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Maheshwari A, Finger PT, Iacob CE. Occult anterior uveal melanomas presenting as extrascleral extension. Br J Ophthalmol 2023; 107:1698-1703. [PMID: 36126107 PMCID: PMC10646849 DOI: 10.1136/bjo-2022-321837] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/17/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the management of patients with occult anterior uveal melanomas presenting with extrascleral extension. METHODS AND ANALYSIS Retrospective case series including five patients with small pigmented nodular mass on the episclera. Each lesion was documented by slit-lamp photography and measured with high-frequency ultrasound imaging (ultrasound biomicroscopy). Diagnosis of uveal melanoma was confirmed by biopsy with lamellar sclerectomy. Immediate scleral patch graft repair was performed. Later, each tumour was treated with palladium-103 ophthalmic plaque brachytherapy. The mean plaque diameter was 12 mm (median, 12; range, 10-14). A mean apex prescription dose of 87 Gy (median, 84.5; range, 82.3-99.2) to a tumour depth of 2 mm from the inner sclera delivered over 7 continuous days. The main outcome measures were best-corrected visual acuity, changes in tumour and scleral characteristics and complications. RESULTS During each surgery, residual tumour was visualised within an emissary passageway at the deep plane of scleral resection. At a mean of 80 months (median, 57; range, 24-159) follow-up, no patients experienced graft infection, scleromalacia or rejection. Biopsy was required to establish the diagnosis, transillumination failed, and therefore ultrasound measurements were used to determine the plaque size required to treat the relatively occult intraocular component. Despite these challenges, there were no cases of local tumour recurrence, secondary enucleation or metastatic disease. Attributed to cataract surgery, visual acuities improved in three patients and two were stable. CONCLUSION Extrascleral uveal melanoma extension can occur with undetectable, occult intraocular tumours. In these cases, plaque radiation effectively induced local tumour control, preserved vision and prevented metastasis.
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Affiliation(s)
- Abhilasha Maheshwari
- Ocular Tumor, Orbital Disease, and Ophthalmic Radiation Therapy, The New York Eye Cancer Center, New York, NY, USA
| | | | - Codrin E Iacob
- Pathology and Laboratory Science, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
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Adjuvant External Beam Radiotherapy Following Enucleation of Eyes With Extraocular Extension From Uveal Melanoma. Ophthalmic Plast Reconstr Surg 2021; 37:S48-S53. [PMID: 33009323 DOI: 10.1097/iop.0000000000001800] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To report local disease control and all-cause mortality in patients with extraocular extension (EOE) of uveal melanoma undergoing enucleation followed by observation or external beam radiotherapy (EBRT). METHODS Charts of patients enucleated between January 1, 1997 and December 31, 2019, with histopathological evidence of EOE of uveal melanoma were reviewed. RESULTS The cohort comprised 51 patients with a mean age of 67 ± 15 years, 22 (43%) of whom underwent adjuvant postenucleation EBRT. Risk factors for metastasis included presence of epithelioid cells (29/45; 88%), closed loops (20/43; 47%), monosomy 3 (16/25; 64%), and gain of 8q (20/22; 91%). Patients undergoing EBRT had more extensive EOE (median: 5.1 mm vs. 2.6 mm, p = 0.008) and surgical excision was less likely to be histologically complete (2/20; 10% vs. 14/25; 56%, p = 0.002). Local side effects following EBRT were seen in 64% (14/22). At latest follow up, 59% of patients (30/51) were alive, with a median follow up of 1.8 years (interquartile range: 2.9; range: 0.1-6.5]. By Kaplan-Meier survival analysis, the 5- and 10-year overall survival rates were 56% and 12%, respectively. There was no difference in all-cause mortality between those receiving adjuvant EBRT and those who were observed (log rank, p = 0.273). No cases of orbital recurrence were documented. CONCLUSIONS Orbital EBRT causes significant morbidity. Cases with relatively small EOE undergoing enucleation can be safely observed, without adjuvant EBRT. Multicenter studies are required to better assess the role of EBRT when EOE is more extensive.
