The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. The American College of Surgeons Commission on Cancer and the American Cancer Society

BACKGROUND

This study reviews the case-mix characteristics, management, and outcomes of melanoma cases occuring in the U.S. within the last decade.

METHODS

Analyses of the National Cancer Data Base (NCDB) were performed on cases diagnosed between 1985 through 1994. A total of 84,836 cases comprised of cutaneous and noncutaneous melanomas were evaluated.

RESULTS

The percentages of melanomas that were cutaneous, ocular, mucosal, and unknown primaries were 91.2%, 5.2%, 1.3%, and 2.2%, respectively. For cutaneous melanomas, the proportion of patients presenting with American Joint Committee on Cancer Stages 0, I, II, III, and IV were 14.9%, 47.7%, 23.1%, 8.9%, and 5.3%, respectively. Factors associated with decreased survival included more advanced stage at diagnosis, nodular or acral lentiginous histology, increased age, male gender, nonwhite race, and lower income. Multivariate analysis identified stage, histology, gender, age, and income as independent prognostic factors. For ocular melanomas, 85.0% were uveal, 4.8% were conjunctival, and 10.2% occurred at other sites. During the study period, there was a large increase in the proportion of ocular melanoma patients treated with radiation therapy alone. For mucosal melanomas, the distribution of head and neck, female genital tract, anal/rectal, and urinary tract sites was 55.4%, 18.0%, 23.8%, and 2.8%, respectively. Patients with lymph node involvement had a poor prognosis. For unknown primary melanomas, the distribution of metastases as localized to a region or multiple sites at presentation was 43.0% and 57.0%, respectively. Surgical treatment of patients with unknown primary site of the melanoma resulted in better survival compared with no treatment.

CONCLUSIONS

Treatment of early stage cutaneous melanoma resulted in excellent patient outcomes. In addition to conventional prognostic factors, socioeconomic factors were found to be associated with survival.

Epidemiologic aspects of uveal melanoma

Although the underlying cause or causes of uveal melanoma have yet to be elucidated, important insights may be gained by examining the epidemiologic features of the disease. Uveal melanoma is an uncommon cancer with an incidence of only six cases per million population per year. It is most often diagnosed in the sixth decade and is somewhat more common in males. Apart from sporadic reports of family clusters, uveal melanoma is not considered an inherited disease. Whether some environmental exposure triggers the development of uveal melanoma remains an open question. Sunlight has been proposed as an environmental risk factor because sunlight is known to cause melanoma of the skin and both diseases are rare in nonwhite races. Unlike cutaneous melanoma, however, rates have not been increasing over time and do not vary by latitude. This paper evaluates the available evidence for sunlight and other potential risk factors for uveal melanoma, highlighting areas requiring further research.

Incidence of uveal melanoma in the United States: 1973-1997

PURPOSE

To determine the incidence of primary uveal melanoma in the United States over a 25-year period from 1973 to 1997.

DESIGN

Systematic review of existing databases.

PARTICIPANTS

Two thousand four hundred ninety-three patients with primary uveal melanoma (International Classification of Oncology [ICDO-2] codes C69.3 [choroid melanoma] and C69.4 [ciliary body and iris]) derived from the Surveillance, Epidemiology, and End Results (SEER) program database in the United States from 1973 to 1997.

METHODS

The significance of trend in age-adjusted incidence rate was determined using chi-square test, and 95% confidence intervals were calculated.

MAIN OUTCOME MEASURES

The age-adjusted incidence rate.

RESULTS

There was a total of 2493 cases of uveal melanoma, representing 2.9% of all recorded cases of melanoma. Almost all cases (99.4%) were reported by the hospitals, and histopathologic confirmation was available in 81.3% of cases. The mean age-adjusted incidence of uveal melanoma in the United States was 4.3 per million (4.1-4.5; 95% confidence interval [CI]). Most cases (97.8%) occurred in the white population. There was significant variation of incidence between genders (males, 4.9 [4.6-5.2] 95% CI interval; females, 3.7 [3.5-3.9] 95% CI interval). There was no significant variation of incidence by the geographic location of the registry and over the entire period of observation (chi-square test).

