Development of metastatic disease after enrollment in the COMS trials for treatment of choroidal melanoma: Collaborative Ocular Melanoma Study Group Report No. 26

OBJECTIVE

To describe the time between treatment for choroidal melanoma and first diagnosis of metastatic disease, sites of metastasis, treatments for metastasis, and time between diagnosis of metastasis and death.

DESIGN

Prospective, longitudinal follow-up of patients diagnosed with choroidal melanoma who were enrolled in 2 randomized trials conducted by the Collaborative Ocular Melanoma Study Group.

METHODS

Systemic and laboratory evaluations were performed during follow-up according to a standard protocol for 2320 patients enrolled in the Collaborative Ocular Melanoma Study trials without evidence of melanoma metastasis or other primary cancer at baseline.

RESULTS

Seven hundred thirty-nine patients were diagnosed with at least 1 site of metastasis during follow-up after treatment for choroidal melanoma. Five- and 10-year cumulative metastasis rates were 25% (95% confidence interval, 23%-27%) and 34% (95% confidence interval, 32%-37%), respectively. Liver was the most common site (89%). The death rate following the report of melanoma metastasis was 80% at 1 year (95% confidence interval, 77%-83%) and 92% at 2 years (95% confidence interval, 89%-94%). Overall survival after metastasis did not vary by baseline size of primary tumor nor treatment for metastasis (when known). Long-term survival after diagnosis of metastasis was uncommon; only 8 patients survived 5 or more years.

CONCLUSION

Metastasis rate increased significantly with increasing primary tumor dimensions at time of patient enrollment. Prognosis after metastatic disease remains poor. Effective methods are needed to prevent, diagnose, and treat metastasis from choroidal melanoma.

Assessment of metastatic disease status at death in 435 patients with large choroidal melanoma in the Collaborative Ocular Melanoma Study (COMS): COMS report no. 15

BACKGROUND

A systematic review and assessment of disease-related mortality as part of standardized prospective patient follow-up and evaluation within a multicenter clinical trial have been lacking in previous studies of choroidal melanoma.

OBJECTIVE

To describe disease status at death in patients with large choroidal melanoma treated and followed up in the Collaborative Ocular Melanoma Study (COMS).

DESIGN

Analysis of reviews of patient status at death performed by the COMS Mortality Coding Committee using available clinical and histopathologic information.

SETTING AND PATIENTS

Reviews of deaths as of July 31, 1997, the cutoff date for reporting initial mortality findings.

INTERVENTIONS

Patients were treated by either enucleation preceded by external beam radiotherapy or enucleation only.

MAIN OUTCOME MEASURES

Disease status at the time of death and certainty associated with the coding of disease status, sites of metastasis, and availability of autopsy.

RESULTS

Of 1003 patients enrolled in the trial, 457 had died; the estimated median survival from time of enrollment was 7.4 years. Disease status at time of death had been reviewed for 435 deaths (95%). The autopsy rate was 6%. A total of 269 patients (62%) had histopathologically confirmed melanoma metastasis at the time of death, and metastasis was suspected in 92 additional patients (21%) on the basis of imaging and tests but without tissue confirmation. The common sites were liver (93%), lung (24%), and bone (16%); multiple sites were identified in 87% of patients with metastasis. The likelihood of 3 or more sites increased more than 4-fold when autopsy results were available.

CONCLUSIONS

Detailed mortality coding following a standard protocol provides the most accurate reporting to date of disease-related mortality in patients with choroidal melanoma and also identifies difficulties. Guidelines for the evaluation of future patients in clinical studies of choroidal melanoma are suggested.

Anatomic Relationship between Lamina Cribrosa, Intraocular Space, and Cerebrospinal Fluid Space

PURPOSE

The lamina cribrosa, as the main structural element of the optic nerve head, forms a pressure barrier between the intraocular space and the retrobulbar space. The function as a pressure barrier may have importance for the pathogenesis of ocular diseases related to intraocular pressure and/or cerebrospinal fluid (CSF) pressure, such as the glaucomas. The purpose of the present study was to examine the anatomic relationship between the lamina cribrosa, the intraocular pressure space, and the retrobulbar cerebrospinal pressure space in eyes with glaucoma.

METHODS

The study included 53 globes enucleated because of malignant choroidal melanoma (n = 42) without involvement of the optic nerve (control group) or because of painful absolute secondary angle-closure glaucoma (n = 11; glaucoma group). Anterior-posterior histologic sections through the pupil and the optic disc were morphometrically evaluated.

RESULTS

In the glaucoma group compared with the control group, the lamina cribrosa was significantly (P < 0.001) thinner, the part of the outer lamina cribrosa surface directly exposed to the pia mater and indirectly exposed to the CSF space was significantly (P = 0.001) wider, and the shortest distance between the intraocular space and the CSF space was significantly (P < 0.001) shorter. The posterior lamina cribrosa surface in direct contact with the pia mater was located close to the optic disc border.

CONCLUSIONS

The thickness of the lamina cribrosa and the anatomic relationships between the intraocular space and the CSF space differ significantly between normal and glaucomatous eyes. The findings may be of importance for the pathogenesis of glaucomatous optic neuropathy.