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Seibel I, Riechardt AI, Erb-Eigner K, Böker A, Cordini D, Heufelder J, Joussen AM. Proton Beam Irradiation: A Safe Procedure in Postequatorial Extraocular Extension From Uveal Melanoma. Am J Ophthalmol 2018; 191:49-53. [PMID: 29655645 DOI: 10.1016/j.ajo.2018.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 03/31/2018] [Accepted: 04/04/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE This study was performed to show long-term outcomes concerning metastasis rates and local recurrence rates after primary proton beam therapy in uveal melanoma with posterior extraocular extension (EOE) with the main focus on optic nerve invasion. DESIGN Retrospective case series. METHODS All patients treated with primary proton beam therapy for choroidal or ciliary body melanoma with posterior EOE between July 1998 and August 2010 were included. EOE was detected either upon sonography at primary examination or during the surgical application of tantalum clips onto the sclera. Ultrasound was performed in each patient before surgery, and if EOE was detected, a magnetic resonance imaging (MRI) scan was performed to confirm EOE. All patients with tumors exceeding 6 mm in thickness or abutting the optic disc received a 1.5 Tesla MRI scan after clip surgery. To assess EOE during follow-up, either ultrasound examinations or-if initially detected only by MRI-MRI scans were performed during follow-up. RESULTS A total of 27 patients underwent primary proton beam therapy. The EOE was separated into 3 growth types: optic nerve infiltration in 10 patients, vortex vein infiltration in 9 patients, and transscleral growth postequatorially in 8 patients. No local recurrences were found during the overall median follow-up of 80 months (11-168 months). Metastasis rates correlated with AJCC stages but not EOE volume. CONCLUSION This study shows that posterior EOE can safely be treated by proton beam therapy, even if the optic nerve is infiltrated. MRI enables safe detection of optic nerve invasion.
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Affiliation(s)
- Ira Seibel
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Aline I Riechardt
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Alexander Böker
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dino Cordini
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany; BerlinProtonen am Helmholtz-Zentrum Berlin für Materialien und Energie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Heufelder
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany; BerlinProtonen am Helmholtz-Zentrum Berlin für Materialien und Energie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Antonia M Joussen
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Villegas VM, Monagas M, Campbell J, Murray TG, Serrano L. Selective Intra-Arterial Embolization for Advanced Extrascleral Uveal Melanoma. Ocul Oncol Pathol 2017; 4:44-47. [PMID: 29344498 DOI: 10.1159/000477772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 05/22/2017] [Indexed: 11/19/2022] Open
Abstract
Purpose To report a treatment approach for advanced extrascleral uveal melanoma. Methods We performed clinical examination including magnetic resonance imaging, computed tomography, angiography, and histopathologic analysis. Case A 49-year-old healthy woman presented with a 7-year history of an enlarging pigmented mass in her right orbit. Malignant melanoma was diagnosed after biopsy with immunohistochemical stains. Treatment included selective intra-arterial embolization. Results A significant reduction in tumor burden was seen 3 months after intra-arterial embolization. No complications were associated with the treatment. Conclusion Selective intra-arterial embolization may allow adequate palliative therapy in select cases of advanced extrascleral uveal melanoma.
