Vascular endothelial growth factor (VEGF) and hypoxia inducible factor-1 alpha (HIF-1ɑ) in lacrimal gland Adenoid cystic carcinoma: Correlation with clinical outcome

PURPOSE

VEGF and HIF-1α are important regulators of angiogenesis, overexpressed in various tumors. Lacrimal gland Adenoid cystic carcinoma (ACC) is a malignant tumor whose angiogenic properties remain unexplored. This study was designed to evaluate the expression of HIF-1α and VEGF in lacrimal gland ACC.

METHODS

VEGF and HIF-1α immunoexpression was undertaken in 30 lacrimal gland ACC cases. mRNA expression of VEGF and HIF-1α was analysed in 17 cases by quantitative real time PCR. The results obtained were correlated with clinicopathological features and survival of the patients to determine the prognostic significance.

RESULTS

Immunoexpression of HIF-1α and VEGF was seen in 36.6% and 46.6% ACC cases. HIF-1α expression showed significant association with advanced T-stage (P = 0.001) and VEGF with intracranial extension (P = 0.014) and solid histological pattern (P = 0.045). HIF-1α mRNA expression was seen in 29.4% cases and showed significant association with perineural invasion (P = 0.027). Recurrence occurred in 60%, distant metastasis in 20% and death in 20% cases. Survival analysis revealed that patients with HIF-1α, VEGF immunoexpression, solid histological pattern, perineural invasion, bone erosion, intracranial extension, metastasis, advanced T-stage, and exenteration had poor survival. On multivariate analysis VEGF immunoexpression (hazard ratio, 16.785; 95% confidence interval, 1.872-150.495; P = 0.012) was the most significant poor prognostic factor.

CONCLUSIONS

This study demonstrates that VEGF is a potential predictor for poor clinical outcome in lacrimal gland Adenoid cystic carcinoma.

Prognostic factors for local recurrence and survival and impact of local treatments on survival in lacrimal gland carcinoma

BACKGROUND/AIMS

To identify prognostic factors for local recurrence, distant metastasis and disease-specific survival (DSS) for lacrimal gland carcinoma.

METHODS

All consecutive patients with lacrimal gland carcinoma treated from January 1998 through December 2018 were included. Log-rank tests and univariate Cox proportional hazards regression models were used to study risk factors and survival.

RESULTS

Overall, 55 patients were included in this study, and 5 patients were excluded from the survival analysis. Median age was 46 years (range: 10-76). 43 patients (78%) had adenoid cystic carcinoma (ACC). 31 patients (56%) had T2 disease at presentation. 28 patients (51%) underwent orbital exenteration with or without adjuvant radiotherapy or chemoradiation, 26 (47%) underwent eye-sparing surgery with or without adjuvant radiotherapy or chemoradiation, and 1 received palliative chemoradiation. 11 patients (22%) experienced local recurrence; 14 (29%) experienced distant metastasis. Five- and 10-year local-recurrence-free survival rates were 0.71 (95% CI 0.58 to 0.88), and 5- and 10-year distant-metastasis-free survival rates were 0.67 (95% CI 0.53 to 0.85) and 0.49 (95% CI 0.30 to 0.81), respectively. There was no significant difference in risks of local recurrence, distant metastasis or DSS between ACC patients who had orbital exenteration and those who had eye-sparing surgery. Perineural invasion was negatively associated with local-recurrence-free survival (p=0.02). Among patients with ACC, basaloid/solid histologic type was associated with significantly worse DSS than non-basaloid/solid histologic type (p<0.01).

CONCLUSIONS

For lacrimal gland carcinoma, orbital exenteration with adjuvant therapy and eye-sparing surgery with adjuvant therapy are associated with similar recurrence outcomes. Eye-sparing surgery is associated with better DSS. Perineural invasion is a risk factor for local recurrence. ACC with basaloid/solid subtype correlates with worse DSS.

Identification of prognostic genes in uveal melanoma microenvironment

Background

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults. Many previous studies have demonstrated that the infiltrating of immune and stromal cells in the tumor microenvironment contributes significantly to prognosis.

Methods

Dataset TCGA-UVM, download from TCGA portal, was taken as the training cohort, and GSE22138, obtained from GEO database, was set as the validation cohort. ESTIMATE algorithm was applied to find intersection differentially expressed genes (DEGs) among tumor microenvironment. Kaplan-Meier analysis and univariate Cox regression model were performed on intersection DEGs to initial screen for potential prognostic genes. Then these genes entered into the validation cohort for validation using the same methods as that in the training cohort. Moreover, we conducted correlation analyses between the genes obtained in the validation cohort and the status of chromosome 3, chromosome 8q, and tumor metastasis to get prognosis genes. At last, the immune infiltration analysis was performed between the prognostic genes and 6 main kinds of tumor-infiltrating immune cells (TICs) for understanding the role of the genes in the tumor microenvironment.

Results

959 intersection DEGs were found in the UM microenvironment. Kaplan-Meier and Cox analysis was then performed in the training and validation cohorts on these DEGs, and 52 genes were identified with potential prognostic value. After comparing the 52 genes to chromosome 3, chromosome 8q, and metastasis, we obtained 21 genes as the prognostic genes. The immune infiltration analysis showed that Neutrophil had the potential prognostic ability, and almost every prognostic gene we had identified was correlated with abundances of Neutrophil and CD8+ T Cell.

Conclusions

Identifying 21 prognosis genes (SERPINB9, EDNRB, RAPGEF3, HFE, RNF43, ZNF415, IL12RB2, MTUS1, NEDD9, ZNF667, AZGP1, WARS, GEM, RAB31, CALHM2, CA12, MYEOV, CELF2, SLCO5A1, ISM1, and PAPSS2) could accurately identify patients' prognosis and had close interactions with Neutrophil in the tumor environment, which may provide UM patients with personalized prognosis prediction and new treatment insights.

Treatment outcomes after definitive radio(chemo)therapy for 17 lacrimal sac squamous cell carcinoma

OBJECTIVES

Tumors of the lacrimal sac are rare and life-threatening. Because of their rarity, no extensive clinical data on their management and prognosis exist. We investigated the application of definitive radiation therapy and its outcome in patients with lacrimal sac squamous cell carcinoma (LSSCC).

METHODS

We retrospectively studied 17 patients with LSSCC at a single institution between 2003 and 2017. All the patients were treated with definitive radiotherapy, and 11 patients were delivered with cisplatin-based chemotherapy. The patients' clinical records were reviewed for symptoms, pathological types, the volume and dosimetry of the tumors and their adjacent structures, radiation coverage of lymph node drainage areas, treatment outcomes, and complications from definitive radiotherapy.

RESULTS

Median follow-up was 38.9 months, and age at diagnosis was 48 years.The 2-year and 5-year overall survival, progression-free survival, locoregional control, and disease metastasis-free survival rates were 94.1 and 84.7%, 88.2 and 73.5%, 93.8%, 94.1, and 78.4%, respectively. A total dose of 6600-7000 cGy was prescribed to the tumor. Levels Ⅰb, Ⅶa, Ⅷ, and Ⅸ were covered with the clinical target volume regardless of lymph involvement. Acute Grade 3 radiation dermatitis occurred in seven patients (17.6%), but no acute Grade 4 or Grade 5 toxicity of any type occurred. Seven (41.2%, 7/17) of the treated eyes had moderated vision impairments; 17.6% (3/17) of patients developed cataracts, and glaucoma and radiation retinopathy were found in 5.9% (1/17) of patients.

CONCLUSIONS

Definitive radiotherapy could be a treatment option for those who refuse surgery or have unresectable LSSCC.