Radiation therapy for choroidal melanoma

Radiotherapy offers patients with malignant melanoma of the choroid an eye and a vision-sparing alternative to enucleation. The most commonly used forms of radiotherapy are ophthalmic plaque brachytherapy and charged-particle (external beam) radiotherapy. Unfortunately, after all forms of radiotherapy for choroidal melanoma many patients experience sight-limiting side effects, and an average of 16.3% of patients treated with radiotherapy subsequently require enucleation because of tumor regrowth or uncontrollable neovascular glaucoma. The severity, location, and incidence of radiation-induced complications are related to the type of radiation used, its method of delivery, amount of radiation delivered to normal ocular structures, the size and location of the tumor, as well as its response to irradiation. Current research is directed toward developing methods to reduce the amount of radiation delivered to normal structures, e.g., adding heat to radiotherapy. The true viability and metastatic potential of irradiated uveal melanoma cells has not been established, although clinical studies have reported local control of choroidal melanoma in 81-100% (mean = 92.8%) of cases. The purpose of this review is to present the world's experience with radiotherapy for choroidal melanoma, information that will contribute to patient education and informed consent.

The prognostic value of tumor blood vessel morphology in primary uveal melanoma

BACKGROUND

It is possible to identify at least nine vascular patterns in melanomas of the ciliary body and choroid from histologic sections. An association between the presence of at least one closed vascular loop and death from metastases was shown in a matched-pair, case-control study of 40 patients whose eyes were removed for ciliary body or choroidal melanomas.

METHODS

Two independent observers who were masked to the follow-up of patients examined histologic preparations of 234 eyes removed for ciliary body or choroidal melanomas for the presence of each of the tumor vascular patterns. Statistical analyses included tests for interobserver reliability, Kaplan-Meier survival curves, and the fitting of Cox regression models.

RESULTS

The detection of each of the nine vascular patterns is highly reproducible. The Cox model indicates that the presence of vascular networks, defined as at least three back-to-back closed vascular loops, is the feature most strongly associated with death from metastatic melanoma. Other significant factors in the Cox model include (in descending order of importance) largest tumor dimension, mitoses, the parallel with cross-linking vascular pattern, age, the presence of tumor-infiltrating lymphocytes, and male gender.

CONCLUSIONS

The presence of vascular networks provides the most significant association with death from metastatic melanoma of all variables tested. The presence of this pattern should be recorded on pathology reports. If it becomes possible to detect this vascular pattern clinically using a noninvasive imaging technique, then ophthalmologists may be able to determine the likely biologic behavior of a melanoma before resorting to the removal of tissue.

Collaborative ocular melanoma study (COMS) randomized trial of I-125 brachytherapy for medium choroidal melanoma. I. Visual acuity after 3 years COMS report no. 16

OBJECTIVE

To report visual acuity during the first three years after iodine 125 (I(125)) brachytherapy for medium-sized choroidal melanoma and to identify important baseline and treatment factors associated with posttreatment visual acuity in a group of patients who were treated and observed prospectively as part of a large, randomized clinical trial.

DESIGN

Observational case series within a randomized, multicenter study.

PARTICIPANTS

Patients enrolled in the Collaborative Ocular Melanoma Study randomized trial of I(125) brachytherapy versus enucleation had choroidal melanoma of at least 2.5 mm but no more than 10.0 mm in apical height, and no more than 16.0 mm in largest basal dimension. One thousand three hundred seventeen patients enrolled from February 1987 through July 1998; 657 patients were assigned to I(125) brachytherapy. Visual acuity data for 623 patients who received I(125) brachytherapy as randomly assigned and who have been observed for at least 1 year were analyzed for this report.

METHODS

Under study protocol, an ophthalmic evaluation, including best-corrected visual acuity measurement of each eye, was performed at baseline, every 6 months thereafter for 5 years, and once yearly thereafter. Two poor vision outcomes, visual acuity of 20/200 or worse that was confirmed at the next follow-up examination and loss of six lines or more of visual acuity from baseline that was confirmed at the next follow-up examination, were analyzed to identify baseline and treatment characteristics that were associated with posttreatment visual acuity.

RESULTS

At baseline, median visual acuity in the eye with choroidal melanoma was 20/32, with 70% of eyes having 20/40 or better and 10% of eyes having 20/200 or worse visual acuity. Three years after I(125) brachytherapy, median visual acuity was 20/125, with 34% having 20/40 or better and 45% having 20/200 or worse visual acuity, including eyes that were enucleated within 3 years of treatment. Life-table estimates of percentages of patients who lost six or more lines of visual acuity from baseline, a quadrupling of the minimum angle of resolution, with this finding confirmed at the next 6-month follow-up examination, were 18% by 1 year, 34% by 2 years, and 49% by 3 years after treatment. Life-table estimates of percentages of patients with baseline visual acuity better than 20/200 whose visual acuity decreased to 20/200 or worse, confirmed at the next follow-up examination, were 17% by 1 year, 33% by 2 years, and 43% by 3 years after treatment. As soon as a poor vision outcome was observed, improvement of visual acuity to a level that no longer met the definition for a poor vision outcome was rare. Greater baseline tumor apical height and shorter distance between the tumor and the foveal avascular zone (FAZ) were the factors most strongly associated with loss of six or more lines of visual acuity after treatment. These two factors and baseline visual acuity also were strongly associated with visual acuity 20/200 or worse after treatment. Patient history of diabetes, presence of tumor-associated retinal detachment, and tumors that were not dome shaped also were associated with greater risk for both of the poor vision outcomes.

CONCLUSIONS

Forty-three percent to 49% of treated eyes had substantial impairment in visual acuity by 3 years after I(125) brachytherapy, defined as a loss of six or more lines of visual acuity from the pretreatment level (49% of eyes) or visual acuity of 20/200 or worse (43% of eyes) that was confirmed at the next 6-month examination. Patients with a history of diabetes and patients whose eyes had thicker tumors, tumors close to or beneath the FAZ, tumor-associated retinal detachment, or tumors that were not dome shaped were those most likely to have a poor visual acuity outcome within 3 years after I(125) brachytherapy.

