Adjuvant systemic treatment for high-risk resected non-cutaneous melanomas: What is the evidence?

Non-cutaneous melanomas (mucosal, uveal, leptomeningeal, unknown primaries) represent around 5-10 % of all melanoma diagnoses. Non-cutaneous melanomas demonstrate differences in tumour biology, generally present with more advanced stages and have an overall poorer prognosis compared to skin melanomas. The cornerstone of their treatment is surgery followed by radiotherapy in some cases. Unfortunately, in many of these patients their melanoma will recur. Adjuvant therapy for non-cutaneous melanomas remains controversial. To date, almost all of the tested adjuvant agents have failed to demonstrate any benefit; the two randomised positive trials were criticized for methodological reasons, small sample size and conflicting results. The aim of this review is to assess the current evidence on systemic adjuvant treatments for high-risk resected non-cutaneous melanomas. We also provide a summary table with the currently recruiting clinical trials in these settings and we discuss some strategies to improve trial design in this particularly niche area of oncology.

Translation of single-cell transcriptomic analysis of uveal melanomas to clinical oncology

Uveal melanoma (UM) is an aggressive and deadly neoplasm. In recent decades, great efforts have been made to obtain a more comprehensive understanding of genetics, genomics and molecular changes in UM, enabling the identification of key cellular processes and signalling pathways. Still, there is no effective treatment for the metastatic disease. Intratumoural heterogeneity (ITH) is thought to be one of the leading determinants of metastasis, therapeutic resistance and recurrence. Crucially, tumours are complex ecosystems, where cancer cells, and diverse cell types from their microenvironment engage in dynamic spatiotemporal crosstalk that allows cancer progression, adaptation and evolution. This highlights the urgent need to gain insight into ITH in UM and its intersection with the microenvironment to overcome treatment failure. Here we provide an overview of the studies and technologies to study ITH in human UMs and tumour micro-environmental composition. We discuss how to incorporate ITH into clinical consideration for the purpose of advocating for new clinical management. We focus on the application of single-cell transcriptomic analysis and propose that understanding the driving forces and functional consequences of the observed tumour heterogeneity holds promise for changing the treatment paradigm of metastatic UMs, surmounting resistance and improving patient prognosis.

Unilateral retinoblastoma with contralateral isolated choroidal Melanocytosis: case report of an unexpected presentation

Background

Congenital ocular melanocytosis has been shown to be extremely uncommon in studies of numerous infants and children with retinoblastoma and disorders such as retinopathy of prematurity.

Case presentation

A 33-month-old Caucasian boy presented with a solid white predominantly endophytic retinoblastoma filling most of the nasal aspect of the fundus and extensive vitreous seeding. Fundus exam of the contralateral eye showed a broad-based flat melanotic area of the choroid extending from the subfoveal region to the ora serrata temporally. The child was treated by enucleation of the retinoblastoma-containing eye (homozygous non-germline RB1 mutation) and is being monitored annually. The patient has been followed for 4 years.

Conclusions

This rare presentation of advanced unilateral retinoblastoma and contralateral isolated choroidal melanocytosis in a young child emphasizes the importance of detailed fundus mapping of the non-affected eye and has potential implications due to the increased incidence of uveal melanoma later in life.

[Management of uveal melanomas, guidelines for oncologists]

Uveal melanomas are the most frequent primary malignant eye tumor. Enucleation was historically the gold standard. Since then, several studies showed that conservative treatments did not increase the risk of metastasis or survival. Choroidal melanomas are both radioresistant and located close to visual structures (the optic nerve and macula) of the eye, which may be preserved in some settings without compromising tumor control, as this is the first priority. Different types of radiation therapy may be used for such tumors: brachytherapy and charged particles, including proton beam therapy. If visual prognosis is dependent to the local treatment, the vital prognosis is dependent on the metastatic risk, with a risk of liver involvement in 20 to 50% of patients, depending on tumor size and genomics. Median survival after the discovery of liver metastases is about 15 months. The management of these patients is often complex. Systemic therapies (chemotherapy, targeted therapies, immunotherapy, etc.) yield limited response rates and although local treatments of liver metastases are promising, they are only feasible in selected patients. The mission of the MELACHONAT national network is to improve the management of patients regardless of the stage of the disease. The patient association ANPACO is dedicated to help uveal melanoma patients in their health care path and to promote knowledge dissemination within the patient community. The aim of this review is to focus on the local treatments of uveal melanomas as well as the management of their metastatic evolution.

Gamma Knife radiosurgery for locally recurrent choroidal melanoma following plaque radiotherapy

Background

For the majority of eyes with choroidal melanoma, radiation therapy is the treatment of choice. Local recurrence after radiation therapy can occur, however, and when it does, salvaging the globe with useful vision is atypical.

Case presentation

We report a case of late, local failure 7 years following previous brachytherapy successfully managed with Gamma Knife radiosurgery (GKR). With 3 years of follow up after GKR, the visual acuity is 20/20 and there is no evidence of systemic metastases.

Conclusion

To our knowledge, this is the first report of successful salvage GKR therapy after brachytherapy failure in an eye with choroidal melanoma. GKR is an option for select cases of local recurrence after radiation plaque brachytherapy.