ADVANCES IN KNOWLEDGE

Radiation alone is a treatment option for LSSCC.

Clinical Features Predictive of Survival in Patients With Vitreoretinal Lymphoma: Analysis of 70 Patients at a Single Ocular Oncology Center

PURPOSE

The aim of this study was to identify clinical factors predictive of time to central nervous system (CNS) lymphoma or death in patients with vitreoretinal lymphoma (VRL).

DESIGN

Retrospective cohort study.

METHODS

Patients with VRL (n = 95 patients) from Januray 1, 1984 to July 30, 2018 were identified at a single ocular oncology center and records were retrospectively reviewed. Outcomes included Kaplan-Meier estimated time to CNS lymphoma and death.

RESULTS

There were 95 patients with VRL diagnosed at mean age 67 years, of which 70 patients had follow-up with the ocular oncology service. Mean time to CNS lymphoma in patients with isolated VRL was 56 months and did not differ by age, sex, bilateral ocular involvement, retinal infiltration, subretinal pigment epithelial (sub-RPE) infiltration, or treatment with prophylactic systemic chemotherapy (P > 0.05). Mean time to death was 66 months and did not differ when comparing those with CNS lymphoma diagnosed before VRL versus after VRL versus no CNS lymphoma at any time (67 vs 60 vs 64 months, P > 0.05). Presence of sub-RPE infiltration was associated with shorter mean time to death (46 vs 76 months, P = 0.04, odds ratio 1.9). Older patient age was associated with increased risk of death (odds ratio 1.0, P = 0.02). The mean time to death did not differ by sex, bilateral ocular involvement, retinal infiltration, timing of CNS or systemic lymphoma, or treatment with prophylactic systemic chemotherapy (P > 0.05).

CONCLUSIONS

Patients with VRL presenting with sub-RPE infiltration could have shorter mean survival time. Further studies are required to confirm these findings and determine whether sub-RPE infiltration is associated with more aggressive CNS lymphoma.

The Collaborative Ocular Melanoma Study: An Overview

BACKGROUND

The Collaborative Ocular Melanoma Study (COMS) is a 3-arm study that includes two multicenter randomized clinical trials designed to compare the effectiveness of brachytherapy to enucleation for treatment of medium-size choroidal melanomas, and the effectiveness of enucleation with and without preoperative external-beam radiotherapy for large choroidal melanomas. The third arm is an observational study of small choroidal melanomas. Patient accrual ran from 1987 to 1998.

METHODS

A review of COMS published reports was conducted.

RESULTS

There is no difference in 5-year all-cause mortality for large- and medium-size choroidal melanomas with COMS-designated treatments. Preoperative radiation for large choroidal melanomas does not improve survival. The accuracy of the clinical diagnosis of choroidal melanoma is excellent.

CONCLUSIONS

Data from the trials are still being collected and analyzed, but primary outcomes will unlikely change significantly in the future. Similar rates of mortality after treatment with enucleation and brachytherapy shift the emphasis of selection of therapy to secondary outcomes such as preservation of vision. The findings highlight the need to better understand the biological mechanisms and timing of hematogenous dissemination to achieve an appreciable impact on choroidal melanoma survival.

Epidemiology and survival outcomes of ocular and mucosal melanomas: a population-based analysis

Extracutaneous melanomas are poorly characterized tumors that include ocular (OM), mucosal (MM) and leptomeningeal melanomas, often lacking standardized staging and treatment guidelines. We analyzed cases of cutaneous melanoma (CM, N = 219,890), OM (N = 7,069) and MM (N = 2,755) of different anatomical origins, diagnosed between 1988 and 2010, recorded in the Surveillance Epidemiology and End Results (SEER) database. Relative survival was studied in patients grouped by summary stage classification (localized, regional or distant disease) and in multivariate models adjusting for varying distribution of baseline factors. Unlike in CM, the incidence rate in MM increased exponentially with age. Five-year relative survival was significantly worse for OM (78%) and for most mucosal sites (aggregate 34%, range 3-69%) compared with CM (89%). The differences between primary sites were particularly pronounced in localized disease, with a hazard ratio of 5.7 for OM, 4.3-9.0 for external genital or oral cavity MM and 19.8-90.4 for other mucosal locations. Melanomas of the pharynx, gastrointestinal, urinary tract and vagina had poor outcomes regardless of clinical stage. In contrast to CM, there was no evidence of improved survival in OM and MM during the study period. A substantial proportion of patients with operable OM or MM underwent radical organ resections (13-88% depending on site and stage) or perioperative radiotherapy (0-66%). In conclusion, extracutaneous melanomas have a markedly worse survival than CM and aggressive locoregional management appears to be insufficient for their control. Because of poor outcomes in MM, studies of systemic therapy are warranted regardless of the extent of disease at presentation.

Transitional cell tumours of the lacrimal drainage apparatus

BACKGROUND

Tumours of the lacrimal drainage apparatus (LDA) are very rare, but can be life-threatening. Seventy percent of lacrimal sac tumours are of epithelial origin, and transitional cell tumours represent an interesting sub-group of these epithelial tumours.

METHODS

A retrospective review of cases of LDA transitional cell tumours co-managed at the Royal National Throat Nose and Ear Hospital and Moorfields Eye Hospital, London.

RESULTS

Twenty cases of transitional cell tumours of the LDA were identified, comprising 10 transitional cell papillomas (TCPs) and 10 transitional cell carcinomas (TCCs). All cases were resected through a modified lateral rhinotomy approach. Limited resection of orbital fat with preservation of orbital functions was required for 2 cases of TCC. Fractionated external beam radiotherapy was administered in 7 cases of TCC. The mean follow up was 80 months (range 11 months-16 years). Recurrences were detected in 4 cases, which were managed by further surgery. Two cases have been lost to follow-up, but the 18 other patients are currently alive and disease free.

CONCLUSION

A favourable outcome can be achieved with transitional cell tumours of the LDA when an optimum management plan is followed.

Treatment of primary intraocular melanoma

The treatment of intraocular melanoma has evolved recently. Enucleation has been superseded largely by brachytherapy, proton beam radiotherapy, stereotactic irradiation, trans-scleral local resection, transretinal resection and diode laser phototherapy. Many patients develop metastatic disease, which usually involves the liver and occurs hematogenously. Disseminated disease rarely responds to therapy, and is usually fatal within 1 year of the onset of symptoms. Uveal melanomas develop characteristic chromosomal abnormalities, such as loss of chromosome 3. This is associated with a reduction in the 5-year survival from approximately 95% to less than 50%.

Transitional cell tumours of the lacrimal drainage apparatus

BACKGROUND

Tumours of the lacrimal drainage apparatus (LDA) are very rare, but can be life-threatening. Seventy percent of lacrimal sac tumours are of epithelial origin, and transitional cell tumours represent an interesting sub-group of these epithelial tumours.

METHODS

A retrospective review of cases of LDA transitional cell tumours co-managed at the Royal National Throat Nose and Ear Hospital and Moorfields Eye Hospital, London.

RESULTS

Twenty cases of transitional cell tumours of the LDA were identified, comprising 10 transitional cell papillomas (TCPs) and 10 transitional cell carcinomas (TCCs). All cases were resected through a modified lateral rhinotomy approach. Limited resection of orbital fat with preservation of orbital functions was required for 2 cases of TCC. Fractionated external beam radiotherapy was administered in 7 cases of TCC. The mean follow up was 80 months (range 11 months-16 years). Recurrences were detected in 4 cases, which were managed by further surgery. Two cases have been lost to follow-up, but the 18 other patients are currently alive and disease free.