Accuracy of diagnosis of choroidal melanomas in the Collaborative Ocular Melanoma Study. COMS report no. 1

In the 3-year period during which patients were enrolled into the Collaborative Ocular Melanoma Study, 413 eyes with clinical diagnoses of choroidal melanoma were examined histopathologically as of December 31, 1989. Four hundred eleven of these eyes were found to be diagnosed correctly. One eye, removed after preoperative external beam radiation, was found to have a hemangioma. The second eye, removed after radioactive iodine plaque placement, was described as a magnocellular nevus (melanocytoma) by four of the five pathologists on the Collaborative Ocular Melanoma Study Pathology Review Committee. The Collaborative Ocular Melanoma Study misdiagnosis rate of 0.48% is the lowest ever reported. The major challenge with regard to posterior uveal melanomas is no longer that of correct diagnosis but rather determination of the optimal treatment.

Hemangioma of the choroid. A clinicopathologic study of 71 cases and a review of the literature

This is a clinicopathologic study of 71 hemangiomas of the choroid. The cases were divided into three groups: Group 1 consisted of 45 cases of solitary choroidal hemangiomas (not related to any systemic disease); Group 2 comprised 17 cases with unequivocal evidence of Sturge-Weber syndrome; and Group 3 included 9 cases, 6 of which were classified as "probably Sturge-Weber syndrome." Clinically, many differences were found that established a clear distinction between Groups 1 and 2. Histopathologically, the solitary hemangiomas were well-circumscribed tumors that showed a sharply demarcated pushing margin causing compression of melanocytes and choroidal lamellae. About 70% of these tumors were located temporally (at the posterior pole). In contrast, the lesions in the Sturge-Weber syndrome showed a diffuse angiomatosis involving more than one-half of the choroid, as well as the episcleral and intrascleral perilimbal plexuses. The cause and pathogenesis of these lesions are discussed.

Histopathologic characteristics of uveal melanomas in eyes enucleated from the Collaborative Ocular Melanoma Study. COMS report no. 6

PURPOSE

To describe the principal histopathologic findings in a series of 1,527 globes with uveal melanoma and the relationship of these findings to each other.

METHODS

All eyes enucleated in the Collaborative Ocular Melanoma Study (COMS) were examined independently by three ophthalmic pathologists and the findings recorded on a data form. A composite of findings was obtained after adjudication.

RESULTS

The diagnosis was choroidal melanoma in 1,527 (99.7%) of 1,532 cases examined. Misdiagnoses were metastatic adenocarcinoma (four) and hemangioma (one). Spindle cell (9.0%), mixed cell (86.0%), and epithelioid cell (5.0%) types were observed. Medium tumors were located more posteriorly than large tumors. Considerable local invasion was seen: rupture of Bruch's membrane (87.7%), invasion of the retina (49.1%), tumor cells in the vitreous (25.2%), vortex vein invasion (8.9%), invasion of tumor vessels by tumor cells (13.8%), and invasion into emissary canals (55.0%). Overall, 81.1% demonstrated local invasion, excluding rupture of Bruch's membrane. Scleral invasion was present in 55.7% of eyes, and extrascleral extension was present in 8.2%. Mitotic activity was significantly reduced in eyes that had received preenucleation radiation treatment (P < .001). The number of macrophages in the tumor increased with increased pigmentation (P < .001) and increased necrosis (P < .01).

CONCLUSION

The accuracy of diagnosis in the COMS is high, with histopathologic confirmation of the diagnosis at 99.7%. Extensive local invasion of the tumor was seen. Preenucleation irradiation significantly reduced the number of mitotic figures. An association was found regarding the presence of macrophages, the level of pigmentation, and degree of necrosis.

Transpupillary thermotherapy in choroidal melanomas

OBJECTIVE

To determine safety and efficacy of transpupillary thermotherapy (TTT) as a new treatment for choroidal melanoma.

METHODS AND PATIENTS

To perform TTT, diode laser energy at 810 nm was used with a beam diameter of 1.5 to 4.5 mm for a 1-minute exposure. All 12 patients had choroidal melanoma. Six had had insufficient response to ruthenium 106 (106Ru) brachytherapy. Three patients with tumors more than 5 mm in height were treated simultaneously with 106Ru and TTT. Three patients with juxtapapillary or macular tumors were treated by TTT only.

RESULTS

All but one tumor exhibited a reduction of tumor height in a follow-up period of 3 to 14 months. Side effects were minimal. Severe visual loss occurred in two patients due to radiation retinopathy, in two patients whose foveas were included in the TTT area, and in one patient resulting from a serous retinal detachment that extended over the posterior pole.

CONCLUSIONS

Treatment with TTT may be useful as a complementary modality to brachytherapy. A longer follow-up period is required for final evaluation.

The American Brachytherapy Society recommendations for brachytherapy of uveal melanomas

PURPOSE

This article presents the American Brachytherapy Society (ABS) guidelines for the use of brachytherapy for patients with choroidal melanomas.

METHODS

Members of the ABS with expertise in choroidal melanoma formulated brachytherapy guidelines based upon their clinical experience and a review of the literature. The Board of Directors of the ABS approved the final report.