CONCLUSIONS

The mean age-adjusted incidence of uveal melanoma (4.3 per million) in the United States is similar to that reported from European countries. The age-adjusted incidence rate of uveal melanoma has remained stable for the past 25 years.

Incidence of uveal melanoma in Europe

PURPOSE

To estimate incidence rates of uveal melanoma in Europe from 1983 to 1994.

DESIGN

Incidence analysis of data from cancer registries adhering to the European Cancer Registry-based study on survival and care of cancer patients (EUROCARE) (cases diagnosed from 1983 to 1994).

PARTICIPANTS

Data of 6673 patients with ocular melanoma (as defined by International Classification of Diseases for Oncology morphology codes 8720 to 8780 [melanoma] and International Classification of Diseases 9 (ICD9) codes 190.0 [iris and ciliary body], 190.5 [retina], 190.6 [choroid], and 190.9 [unspecified ocular location]) from 33 cancer registries of 16 European countries.

METHODS

Incidence rate ratios (IRRs) were obtained from a multilevel Poisson regression model.

MAIN OUTCOME MEASURES

Incidence rates and IRRs associated with demographic and geographic variables.

RESULTS

Standardized incidence rates increased from south to north across registries, from a minimum of <2 per million in registries of Spain and southern Italy up to >8 per million in Norway and Denmark. The inclusion of tumors with unspecified ocular location (code 190.9) increased incidence rates in most United Kingdom registries, but not in the other geographic areas, where this code was seldom used for uveal melanomas. Incidence increased noticeably up to age 55 (IRR, 1.46 per 5 years; 95% confidence interval [CI], 1.36-1.57) but leveled off after age 75 (IRR, 0.99 per 5 years; 95% CI, 0.93-1.05), with intermediate levels midway (IRR, 1.18 per 5 years; 95% CI, 1.12-1.23). It was also higher in males (IRR, 1.22; 95% CI, 1.16-1.28). Rates were stable during the study period, but a cohort effect was evidenced, accounting for higher incidence rates in people born during the period 1910 to 1935 (P = 0.005). Incidence increased with latitude (P = 0.008), which explained most differences in rates among areas.

CONCLUSIONS

In this large series of uveal melanomas, we found stable incidence during the years 1983 to 1994. The north-to-south decreasing gradient supports the protective role of ocular pigmentation. European ophthalmologists should develop guidelines to standardize the coding of tumors treated conservatively using the ICD classification to improve the registration and surveillance of uveal melanoma by cancer registries.

Uveal melanoma: From diagnosis to treatment and the science in between

Melanomas of the choroid, ciliary body, and iris of the eye are collectively known as uveal melanomas. These cancers represent 5% of all melanoma diagnoses in the United States, and their age-adjusted risk is 5 per 1 million population. These less frequent melanomas are dissimilar to their more common cutaneous melanoma relative, with differing risk factors, primary treatment, anatomic spread, molecular changes, and responses to systemic therapy. Once uveal melanoma becomes metastatic, therapy options are limited and are often extrapolated from cutaneous melanoma therapies despite the routine exclusion of patients with uveal melanoma from clinical trials. Clinical trials directed at uveal melanoma have been completed or are in progress, and data from these well designed investigations will help guide future directions in this orphan disease. Cancer 2016;122:2299-2312. © 2016 American Cancer Society.

Uveal melanoma: epidemiologic aspects

Melanomas of the ocular and adnexal structures comprise approximately 5% of all melanomas. The majority (85%) of ocular melanomas are uveal in origin; primary conjunctival and orbital melanomas are rare. The diagnosis of uveal melanoma is made by clinical examination including indirect ophthalmoscopy and by ancillary studies such as fluorescein angiography and ultrasonography. Metastases to the liver develop within 15 years after the initial diagnosis and treatment in approximately 50% of patients with posterior uveal melanoma; however, clinically evident metastatic disease at the time of initial presentation is uncommon, indicating that there is early subclinical metastasis in most cases.

The association between host susceptibility factors and uveal melanoma: a meta-analysis

OBJECTIVE

To conduct a meta-analysis, using observational studies, to examine the association between host susceptibility factors and uveal melanoma.