CONCLUSION

A favourable outcome can be achieved with transitional cell tumours of the LDA when an optimum management plan is followed.

Phase II trial of sorafenib in combination with carboplatin and paclitaxel in patients with metastatic uveal melanoma: SWOG S0512

BACKGROUND

Sorafenib, a multikinase inhibitor of cell proliferation and angiogenesis, inhibits the mitogen-activated protein kinase pathway that is activated in most uveal melanoma tumors. This phase II study was conducted by the SWOG cooperative group to evaluate the efficacy of sorafenib in combination with carboplatin and paclitaxel (CP) in metastatic uveal melanoma.

METHODS

Twenty-five patients with stage IV uveal melanoma who had received 0-1 prior systemic therapy were enrolled. Treatment included up to 6 cycles of carboplatin (AUC = 6) and paclitaxel (225 mg/m(2)) administered IV on day 1 plus sorafenib (400 mg PO twice daily), followed by sorafenib monotherapy until disease progression. The primary endpoint was objective response rate (ORR); a two-stage design was used with the study to be terminated if no confirmed responses were observed in the first 20 evaluable patients. Secondary efficacy endpoints included progression-free survival (PFS) and overall survival (OS).

RESULTS

No confirmed objective responses occurred among the 24 evaluable patients (ORR = 0% [95% CI: 0-14%]) and the study was terminated at the first stage. Minor responses (tumor regression less than 30%) were seen in eleven of 24 (45%) patients. The median PFS was 4 months [95% CI: 1-6 months] and the 6-month PFS was 29% [95% CI: 13%-48%]. The median OS was 11 months [95% CI: 7-14 months].

CONCLUSION

In this study, the overall efficacy of CP plus sorafenib in metastatic uveal melanoma did not warrant further clinical testing when assessed by ORR, although minor tumor responses and stable disease were observed in some patients.

TRIAL REGISTRATION

ClinicalTrials.govNCT00329641.

Survival and complications following γ knife radiosurgery or enucleation for ocular melanoma: a 20-year experience

BACKGROUND

We present our experience in treating ocular melanoma at the National Centre for Stereotactic Radiosurgery in Sheffield, UK over the last 20 years.

METHOD

We analysed 170 patients treated with Gamma Knife radiosurgery, recorded the evolution of visual acuity and complication rates, and compared their survival with 620 patients treated with eye enucleation. Different peripheral doses (using the 50% therapeutic isodose) were employed: 50-70 Gy for 24 patients, 45 Gy for 71 patients, 35 Gy for 62 patients.

FINDINGS

There was no significant difference in survival between the 35-Gy, 45-Gy and 50- to 70-Gy groups when compared between themselves (p = 0.168) and with the enucleation group (p = 0.454). The 5-year survival rates were: 64% for 35 Gy, 62.71% for 45 Gy, 63.6% for 50-70 Gy and 65.2% for enucleated patients. Clinical variables influencing survival for radiosurgery patients were tumour volume (p = 0.014) and location (median 66.4 vs 37.36 months for juxtapapillary vs peripheral tumours, respectively; p = 0.001), while age and gender did not prove significant. Regarding complications, using 35 Gy led to more than a 50% decrease, when compared with the 45-Gy dose, in the incidence of cataract, glaucoma and retinal detachment. Retinopathy, optic neuropathy and vitreous haemorrhage were not significantly influenced. Blindness decreased dramatically from 83.7% for 45 Gy to 31.4% for 35 Gy (p = 0.006), as well as post-radiosurgery enucleation: 23.9% for 45 Gy vs 6.45% for 35 Gy (p = 0.018). Visual acuity, recorded up to 5 years post-radiosurgery, was significantly better preserved for 35 Gy than for 45 Gy (p = 0.0003).

CONCLUSIONS

Using 35 Gy led to a dramatic decrease in complications, vision loss and salvage enucleation, while not compromising patient survival.

Bovine enucleation: A retrospective study of 53 cases (1998-2006)

Medical records of 53 cattle undergoing enucleation (1998-2006) were reviewed. Assessments of the outcomes were done via client surveys. Descriptive statistics were generated on the affected population, the underlying disease, the complications, and the length of retention within the herd. Hereford cattle comprised the majority of the cases (30/53; 57%). Most cattle (84.9%) were diagnosed with ocular squamous cell carcinoma (OSCC). Follow-up information was available for 22 cattle. Para-orbital infection was documented in 10 of 53 cattle (19%). Five cattle died of various causes 2 months to several years after enucleation. One cow was culled due to recurrence of OSCC. Fifteen cattle were retained within their respective herds. This study documents that orbital infections are common, and recurrence of OSCC is infrequent in cattle having undergone enucleation.

Trends in survival of patients diagnosed with cancers of the brain and nervous system, thyroid, eye, bone, and soft tissues in the Nordic countries 1964-2003 followed up until the end of 2006

BACKGROUND

Diagnoses of cancer of the brain, thyroid, eye, bone, and soft tissues are categorised by heterogeneity in disease frequency, survival, aetiology and prospects for curative therapy. In this paper, temporal trends in patient survival in the Nordic countries are considered.

MATERIAL AND METHODS

Age-standardised incidence and mortality rates, 5-year relative survival, and excess mortality rates for varying follow-up periods are presented, as are age-specific 5-year relative survival by country, sex and 5-year diagnostic period.

RESULTS

Brain cancer incidence rates have been rising but mortality has been relatively stable, with 5-year survival uniformly increasing from the early-1970s, particularly in younger patients. Five-year survival from brain cancer among men varies between 45% and 50% for men and 60% to 70% in women, with excess deaths decreasing with time in each of the Nordic populations. Age-standardised incidence rates of thyroid cancer have been mainly increasing during the 1960s and 1970s, although trends thereafter diverge, with 5-year relative survival increasing 20-30 percentage points over the last 40 years to around 80-90%. Thyroid cancer survival is consistently lower in Denmark, particularly in patients diagnosed aged over 60, while there is less geographic variation in excess deaths three months beyond initial diagnosis. Relative survival from eye cancer increased with time from approximately 60% in 1964-1968 to 80% 1999-2003, while for bone sarcoma, incidence rates remained stable, mortality rates declined, and 5-year survival increased slightly to around 55-65%. Soft tissue sarcoma incidence and survival have been slowly increasing since the 1960s, with little variation in survival (around 65%) for the most recent period.

CONCLUSIONS

There have been some notable changes in survival that can be linked to epidemiological and clinical factors in different countries over time. Time-varying proportions of the major histological subtypes might however have affected the survival estimates for a number of the cancer forms reviewed here.

Non-ocular cancer in retinoblastoma survivors

The risk of non-ocular cancer has been investigated in 150 surviving Danish patients with retinoblastoma diagnosed in the period 1943-1984. None of the patients had been treated with chemotherapeutic drugs. The overall relative risk of non-ocular cancer was 4.2 (95% confidence limits, 1.1-11.5). In the subgroups of hereditary retinoblastoma, the relative risk was 15.4 (95% confidence limits, 2.6-50.8), and in the subgroups of non-hereditary retinoblastoma the relative risk was 1.7 (95% confidence limits (0.1-8.5). The risk of cancer among 267 parents of retinoblastoma children was not different from that of the general population.