RESULTS

Episcleral plaque brachytherapy is a complex procedure and should only be undertaken in specialized medical centers with expertise in this sophisticated treatment program. Recommendations were made for patient selection, techniques, dose rates, and dosages. Most patients with very small uveal melanomas (<2.5 mm height and <10 mm in largest basal dimension) should be observed for tumor growth before treatment. Patients with a clinical diagnosis of medium-sized choroidal melanoma (between 2.5 and 10 mm in height and <16 mm basal diameter) are candidates for episcleral plaques if the patient is otherwise healthy and without metastatic disease. A histopathologic verification is not required. Small melanomas may be candidates if there is documented growth; some patients with large melanomas (>10 mm height or >16 mm basal diameter) may also be candidates. Patients with large tumors or with tumors at peripapillary and macular locations have a poorer visual outcome and lower local control that must be taken into account in the patient decision-making process. Patients with gross extrascleral extension, ring melanoma, and tumor involvement of more than half of the ciliary body are not suitable for plaque therapy. For plaque fabrication, the ophthalmologist must provide the tumor size (including basal diameters and tumor height) and a detailed fundus diagram. The ABS recommends a minimum tumor (125)I dose of 85 Gy at a dose rate of 0.60-1.05 Gy/h using AAPM TG-43 formalism for the calculation of dose. NRC or state licensing guidelines regarding procedures for handling of radioisotopes must be followed.

CONCLUSIONS

Brachytherapy represents an effective means of treating patients with choroidal melanomas. Guidelines are established for the use of brachytherapy in the treatment of choroidal melanomas. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose reporting policies. These guidelines will be modified as further clinical results become available.

An evaluation of enucleation in the management of uveal melanomas

Uveal melanomas are slow growing tumors that may infiltrate out of the eye, mainly following ciliary vessels or nerves, or invade blood vessels, but only rarely do they produce metastatic disease before discovery and treatment. There are, however, large gaps in our knowledge of the frequency and rate of growth of small tumors to those of moderate or large size. We have estimated the mortality from untreated uveal melanomas to be 1% per year or less. Almost all information concerning prognostic factors has been gained from studies based on cases treated by enucleation. The same information is not necessarily applicable to untreated tumors. A study of deaths from metastatic uveal melanomas reveals a striking relationship to enucleation, regardless of whether one deals with cases in which the eye had been symptomatic for a long or short time. Following a low preoperative mortality of 1% or less, the annual mortality rises to about 4% during the first year and then peaks at 8 to 12% during the second year, tapering off during the next three to five years to return to a remarkably constant level of 1 to 2% thereafter. We postulated that this relationship of peak mortality to enucleation is attributable mainly to an often overwhelming dissemination of tumor cells taking place during surgery or to a lowering of the host's immunologic defense mechanisms as a consequence of the operation, or both. We urge the pooling of all available information gained from clinical studies made on untreated tumors and recommend prospective studies of a variety of other methods of treating uveal melanomas in addition to the standard enucleation.

Combination of clinical factors predictive of growth of small choroidal melanocytic tumors

OBJECTIVE

To better define the effect of individual risk factors and combinations thereof on the growth of small choroidal melanocytic tumors.

DESIGN

Retrospective analysis.

SETTING

Clinical practice of ocular oncology.

PATIENTS

The study included 1287 patients with small suspicious choroidal melanocytic tumors, measuring 3 mm or less in thickness, managed with observation.

RESULTS

On multivariate analysis, the clinical risk factors predictive of growth of small choroidal melanocytic tumors include tumor thickness greater than 2.0 mm, posterior tumor margin touching the disc, visual symptoms, orange pigment, and subretinal fluid. Tumor growth was detected in 4% of those patients with no risk factors. Growth was detected in approximately 36% of patients with 1 risk factor, 45% of patients with 2 risk factors, 50% of patients with 3 risk factors, 51% of patients with 4 risk factors, and 56% of patients with all 5 risk factors. The combination of risk factors offering the greatest risk for growth was tumor thickness greater than 2.0 mm, tumor margin touching disc, and subretinal fluid that was associated with tumor growth in 63% of the affected patients. The relative risk for growth was 1.9 for 1 factor, 3.8 for 2 factors, 7.4 for 3 factors, 14.1 for 4 factors, and 27.1 for all 5 risk factors combined.

CONCLUSIONS

Five risk factors for growth of small choroidal melanocytic tumors have been identified. The combinations of various factors increase the risk for tumor growth from 4% if no factors are present to more than 50% if 3 or more risk factors are present. These factors may be important when counseling patients with small suspicious choroidal melanocytic tumors.

Factors predictive of growth and treatment of small choroidal melanoma: COMS Report No. 5. The Collaborative Ocular Melanoma Study Group

OBJECTIVES

To describe time to tumor growth of a prospectively followed group of patients with small choroidal melanoma and to determine baseline clinical and photographic characteristics associated with time to growth.

METHODS

The Collaborative Ocular Melanoma Study (COMS) is a set of clinical trials designed to compare radiotherapy and enucleation in the treatment of medium- and large-size choroidal melanoma. From December 1986 to August 1989, patients with small choroidal melanoma, not large enough to be eligible for the COMS clinical trials, were offered participation in a nonrandomized prospective follow-up study. Small choroidal melanomas were defined as 1.0 to 3.0 mm in apical height and 5.0 to 16.0 mm in largest basal dimension. A total of 204 patients were enrolled in the study and were followed up annually through August 1989. An assessment of current size of tumor, treatment status, and vital status was conducted in 1993-1994; an additional assessment of treatment and vital status was performed in 1995-1996.