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Affiliation(s)
- Víctor M Villegas
- Department of Ophthalmology, University of Puerto Rico, Río Piedras, Puerto Rico.,Bascom Palmer Eye Institute, University of Miami, FL, USA
| | - Mariola Monagas
- Department of Ophthalmology, University of Puerto Rico, Río Piedras, Puerto Rico
| | - Joseph Campbell
- Department of Ophthalmology, University of Puerto Rico, Río Piedras, Puerto Rico
| | | | - Luis Serrano
- Department of Ophthalmology, University of Puerto Rico, Río Piedras, Puerto Rico
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Cho Y, Chang JS, Yoon JS, Lee SC, Kim YB, Kim JH, Keum KC. Ruthenium-106 Brachytherapy with or without Additional Local Therapy Shows Favorable Outcome for Variable-Sized Choroidal Melanomas in Korean Patients. Cancer Res Treat 2017; 50:138-147. [PMID: 28343376 PMCID: PMC5784633 DOI: 10.4143/crt.2016.391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 03/03/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to report clinical outcomes of ruthenium-106 (106Ru) brachytherapy with or without additional local therapy for choroidal melanomas in Korean patients. Materials and Methods A total of 88 patients diagnosed with choroidal melanomas were treated with 106Ru brachytherapy between 2006 and 2012. Patients were divided into two groups according to their tumor height: a large group (≥ 6 mm, n=50) and a small group (< 6 mm, n=38). Most patients in the large group received combined therapy with local excision and/or transpupillary thermotherapy. In general, 85-95 Gy was administered to the apex of the tumor, while 100 Gy was administered to the point 2-6 mm from the outer surface of the sclera for patients undergoing combined therapy. Results The median follow-up duration was 30 months. The 3-year local control rate was significantly higher in the small group than in the large group (94% vs. 70%, p=0.047). The free from distant metastasis (FFDM) rate and the overall survival (OS) rate were also higher in patients in the small group (3-year FFDM, 97% vs. 76%; p=0.031 and 3-year OS, 97% vs. 72%; p=0.036). A total of 13 patients underwent enucleation. The eye-preservation rate was also higher in the small group (3-year eye-preservation rate, 94% vs. 70%; p=0.050), and tumor height was a significant prognostic factor for eye-preservation. Conclusion 106Ru brachytherapy showed favorable outcomes in small choroidal melanomas in Korean patients. Although additional local treatment could improve eye-preservation rate for large tumors, other strategies should be considered for disease control.
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Affiliation(s)
- Yeona Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sook Yoon
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Chul Lee
- Department of Ophthalmology, Institute of Vision Research, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Ho Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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Finger PT, Tena LB, Semenova E, Aridgides P, Choi WH. Extrascleral extension of choroidal melanoma: Post-enucleation high-dose-rate interstitial brachytherapy of the orbit. Brachytherapy 2014; 13:275-80. [DOI: 10.1016/j.brachy.2013.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/28/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
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Scleral Patch Grafts in the Management of Uveal and Ocular Surface Tumors. Ophthalmology 2012; 119:2631-6. [DOI: 10.1016/j.ophtha.2012.06.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/15/2012] [Accepted: 06/15/2012] [Indexed: 11/19/2022] Open
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Long-term follow-up of 42 patients with small ciliary body tumors with ultrasound biomicroscopy. Am J Ophthalmol 2010; 149:616-22. [PMID: 20346778 DOI: 10.1016/j.ajo.2009.11.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 11/13/2009] [Accepted: 11/17/2009] [Indexed: 11/22/2022]
Abstract
PURPOSE To establish the growth behavior of small ciliary body tumors in a relatively large cohort of patients over an extended period. DESIGN Retrospective, noncomparative case series. METHODS Ciliary body tumors less than 4 mm in size within the penetration power of ultrasound biomicroscopy (UBM) were included. Tumor height was assessed by ultrasound biomicroscopy. Tumor growth was defined as an increase in height of at least 20% from baseline, as measured on 2 consecutive UBM readings. The data were collected longitudinally, and a statistical analysis was performed. RESULTS Forty-two patients were included in the study with a median follow-up of 9.0 years (range, 1.0 to 17.2 years). The median age was 59 years (range, 17 to 82 years). Median initial tumor height was 2.05 mm (range, 1.11 to 3.80 mm). The overall average rate of growth was 0.0014 mm per year (P = .68). The 5- and 10-year accumulative tumor growth rates were 12% and 29%, respectively. In the first 3 years after diagnosis, the growth rate of ciliary body lesions with an initial tumor thickness less than or equal to 2 mm was 0.054 mm per year (P = 0.0001); thereafter, tumor size appeared to stabilize. Tumors with an initial thickness greater than 2 mm showed a small but significant rate of regression of 0.0125 mm per year (P = 0.04). CONCLUSIONS Most small tumors of the ciliary body show little growth over an extended period and can be managed conservatively without invasive diagnostic interventions. However, long-term follow-up is required. Indications for treatment include growth in height or lateral extension, extrascleral extension or the need for cataract surgery.