Experimental studies of photodynamic therapy in a retinoblastoma-like tumour

Combination therapy with a purified hematoporphyrin derivative, Photofrin II, and red light (photodynamic therapy) was investigated in a retinoblastoma-like tumour growing in the eyes of rats in vivo and in cell cultures. There was a marked dose-response relationship between Photofrin II and the light energy both in vitro and in vivo. Up to 33% of the tumours could be controlled in vivo. In vivo/in vitro assays indicated Photofrin II uptake in the tumour cells in vivo in relation to the administered doses. Studies of cell death kinetics suggested that the mechanisms of photodynamic therapy were both a primary cell kill effect and a secondary tissue destruction, probably as a consequence of vascular damage.

Mortality in an ophthalmic ward at a tertiary eye unit in Zimbabwe

OBJECTIVE

To review and determine the attributed causes of deaths among patients who died in Sekuru Kaguvi Hospital (SKH) Eye Unit Wards between August 1984 and October 2008

STUDY DESIGN

Retrospective study of completed BD12 forms and case records of inpatients who died betweenAugust 1984 and October 2008.

SETTING

Sekuru Kaguvi Hospital Eye Unit, Parirenyatwa Group ofHospitals, Harare, Zimbabwe.

RESULTS

Eighty three deaths occurred in the unit during the 24 year period, 51% were females and 33.7% were children below 13 years of age. Ninety three percent of deaths among children were attributed to neoplasias, while 22% of deaths among adults were attributed to infections. Non-ophthalmic causes of deaths were seen among adults.

CONCLUSION

Malignancies are the commonest attributable causes of mortality in the Ophthalmic Wards at Sekuru Kaguvi Hospital Eye Unit. Resource mobilization is essential to improve Eye Care Services.

[The clinical findings and prognosis of 28 cases of intraocular lymphoma]

BACKGROUND

Although the prognosis of intraocular lymphoma has improved due to the recent progress in diagnosis, the survival prognosis of this disease remains unclear.

SUBJECTS AND RESULTS

We reviewed the records of 28 patients (male/female ratio, 6/22) with intraocular lymphoma diagnosed and treated at Tokyo Medical University Hospital during the past 20 years. The mean age at presentation was 63.3 years. The mean follow-up period was 33.5 +/- 28.5 months (mean +/- SD). The most frequent presenting symptom was visual loss or blurred vision. On ophthalmological examination, the most common sign was vitreous opacity. Ocular disease concurrent with central nervous system (CNS) involvement was observed in 46.4%, while localized ocular disease was found in 25.0% of the patients. Intraocular lymphoma occurred as the primary lymphoma in 78.6%, and as ocular relapse of the primary CNS lymphoma in 14.3% of the cases. The 5-year survival rate was 63.1% and most of the deaths were in patients with CNS involvement.

CONCLUSION

Although the number of cases was limited, we were able to clarify the clinical manifestations and prognosis for Japanese patients with intraocular lymphoma.

Impact of an education program on late diagnosis of retinoblastoma in Honduras

BACKGROUND

In developed countries, more than 90% of children with retinoblastoma present with limited-stage disease and are cured; however, in countries with limited resources, like Honduras, most patients present with advanced disease and cure rates are less than 50%. Early diagnosis is necessary to improve the survival of children with retinoblastoma in these countries.

PROCEDURE

We describe the preliminary results of a retinoblastoma education program linked to a national vaccination campaign in Honduras. Posters and flyers were designed to be accessible to poorly educated readers, to convey the severity of retinoblastoma, and to provide contact information. Charts and an electronic database were reviewed to determine age at diagnosis, presenting signs and symptoms, date of diagnosis, and outcome.

RESULTS

During the eight previous years (July 1995-June 2003), 73% of the 59 diagnosed cases of retinoblastoma were extraocular; in contrast, during the post-campaign period (June 2003-January 2005), only 35% of the 23 diagnosed cases showed extraocular spread (P = 0.002). More than one-third of patients in both time periods either refused therapy or abandoned treatment.

CONCLUSION

This inexpensive approach is an effective first step toward improving survival of childhood retinoblastoma. Abandonment and refusal of therapy are continuing obstacles.

Radiotherapy for orbital lymphoma : outcome and late effects

PURPOSE

To analyze the effectiveness of radiotherapy in the management of orbital non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

42 patients (median age 64.5 years) were reviewed retrospectively. The median follow-up period was 58 months. 26 patients had stage IE orbital lymphoma (22 indolent, four aggressive NHLs). 16 patients had advanced NHLs in stages II-IV with orbital involvement (eleven indolent, five aggressive NHLs). The median radiation dose was 40 Gy (20-46 Gy) for indolent lymphoma and 44 Gy (20-48 Gy) for aggressive lymphoma. Patients with stage IE were treated with at least 30 Gy.

RESULTS

The 5-year local control rate for patients with stage I was 100%, the 5-year overall survival 91%. Two distant relapses were found, but no lymphoma-related death was detected. The 5-year local control rate for patients in stages II, III, and IV was 80%. Two local failures were detected. The 5-year overall survival for the advanced stages was 47%, nine patients with stages III and IV died due to systemic progression of lymphoma. Acute, radiotherapy-related complications grade 3/4 were not observed. Late effects grade 1/2 were documented in 45%. Six patients, treated with doses of > 36 Gy, developed grade 3 complications (four cataract, two dryness).

CONCLUSION

Radiotherapy alone yields excellent local control and overall survival rates in orbital lymphoma stage IE. Local irradiation is also well tolerated and effective in advanced NHL stages with orbital infiltration. Doses of > 36 Gy resulted in an increase of late complications.

Primary intraocular lymphoma: an International Primary Central Nervous System Lymphoma Collaborative Group Report

BACKGROUND

Primary intraocular lymphoma (PIOL) is an uncommon subset of primary central nervous system lymphoma. Because it is rare and difficult to diagnose, the natural history and optimal management are unknown.

PATIENTS AND METHODS

A retrospective study of 83 HIV negative, immunocompetent PIOL patients was assembled from 16 centers in seven countries.

RESULTS

Median age at diagnosis was 65. Median ECOG performance status was 0. Presenting symptoms included blurred vision, decreased visual acuity, and floaters. Median time to diagnosis was 6 months. Diagnosis was made by vitrectomy (74), choroidal/retinal biopsy (6) and ophthalmic exam (3). Eleven percent had positive CSF cytology. Initial treatment was categorized as focal in 23 (intra-ocular methotrexate, ocular radiotherapy) or extensive in 53 (systemic chemotherapy, whole brain radiotherapy). Six received none; details are unknown in one. Forty-seven relapsed: brain 47%, eyes 30%, brain and eyes 15%, and systemic 8%. Median time to relapse was 19 months. Focal therapy alone did not increase risk of brain relapse. Median progression free (PFS) and overall survival (OS) were 29.6 and 58 months, respectively, and unaffected by treatment type.

CONCLUSION

Treatment type did not affect relapse pattern, median PFS or OS. Focal therapy may minimize treatment toxicity without compromising disease control.

Primary ocular adnexal MALT lymphoma: a long-term follow-up study of 114 patients

BACKGROUND

Although primary ocular adnexal MALT (mucosa-associated lymphoid tissue) lymphoma (POAML) is a recently recognized unique entity, its natural history, prognostic factors, behavior of progression and death, and standard initial management have not been fully elucidated.

METHODS

The data of 114 patients with histologically verified POAML who were treated at our institution between 1970 and 2003 were retrospectively analyzed.

