FFA. Obvious retina damage, especially in the outer layers, was observed by histology in all the lesions that appeared whitened. In the CNV there was congestion and less damage in the overlying retina than in normal retina on day 1 after TTT. Apoptosis was detected in all retinal layers and CNV lesions by TUNEL. In normal eyes, after TTT, Hsp70 expression was increased in the inner layers of the retina and some of the cells in the choroid. Hsp70 was also increased in laser-induced CNV. Two weeks after TTT, the CNV showed a tendency for fibrosis by Masson staining. FFA did not show much change in the CNV lesions 2 weeks after TTT.

CONCLUSION

Subthreshold TTT has adverse effects on the overlying retina and thus is likely to cause significant functional and morphological long-term sequelae. Subthreshold TTT can cause apoptosis in laser-induced CNV in rats.

TRANSPUPILLARY THERMOTHERAPY

PURPOSE

To correlate changes in primate fundus after transpupillary thermotherapy (TTT) at two wavelengths.

METHODS

Twelve primate eyes were treated with TTT using a wavelength of 635 nm (n=7) or 810 nm (n=5). Laser parameters were as follows: 635 nm (spot size, 1 mm; duration, 30-8 seconds; and fluence [power over time], 20-91.4 J/cm) and 810 nm (spot size, 2 mm; duration, 60 seconds; and fluence, 96-436 J/cm). Fundus photography, fluorescein and indocyanine green angiography, and enucleation were performed at time 0 or 2 weeks after TTT for histologic analysis.

RESULTS

Threshold for fundus lesions (91.4 J/cm at 635 nm and 191 J/cm at 810 nm), acute and chronic retinal damage shown by histologic analysis (79.2 J/cm at 635 nm and 96 J/cm at 810 nm), and choroidal vessel occlusion (50 J/cm at 635 nm and 96 J/cm at 810 nm) were lower at 635 nm. Disorganization of the retina and retinal pigment epithelium was seen for both wavelengths at time 0 and 2 weeks after TTT. Occlusion of the choriocapillaris and choroidal stromal vessels was noted only in specimens obtained 2 weeks after TTT.

CONCLUSIONS

TTT resulted in acute and delayed damage to the neurosensory retina that persisted at 2 weeks. The 635-nm wavelength demonstrated a lower threshold fluence for visible fundus lesions, retinal damage, and choroidal vascular occlusion than the 810-nm laser.

Transpupillare Thermotherapie (TTT) von Aderhautmelanomen

BACKGROUND

An increasing number of orbital recurrences after TTT have been reported; the aim of our paper was to present our long-term results after a maximum follow-up of 8 years and 2 months.

PATIENTS AND METHOD

Among 18 eyes, 10 tumors were classified as small, and 8 as medium sized (with a maximum prominence of 5.6 mm): 5 melanomas had a juxtapapillary location, 6 a macular (or juxtamacular) location, and 7 were located in the midperiphery of the fundus.

RESULTS

After a median follow-up of 7 years in seven tumors a complete regression (scar formation) could be achieved, and in six a partial regression (with a maximum residual prominence of 2.9 mm) could be seen. In three patients a recurrence was treated either by another TTT or a Ruthenium-106 plaque; in another two recurrences, enucleation had to be performed. In none of the cases has an orbital recurrence occurred so far.

CONCLUSION

To prevent recurrences, adequate technique and appropriate selection of patients are mandatory in our opinion (no tumors higher than 3 mm). The higher the tumor prominence, the greater the chance of recurrences. Amelanotic melanomas and macular melanomas seem to respond poorly to thermotherapy.

Echographic examination with new generation contrast agent of choroidal malignant melanomas

PURPOSE

To determine the efficacy of echography with new generation contrast agents in visualizing vascularization of choroidal malignant melanomas.

METHODS

An echographic contrast medium consisting of phospholipidic microbubbles filled with sulphur hexafluoride (Sonovue) was used to visualize microcirculation in 25 cases of choroidal lesions already diagnosed with standardized echography (21 choroidal malignant melanomas, four disciform lesions).

RESULTS

In untreated malignant melanomas contrast agent echography revealed the presence of a dense microcirculation inside the mass. In one case vitreal seeding of the contrast agent was detectable before enucleation and histological examination revealed the presence of tumoral cells. In 12 cases treated with transpupillary thermotherapy, contrast agent echographic evaluation showed heavy regression of microcirculation after 1 week, confirmed in one case by histology, and a reduction of 70-80% in dimensions after 6 months (which appeared to have stabilized at subsequent examinations). In four cases treated with proton beam brachytherapy 2 years prior to our examination, contrast agent echography showed the absence of a microvascular network and the presence of large vessels and blood lakes. In four cases of disciform lesion, deep and superficial retina-associated vascularization was observed, with a weak spread of contrast agent inside the lesion.

CONCLUSION

Live representation with good resolution of choroidal malignant melanoma microcirculation was obtained.