Outcomes of treatment with stereotactic radiosurgery or proton beam therapy for choroidal melanoma

AIM

To present our experience of the use of stereotactic radiosurgery and proton beam therapy to treat posterior uveal melanoma over a 10 year period.

METHODS AND MATERIALS

Case notes of patients treated with stereotactic radiosurgery (SRS), or Proton beam therapy (PBT) for posterior uveal melanoma were reviewed. Data collected included visual acuity at presentation and final review, local control rates, globe retention and complications. We analysed post-operative visual outcomes and if visual outcomes varied with proximity to the optic nerve or fovea.

RESULTS

191 patients were included in the study; 85 and 106 patients received Stereotactic radiosurgery and Proton beam therapy, respectively. Mean follow up period was 39 months in the SRS group and 34 months in the PBT group. Both treatments achieved excellent local control rates with eye retention in 98% of the SRS group and 95% in the PBT group. The stereotactic radiosurgery group showed a poorer visual prognosis with 65% losing more than 3 lines of Snellen acuity compared to 45% in the PBT group. 33% of the SRS group and 54% of proton beam patients had a visual acuity of 6/60 or better.

CONCLUSIONS

Stereotactic radiosurgery and proton beam therapy are effective treatments for larger choroidal melanomas or tumours unsuitable for plaque radiotherapy. Our results suggest that patients treated with proton beam therapy retain better vision post-operatively; however, possible confounding factors include age, tumour location and systemic co-morbidities. These factors as well as the patient's preference should be considered when deciding between these two therapies.

Failure of intravitreal bevacizumab in the treatment of choroidal metastasis

BACKGROUND

Metastasis to choroid is the most common intraocular malignancy, arising most frequently from carcinoma of breast in women and lung in men. Recent case reports have described successful use of intravitreal bevacizumab to achieve local control of such tumours.

MATERIALS AND METHODS

Five cases of choroidal metastases from varying primaries: breast, lung, and colon were treated with intravitreal bevacizumab, and tumour response observed and documented with serial photographs and B-scans.

RESULTS

Four of the five tumours were seen to progress despite intravitreal bevacizumab treatment.

CONCLUSIONS

Intravitreal bevacizumab as the primary treatment of choroidal metastases is not recommended and should not delay more effective alternative treatments.

Three cases of intraocular mesectodermal leiomyoma expressing progesterone and androgen receptors

BACKGROUND/AIMS

A prospective study identified three patients between 2004 and 2010 with mesectodermal leiomyoma. The study was conducted to analyse the presence or absence of sex steroid hormone receptors in mesectodermal leiomyomas.

METHODS

The clinical features were collated. All three patients had operative procedures to either remove or sample the mesectodermal leiomyomas. The tissue was fixed in formalin and exposed to conventional histological processing. Immunohistochemistry using antibodies to androgen (AR), oestrogen (ER), and progesterone (PR) receptors was performed, followed by stain scoring to assess for expression status.

RESULTS

All three cases were confirmed by histology to be examples of mesectodermal leiomyomas. All three expressed sex steroid hormone receptors. One case expressed both PR and AR, one case PR only and another case AR only. None of the cases expressed ER receptors.

CONCLUSION

All three cases displayed some sex steroid hormone receptor expression. This is supportive evidence that sex steroid hormones may have a role in the pathogenesis of this tumour and suggest that it may be amenable to hormonal manipulation therapy, in a manner similar to conventional uterine leiomyomas.

Bovine pericardium (Tutopatch) wrap for hydroxyapatite implants

PURPOSE

To evaluate bovine pericardium (Tutopatch) as a wrapping material for hydroxyapatite implants in patients undergoing enucleation for uveal melanoma.

METHOD

Prospective cohort study of patients who had enucleation for uveal melanoma between January 2003 and August 2003 were included in the study. Any patient with less than 3 months follow-up was excluded. Enucleation was performed under general anaesthesia followed by insertion of hydroxyapatite implants wrapped in bovine pericardium (Tutopatch). The recti muscles were sutured directly to the wrap. The tenon's capsule and conjunctiva were closed in two layers. A conformer was inserted at 1 week and artificial eye at 2-3 months. The patients were followed up regularly and were assessed for cosmetic result, exposure of implant, and the need for any further surgical procedures.

RESULTS

A total of 19 patients (seven male and 12 female) were included in the study. Median age at diagnosis was 63 years (range 38-80 years). Median follow-up was 26 months (range 22-30 months). No patient developed postoperative complications of wound dehiscence. The overall cosmetic result was excellent in all the patients. The rate of postoperative complications compared favourably with published data using other wrapping materials/implants.