RESULTS

With a median follow-up duration of 5.7 years (0.6-34.0), estimated overall survival (OS) rate and progression-free survival (PFS) rate at 10 years was 89% and 57%, respectively. Thirteen (11%) patients died, but only three (3%) of them due to progressive lymphoma. Thirty-one (27%) patients progressed: eight who progressed at contra lateral sites were limited to those who had initially involved in the orbit (P = 0.036) and their OS and PFS were significantly longer (P = 0.035 and 0.039, respectively). Patients who initially received radiation-containing therapy were superior in PFS but not in OS to those initially treated with other modalities (P = 0.016 and 0.091, respectively). When we compared the outcomes of the observation cohort and the immediate therapy cohort, there were no significant differences in OS and PFS (P = 0.499 and 0.073, respectively).

CONCLUSIONS

The majority of patients with POAML showed the behaviors of localized and indolent diseases. Our preliminary observation that no initial therapy is an acceptable approach for selected patients was confirmed. Considering the possible heterogeneity of POAML among initial sites, further investigations are warranted.

Trends in eye cancer mortality among children in Brazil, 1980-2002

BACKGROUND

In the last few decades mortality from childhood cancers has shown substantial declines in industrialized countries, with smaller favorable trends in South America.

OBJECTIVE

This study describes mortality trends in childhood eye cancer in Brazil from 1980 to 2002.

PROCEDURE

Age-specific eye cancer death rates (0-4, 5-9, and 10-14 years) were calculated according to gender. Age-standardized mortality rates for children under 15 years were obtained through the direct method, using the 1960 world population as the standard. Trends in mortality were modeled using linear regression methods, with the age-standardized mortality coefficient (3-year centered moving average) as the dependent variable and the calendar year as the independent variable.

RESULTS

The age-standardized mortality rates among the boys decreased from 0.14/100,000 habitants in 1981 and 1985 to 0.06 in 1994, whereas the observed corresponding decline among girls was from 0.17/100,000 habitants in 1982 and 1983 to 0.07 in 2001. Statistically significant declining trends in eye cancer mortality rates were observed for boys (r(2) adjusted = 0.54, P < 0.001) and also for girls (r(2) adjusted = 0.53, P < 0.001). When only subsite retina was analyzed a statistically significant decrease in mortality coefficients was also noted for males (r(2) adjusted = 0.55, P < 0.001) and females (r(2) adjusted = 0.32, P = 0.005).

CONCLUSIONS

A consistent decrease in eye cancer mortality rates was noted in Brazil. In the absence of changes in incidence rates, this decline could be attributed to the improvement in treatment protocols and survival.

Detection of the bcl-2 t(14;18) translocation and proto-oncogene expression in primary intraocular lymphoma

PURPOSE

Primary intraocular lymphoma (PIOL) is a diffuse large B cell lymphoma that initially infiltrates the retina, vitreous, or optic nerve head, with or without central nervous system involvement. This study examined the expression of the bcl-2 t(14;18) translocation, the bcl-10 gene, and high expression of bcl-6 mRNA in PIOL cells.

METHODS

Microdissection and PCR analysis were used to examine vitreous specimens in patients with PIOL for the presence of bcl-2 t(14;18) translocations, the bcl-10 gene, and expression of bcl-6 mRNA. A medical record review was also conducted to determine whether the bcl-2 t(14;18) translocation correlated with prognosis.

RESULTS

Forty of 72 (55%) PIOL patients expressed the bcl-2 t(14;18) translocation at the major breakpoint region. Fifteen of 68 (22%) patients expressed the translocation at the minor cluster region. The bcl-10 gene was detected in 6 of 26 (23%) patients, whereas 4 of 4 (100%) PIOL patients expressed higher levels of bcl-6 mRNA compared with inflammatory lymphocytes. An analysis of clinical outcome in 23 PIOL patients revealed no significant association between bcl-2 t(14;18) translocations and survival or relapse. However, patients with the translocation were significantly younger.

CONCLUSIONS

PIOL has unique molecular patterns of bcl-2, bcl-10, and bcl-6 when compared with other systemic lymphomas. This study lays the foundation for future studies aimed at exploring the genotypic classification of PIOL based on the quantitative molecular framework of gene expression profiling, with the goal of providing useful adjuncts to the pathologic diagnosis of this complex disease.

Nuclear bcl10 expression characterizes a group of ocular adnexa MALT lymphomas with shorter failure-free survival

Ocular adnexa B-cell lymphomas are a relatively rare group of extranodal lymphomas, marginal-zone B-cell lymphomas of mucosa-associated lymphoid tissue (MALT lymphomas) being the most frequent type at this location. As with other nongastrointestinal MALT lymphomas, ocular adnexa MALT lymphomas have distinct characteristics from those of the gastric MALT model, implying specific pathogenic events, which could be of interest in the prediction of clinical behavior and the choice between therapeutic options. In a series of 39 cases of ocular adnexa MALT lymphomas, studied using a tissue microarray, we observed that the most frequent alteration was related to apoptosis regulation. Thus, caspase 3 activity was completely abolished, and phosphorylated IkappaBalpha, a marker of NF-kappaB activation, showed increased expression, while cases with an increased number of large cells displayed increased expression of survivin and other cell-cycle-related proteins, such as cyclin A, cyclin E and Ki67, and p16 expression was reduced. There were no occurrences of t(11;18)(q21,q21), while 5/37 cases exhibited t(14;18)(q32;q21). Aberrant nuclear expression of bcl10 was observed in 11 cases, independently of the presence of translocations, and was significantly associated with phosphorylated IkappaBalpha expression and a reduced TdT-mediated biotin-dUTP nicked-end labeling apoptotic index. Moreover, patients with tumoral bcl10 nuclear expression showed shorter failure-free survival.

Survival in extra-orbital metastatic retinoblastoma:treatment results

INTRODUCTION

Retinoblastoma (RB) is the most frequent malignant eye tumor in childhood. In developing countries advanced stages are common. The purpose of this paper is to present our 21-year clinical experience with metastatic extra ocular RB patients treated with 5 different chemotherapy schemas at a single Mexican Pediatric referral center.

MATERIALS AND METHODS

A retrospective analysis was carried out reviewing the clinical characteristics of patients with metastatic RB. The information analyzed included the delay in diagnosis after first symptoms, age, sex, ocular staging, and anatomic site of metastases, treatment scheme, initial response and status at the last contact or date of death.

RESULTS

Eighty-one patients were included; age range was from 3 to 80 months. The most common site of metastasis was central nervous system (83.9%). From those patients treated with chemotherapy (n = 74), 89.2% presented a complete initial response (n = 66). Early mortality occurred in 7 cases before any treatment. Fifty-six received treatment and died with progressive disease. All patients without radiotherapy died with tumor activity (n = 15). The use of cisplatin was related with longer disease free intervals; no other variable was related with survival. Four patients were alive and disease free at 33 to 144.3 months of follow up from diagnosis. The prevalent cause of death was tumor progression.

CONCLUSIONS

In our experience, metastatic RB has a very high mortality rate in spite of the use of different chemotherapy regimens.

Canine limbal melanoma: 30 cases (1992-2004). Part 2. Treatment with lamellar resection and adjunctive strontium-90beta plesiotherapy - efficacy and morbidity

OBJECTIVES

To evaluate the efficacy of lamellar resection and adjunctive 90Sr-beta plesiotherapy in the management of canine limbal melanoma and the frequency and morbidity of early and late-onset side effects following treatment.

DESIGN

Retrospective study.

ANIMALS STUDIED

Thirty dogs treated for limbal melanoma at the Animal Health Trust (AHT), between 1992 and 2004.

METHODS

Medical records were reviewed and information collected on the radiation dose administered, duration of follow-up, and the frequency of early- and late-onset ocular side effects. Follow-up information was obtained by re-examination of patients or completion of a telephone interview with the referring veterinary surgeons or the owners.