Uveal Melanoma UK National Guidelines

The United Kingdom (UK) uveal melanoma guideline development group used an evidence based systematic approach (Scottish Intercollegiate Guidelines Network (SIGN)) to make recommendations in key areas of uncertainty in the field including: the use and effectiveness of new technologies for prognostication, the appropriate pathway for the surveillance of patients following treatment for primary uveal melanoma, the use and effectiveness of new technologies in the treatment of hepatic recurrence and the use of systemic treatments. The guidelines were sent for international peer review and have been accredited by NICE. A summary of key recommendations is presented. The full documents are available on the Melanoma Focus website.

Outcomes of medium choroidal melanomas treated with ruthenium brachytherapy guided by three-dimensional pretreatment modeling

PURPOSE

The Collaborative Ocular Melanoma Study (COMS) established iodine-125 (I-125) plaque brachytherapy for eye preserving treatment of medium-sized choroidal melanomas in the United States. Eye Physics I-125 plaque treatment modeled with Plaque Simulator (PS) software yields similar results to COMS. Herein, we report results from a series of 15 patients treated with ruthenium-106 (Ru-106) plaque brachytherapy using PS pretreatment modeling for plaque localization and dosimetry.

METHODS AND MATERIALS

Fifteen patients with medium-sized choroidal melanomas (2.84-5.5 mm in apical height and a basal diameter of 7.8-12.6 mm) treated with ruthenium brachytherapy from 2003 to 2005 were evaluated retrospectively. Baseline and followup data were evaluated for tumor height, best corrected visual acuity, radiation retinopathy, radiation optic neuropathy, postradiation cataract formation, diplopia, and ptosis. Tumor response for both Ru-106 and I-125 plaques planned using the same PS pretreatment modeling was evaluated and compared.

RESULTS

Isotope-specific radiation profiles were compared, and rates of local treatment failure (0%), optic neuropathy (6.7%), retinopathy (20%), and cataracts (33%) were evaluated. Five year-treated tumor heights were approximately 0.61 ± 0.29 (I-125, n = 16) and 0.53 ± 0.17 (Ru-106, n = 6) of their heights at diagnosis.

CONCLUSIONS

This patient subset had background characteristics very similar to those of the COMS and patients treated at our institution with I-125 plaques. Treatment response was equivalent although radiation complications occurred slightly less frequently in the Ru-106 group compared with those treated with I-125. Image-guided three-dimensional pretreatment modeling for plaque localization and dosimetry seems to work equally as well for Ru as for I-125 plaques and justifies more extensive investigation.

Choroid Melanoma - A Rare Case Report

Uveal tract encomprise melanomas of the iris, ciliary body and the choroid. The choroid melanomas are more frequent to occur in comparison to iris and ciliary body melanomas. Choroid melanoma though rare, is the most common occurring intraocular malignancy amongst the adults. Incidence of occurrence of choroid melanoma is around 20 per million cases per year globally. The uveal tract pigment producing melanocytes are the origin for the melanoma in the eye. Melanomas tend to commonly arise from sixth decade of age with increasing incidence with progressive age. We present a rare case choroidal melanoma, in a 65-year-old adult, who presented with three months history of headache and gradual dimunision of vision, his investigations revealed clinical diagnosis of choroid melanoma , an enucleation was carried.

Biology of advanced uveal melanoma and next steps for clinical therapeutics

Uveal melanoma is the most common intraocular malignancy although it is a rare subset of all melanomas. Uveal melanoma has distinct biology relative to cutaneous melanoma, with widely divergent patient outcomes. Patients diagnosed with a primary uveal melanoma can be stratified for risk of metastasis by cytogenetics or gene expression profiling, with approximately half of patients developing metastatic disease, predominately hepatic in location, over a 15-yr period. Historically, no systemic therapy has been associated with a clear clinical benefit for patients with advanced disease, and median survival remains poor. Here, as a joint effort between the Melanoma Research Foundation's ocular melanoma initiative, CURE OM and the National Cancer Institute, the current understanding of the molecular and immunobiology of uveal melanoma is reviewed, and on-going laboratory research into the disease is highlighted. Finally, recent investigations relevant to clinical management via targeted and immunotherapies are reviewed, and next steps in the development of clinical therapeutics are discussed.

[Cytogenetic analysis of choroidal melanoma]

PURPOSE

To investigate the presence of known cytogenetic alterations of choroidal melanoma in a series of patients diagnosed and treated in our Ocular Oncology Service. A review of the present literature on this topic is also presented.

METHODS

Microsatellite analysis (MSA) studies on loss of heterozygosity (LOH) of chromosome 3, as well as multiplex ligation prove amplification (MLPA) on chromosomes 1, 3, 6 and 8, were performed on enucleation or local resection samples obtained from a total of 27 patients, over a 2 year period.

RESULTS

Twenty patients showed at least one of the cytogenetic alterations looked for. A total of 11 cases were found that showed LOH of chromosome 3 (44%), 8 gains of chromosome 8 (30%), 8 gains of chromosome 6p (30%), and 7 partial or total losses of chromosome 1 (26%).

CONCLUSIONS

This is the first study on the cytogenetics of choroidal melanoma performed in our country. The results are similar to that published in the literature. Cytogenetic analysis provides more accurate knowledge on a vital individual prognosis. It also may become a valuable tool for establishing the most adequate follow-up regimes, and the need for adjuvant therapies.