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Stålhammar G. Delays between Uveal Melanoma Diagnosis and Treatment Increase the Risk of Metastatic Death. Ophthalmology 2024; 131:1094-1104. [PMID: 37995852 DOI: 10.1016/j.ophtha.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023] Open
Abstract
PURPOSE To investigate if the interval between diagnosis and treatment of posterior uveal melanoma (UM) is associated with metastatic death. DESIGN Retrospective, single-center cohort study. PARTICIPANTS A total of 1145 patients consecutively diagnosed with posterior UM at St. Erik Eye Hospital, Stockholm, Sweden, from 2012 to 2022, with recorded dates of diagnosis and primary treatment. This cohort represents 81% of all diagnosed patients in Sweden during this period. METHODS Data on the interval between diagnosis and treatment were collected for all patients. Its prognostic importance was examined with univariate and multivariate competing risks regressions, and cumulative incidence analyses. MAIN OUTCOME MEASURES Incidence of metastatic death (UM mortality) for patients with prompt (< 1 month from diagnosis) versus delayed treatment (≥ 1 month) and subdistribution hazard ratios (exp(βj)) for every additional 10-day delay in treatment. RESULTS The mean interval between diagnosis and treatment was 34 days (SD, 56, range, 0-932). Patients treated promptly had larger tumors at diagnosis, but there were no differences in patient age, tumor distance to the optic disc, rates of ciliary body involvement (CBI) or extraocular extension (EXE), or symptom duration before diagnosis. Those who were treated more than 1 month after diagnosis had greater UM mortality in American Joint Committee on Cancer (AJCC) stage II and III. In stage I, UM mortality for delayed treatment was lower for the first 10 years, followed by a marked spike in the 11th year. In multivariate competing risks regressions of all 1145 patients with tumor diameter, thickness, CBI, and EXE as covariates, the risk for UM mortality increased with 1% for every additional 10-day delay in treatment (exp(βj) 1.01). Among 355 patients treated with enucleation, this delay was associated with UM mortality, independent of AJCC stage, cytomorphology, and level of immunohistochemical BAP-1 expression. CONCLUSIONS Increasing time between diagnosis and treatment of UM is associated with a higher risk of metastatic death. These results challenge a central concept in the understanding of metastatic progression and may indicate the existence of late metastatic seeding. They also underscore the importance of prompt treatment. Validation in independent cohorts is recommended. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Gustav Stålhammar
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden; Ocular Oncology Service and St. Erik Ophthalmic Pathology Laboratory, St. Erik Eye Hospital, Stockholm, Sweden.
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Gill VT, Sabazade S, Herrspiegel C, Ewens KG, Opalko A, Dan N, Christersdottir T, Berg Rendahl A, Shields CL, Seregard S, Ganguly A, Stålhammar G. A prognostic classification system for uveal melanoma based on a combination of patient age and sex, the American Joint Committee on Cancer and the Cancer Genome Atlas models. Acta Ophthalmol 2023; 101:34-48. [PMID: 35801361 PMCID: PMC10083913 DOI: 10.1111/aos.15210] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/12/2022] [Accepted: 06/21/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To revisit the independent importance of ciliary body involvement (CBI), monosomy 3 (M3), tumour size, histological and clinical factors in uveal melanoma (UM) and to devise a new prognostic classification based on a combination of the American Joint Committee on Cancer (AJCC) and the Cancer Genome Atlas (TCGA) models. METHODS Two cohorts with a total of 1796 patients were included. Clinicopathological factors were compared between patients with and without CBI and M3. Development of the prognostic classification was performed in a training cohort and was then tested in two independent validation cohorts. RESULTS Tumours with CBI were more common in women, had greater apical thickness, greater basal tumour diameter, greater rates of vasculogenic mimicry and greater rates of M3, were more often asymptomatic at diagnosis and had poorer 5- and 10-year globe conservation rates (p < 0.023). In multivariate logistic regression, patient age at diagnosis, tumour diameter and CBI were independent predictors of M3 (p < 0.001). In multivariate Cox regression, male sex, age at diagnosis, tumour diameter, M3 and CBI were independent predictors of metastasis. The proposed prognostic classification combined patient age, sex, CBI, extraocular extension, M3, 8q (optional) and tumour size, and demonstrated greater prognostic acumen than both AJCC 4 T categories and TCGA groups A to D in validation cohorts. CONCLUSIONS Tumour size does not confound the prognostic implication of CBI, M3, male sex and age at diagnosis in UM. These factors were included in a new prognostic classification that outperforms AJCC T category and TCGA groups.