RESULTS

Recurrence of limbal melanoma occurred in 1 of 30 cases (3%; 95% CI: 0.2-14%). One or more side effects occurred in 16 of 30 cases (53%; 95% CI: 28.1-74.9). The occurrence of side effects was not associated with the number of sites treated or the total surface dose of radiation. Short-term side effects were reported in 16/30 cases (53%) and included corneal scarring (12/30), corneal neovascularization (6/30), conjunctivitis with or without granulation tissue formation (5/30), lipid keratopathy (1/30), and localized bullous keratopathy (2/30). Long-term side effects were reported in 6 of 30 cases (20%) cases and included deep scleral thinning (5/30), focal scleromalacia (3/30), globe perforation (2/30), lipid keratopathy (3/30), localized bullous keratopathy (1/30), and sectoral cortical cataract (1/30).

CONCLUSIONS

Lamellar resection and adjunctive 90Sr-beta plesiotherapy is relatively easy to perform, is minimally invasive, and extremely well tolerated by patients. The treatment is highly efficacious in the management of canine limbal melanoma. Modification of the radiation dosimetry, in particular reducing the total dose of radiation and the dose per radiation fraction, is necessary to reduce the incidence of late onset side effects.

[Retinoblastoma]

Retinoblastomas are the most frequent intraocular tumors in childhood. Untreated, the tumor is almost always fatal. Using a multidisciplinary approach combining the efforts of ophthalmologists, radiation oncologists, pediatric oncologists and geneticists a survival rate of more than 95% can be achieved. Molecular genetic research on the origin of retinoblastomas has substantially helped in our understanding of the origin of malignant tumors in general, as well as to the key role of the Rb-1 gene as a tumor suppressor.

Clinical analysis of the effect of intraarterial cytoreductive chemotherapy in the treatment of lacrimal gland adenoid cystic carcinoma

PURPOSE

To determine the effect of intraarterial cytoreductive chemotherapy (IACC) as an adjunct to conventional surgery and radiation therapy for lacrimal gland adenoid cystic carcinoma (ACC).

DESIGN

A retrospective, comparative, interventional case series.

METHODS

setting: Institutional. patient population: Nine consecutive patients with lacrimal gland ACC were treated with IACC, followed by orbital exenteration and chemoradiotherapy. This case series was compared with a series of seven patients treated by conventional local therapies in the same institution. intervention procedure: Clinical records, imaging studies, histologic sections, and archival specimens from all 16 patients were reviewed. Information analyzed included site of disease, histologic characteristics, extent of disease, incidence of locoregional recurrence or distant metastases, and disease-free survival and overall survival time. main outcome measure: The effect of IACC was assessed by the radiographic and histologic response and survival outcome in comparison to a historical cohort of patients managed by conventional local therapies.

RESULTS

The difference between the carcinoma cause-specific death rate of the study group versus conventional treatment was significant (P = .029, log rank test). The cumulative 5-year carcinoma cause-specific death rate in the IACC treated group was 16.7% compared with 57.1% in the conventional treatment group. The cumulative 5-year recurrence rate in the IACC treated group was 23.8% compared with 71.4% in the conventional treatment group.

CONCLUSIONS

The preliminary data suggest that IACC as an integral component of a multimodal treatment strategy is potentially effective in improving local disease control and overall disease-free survival in lacrimal gland adenoid cystic carcinoma.

Intraocular lymphoma 2000-2005: results of a retrospective multicentre trial

BACKGROUND

The prognosis of intraocular lymphoma (IOL) is poor, and the optimal treatment has yet to be defined. This study assesses the clinical characteristics and outcome of patients with IOL diagnosed and treated in the new millennium.

METHODS

Patient data in this retrospective multicentre study were compiled by standardised questionnaires sent to seven university ophthalmology departments. All cases diagnosed with primary and secondary IOL in the past 5 years not associated with HIV infection were included.

RESULTS

Twenty-two patients, 11 men and women; median age 64 (range 38-83) years, median Karnofsky performance status 90% (range 50-100%), were included. Nineteen patients had primary IOL (PIOL): 13 a newly diagnosed disease and six an ocular relapse of primary central nervous system lymphoma (PCNSL). Three patients had secondary IOL. First-line treatment for IOL included systemic chemotherapy in 13 cases, ocular radiation in six and intraocular chemotherapy in three. Complete remission was achieved in 14/20 evaluable patients, partial remission in five and stable disease in one. All patients treated with ifosfamide (IFO) or trofosfamide (TRO) (n=8) responded. Median progression-free survival (PFS) and overall survival were 10 (range 1+ to 44.5+) and 22.5 (range 1+ to 49+) months, respectively. Patients with newly diagnosed PIOL and ocular relapse of PCNSL had a median PFS of 10 (range 1+ to 44.5+) and 6 (range 2 to 6+) months, respectively. Median PFS was 12 (range 3+ to 22.5+) months after systemic and 5.5 (range 1+ to 44.5+) months after local first-line therapy.

CONCLUSIONS

The prognosis of PIOL is similar to that of PCNSL without ocular involvement. Systemic therapy possibly prolongs PFS as compared with local management of (P)IOL. The high response rate to monotherapy with IFO and TRO is promising.

A phase II study of biochemotherapy for advanced melanoma incorporating temozolomide, decrescendo interleukin-2 and GM-CSF

Metastatic malignant melanoma remains a very difficult disease to treat. Previous phase II studies using biochemotherapy (combination of platinum-containing chemotherapy with IL-2 and IFNalpha) have shown response rates of about 50%. However, a site of frequent relapse is in the central nervous system (CNS). Temozolomide is an oral alkylating agent that has equivalent activity to dacarbazine, but it has the advantage of CNS penetration. We report the results of a phase II study using a novel biochemotherapy regimen containing temozolomide, cisplatin, decrescendo IL-2, IFNalpha, and GM-CSF in the treatment of stage IV melanoma. Seventy-one patients with histologically confirmed metastatic melanoma were enrolled between June 1998 and October 1999. Prior chemotherapy or IL-2 was not permitted. The median age was 54 years (range 22-72). Twenty-one patients (30%) had a history of treated brain metastases. Patients received temozolomide 150 mg/m2 orally days 1-5, cisplatin 30 mg/m2 IV days 1-3, IFNalpha 5 MU/m2 SQ on days 1-5, and IL-2 was administered in a decrescendo fashion according to the following schedule: day 1: 18 MU/m2 continuous IV infusion over 6 hours; day 2: 18 MU/m2 continuous IV infusion over 12 hours; day 3: 9 MU/m2 subcutaneously q12 hours; day 4: 4.5 MU/m2 subcutaneously x 1. Patients were also given GM-CSF 250 microg subcutaneously days 6-25. The cycles were repeated every 4 weeks. Partial responses were seen in 10 of the 71 patients (14%) with a median duration of response of 9.4 months. There were no complete responses. The median survival for all patients was 8.6 months. Further studies of this novel biochemotherapy regimen are not indicated. Other schedules that incorporate temozolomide and/or GM-CSF and further studies to define the optimal method of delivering IL-2 should be pursued.

Lymphoproliferative disease of the ocular adnexa: a clinical and pathologic study with statistical analysis of 69 patients

PURPOSE

To evaluate the clinical features, treatment, and outcomes of a cohort of patients with ocular adnexal lymphoproliferative disease classified according to the World Health Organization modification of the Revised European-American Classification of Lymphoid neoplasms and to perform a robust statistical analysis of these data.