RESULTS

Of 188 small tumors not treated at the time of study enrollment, 46 grew during follow-up to a size that was large enough to be eligible for the COMS clinical trials. The Kaplan-Meier estimates of proportion of tumors that grew were 21% (95% confidence interval, 14%-27%) by 2 years and 31% (95% confidence interval, 23%-39%) by 5 years. Factors significantly associated with time to growth in a Cox proportional hazards regression model were greater initial tumor thickness and diameter, presence of orange pigment, absence of drusen, and absence of areas of retinal pigment epithelial changes adjacent to the tumor.

CONCLUSIONS

Of small choroidal melanomas initially managed by observation, 21% demonstrated growth by 2 years and 31% by 5 years. The clinical and photographic features of these tumors confirm previous findings and are useful in identifying patients with small tumors at highest risk of short-term growth.

Clinicopathological correlation of polypoidal choroidal vasculopathy revealed by ultrastructural study

AIMS

To describe the clinical and histopathological findings in a patient with polypoidal choroidal vasculopathy.

METHODS

A 76 year old Japanese man had a discrete, orange-red lesion of 1 disc diameter in the macula, with the fluorescein and indocyanine green angiographic and optical coherence tomographic findings compatible with polypoidal choroidal vasculopathy. He underwent a surgical removal of the macular lesion, followed by light and electron microscopic examinations.

RESULTS

The histopathological examination revealed that the specimen consisted of degenerated retinal pigment epithelium-Bruch's membrane-choriocapillaris complex and inner choroid. A tortuous, unusually dilated venule was present adjacent to an arteriole with marked sclerotic changes, appearing to form arteriovenous crossing. These vessels seemed to represent native inner choroidal vessels, and had haemorrhage per diapedesis. Blood cells and fibrin filled the lumina of the vessels and accumulated in the extravascular spaces, indicating vascular stasis.

CONCLUSION

Hyperpermeability and haemorrhage due to stasis of a dilated venule and an arteriole involved by sclerosis at the site where they cross in the inner choroid might cause oedema and degeneration of the tissue. Voluminous accumulation of blood cells and fibrin might generate elevation of tissue pressure sufficient to displace the weakened lesion anteriorly. The result suggests that the polypoidal vessels in this case represent abnormality in the inner choroidal vasculature.

Screening for metastasis from choroidal melanoma: the Collaborative Ocular Melanoma Study Group Report 23

PURPOSE

To describe the predictive value of liver function tests (LFTs), chest x-ray, and diagnostic imaging for detecting melanoma metastasis during routine follow-up after treatment for choroidal melanoma.

MATERIALS AND METHODS

Prospective longitudinal follow-up of patients enrolled onto two randomized trials was conducted by the Collaborative Ocular Melanoma Study (COMS) Group. Baseline and annual or semiannual systemic and laboratory evaluations were performed according to a standard protocol for 2320 patients enrolled on the COMS.

RESULTS

COMS patients were screened annually for metastasis and new cancers using LFTs (alkaline phosphatase, AST, ALT, or bilirubin). Elevated findings (1.5 to 2 times upper limit of normal) on LFT prompted a diagnostic or imaging test to confirm or rule out cancer recurrence. Of 714 patients with clinical reports of metastasis, 675 patients died. Of these 675 patients, all but four had either histopathologically confirmed or clinically suspected metastatic melanoma present at the time of death. Among all patients, the 5-year cumulative diagnosis rate of metastatic melanoma was 24% (95% CI, 22% to 27%). Based on all patients with reported metastasis, the sensitivity, specificity, positive predictive value and negative predictive value associated with at least one abnormal LFT before first diagnosis of metastasis at any site was 14.7%, 92.3%, 45.7% and 71.0%, respectively.

CONCLUSION

Use of LFTs results followed by diagnostic tests has high specificity and predictive values but low sensitivity. Better tests are needed to identify earlier metastatic disease associated with choroidal melanoma.

Proton beam radiotherapy of choroidal melanoma: The Liverpool-Clatterbridge experience

PURPOSE

To report on outcomes after proton beam radiotherapy of choroidal melanoma using a 62-MeV cyclotron in patients considered unsuitable for other forms of conservative therapy.

METHODS AND MATERIALS

A total of 349 patients with choroidal melanoma referred to the Liverpool Ocular Oncology Centre underwent proton beam radiotherapy at Clatterbridge Centre for Oncology (CCO) between January 1993 and December 2003. Four daily fractions of proton beam radiotherapy were delivered, with a total dose of 53.1 proton Gy, and with lateral and distal safety margins of 2.5 mm. Outcomes measured were local tumor recurrence; ocular conservation; vision; and metastatic death according to age, gender, eye, visual acuity, location of anterior and posterior tumor margins, quadrant, longest basal tumor dimension, tumor height, extraocular extension, and retinal invasion.

RESULTS

The 5-year actuarial rates were 3.5% for local tumor recurrence, 9.4% for enucleation, 79.1% for conservation of vision of counting fingers or better, 61.1% for conservation of vision of 20/200 or better, 44.8% for conservation of vision of 20/40 or better, and 10.0% for death from metastasis.

CONCLUSION

Proton beam radiotherapy with a 62 MeV cyclotron achieves high rates of local tumor control and ocular conservation, with visual outcome depending on tumor size and location.

Estimating the risk of malignant transformation of a choroidal nevus

PURPOSE

To estimate the risk of malignant transformation of a choroidal nevus in the white population.

DESIGN

Systematic literature review.

