Magnetic Resonance Imaging in the Clinical Care for Uveal Melanoma Patients-A Systematic Review from an Ophthalmic Perspective

Patient-specific mapping of fundus photographs to three-dimensional ocular imaging

BACKGROUND

Ocular proton beam therapy (OPT) planning would benefit from an accurate incorporation of fundus photographs, as various intra-ocular structures, such as the fovea, are not visible on conventional modalities such as Magnetic Resonance Imaging (MRI). However, the use of fundus photographs in OPT is limited, as the eye's optics induce a nonuniform patient-specific deformation to the images.

PURPOSE

To develop a method to accurately map fundus photographs to three-dimensional images.

METHODS

Personalized optical raytracing simulations were performed for 27 subjects, using subject-specific eye models based on corneal topography, biometry, and MRI. Light rays were traced through the eye for angles of 0°-85° with respect to the optical axis, in steps of 5°. These simulations provided a reference mapping between camera angles and retinal locations and were used to develop a mapping method without raytracing. The accuracy of this and earlier proposed methods was evaluated. Finally, the most accurate method was implemented in RayOcular, an image-based OPT planning system, and the fundus photography-based tumor contour was compared with MRI.

RESULTS

When a patient-specific second nodal point is taken as a reference to describe the retinal location, the camera, and retinal angles show a strong linear relation with a small variation between subjects. At a camera angle of 60°, for example, a corresponding retinal angle of 59.9° ± 0.4° (mean ± SD) was found. When this linear relation is used to predict the corresponding retinal location (without raytracing) of a camera angle of 40°, the mean (Euclidian distance) error in the retinal location was 0.02 mm (SD = 0.06 mm), which was significantly (p < 0.001) lower than earlier proposed methods including EYEPLAN 4.16 mm (SD = 0.25 mm), the Lamberth projection -0.12 mm (SD = 0.46 mm) or polar projection 0.26 mm (SD = 0.57 mm). When implemented in the fundus view of RayOcular, the median distance between contours based on MRI and fundus photography was 0.2 mm (IQR = 0.1-0.3 mm).

CONCLUSIONS

The second nodal point provides a patient-specific reference for an accurate mapping of fundus photographs to three-dimensional images with sub-millimeter errors.

Evaluation of MRI Safety of Ru-106 Eye Applicators

Introduction

Ruthenium-106 brachytherapy is a primary treatment for uveal melanoma (UM), the most common intra-ocular malignancy in adults. This study evaluated the safety of Ru-106 applicators at 3 Tesla (T) MRI and their impact on image quality.

Methods

Magnetic attraction and eddy currents were tested on a 20-mm-diameter Ru-106 applicator using a nylon string and a porcine eye. Safety criteria were defined by ocular oncologists, comparing magnetic field interactions to the forces exerted on the eye during surgery. Five UM patients were scanned at 3T MRI with the applicator in situ using both conventional anatomical sequences and scans optimised to reduce metal artefacts.

Results

Minimal magnetic interactions were observed. Eddy currents caused slight lagging during fast movements and temporary detachment of the applicator of the porcine eye in conditions that were considered unrealistic for clinical scans. Significant susceptibility artefacts compromised image quality of the affected eye.

Conclusion

Patients with Ru-106 applicators can be safely used in 3T MRI with some simple precautions. MR image quality of the eye was poor due to major susceptibility artefacts; however, imaging of extra-ocular anatomy is feasible.

Measurement of Melanocytic Choroidal Lesions: Ultrasound Versus Ultrawide-Field Fundus Imaging System

OBJECTIVES

The aim of this study was to establish the concordance between conventional 20 Mhz ultrasonography and an ultrawide-field (UWF) imaging system (Optos® California) in the measurement of basal diameters of melanocytic choroidal tumors.