METHODS

A review of 132 published reports on risk factors for uveal melanoma revealed 10 case-control studies that provided enough information to calculate odds ratios (ORs) and standard errors for host susceptibility factors. Data from these studies were extracted and categorized. Summary statistics were calculated for all risk factors reported by at least 4 independent studies.

RESULTS

Summary statistics using meta-analysis are presented as ORs and their 95% confidence intervals (CIs). Statistically significant risk factors include light eye color (OR, 1.75 [95% CI, 1.31-2.34]), using 10 studies (1732 cases); fair skin color (OR, 1.80 [95% CI, 1.31-2.47]), using 5 studies (586 cases); and ability to tan (OR, 1.64 [95% CI, 1.29-2.09]), using 6 studies (1021 cases). Blond or red hair color, using 7 studies (1012 cases), was not a statistically significant independent risk factor (OR, 1.02 [95% CI, 0.82-1.26]).

CONCLUSION

This meta-analysis yielded strong evidence associating the host susceptibility factors of iris color, skin color, and ability to tan with uveal melanoma.

Sunlight exposure as risk factor for intraocular malignant melanoma

In a case-control study, we compared 444 patients with intraocular malignant melanoma with matched controls to evaluate the role of exposure to ultraviolet radiation and other risk factors in the pathogenesis of this tumor. Persons born in the southern United States had a relative risk of 2.7 (95 per cent confidence interval, 1.3 to 5.9) as compared with those born in the North. Subjects with brown eyes were protected as compared with those with blue eyes (relative risk, 0.6; 95 per cent confidence interval, 0.4 to 0.8), but complexion and hair color were not important risk factors. Patients with intraocular malignant melanoma were also more likely to have spent time outdoors in their gardens, to have sunbathed, and to have used sunlamps. Rarely wearing hats, visors, or sunglasses while in the sun was a risk factor for the disease (relative risk, 1.9; 95 per cent confidence interval, 1.6 to 2.2). These data suggest that sunlight exposure is an important risk factor for intraocular melanoma.

Lifetime prevalence of uveal melanoma in white patients with oculo(dermal) melanocytosis

OBJECTIVE

In the white population, an association between oculo(dermal) melanocytosis (ODM) and uveal melanoma is well recognized. However, the lifetime prevalence of uveal melanoma in the ODM population is not known. This study was designed to determine the lifetime prevalence of uveal melanoma among patients with ocular melanocytosis.

DESIGN

Fifty-six white patients manifesting ODM with uveal melanoma formed the basis of the study.

MAIN OUTCOME MEASURES

Published prevalence rates of ODM and uveal melanoma were used for calculations using Bayes' theorem.

RESULTS

The lifetime prevalence of uveal melanoma in white patients with ODM is estimated to be 2.6 x 10(-3). The median age at diagnosis of uveal melanoma in the ODM population was similar to a randomly selected population (60.5 years and 62.5 years, respectively). In the vast majority of patients (90%) with ODM-associated uveal melanoma, the uveal melanoma was diagnosed between the ages of 31 years and 80 years.

CONCLUSIONS

One of about 400 patients with ODM followed for life is estimated to develop uveal melanoma. Excessive melanocytes in the uveal tract in ODM may provide the biologic basis for susceptibility to the development of uveal melanoma. Patients with ODM should be monitored ophthalmoscopically, especially during the susceptible period, for the development of uveal melanoma. The authors suggest that a national registry of ODM patients be created and prospective data collected to better assess the risk of developing uveal melanoma.

Intermittent and chronic ultraviolet light exposure and uveal melanoma: a meta-analysis

OBJECTIVE

To examine the association between ultraviolet light exposure and uveal melanoma.

DESIGN

Meta-analysis.

METHODS

A review of 133 published reports on risk factors for uveal melanoma revealed 12 studies that provided sufficient information to calculate odds ratios (ORs) and standard errors for ultraviolet light exposure factors. Data from these studies were extracted and categorized into intermittent ultraviolet exposure factors (welding, outdoor leisure, photokeratitis) and chronic ultraviolet exposure factors (occupational sunlight exposure, birth latitude, lifetime ultraviolet exposure index). Summary statistics were calculated for all risk factors reported by > or =4 independent studies.

MAIN EXPOSURE MEASURES

Welding, outdoor leisure, photokeratitis, occupational sunlight exposure, birth latitude, and lifetime ultraviolet exposure index.