METHODS

A literature review was performed to obtain data on the prevalence of choroidal nevi in the white population. Data from studies that used indirect ophthalmoscopy or otherwise corrected data to include the entire fundus were selected. Only studies reporting on the United States population were included. The number of affected individuals was estimated using 2000 U.S. census data. The estimate of annual incident choroidal melanoma cases in the corresponding age- and race-matched population was calculated using the Surveillance, Epidemiology, and End Result database (1973-2000). Average annual age-specific incidence rates for 1973 to 2000 for each of the 5-year age groups (adjusted for the U.S. 2000 population) were calculated and applied to the corresponding census data. The ratio of numbers of affected individuals with choroidal melanoma and choroidal nevi gave the annual rate of malignant transformation of a choroidal nevus.

MAIN OUTCOME MEASURES

Annual rate of malignant transformation of a choroidal nevus in the white population of the U.S.

RESULTS

The prevalence of choroidal nevus in the white U.S. population ranged from 4.6% to 7.9%. It was estimated that, on average, 8864625 individuals in the U.S. had a choroidal nevus. The number of individuals with choroidal melanoma in the corresponding age- and race-matched population ranged from 989 to 1008 (mean, 1002). The annual rate of malignant transformation of a choroidal nevus was estimated to be 1 in 8845.

CONCLUSIONS

If it is assumed that all choroidal melanomas arise from preexisting nevi, then the published data suggest a low rate (1/8845) of malignant transformation of a choroidal nevus in the U.S. white population.

Optic nerve invasion of retinoblastoma. Metastatic potential and clinical risk factors

BACKGROUND

Optic nerve invasion is one of the predictors for retinoblastoma metastases. This study was designed to investigate the risk of optic nerve invasion and clinical features that may identify those children with optic nerve invasion.

METHODS

We reviewed the charts of 289 children with retinoblastoma treated initially with enucleation. Logistic regression analysis was performed to assess the risk for metastases from varying degrees of optic nerve invasion and to assess the clinical and histopathologic predictors of optic nerve invasion.

RESULTS

There were 84 eyes (29%) with optic nerve invasion. The invasion was prelamina cribrosa in 44 cases (15%), up to but not posterior to the lamina cribrosa in 21 cases (7%), posterior to the lamina cribrosa but not to the cut end of the optic nerve in 17 cases (6%), and to the site of optic nerve transection in 2 cases (1%). Patients with optic nerve invasion were more likely to develop metastasis (P = 0.0016), particularly those with invasion to the postlaminar and cut section of the optic nerve (P = 0.0001). Development of metastasis was not statistically associated with laminar or prelaminar involvement. If those patients with choroidal invasion simultaneous with optic nerve invasion were excluded from evaluation, the presence of optic nerve invasion alone was not significant for development of metastasis. The clinical factors found to be predictive for optic nerve invasion from a univariate analysis included exophytic growth pattern (P = 0.011), elevated intraocular pressure (> 22 mm Hg) (P = 0.02), and tumor thickness greater than or equal to 15 mm (P = 0.03). The histopathologic factor significantly associated with optic nerve invasion (univariate analysis) was simultaneous choroidal invasion (P = 0.001). A trend toward an association with optic nerve invasion was found with vitreous hemorrhage (P = 0.06), iris neovascularization (P = 0.10), and poorly differentiated retinoblastoma (P = 0.07). A multivariate analysis showed the most significant clinical factors to be exophytic growth pattern (P = 0.002), tumor thickness greater than or equal to 15 mm (P = 0.01), and vitreous hemorrhage (P = 0.05).

CONCLUSIONS

Optic nerve invasion of retinoblastoma beyond the lamina cribrosa is associated with a greater metastatic risk. Large exophytic retinoblastoma with secondary glaucoma is at highest risk for optic nerve invasion.

Choroidal osteoma

This review details the characteristic clinical features, diagnostic approaches, management, and prognosis of the choroidal osteoma. A comprehensive differential diagnosis is organized to help the ophthalmologist differentiate this tumor from conditions which can sometimes be clinically similar, such as amelanotic choroidal melanoma and nevus, metastatic choroidal carcinoma, choroidal hemangioma, metastatic and dystrophic intraocular calcification, and others. The pathology of the choroidal osteoma is illustrated and several theories of the pathogenesis of this tumor including the possibilities of a choristomatous, inflammatory, and hereditary etiology are discussed. The recently recommended therapeutic technique of photocoagulation of subretinal neovascularization associated with choroidal osteoma are discussed.

Primary transpupillary thermotherapy for small choroidal melanoma in 256 consecutive cases: outcomes and limitations

OBJECTIVE

The objective of this report was to evaluate ocular and systemic outcomes after primary transpupillary thermotherapy for choroidal melanoma and to identify the limitations of this treatment method.

DESIGN

Noncomparative interventional case series.

PARTICIPANTS

The participants included 256 patients with newly diagnosed choroidal melanoma.

MAIN OUTCOME MEASURES

The outcome measures included local tumor recurrence and visual acuity.