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Affiliation(s)
- Viktor T Gill
- Department of Pathology, Västmanland Hospital Västerås, Västerås, Sweden.,Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden
| | - Shiva Sabazade
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Christina Herrspiegel
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Kathryn G Ewens
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Nicole Dan
- St. Erik Eye Hospital, Stockholm, Sweden
| | - Tinna Christersdottir
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Alexander Berg Rendahl
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Carol L Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stefan Seregard
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Arupa Ganguly
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustav Stålhammar
- Department of Clinical Neuroscience, Division of Eye and Vision, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
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Gill V, Herrspiegel C, Sabazade S, Fili M, Bergman L, Damato B, Seregard S, Stålhammar G. Trends in Uveal Melanoma Presentation and Survival During Five Decades: A Nationwide Survey of 3898 Swedish Patients. Front Med (Lausanne) 2022; 9:926034. [PMID: 35721086 PMCID: PMC9200980 DOI: 10.3389/fmed.2022.926034] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background In contrast to most other cancers, uveal melanoma (UM) is characterized by an absence of major improvements in patient survival during the last several decades. In this study, we examine changes in incidence rates, patient age and tumor size at diagnosis, treatment practices and survival for patients diagnosed in Sweden during the period 1960-2010. Methods All patients diagnosed with posterior UM between January 1st, 1960, and December 31st, 2009, in Sweden, were included (n = 3898). Trends in incidence, primary treatment modality, patient age and tumor size were analyzed. Disease-specific survival was plotted in Kaplan-Meier curves and the cumulative incidence of UM-related mortality was evaluated in competing risk analysis. Results Crude (6.5-11.6 cases/million/year) and age-standardized incidence rates (5.6-9.6 cases/million/year) varied between individual years during the study period, but both had a stable linear trend overall (p ≥ 0.12). Gradually, plaque brachytherapy with ruthenium-106 replaced enucleation as the most common primary treatment. The mean patient age at diagnosis increased from 59.8 years in 1960 to 66.0 in 2009. Conversely, the mean tumor size became gradually smaller during the period. In linear regression, the basal diameter and tumor apical thickness decreased with a slope coefficient of -0.03 mm (p = 0.012) and -0.05 mm (p = 1.2 × 10-5) per year after 1960, respectively. Patients diagnosed after 1990 had significantly better disease-specific survival than patients diagnosed before 1990 (p = 2.0 × 10-17). Similarly, the cumulative incidence of UM-related mortality was highest for patients diagnosed 1960-1969 and 1970-1979, with slightly lower incidences for patients diagnosed 1980-1989 and even lower for those diagnosed after 1990 (p = 7.1 × 10-13). The incidence of mortality from other causes than UM did not differ between periods (p = 0.16). Conclusion In the period from 1960-2010, crude and age-standardized incidence rates of UM have remained stable in Sweden. Several other aspects have changed: Plaque brachytherapy with ruthenium-106 has replaced enucleation as the most common primary treatment modality; patients have become older and their tumors smaller at the time of diagnosis; and their survival has improved. This might indicate a beneficial survival effect of earlier diagnosis and treatment, but the potential influence from lead-time bias should be taken into consideration.
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Affiliation(s)
- Viktor Gill
- Department of Pathology, Västmanland Hospital Västerås, Västerås, Sweden.,Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Christina Herrspiegel
- Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Shiva Sabazade
- Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Maria Fili
- St. Erik Eye Hospital, Stockholm, Sweden
| | | | - Bertil Damato
- St. Erik Eye Hospital, Stockholm, Sweden.,Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom.,Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Stefan Seregard
- Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
| | - Gustav Stålhammar
- Division of Eye and Vision, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,St. Erik Eye Hospital, Stockholm, Sweden
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The long-term prognosis of patients with untreated primary uveal melanoma: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2022; 172:103652. [PMID: 35304261 DOI: 10.1016/j.critrevonc.2022.103652] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 02/02/2023] Open
Abstract
PURPOSE To examine patient survival in untreated primary uveal melanoma. METHODS Systematic review and meta-analysis. RESULTS Seven studies with a total of 19 patients were included. Fifteen patients died from metastases during a median follow-up of > 20 years. When excluding two patients with iris melanoma, fifteen of 17 patients with choroidal or ciliary body melanoma developed metastases. The cumulative disease-specific survival for these 17 patients was 71% at five years, 29% at 10 years, 18% at 15 years and 11% at 30 years. This was significantly worse than the survival in comparison cohorts of both medium-sized and large treated tumors (p < 0.001). CONCLUSIONS Among the exceedingly rare published patients with untreated primary uveal melanoma, 80-90% have developed metastases and their disease-specific survival seems to be shorter than treated patients. This could indicate that some metastases might be prevented by primary tumor treatment.
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Sabazade S, Herrspiegel C, Gill V, Stålhammar G. Correction to: No differences in the long-term prognosis of iris and choroidal melanomas when adjusting for tumor thickness and diameter. BMC Cancer 2022; 22:32. [PMID: 34983436 PMCID: PMC8725560 DOI: 10.1186/s12885-021-09167-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Shiva Sabazade
- St. Erik Eye Hospital, Eugeniavägen 12, 17164, Stockholm, Sweden.,Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Christina Herrspiegel
- St. Erik Eye Hospital, Eugeniavägen 12, 17164, Stockholm, Sweden.,Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Viktor Gill
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Pathology, Västmanland Hospital Västerås, Västerås, Sweden
| | - Gustav Stålhammar
- St. Erik Eye Hospital, Eugeniavägen 12, 17164, Stockholm, Sweden. .,Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
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