RESULTS

For intermittent ultraviolet exposure, welding was found to be a significant risk factor (5 studies, 1137 cases; OR, 2.05 [95% confidence interval [CI], 1.20-3.51]). Outdoor leisure was found to be nonsignificant (4 studies, 1332 cases; OR, 0.86 [95% CI, 0.71-1.04]). Photokeratitis conferred susceptibility in 3 reports studying this variable, but there were too few studies to validate meta-analyses. For chronic ultraviolet exposure, meta-analysis found occupational sunlight exposure to be a borderline nonsignificant risk factor for development of uveal melanoma (4 studies, 572 cases; OR, 1.37 [95% CI, 0.96-1.96]). Latitude of birth was found to be nonsignificant (5 studies, 1765 cases; OR, 1.08 [95% CI, 0.67-1.74]).

CONCLUSION

This meta-analysis yielded inconsistent results associating ultraviolet light with development of uveal melanoma. There was evidence implicating welding as a possible risk factor for uveal melanoma.

Occupational risk factors, ultraviolet radiation, and ocular melanoma: a case-control study in France

BACKGROUND

Ultraviolet radiation has been suspected as a possible cause of ocular melanoma. Because this association is controversial, we examine the role of occupational exposure to ultraviolet radiation on the occurrence of this rare cancer.

MATERIAL AND METHODS

A population-based case-control study was conducted in 10 French administrative areas (départements). Cases were 50 patients with uveal melanoma diagnosed in 1995-1996. Controls were selected at random from electoral rolls, after stratification for age, gender, and area. Among 630 selected persons, 479 (76%) were interviewed. Data on personal characteristics, occupational history, and detailed information on each job held were obtained from face-to-face interviews using a standardized questionnaire. Estimates of occupational exposure to solar and artificial ultraviolet light were made using a job exposure matrix.

RESULTS

Results show elevated risks of ocular melanoma for people with light eye color, light skin color, and for subjects with several eye burns. The analysis based on the job exposure matrix showed a significantly increased risk of ocular melanoma in occupational groups exposed to artificial ultraviolet radiation, but not in outdoor occupational groups exposed to sunlight. An elevated risk of ocular melanoma was seen among welders (odds ratio = 7.3; 95% confidence interval = 2.6-20.1 for men), and a dose-response relationship with job duration was observed. The study also showed increased risk of ocular melanoma among male cooks, and among female metal workers and material handling operators.

CONCLUSION

Following the present study, the existence of an excess risk of ocular melanoma in welders may now be considered as established. Exposure to ultraviolet light is a likely causal agent, but a possible role of other exposures in the welding processes should not be overlooked.

The possible role of radiofrequency radiation in the development of uveal melanoma

There are few epidemiologic studies dealing with electromagnetic radiation and uveal melanoma. The majority of these studies are exploratory and are based on job and industry titles only. We conducted a hospital-based and population-based case-control study of uveal melanoma and occupational exposures to different sources of electromagnetic radiation, including radiofrequency radiation. We then pooled these results. We interviewed a total of 118 female and male cases with uveal melanoma and 475 controls matching on sex, age, and study regions. Exposure to radiofrequency-transmitting devices was rated as (a) no radiofrequency radiation exposure, (b) possible exposure to mobile phones, or (c) probable/certain exposure to mobile phones. Exposures were rated independently by two of the authors who did not know case or control status. We used conditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs). We found an elevated risk for exposure to radiofrequency-transmitting devices (exposure to radio sets, OR = 3.0, 95% CI = 1.4-6.3; probable/certain exposure to mobile phones, OR = 4.2, 95% CI = 1.2-14.5). Other sources of electromagnetic radiation such as high-voltage lines, electrical machines, complex electrical environments, visual display terminals, or radar units were not associated with uveal melanoma. This is the first study describing an association between radiofrequency radiation exposure and uveal melanoma. Several methodologic limitations prevent our results from providing clear evidence on the hypothesized association.