RESULTS

Before treatment, the mean tumor base was 7.1 mm, and mean tumor thickness was 2.7 mm. Overlying subretinal fluid was present in 215 cases (84%) and orange pigment on the tumor surface in 200 cases (78%). All tumors showed either photographic documentation of growth (114 cases; 45%) or substantial risk factors for growth (142 cases; 55%). After a mean of three treatment sessions, complete tumor control without recurrence was found in 232 cases (91%) and recurrence in 24 cases (9%). The mean time to recurrence was 22 months, and the mean recurrent tumor size was 3.8 mm base and 2.4 mm thick. Of the recurrent tumors, additional thermotherapy was successful in controlling 13 (5%), plaque radiotherapy in 8 (3%), and enucleation in 3 (1%). Using multivariable analysis, the risk factors for tumor recurrence included increasing number of thermotherapy sessions (reflecting less responsive tumor) (P = 0.0001) and optic disc overhung by tumor (P = 0.03). Kaplan Meier estimates revealed that 4% showed recurrence at 1 year, 12% at 2 years, and 22% at 3 years follow-up. When analyzing those 214 patients without multivariable risk factors for recurrence, Kaplan Meier estimates for recurrence were 2% at 1 year, 8% at 2 years, and 10% at 3 years. The visual acuity after treatment was 20/20 to 20/40 in 128 cases (50%), 20/50 to 20/100 in 47 (18%), and 20/200 or worse in 81 (32%). Using multivariable analysis, the most statistically significant factors at initial visit that were predictive of poor visual acuity (20/200 or worse) after treatment included documented tumor growth before treatment (P = 0.0001), mushroom tumor configuration (P = 0.002), initial symptom of blurred vision (P = 0.008), poor initial visual acuity (P = 0.005), superior quadrant tumor location (P = 0.03), underlying diabetes mellitus (P = 0.04), and optic disc overhung by tumor (P = 0.04). Tumor-related mortality occurred in two patients (1%), one of whom showed complete tumor regression to thermotherapy and the other with diffuse choroidal melanoma and local tumor margin recurrence.

CONCLUSIONS

Transpupillary thermotherapy is an effective treatment for certain small choroidal melanomas. Appropriate tumor selection is critical to successful treatment. Patients with tumors abutting or overhanging the optic disc or those requiring more than three sessions for tumor control are more likely to develop ultimate tumor recurrence. Transpupillary thermotherapy can cause damaging effects to the retina, leading to visual loss shortly after treatment.

The Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation of large choroidal melanoma II: initial mortality findings. COMS report no. 10

PURPOSE

To report initial mortality findings from the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of pre-enucleation radiation of large choroidal melanoma.

METHODS

Patients were evaluated for eligibility at one of 43 participating centers in the United States and Canada. Eligible consenting patients were assigned randomly at the time of enrollment to standard enucleation or to external radiation of the orbit and globe prior to enucleation. Eligibility was confirmed at the COMS Coordinating Center, Echography Center, and Photograph Reading Center. Adherence to the radiotherapy protocol was monitored at the Radiological Physics Center. The diagnosis of choroidal melanoma was confirmed following enucleation by a three-member Pathology Review Committee. Patient accrual began in November 1986 and was completed in December 1994; 1,003 patients enrolled. Patients have been followed at annual clinical examinations. Cause of death was coded by a Mortality Coding Committee whose members were not involved in the care of COMS patients; the clinical trial was monitored by an independent Data and Safety Monitoring Committee.

RESULTS

A total of 1,003 patients were enrolled; 506 were assigned to enucleation alone and 497 to pre-enucleation radiation. Treatment groups were well balanced on baseline characteristics. Only nine patients were found to be ineligible after enrollment, seven in the interval between randomization and enucleation and two after enucleation based on histopathology. All but nine patients were treated as assigned; in only six of 491 eyes treated with pre-enucleation radiation was there a major deviation from the radiotherapy protocol. With 5-year outcome known for 801 patients enrolled (80%), the estimated 5-year survival rates and 95% confidence intervals (CIs) were 57% (95% CI, 52% to 62%) for enucleation alone and 62% (95% CI, 57% to 66%) for pre-enucleation radiation. Among the baseline covariates evaluated, only age and longest basal diameter of the melanoma affected the prognosis for survival to a statistically significant degree. The risk of death among patients treated with pre-enucleation radiation relative to those treated with enucleation alone after adjustment for baseline characteristics of patients, eyes, and tumors was 1.03 (95% CI, 0.85 to 1.25). Of 435 deaths classified by the Mortality Coding Committee, 269 patients had histologically confirmed melanoma metastases at the time of death. Estimated 5-year survival rates for this secondary outcome were 72% (95% CI, 68% to 76%) for enucleation alone and 74% (95% CI, 69% to 78%) for pre-enucleation radiation.

CONCLUSIONS

No survival difference attributable to pre-enucleation radiation of large choroidal melanoma, using the COMS fractionation schedule, has been demonstrated to date in this randomized trial. The trial had statistical power of 90% to detect a relative difference in mortality rates between the two treatment arms of 20% or larger. A smaller difference is possible, but a clinically meaningful difference in mortality rates, whether from all causes or from metastatic melanoma, is unlikely.

Factors Predictive of Tumor Growth, Tumor Decalcification, Choroidal Neovascularization, and Visual Outcome in 74 Eyes With Choroidal Osteoma

OBJECTIVE

To evaluate choroidal osteoma for tumor growth, tumor decalcification, related choroidal neovascularization, visual acuity loss, and poor visual acuity.

DESIGN

Retrospective nonrandomized single-center case series.

SETTING

Ocular Oncology Service at Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pa.

PARTICIPANTS

There were 74 eyes of 61 patients with choroidal osteoma evaluated between January 1, 1977, and January 1, 2003.

MAIN OUTCOME MEASURES

The 5 outcome measures included tumor growth, tumor decalcification, related choroidal neovascularization, visual acuity loss of 3 or more Snellen lines, and poor visual acuity of 20/200 or worse.