METHODS

Sixty-nine cases of ocular adnexal lymphoproliferative disease, seen in a tertiary referral center from 1992 to 2003, were included in the study. Lesions were classified by using the World Health Organization modification of the Revised European-American Classification of Lymphoid neoplasms classification. Outcome variables included disease-specific survival, relapse-free survival, local control, and distant control.

RESULTS

Stage IV disease at presentation, aggressive lymphoma histology, the presence of prior or concurrent systemic lymphoma at presentation, and bilateral adnexal disease were significant predictors for reduced disease-specific survival, local control, and distant control. Multivariate analysis found that aggressive histology and bilateral adnexal disease had significantly reduced disease-specific survival.

CONCLUSIONS

The typical presentation of adnexal lymphoproliferative disease is with a painless mass, swelling, or proptosis; however, pain and inflammation occurred in 20% and 30% of patients, respectively. Stage at presentation, tumor histology, primary or secondary status, and whether the process was unilateral or bilateral were significant variables for disease outcome. In this study, distant spread of lymphoma was lower in patients who received greater than 20 Gy of orbital radiotherapy.

Clinical and microdissection genotyping analyses of the effect of intra-arterial cytoreductive chemotherapy in the treatment of lacrimal gland adenoid cystic carcinoma

PURPOSE

To determine the effect of intra-arterial cytoreductive chemotherapy (IACC) as an adjunct of a multimodality protocol for the treatment of lacrimal gland adenoid cystic carcinoma (ACC).

METHODS

This was a retrospective, comparative, consecutive case series. Nine consecutive patients with lacrimal gland ACC were treated with IACC, followed by orbital exenteration and chemoradiotherapy. This case series was compared with a series of seven patients treated by conventional local therapies. Clinical records, imaging studies, histologic sections, and archival specimens from all 16 patients were reviewed. Information analyzed included site of disease, histologic characteristics, extent of disease, local-regional recurrence or distant metastases, and disease-free survival time. Gene analysis was performed on microdissected tissue samples. Mutational allelotyping targeting nine genomic loci using 15 polymorphic microsatellite markers situated in proximity to known tumor suppressor genes serve as markers for the presence of gene deletion. The effect of IACC was assessed by the radiographic response and survival outcome in comparison to a historical cohort of patients managed by conventional local therapies. A fractional mutation index was used to compare the acquired mutational load between different tumors having nonidentical patterns of microsatellite informativeness.

RESULTS

The carcinoma cause-specific death rates between the two treatment groups was significant (P = .029, log-rank test). The cumulative 5-year carcinoma cause-specific death rate was 16.7% in the IACC-treated group compared with 57.1% in the conventional treatment group. 1p36 was the single most common site affected by allelic loss for microsatellite markers in this series.

CONCLUSIONS

The preliminary data suggest that IACC as an integral component of a multimodal treatment strategy is potentially effective in improving local disease control and overall disease-free survival in lacrimal gland ACC. Allelic loss for microsatellite markers at 1p36 may be a common and an early event in ACC formation and progression.

Plaque radiotherapy for choroidal and ciliochoroidal melanomas with limited nodular extrascleral extension

BACKGROUND

Currently available clinical information regarding management of posterior uveal melanomas complicated by nodular extrascleral extension is inadequate to determine the role, if any, for plaque radiotherapy in such patients.

METHODS

The authors performed a retrospective descriptive study of eight patients with a choroidal or ciliochoroidal melanoma complicated by nodular extrascleral extension who were treated by surgical excision of the extrascleral nodule followed immediately by plaque radiotherapy of the intraocular tumour. The calculated volume of the extrascleral nodule was greater than 1 mm3 but less than 1000 mm3 in all cases, and the intraocular tumour was deemed treatable by plaque radiotherapy in all patients.

RESULTS

Four of the eight patients died during available follow-up, three from metastatic melanoma and one from a second cancer. The median length of follow-up for the four surviving patients was 10.1 years. The actuarial 5-year and 10-year all-cause death rates were 37.5% and 53.1% respectively. One of the eight patients experienced local intraocular tumour relapse following plaque therapy and underwent secondary enucleation. None of the patients experienced orbital tumour recurrence or underwent secondary orbital exenteration.

INTERPRETATION

Our results coupled with previously published results from another centre suggest that plaque radiotherapy may be an effective local treatment for selected patients with choroidal or ciliochoroidal melanoma complicated by nodular extrascleral extension. The fact that none of the patients in this series or in the previously reported series experienced orbital recurrence following plaque radiotherapy or required secondary orbital exenteration suggests that plaque therapy may be better than enucleation alone in terms of these end points. These results should not be extrapolated, of course, to patients with massive extrascleral tumour extension or a choroidal or ciliochoroidal melanoma too large for plaque radiotherapy.

Modelling survival after treatment of intraocular melanoma using artificial neural networks and Bayes theorem

This paper describes the development of an artificial intelligence (AI) system for survival prediction from intraocular melanoma. The system used artificial neural networks (ANNs) with five input parameters: coronal and sagittal tumour location, anterior tumour margin, largest basal tumour diameter and the cell type. After excluding records with missing data, 2331 patients were included in the study. These were split randomly into training and test sets. Date censorship was applied to the records to deal with patients who were lost to follow-up and patients who died from general causes. Bayes theorem was then applied to the ANN output to construct survival probability curves. A validation set with 34 patients unseen to both training and test sets was used to compare the AI system with Cox's regression (CR) and Kaplan-Meier (KM) analyses. Results showed large differences in the mean 5 year survival probability figures when the number of records with matching characteristics was small. However, as the number of matches increased to > 100 the system tended to agree with CR and KM. The validation set was also used to compare the system with a clinical expert in predicting time to metastatic death. The rms error was 3.7 years for the system and 4.3 years for the clinical expert for 15 years survival. For < 10 years survival, these figures were 2.7 and 4.2, respectively. We concluded that the AI system can match if not better the clinical expert's prediction. There were significant differences with CR and KM analyses when the number of records was small, but it was not known which model is more accurate.

Ocular presentation of primary central nervous system lymphoma: diagnosis and treatment

Primary ocular lymphoma (POL), a lymphoma of the globe, is a restricted form of primary central nervous system lymphoma (PCNSL) that often progresses to the brain and meninges; frequently it is misdiagnosed until central nervous system (CNS) lymphoma develops. The optimal treatment has not yet been identified. We retrospectively reviewed the course and the treatment of POL in 31 patients. Seventeen patients were treated for isolated POL (group A) and 14 were treated only after CNS disease was diagnosed (group B). The treatment in both groups consisted of systemic chemotherapy, chemotherapy plus radiotherapy (RT) or RT alone. In group A, nine patients (53%) developed CNS progression and five (29%) had ocular recurrence. In group B, seven (50%) had CNS progression and three (21%) ocular relapse. To control for diagnostic lead time, median survival was calculated from initial ocular symptoms and was 60 months in group A and 35 months in group B (P < 0.05). Ocular lymphoma responds to a variety of therapies but treatment with chemotherapy and/or ocular radiotherapy (ORT) failed to prevent CNS progression. Patients whose ocular disease was identified and treated before CNS progression had a significantly improved survival.

Outcomes in patients with adenoid cystic carcinoma of the lacrimal gland

PURPOSE

To evaluate the outcomes among patients with adenoid cystic carcinoma of the lacrimal gland treated at various stages of their disease at a tertiary care cancer center.

METHODS

A retrospective case series of 20 patients with adenoid cystic carcinoma of the lacrimal gland treated at a single institution between 1952 and 2002. Clinical records were available for all 20 patients; histologic sections from 12 of the 20 patients were available for review. Disease-free survival was measured from the completion of treatment; overall survival was measured from the date of initial diagnosis.