Sunlight exposure and pathogenesis of uveal melanoma

Uveal melanoma is the most frequent primary malignant intraocular tumor of adults. Among various non-modifiable risk factors, Caucasian race seems to be the most significant with light skin color, blond hair, and blue eyes being specific risk factors. The racial predisposition to uveal melanoma have been explained on the basis of susceptibility of Caucasian race to oncogenic effects of sunlight. Although there is ample evidence in support of this hypothesis in regard to skin melanoma, the evidence in regard to uveal melanoma is insufficient and contradictory. In the following review, we examine physiologic, epidemiological, and genetic data in order to determine the role of sunlight exposure in the pathogenesis of uveal melanoma.

Epidemiological trends in uveal melanoma

BACKGROUND

There has been a recent evolution in the management of uveal melanoma in regard to prognostic evaluation and treatment modalities. This study aims to evaluate the epidemiological trends of uveal melanoma since 1973 by using the Surveillance, Epidemiology, and End Results (SEER) Registry.

METHODS

A total of 7043 uveal melanoma cases from the SEER database were retrospectively analysed, spanning 1973 to 2009. The main outcome measures were disease specific and overall patient survival.

RESULTS

The mean patient age at diagnosis was 61.4 years, which has increased over the last 37 years. The mean follow-up interval was 85.9 months. The proportion of tumours demonstrating spindle cell histology has decreased. Spindle cell tumours yielded superior disease-specific survival to epithelioid and mixed tumours. The median age at diagnosis of spindle cell tumours (60 years) was significantly younger than epithelioid tumours (65 years) and mixed tumours (64 years old; p < 0.0001). In a Cox proportional hazards regression analysis, tumour histology, T stage and age at diagnosis were associated with disease-specific survival. The prevalence of cutaneous melanoma was increased in patients with uveal melanoma, but the lifetime prevalence of other primary cancers was not appreciably increased.

CONCLUSIONS

The SEER data set demonstrates epidemiological trends in patient age at diagnosis and tumour histology over the last 37 years. Several patient and tumour characteristics are predictors of disease-specific survival. These findings have implications for disease surveillance and prognostic counselling.

High intensity 125-iodine (125I) plaque treatment of uveal melanoma

PURPOSE

Episcleral 125I plaque therapy of uveal melanoma is an important treatment modality to control tumor, salvage the globe, and potentially preserve vision. We retrospectively analyzed our experience in 239 patients to assess treatment outcome with this technique.

METHODS AND MATERIALS

Between 1983 and 1990, 239 uveal melanoma patients were treated with 125I plaques at the University of California, San Francisco. High intensity 125I seeds in the range of 3-20 mCi were used to give a minimum tumor dose of 70 Gy in 4 days. Initial mean tumor size was 10.9 mm x 9.2 mm x 5.5 mm with a range in tumor diameter from 4 to 18 mm and tumor height from 1.9 to 11.1 mm. Best corrected pre-treatment visual acuity was 20/200 or better in 92% of patients.

RESULTS

Local tumor control was maintained in 91.7% of patients with a mean follow-up of 35.9 months; 19 patients had local tumor progression; mean time to progression was 27.3 mo (1.8 to 60.1 mo). Actuarial local control is 82% at 5 years. Multivariate analysis demonstrates significant correlation of local failure with larger maximum tumor diameter (p = 0.0008), closer proximity to the fovea (p = 0.0001), lower radiation dose (p = 0.0437), and smaller ultrasound height (p = 0.0034). The actuarial incidence of distant metastases is 12% at 5 years with multivariate analysis showing significant correlation only with maximum tumor diameter (p = 0.0064). Visual outcome is 20/200 or better in 58% of patients.

CONCLUSION

While the tumor control rates appear favorable, ocular morbidity is significant. A current randomized trial comparing 125I plaque with Helium ion therapy is in progress with specific comparison of tumor control, survival, and visual outcome.