CONCLUSION

Tutopatch is a safe wrapping material for hydroxyapatite orbital implants in patients undergoing enucleation for uveal melanoma.

Photodynamic therapy of circumscribed choroidal haemangioma

AIM

To evaluate efficacy of verteporfin ocular photodynamic therapy (PDT) in treatment of 10 patients with a symptomatic circumscribed choroidal haemangioma.

DESIGN

Prospective non-randomised, interventional case series and critical review of previously published studies.

METHODS

10 consecutive patients (seven primary, two failed transpupillary thermotherapy (TTT), and one failed external beam radiotherapy) with symptomatic circumscribed choroidal haemangioma were treated using verteporfin 6 mg/m2 given as an intravenous infusion over 10 minutes. Diode laser (690 nm) with an intensity of 600 mW/cm2 for 83 seconds (50 J/cm2) was applied 5 minutes after completion of infusion. Single or multiple partially overlapping spots were applied based on the tumour basal dimensions. Periodic follow up with ophthalmoscopy, ultrasonography, and angiographic studies was performed.

RESULTS

All 10 patients showed evidence of regression with flattening of tumour, resolution of subretinal fluid, and reduction of choroidal vasculature on angiograms. The visual acuity either improved or remained stable in eight (80%) patients. Visual loss due to delayed choroidal atrophy was seen in two patients.

CONCLUSIONS

Although verteporfin PDT is an effective treatment for management of symptomatic circumscribed choroidal haemangioma, delayed treatment related effects can lead to visual loss.

Efficacy of photodynamic therapy in circumscribed choroidal haemangioma

PURPOSE

To report efficacy of photodynamic therapy (PDT) in the treatment of three cases of juxtafoveal circumscribed choroidal haemangioma.

METHODS

Data on three patients (two primary, and one failed TTT) treated with verteporfin, 6 mg/m2 given as i.v. infusion over 10 min. Diode laser (690 nm) with an intensity of 600 mW/cm2 for 83 s (50 mJ/cm2) was applied 5 min after completion of infusion. Overlapping multiple spots (2500 microm) were applied to cover the entire surface of the tumour. The mean pretreatment tumour size was 7 mm (base) x 2.2 (thickness) mm. Periodic follow-up with ophthalmoscopy, ultrasonography, and angiographic studies was performed.

RESULTS

All three cases showed complete regression of the tumour with resolution of subretinal fluid, flattening of tumour, and absence of choroidal vasculature on ICG. The visual acuity either improved or remained stable in all three cases. The overlying retinal vessels remained unaffected. There were no ocular or systemic complications.

CONCLUSIONS

PDT is an effective treatment for management of juxtafoveal circumscribed choroidal haemangioma.

Indocyanine green augmented transpupillary thermotherapy in the management of choroidal metastasis from breast carcinoma

PURPOSE

To demonstrate the efficacy of indocyanine green augmented transpupillary thermotherapy (TTT) in the management of choroidal metastasis from breast carcinoma.

METHODS

A retrospective study was performed on 4 women aged 39-59 years with solitary choroidal metastasis from breast carcinoma in whom choroidal metastasis was managed using mTT. All patients had undergone indocyanine green (ICG) augmented TTT using a diode laser (810 nm) treatment to these lesions and had a mean post-treatment follow-up of 13.2 months.

RESULTS

In all the patients there was a gradual regression of the lesion over a mean follow-up of 13.2 months with retention of good visual acuity.

CONCLUSION

Indocyanine green augmented transpupillary thermotherapy is a viable alternative for management of solitary choroidal metastasis from breast carcinoma.

Bilateral sensorineural hearing loss in members of a maternal lineage with mitochondrial point mutation

Pure-tone audiometry was carried out on members of a recently described maternal lineage with sensorineural deafness, harbouring a novel mitochondrial mutation in the gene for tRNA-ser(UCN). This revealed a characteristic pattern of symmetrical bilateral sensorineural hearing losses in each affected individual, predominantly affecting the high-frequencies, but with considerable variability between individuals. No clear correlation was observed between age and severity, but most subjects reported progressive worsening of their condition. Some members of the lineage were found to be heteroplasmic for the tRNA-ser(UCN) mutation. However, the severity of hearing loss was poorly correlated with the representation of the mutant mtDNA, indicating that other, as yet unidentified factors must be involved in the aetiology of this disorder.

Phthirus pubis infestation of the eyelids

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