METHODS

A retrospective study comparing diagnostic tests was conducted in patients with untreated melanocytic choroidal lesions (either nevus or melanoma) who had undergone both UWF imaging and ultrasonography. Only cases with a clear visualization of tumor borders in both imaging modalities were included. Longitudinal and transversal base diameters of the melanocytic tumors were measured by 20 MHz US (one observer) and UWF fundus photography (two observers). Interobserver agreement was assessed for UWF imaging first to validate the technique. Then, UWF imaging measurements were compared with 20 MHz US results.

RESULTS

In total, 106 patient images were reviewed, of which 61 were excluded due to unclear visualization of tumor margins. We found excellent concordance (from ICC and defined Bland-Altman plots) for interobserver and inter-technique agreement in estimating basal diameters when using pseudocolor composite and red laser images by comparing them with 20 MHz US results.

CONCLUSIONS

UWF fundus imaging, when complete visualization of the tumor margins is possible, could be as reliable as ultrasonography in the measurement of the basal diameters of choroidal melanocytic tumors.

PTCOG Ocular Statement: Expert Summary of Current Practices and Future Developments in Ocular Proton Therapy

Although rare cancers, ocular tumors are a threat to vision, quality of life, and potentially life expectancy of a patient. Ocular proton therapy (OPT) is a powerful tool for successfully treating this disease. The Particle Therapy Co-Operative Ocular Group) formulated an Evidence and Expert-Based Executive Summary of Current Practices and Future Developments in OPT: comparative dosimetric and clinical analysis with the different OPT systems is essential to set up planning guidelines, implement best practices, and establish benchmarks for eye preservation, vision, and quality of life measures. Contemporary prospective trials in select subsets of patients (eg, tumors near the optic disc and/or macula) may allow for dosimetric and clinical analysis between different radiation modalities and beamline systems to evaluate differences in radiation delivery and penumbra, and resultant tumor control, normal tissue complication rates, and overall clinical cost-effectiveness. To date, the combination of multimodal imaging (fundus photography, ultrasound, etc), ophthalmologist assessment, and clip surgery with radiation planning have been keys to successful treatment. Increased use of three-dimensional imaging (computed tomography/magnetic resonance imaging) is anticipated although its spatial resolution might be a limiting factor (eg, detection of flat diffuse tumor parts). Commercially produced ocular treatment-planning systems are under development and their future use is expected to expand across OPT centers. Future continuity of OPT will depend on the following: (1) maintaining and upgrading existing older dedicated low-energy facilities, (2) maintaining shared, degraded beamlines at large proton therapy centers, and (3) developing adapted gantry beams of sufficient quality to maintain the clinical benefits of sharp beam conformity. Option (1) potentially offers the sharpest beams, minimizing impact on healthy tissues, whereas (2) and (3) potentially offer the advantage of substantial long-term technical support and development as well as the introduction of new approaches. Significant patient throughputs and close cooperation between medical physics, ophthalmology, and radiation therapy, underpinned by mutual understanding, is crucial for a successful OPT service.

Quantitative Perfusion-Weighted Magnetic Resonance Imaging in Uveal Melanoma

Purpose

Perfusion-weighted imaging (PWI; magnetic resonance imaging [MRI]) has been shown to provide valuable biological tumor information in uveal melanoma (UM). Clinically used semiquantitative methods do not account for tumor pigmentation and eye movement. We hypothesize that a quantitative PWI method that incorporates these, provides a more accurate description of tumor perfusion than the current clinical method. The aim of this study was to test this in patients with UM before and after radiotherapy.

Methods

Perfusion-weighted 3T MRIs were retrospectively analyzed in 47 patients with UM before and after radiotherapy. Tofts pharmacokinetic modeling was performed to determine vascular permeability (Ktrans), extracellular extravascular space (ve), and reflux rate (kep). These were compared with semiquantitative clinical parameters including peak intensity and outflow percentage.