Descriptive epidemiology of malignant mucosal and uveal melanomas and adnexal skin carcinomas in Europe

This work provides descriptive epidemiological data of malignant mucosal and uveal melanomas and adnexal skin carcinomas in Europe as defined as in the RARECARE project. We analysed 8669 incident cases registered in the period 1995-2002 by 76 population-based cancer registries (CRs), and followed up for vital status to 31st December 2003. Age-standardised incidence to the European standard population was obtained restricting the analysis to 8416 cancer cases collected by 64 not specialised CRs or with information available only for some anatomical sites. Period survival rates at 2000-2002 were estimated on 45 CRs data. Twenty-two CRs which covered the period 1988-2002 were analysed to obtain the 15-year prevalence (1st January 2003 as reference date). Complete prevalence was calculated by using the completeness index method which estimates surviving cases diagnosed prior to 1988 ('unobserved' prevalence). The expected number of new cases per year and of prevalent cases in Europe was then obtained multiplying the crude incidence and complete prevalence rates to the European population at 2008. We estimated 5204 new cases per year (10.5 per million) to occur in Europe, of which 48.7% were melanomas of uvea, 24.8% melanomas of mucosa and 26.5% adnexal carcinomas of the skin. Five-year relative survival was 40.6% and 68.9% for mucosal and uveal melanomas, respectively. Adnexal skin carcinomas showed a good prognosis with a survival of 87.7% 5 years after diagnosis. Northern Europe, United Kingdom (UK) and Ireland showed the highest 5-year survival rate for uveal melanomas (72.6% and 73.4%), while Southern Europe showed the lowest rate (63.7%). More than 50,000 persons with a past diagnosis of one of these rare cancers were estimated to be alive at 2008 in Europe, most of them (58.8%, n=29,676) being patients with uveal melanoma. Due to the good prognosis and high incidence of uveal melanomas, these malignancies are highly represented among the long-term survivors of the studied rare cancer types. Therefore, maximising quality of life is particularly important in treatment of uveal melanoma. As regards mucosal melanomas, the centralisation of treatment to a select number of specialist centres as well as the establishment of expert pathology panels should be promoted. The geographical differences in incidence and survival should be further investigated analysing the centre of treatment, the stage at diagnosis and the treatment.

Uveal and Conjunctival Malignant Melanoma in Denmark, 1943–97: Incidence and Validation Study

PURPOSE

To study the incidence of malignant melanoma in the ocular region in Denmark during the period 1943-97.

METHODS

The patients were mainly identified through the Danish Cancer Registry. Age-period-cohort modelling of the incidence rates was done based on age at diagnosis, calendar period and birth cohort in 5-year groups and for each gender.

RESULTS

The age-standardized incidence of malignant melanoma in the ocular region was 0.78 for men (N = 1327) and 0.65 for women (N = 1242) per 100,000 person-years. Calendar period and birth cohort had no effect on the incidence in the ocular region or in the topography subgroups choroid/ciliary body and conjunctiva. However, the incidence increased with birth cohort for iris melanomas.

CONCLUSIONS

The incidence of malignant melanoma in the ocular region was stable in contrast to a major increase in cutaneous melanoma in Denmark during the period 1943-97. The incidence of iris melanomas increased substantially, whereas the rate was stable for choroid/ciliary body and conjunctival melanomas.

Immunotherapy for the Treatment of Uveal Melanoma: Current Status and Emerging Therapies

PURPOSE OF REVIEW

Uveal melanoma is a distinct subset of melanoma with a biology and treatment approach that is unique from that of cutaneous melanoma. Here we will review the current data evaluating immunotherapies in both the adjuvant and metastatic settings in uveal melanoma.

RECENT FINDINGS

In the adjuvant setting, interferon demonstrated no survival benefit in uveal melanoma, and studies evaluating immune-based strategies such as vaccine therapy are ongoing. Anti-CTLA-4 and anti-PD-1/ PD-L1 blockade in uveal melanoma have been evaluated in several small prospective and/or retrospective studies with rare responses and no overall survival benefit demonstrated. Ongoing studies evaluating combination checkpoint inhibition and other antibody-based therapies are ongoing. Although immunotherapy with anti-CTLA-4 and anti-PD-1 agents has dramatically changed the treatment approach to cutaneous melanoma, its success in uveal melanoma has been much more limited. Clinical trial participation should be prioritized in patients with uveal melanoma.

Mode of presentation and time to treatment of uveal melanoma in Finland

AIMS

To investigate the current referral pattern and delays in treatment of patients with primary uveal melanoma.