RESULTS

At 5 and 10 years, Kaplan-Meier analysis revealed tumor growth in 22% and 51% of eyes, tumor decalcification in 28% and 46% of eyes, choroidal neovascularization in 31% and 31% of eyes, visual acuity loss in 26% and 45% of eyes, and poor visual acuity in 45% and 56% of eyes, respectively. The clinical factor predictive of tumor growth was absent overlying retinal pigment epithelial alterations. The factor predictive of decalcification was irregular tumor surface. Of the 15 tumors that showed partial decalcification at the first visit, there was no further tumor growth in any case. Of the remaining 12 tumors that later developed decalcification, tumor growth, if it occurred, was along the margin opposite the decalcification. No tumor showed growth in the region of decalcification. Factors predictive of choroidal neovascularization included irregular tumor surface and subretinal hemorrhage. In 6 eyes that had both choroidal neovascularization and tumor decalcification, the neovascularization was detected prior to or at the same time as the decalcification. The factor predictive of visual acuity loss was presence of subretinal fluid whereas the factors predictive of poor visual acuity included symptoms and tumor decalcification. A comparison of eyes with subfoveal vs extrafoveal choroidal osteoma showed poor visual acuity in 15 (34%) of 44 eyes and 3 (10%) of 30 eyes, respectively. Eyes with decalcified choroidal osteomas manifested poor visual acuity in 13 (48%) of 27 eyes whereas those with nondecalcified tumors showed poor visual acuity in 5 (11%) of 47 eyes.

CONCLUSIONS

Choroidal osteoma showed evidence of growth in 51% of eyes and decalcification in nearly 50% of eyes by 10 years. Tumors with any degree of decalcification at the initial visit showed no further growth. Overall, poor visual acuity of 20/200 or worse was found in 56% of eyes by 10 years, and decalcified subfoveal choroidal osteomas displayed a particularly poor visual prognosis.

Transpupillary thermotherapy for choroidal melanoma: tumor control and visual results in 100 consecutive cases

OBJECTIVE

The authors evaluated the results of primary transpupillary thermotherapy for choroidal melanoma in 100 cases.

DESIGN

Prospective nonrandomized analysis of treatment method.

PARTICIPANTS

One hundred patients with choroidal melanoma were studied.

MAIN OUTCOME MEASURES

Tumor response, ocular side effects, and visual results.

RESULTS

Of 100 consecutive patients with choroidal melanoma treated with transpupillary thermotherapy, the mean tumor basal diameter was 7.1 mm and tumor thickness was 2.8 mm. The tumor margin touched the optic disc in 34 eyes (34%) and was beneath the fovea in 42 eyes (42%). Documented growth was present in 64 eyes (64%), and known clinical risks for growth were present in all of the remaining 36 eyes (36%), with an average of 4 of 5 statistical risk factors for growth per tumor. After a mean of three treatment sessions and 14 months of follow-up, the mean tumor thickness was reduced to 1.4 mm. Treatment was successful in 94 eyes (94%) and failed in 6 eyes (6%). Three patients with amelanotic tumors showed no initial response to thermotherapy, but subsequent intravenous indocyanine green administration during thermotherapy resulted in improved heat absorption and tumor regression to a flat scar. The six eyes classified as treatment failures included four eyes with tumors that showed partial or no response to thermotherapy, thus requiring plaque radiotherapy or enucleation, and two eyes with recurrence, subsequently controlled with additional thermotherapy. After treatment, the visual acuity was the same (within 1 line) or better than the pretreatment visual acuity in 58 eyes (58%) and worse in 42 eyes (42%). The main reasons for poorer vision included treatment through the foveola for subfoveal tumor (25 eyes), retinal traction (10 eyes), retinal vascular obstruction (5 eyes), optic disc edema (1 eye), and unrelated ocular ischemia (1 eye). Temporal location (versus nasal and superior, P = 0.02) and greater distance from the optic disc (P = 0.04) were risks for retinal traction.

CONCLUSIONS

Transpupillary thermotherapy may be an effective treatment for small posterior choroidal melanoma, especially those near the optic disc and fovea. Despite satisfactory local tumor control, ocular side effects can result in decreased vision. Longer follow-up will be necessary to assess the impact of thermotherapy on ultimate local tumor control and metastatic disease.

Comparison of episcleral plaque and proton beam radiation therapy for the treatment of choroidal melanoma

PURPOSE

To compare the efficacy of iodine-125 (125I) and ruthenium-106 (106Ru) episcleral plaque radiation therapy and proton beam radiation therapy (PBRT) in the treatment of choroidal melanoma.

DESIGN

A retrospective, nonrandomized comparative study.

METHODS

Charts of patients treated with 125I, 106Ru, and PBRT for choroidal melanoma between January 1988 and June 1996 at St. Bartholomew's Hospital and Moorfields Eye Hospitals were reviewed.

MAIN OUTCOME MEASURE

Local control of choroidal melanomas after 125I, 106Ru, or PBRT.

RESULTS

A total of 597 patients were identified (125I = 190, 106Ru = 140, PBRT = 267). Patients treated with 106Ru had a significantly greater risk of local tumor recurrence than did patients treated with either 125I (P = 0.0133; confidence interval [CI], 1.26-7.02; risk ratio, 2.97) or PBRT (P = 0.0097; CI, 1.30-6.66; risk ratio, 2.94). A stepwise Cox proportional hazard model found maximal basal diameter to be a significant covariate (P = 0.0033).

CONCLUSION

Patients treated with 106Ru had a significantly greater risk of local tumor recurrence than did those patients treated with either 125I or PBRT.