Results

The effect of tumor pigmentation on peak intensity and outflow percentage was statistically significant (P < 0.01) and relative peak intensity was significantly different between melanotic and amelanotic tumors (1.5 vs. 1.9, P < 0.01). Before radiotherapy, median tumor Ktrans was 0.63 min-1 (range = 0.06-1.42 min-1), median ve was 0.23 (range = 0.09-0.63), and median kep was 2.3 min-1 (range = 0.6-5.0 min-1). After radiotherapy, 85% showed a decrease in Ktrans and kep (P < 0.01). Changes in tumor pigmentation before and after radiotherapy were small and not significant (median increase in T1 of 33 ms, P = 0.55).

Conclusions

Quantitative PWI parameters decreased significantly after radiotherapy and can therefore can serve as an early biomarker for treatment response assessment. However, due to the nonsignificant changes in tumor pigmentation before and after radiotherapy, the current semiquantitative method appears to be sufficiently sensitive for detection of changes in tumor perfusion.

Uveal Melanoma: Comprehensive Review of Its Pathophysiology, Diagnosis, Treatment, and Future Perspectives

Uveal melanoma (UM) is the most common intraocular malignancy in adults. Recent advances highlight the role of tumor-derived extracellular vesicles (TEV) and circulating hybrid cells (CHC) in UM tumorigenesis. Bridged with liquid biopsies, a novel technology that has shown incredible performance in detecting cancer cells or products derived from tumors in bodily fluids, it can significantly impact disease management and outcome. The aim of this comprehensive literature review is to provide a summary of current knowledge and ongoing advances in posterior UM pathophysiology, diagnosis, and treatment. The first section of the manuscript discusses the complex and intricate role of TEVs and CHCs. The second part of this review delves into the epidemiology, etiology and risk factors, clinical presentation, and prognosis of UM. Third, current diagnostic methods, ensued by novel diagnostic tools for the early detection of UM, such as liquid biopsies and artificial intelligence-based technologies, are of paramount importance in this review. The fundamental principles, limits, and challenges associated with these diagnostic tools, as well as their potential as a tracker for disease progression, are discussed. Finally, a summary of current treatment modalities is provided, followed by an overview of ongoing preclinical and clinical research studies to provide further insights on potential biomolecular pathway alterations and therapeutic targets for the management of UM. This review is thus an important resource for all healthcare professionals, clinicians, and researchers working in the field of ocular oncology.

An optimized 3T MRI scan protocol to assess iris melanoma with subsequent histopathological verification - A prospective study

INTRODUCTION

Magnetic resonance imaging (MRI) has demonstrated high levels of tissue contrast, accuracy and reproducibility in evaluating posterior uveal melanoma. Owing to smaller size, the role of MRI in detecting and characterising iris melanoma has not yet been explored.

AIMS

To develop a protocol to image iris melanoma and describe the MRI characteristics of histopathological-confirmed iris melanoma.

MATERIALS AND METHODS

An optimised MRI protocol, using a 3T MRI scanner and a 32-channel head coil, was developed to image iris tumours. A prospective, single-centre, 12-month study was conducted on all patients with lesions suspicious for iris melanoma. All patients were offered an MRI scan in addition to the standardised clinical procedures. Image quality comparison was made with existing clinical investigations. Iris melanoma characteristics on MRI are described.

RESULTS

A successful optimised MRI scan protocol was developed that was able to detect and characterise iris melanoma. One normal participant and five patients with subsequent histopathological-confirmed iris melanoma (n = 6) were recruited. Four patients completed the full MRI sequence. All iris melanoma were detected on at least one T1- or T2-weighted images. When compared to the vitreous, all iris melanomas demonstrated hyper-intensity on T1-weighted images and hypo-intensity on T2-weighted images. On T1-mapping, T1-values of iris melanoma demonstrated an inverse relationship with the degree of tumour pigmentation.

CONCLUSIONS

This study highlights an optimised, easily reproducible MRI scan protocol to image iris melanoma. Numerous MR imaging characteristics of iris melanoma are reported for the first time and a potential non-invasive tumour biomarker is described.