METHODS

184 consecutive Finnish patients with uveal melanoma diagnosed between July 1994 and June 1999 were eligible, and 159 were enrolled (inclusion rate, 86%). Their mean age was 60 years (range 14-87). The dates of visits to dispensing optician, physician, ophthalmologist and ocular oncologist, the presence of symptoms, and reason for consultation were determined by structured telephone interview. Time intervals to treatment planning and treatment were calculated.

RESULTS

139 patients (87%) had symptoms at presentation and 44 patients (28%) had been seen by an ophthalmologist less than 2 years previously. The median height of the tumour was 6 mm (range, 1.0-17.0) and its largest basal diameter 11 mm (range 2.5-22.0) at diagnosis. Melanoma developed from a previously detected presumed naevus in 13 patients (8%). When the first contact was a dispensing optician (15%) the median time to treatment planning was 22 days (range 1-1156). When a physician other than an ophthalmologist (19%) was contacted the delay was 68 days (range 0-1283) and when an ophthalmologist (65%) was seen it was 34 days (range 1-1426). These differences were not significant (p=0.32). The chance of being referred at first visit was 89%. Median time to treatment was not associated with symptoms (p=0.16) and tumour volume (p=0.29), but it was significantly different between patients who were and were not referred at first visit (140 days v 34 days; p<0.001) and between those treated by ruthenium and iodine brachytherapy (59 days v 33 days; p=0.009).

CONCLUSIONS

Analysis of delays in management indicates that earlier treatment could be achieved if dilated fundus examinations were performed without exceptions, all suspicious naevi were referred for a second opinion, and if the patients with melanoma were referred to the ocular oncology service concurrently with staging examinations done at the regional hospital.

Intraocular melanoma linked to occupations and chemical exposures

We conducted a case-control study in the western United States to determine the relation between occupations or chemical exposures and increased risk of uveal melanoma. Among men (221 patients, 447 controls), we found increased risks for occupational groups who had intense exposure to ultraviolet light [odds ratio (OR) = 3.0; 95% confidence interval (CI) = 1.2-7.8], welding exposure (OR = 2.2; 95% CI = 1.3-3.5), and asbestos exposure (OR = 2.4; 95% CI = 1.5-3.9 for most likely exposed). The highest odds ratio was for the small number of men (nine cases, three controls) who were chemists, chemical engineers, and chemical technicians (OR = 5.9; 95% CI = 1.6-22.7). Odds ratios also were elevated for exposures to antifreeze, formaldehyde, pesticides, and carbon tetrachloride, but these findings, based on recall of specific chemical exposures, are more subject to recall bias than the findings based on occupational groups.

International uveal melanoma incidence trends in view of a decreasing proportion of morphological verification

The introduction of eye-preserving therapies for uveal melanoma in the 1970s complicates time trend analyses of the uveal melanoma incidence because the proportion of morphologically verified uveal melanoma has been decreasing over the decades. We carried out incidence trend analyses, based on data from internationally accredited population-based cancer registries throughout the world that take missing data on topography, morphology and basis of diagnosis of eye tumours into account. We selected incidence data of cancer registries that were included in Cancer Incidence In 5 Continents, Volumes VI-VIII covering a registration period of at least 15 years (usually 1983 to 1997) and classified each eye cancer as morphologically verified uveal melanoma, clinically diagnosed uveal melanoma, uveal melanoma identified as DCO case (Death certificate only), possibly uveal melanoma, other eye tumour or unclassifiable eye tumour and calculated age-standardized incidence rates by 3-year calendar periods using the World Standard Population as the reference. The uveal melanoma incidence decline in the United States SEER Caucasian population is due mainly to an incidence decline in the early registration period (from 1974-76 to 1986-88). The data from France and Italy suggest a recent increase in incidence. Uveal melanoma diagnosed clinically increasingly contribute to the overall uveal melanoma incidence over time. Combining all registries, the proportion of morphologically verified uveal melanoma decreased from 82% in 1983-87 to 75% in 1993-97. Uveal melanoma incidence rates remained quite stable during the period 1983-97. The interpretation of uveal melanoma incidence trends is complicated by missing data on topography within the eye, morphology and basis of diagnosis.