RESULTS

The study included 6 men and 14 women. The mean age at diagnosis was 39.5 years. The median follow-up time was 34 months (range, 6 to 264 months). The local/regional treatment modalities included exenteration with bone removal and radiation therapy (RT) in 5 patients, exenteration with RT (no bone removal) in 8 patients, exenteration (no RT or bone removal) in 1 patient, exenteration with bone removal (no RT) in 1 patient, local resection with RT in 3 patients, and local resection without RT in 2 patients. Overall, 16 patients had RT as part of their treatment regimen. Seven patients (35%) had local recurrence. Sixteen patients (80%) had distant metastasis during the study period. At the time of this report, 13 (65%) of the patients had died of disease. The median disease-free survival for the entire group was 18 months. Eight patients had a predominantly basaloid histologic pattern. Ten patients had verifiable histologic evidence of perineural invasion.

CONCLUSIONS

This study underscores the generally grave prognosis for patients with adenoid cystic carcinoma of the lacrimal gland and the difficulty in making any conclusive recommendations for local therapy for this disease.

Ocular Metastases from Breast Carcinoma

Intraocular metastases are the most common malignancy of the eye, and the primary cause is breast cancer. This is a retrospective analysis, which reports the clinical experience of eye metastases in 16 patients during the period of January, 1991, to December, 2002, who attended a tertiary referral center in Mexico City. Mean age at diagnosis was 40 yr (range 24-58). Most of patients were initially in clinical stage IIB-IV. Median time from breast cancer diagnosis to development of ocular metastases was 22.5 mo and from metastatic disease to ocular metastases was 10 mo. Ocular symptoms were decrease of visual acuity, ocular pain, nonspecific symptoms, proptosis, and palpebral edema. Three patients had bilateral ocular metastases. Fourteen patients were treated with radiation, and clinical response was documented in 4/15 eyes; ocular pain responded in three patients with this symptom. No ocular enucleations were performed. One patient developed glaucoma. No other major toxicities were documented. Median survival time was 26 mo and 25% of our patients were alive at a maximum follow-up of 90 mo. This entity requires early recognition in order to preserve the visual function and quality of life of patients with breast cancer, since their prognosis has improved in recent years.

Eye cancer in adults in Uzbekistan, 1978-1998

Incidence rate, age-adjusted and standardized incidence and mortality of malignant eye tumours (METs) in Uzbekistan in 1978-1998 and professional, ethnic, environmental, and geographical factors which could influence it are analyzed. Before 1978, there was no information about patients with METs in Uzbekistan. We gathered 4872 primary new cases, of whom 79.7% (3882 patients) were treated in our department. All samples were statistically tested. Age-adjusted MET incidence has a peak in the 60-69 age subgroup. The highest incidence was in "non-local" ethnic group. Eyelid tumours occurred most frequently, followed by conjunctival, intraocular and orbital tumours. Urban and rural females had higher incidence than urban and rural males. For 10 years, standardized incidence has increased 2.3 and mortality 6.0 times. The highest incidence and mortality were in Karakalpakstan and Khorezm Wiloyat.

Clinical features associated with survival of patients with lymphoma of the ocular adnexa

PURPOSE

Although systemic or eyelid involvement by ocular adnexal lymphoma carries a worse prognosis, there have been few reports of the outcome in relation to clinical presentation. The outcome of malignant ocular adnexal lymphoma was, therefore, related to presenting clinical symptoms and signs.

DESIGN AND METHODS

A retrospective, noncomparative case-note review of 326 patients treated in the Orbital Clinic at Moorfields Eye Hospital. The associations between presenting symptoms or signs and three outcome measures (v.i.) were assessed by univariate and multiple variable regression together with Kaplan-Meier analysis.

MAIN OUTCOME MEASURES

(i) Presence of extra-orbital disease at the time of presentation; (ii) development of systemic lymphoma after new presentation with solely ocular adnexal disease; and (iii) death attributable to widespread lymphoma.

RESULTS

Presentation with disseminated disease was rarer with over 1 year's ophthalmic symptoms (odds ratio (OR) 0.7; 95% CI 0.5-0.9) and much more frequent with bilateral adnexal disease (OR 5.8; 95% CI 3.0-11.2). With solely adnexal disease at presentation, subsequent extra-orbital lymphoma was more frequent and earlier with lacrimal gland disease (as compared to those without; hazard ratio (HR) 1.9; 95% CI 1.2-4.5) or with eyelid disease (compared to those without; HR 2.4; 95% CI 1.2-4.5), or with bilateral disease (compared to unilateral disease; HR 2.6; 95% CI 1.4-5.2). Prior or concurrent systemic disease was the most significant predictive factor for lymphoma-related death (HR 6.8; 95% CI 4.3-10.9), but tumour-related death was also commoner and earlier with bilateral disease (HR 2.4; 95% CI 1.4-4.0) or where a relative afferent papillary defect was present (HR 2.8; 95% CI 1.6-4.9). Similarly, the rate of tumour-related death was slightly less where symptoms had been present for more than a year (HR 0.8; 95% CI 0.7-1.0) and slightly greater in the elderly (HR 1.03; 95% CI 1.01-1.05). Conjunctival lymphoma had the lowest rate of extra-orbital spread and lymphoma-related death, the rate of these two events being sequentially greater for patients with predominantly deep orbital lymphoma, lacrimal gland lymphoma, or eyelid lymphoma.

CONCLUSION

These data suggest that presenting symptoms and signs of patients with ocular adnexal lymphoma are significantly associated with the risk of systemic disease at orbital presentation, the rate of subsequent spread, and the rate of lymphoma-related death.

Ocular adnexal lymphoma: Clinical behavior of distinct World Health Organization classification subtypes

PURPOSE

To evaluate the clinical behavior and treatment outcome of ocular adnexal lymphomas classified by the World Health Organization system, with emphasis on marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT).

MATERIALS AND METHODS

The clinicopathologic materials from 98 consecutive patients treated for ocular adnexal lymphoma were reviewed. Fourteen patients had prior lymphoma and 84 patients had primary disease (75% Stage I, 6% Stage III, and 19% Stage IV). Radiation (photons/electrons) was administered to 102 eyes to a median dose of 30.6 Gy. The mean follow-up was 82 months.

RESULTS

The most common subtypes among the primary patients were MALT (57%) and follicular (18%) lymphoma. The 5-year actuarial local control rate in 102 irradiated eyes was 98%. Among the low-grade lymphomas, the 5-year local control rate correlated with the radiation dose in the MALT lymphoma subgroup (n = 53): 81% for <30 Gy and 100% for > or =30 Gy (p <0.01). For the non-MALT low-grade lymphomas such as follicular lymphoma (n = 30), the local control rate was 100% regardless of dose. For 39 Stage I MALT lymphoma patients treated with radiation alone, the distant relapse-free survival rate was 75% at 5 years and 45% at 10 years. Distant relapses were generally isolated and successfully salvaged by local therapy. The overall survival for this subgroup was 81% at 10 years, with no deaths from lymphoma.

CONCLUSIONS

Dose-response data suggest that the optimal radiation dose for MALT lymphoma of the ocular adnexa is 30.6-32.4 Gy in 1.8-Gy fractions and follicular lymphoma is adequately controlled with doses in the mid-20 Gy range. The substantial risk of distant relapse in Stage I ocular adnexal MALT lymphoma underscores the importance of long-term follow-up for this disease and the need for additional comparative studies of MALT lymphoma of different anatomic sites.