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Krema H, Simpson ER, Pavlin CJ, Payne D, Vasquez LM, McGowan H. Management of ciliary body melanoma with iodine-125 plaque brachytherapy. Can J Ophthalmol 2009; 44:395-400. [DOI: 10.3129/i09-097] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Gray ME, Corrêa ZM, Augsburger JJ, Barrett W. Ciliary body melanoma with limited nodular extrascleral extension and diffuse iris-angle infiltration treated by whole anterior segment plaque radiotherapy. Int Ophthalmol 2007; 27:273-6. [PMID: 17468833 DOI: 10.1007/s10792-007-9077-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 03/11/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Primary uveal malignant melanoma of the ciliary body associated with nodular extrascleral extension, diffuse iris-angle infiltration, and secondary glaucoma is usually treated by prompt enucleation. We report a patient with ciliary body melanoma associated with nodular extrascleral extension and diffuse infiltration of the iris and angle treated conservatively because the fellow eye was blind. METHODS The clinical features and surgical management of a melanoma of the ciliary body with extrascleral extension and diffuse infiltration of the iris and angle are presented. The tumor was treated with focal I-125 plaque radiotherapy followed by supplemental whole anterior segment I-125 plaque radiotherapy. RESULTS The patient has been followed for over 2.5 years since the initial plaque radiotherapy and over 1.5 years since the supplemental whole anterior segment radiotherapy. His visual acuity is correctable to 20/40 OD and there is no evidence of metastatic disease. His glaucoma is well controlled following trabeculectomy and tube shunt procedure. CONCLUSION Whole anterior segment plaque radiotherapy for ciliary body melanoma with diffuse iris-angle infiltration provided palliative local tumor control without significant local complications through available follow-up.
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Affiliation(s)
- Michael E Gray
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Muen WJ, Damato BE. Uveal malignant melanoma with extrascleral extension, treated with plaque radiotherapy. Eye (Lond) 2006; 21:307-8. [PMID: 16946742 DOI: 10.1038/sj.eye.6702581] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Abstract
BACKGROUND/AIMS Orbital exenteration is a psychologically and anatomically disfiguring procedure reserved for the treatment of potentially life threatening malignancies or relentlessly progressive conditions unresponsive to other treatments. In this study the authors aimed to review their experience with exenteration, including indications, outcomes, and reasons for the increased rate of exenterations over the past 15 months. METHOD This retrospective study reviewed operating department records via a computerised database to identify all patients who had undergone exenteration of the orbit from 1 January 1991 to 1 April 2004 inclusive, at the Manchester Royal Eye Hospital. Where case records were unavailable, attempts were made to obtain patient data from general practitioners, local health authorities, and referring hospitals. RESULTS 69 orbits of 68 patients were identified. The mean age of the cohort was 68.2 years, with 33 males and 35 females having undergone exenterations. In total, 31 patients had previously undergone treatments undertaken by the referring specialty with a mean time from the primary procedure to exenteration of 115 months. 14 different tumours were encountered, of which basal cell carcinoma (28), melanoma (10), sebaceous cell carcinoma (nine), and squamous cell carcinoma (six) were the most common. An increasing incidence was observed in cases of BCCs requiring exenteration. 30 patients received orbital prosthesis within an 11 month period post-exenteration. CONCLUSION Exenteration is a procedure performed with increasing frequency in this unit over the past 15 months, the majority the result of BCCs. A large proportion of these exenterations had undergone previous treatments under a variety of non-ophthalmic specialties in other units. Exenterations are disfiguring procedures that may, therefore, be reduced in incidence by aggressive removal at the time of primary removal. Once performed, the cosmetic rehabilitation is long, with multiple postoperative visits, independent of the method used to close the orbital defect.
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Affiliation(s)
- I Rahman
- Manchester Royal Eye Hospital, Lister Centre, Nelson Street, Manchester M13 9WL, UK.
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