Long-term results of helium ion irradiation of uveal melanoma

Between 1978 and 1988, 307 patients with uveal melanoma were irradiated using helium ions at Lawrence Berkeley Laboratory. The length of follow-up ranged from 1-115 months (median 42 months). The 5-year actuarial treatment results were: local control rate, 96.8%, determinate survival rate, 81%, freedom from distant metastases, 76%, eye retention rate, 83%, and risk of developing neovascular glaucoma, 36%. Long-term vision outcome was analyzed in 81 patients with a minimum follow-up of 5 years. Forty-seven percent of patients retained vision of 20/200 or better. The median change in vision was a loss of four lines on the standard eye chart. Thirty-eight percent of patients had visual acuity either improve or remain within two lines of their pretreatment vision. A multivariate analysis identified tumor size as the only independently significant risk factor affecting survival, development of neovascular glaucoma, or the risk of enucleation; no risk factor correlated with local recurrence. Tumor size, tumor-fovea distance, and pretreatment visual acuity were independently significant risk factors influencing vision outcome. These results confirm that helium ion irradiation is an effective treatment for uveal melanoma which combines high rates of local control, survival, and eye retention with a substantial likelihood of long-term vision preservation.

Epidemiological studies of radio frequency exposures and human cancer

Epidemiological studies of radio frequency (RF) exposures and human cancers include studies of military and civilian occupational groups, people who live near television and radio transmitters, and users of mobile phones. Many types of cancer have been assessed, with particular attention given to leukemia and brain tumors. The epidemiological results fall short of the strength and consistency of evidence that is required to come to a conclusion that RF emissions are a cause of human cancer. Although the epidemiological evidence in total suggests no increased risk of cancer, the results cannot be unequivocally interpreted in terms of cause and effect. The results are inconsistent, and most studies are limited by lack of detail on actual exposures, short follow-up periods, and the limited ability to deal with other relevant factors. In some studies, there may be substantial biases in the data used. For these same reasons, the studies are unable to confidently exclude any possibility of an increased risk of cancer. Further research to clarify the situation is justified. Priorities include further studies of leukemia in both adults and children, and of cranial tumors in relationship to mobile phone use.

Are atypical nevi a risk factor for uveal melanoma? A case-control study

Atypical nevi and other potential risk factors for uveal melanoma were studied in 109 uveal melanoma patients and 149 controls. Information concerning employment, medical history, drug use, family history of cancer, excess sun exposure, and blistering sunburn before and after the age of 15 was obtained. A total skin examination was performed and skin type, hair color, eye color, freckles, actinic damage, the total number of common acquired nevi, and the number of clinically atypical nevi were noted. More atypical nevi were found in uveal melanoma patients than in controls (age- and sex-adjusted odds ratio of 2.9 [95% confidence interval 1.2-6.3] for one or two atypical nevi versus none; odds ratio of 5.1 [95% CI 1.3-20.0] for three or more atypical nevi versus none). Light skin types and freckling also prevailed in uveal melanoma cases. In our study, atypical nevi are more common in uveal melanoma patients than in controls. Further studies will have to indicate whether risk factors comparable to those for cutaneous melanoma really exist for uveal melanoma.

Iris Colour and the Risk of Developing Uveal Melanoma

Uveal melanoma (UM) is a global disease which especially occurs in elderly people. Its incidence varies widely between populations, with the highest incidence among Caucasians, and a South-to-North increase in Europe. As northern Europeans often have blond hair and light eyes, we wondered whether iris colour may be a predisposing factor for UM and if so, why. We compared the distribution of iris colour between Dutch UM patients and healthy Dutch controls, using data from the Rotterdam Study (RS), and reviewed the literature regarding iris colour. We describe molecular mechanisms that might explain the observed associations. When comparing a group of Dutch UM patients with controls, we observed that individuals from Caucasian ancestry with a green/hazel iris colour (Odds Ratio (OR) = 3.64, 95% Confidence Interval (CI) 2.57-5.14) and individuals with a blue/grey iris colour (OR = 1.38, 95% CI 1.04-1.82) had a significantly higher crude risk of UM than those with brown eyes. According to the literature, this may be due to a difference in the function of pheomelanin (associated with a light iris colour) and eumelanin (associated with a brown iris colour). The combination of light-induced stress and aging may affect pheomelanin-carrying melanocytes in a different way than eumelanin-carrying melanocytes, increasing the risk of developing a malignancy.