Cobalt plaque versus enucleation for uveal melanoma: comparison of survival rates

Dual-source strength seed loading for eye plaque brachytherapy using eye physics eye plaques: A feasibility study

Purpose

This study quantifies the dosimetric impact of incorporating two iodine-125 (¹²⁵I) seed source strengths in Eye Physics eye plaques for treatment of uveal melanoma.

Material and methods

Plaque Simulator was used to retrospectively plan 15 clinical cases of three types: (1) Shallow tumors (< 5.5 mm) with large base dimensions (range, 16-19 mm); (2) Tumors near the optic nerve planned with notched plaques; and (3) Very shallow (< 3.0 mm) tumors with moderate base dimensions (range, 13.5-15.5 mm) planned with larger plaques than requested by the ocular oncologist. Circular plaques were planned with outer ring sources twice the source strength of inner sources, and notched plaques with the six seeds closest to the notch at twice the source strength.

Results

In cases of type (1), the dual-source strength plan decreased prescription depth, and doses to critical structures were lower: inner sclera -25% ±2%, optic disc -7% ±3%, and fovea -6% ±3%. In four out of five cases of type (2), the dual-source strength plan decreased prescription depth, and dose to inner sclera was lower (-22% ±5%), while dose to optic disc (17% ±7%) and fovea (20% ±12%) increased. In cases of type (3), a smaller dual-source strength plaque was used, and scleral dose was lower (-45% ±3%), whereas dose to optic disc (1% ±14%) and fovea (5% ±5%) increased.

Conclusions

Dual-source strength loading as described in this study can be used to cover tumor margins and decrease dose to sclera, and therefore the adjacent retina, but can either decrease or increase radiation dose to optic disc and fovea depending on location and size of the tumor. This technique may allow the use of a smaller plaque, if requested by the ocular oncologist. Clinical determination to use this technique should be performed on an individual basis, and additional QA steps are required. Integrating the use of volumetric imaging may be warranted.

Every other day stereotactic radiation therapy for the treatment of uveal melanoma decreases toxicity

BACKGROUND AND PURPOSE

To report the long-term results of stereotactic radiosurgery and fractionated stereotactic radiation therapy (SRS/FSRT) in patients with uveal melanoma (UM).

MATERIALS AND METHODS

We retrospectively evaluated the results of patients treated between 2007 and 2019. The primary endpoints were local control (LC), local recurrence-free survival (LRFS), enucleation-free survival (EFS) and treatment toxicity.

RESULTS

443 patients with 445 UMs were treated via CyberKnife®. According to the COMS classification, 70% of the tumors were small/medium and 30% were large. Median total RT dose was 54 Gy, median BED10 was 151 Gy. After a median 74-months follow-up, SRS/FSRT yielded an 83% overall LC rate. The 5- and 10-year LRFS rate was 74% and 56%, respectively. Patient age and the COMS size were prognostic for all survival endpoints. An increased SRS/FSRT dose was associated with higher LRFS and EFS rates. SRS/FSRT-related toxicity was observed in 49% of the eyes. Median visual acuity (VA) significantly deteriorated after SRS/FSRT in 76% of the treated eyes. The overall eye preservation rate was 62%, and the 5- and 10-year EFS rate was 64% and 36%, respectively. The delivery of FSRT every other day resulted in a significantly lower rate of toxicity and enucleation compared to FSRT on consecutive days.

CONCLUSION

A total dose of ≥45 Gy and BED_10Gy ≥ 112.5 SRS/FSRT is associated with a higher LC rate in patients with UM. Despite the favorable outcomes, treatment toxicity is the major limitation of this treatment. Toxicity and enucleation can be minimized by treating the eye every other day.

The Collaborative Ocular Melanoma Study: An Overview

BACKGROUND

The Collaborative Ocular Melanoma Study (COMS) is a 3-arm study that includes two multicenter randomized clinical trials designed to compare the effectiveness of brachytherapy to enucleation for treatment of medium-size choroidal melanomas, and the effectiveness of enucleation with and without preoperative external-beam radiotherapy for large choroidal melanomas. The third arm is an observational study of small choroidal melanomas. Patient accrual ran from 1987 to 1998.

METHODS

A review of COMS published reports was conducted.

RESULTS

There is no difference in 5-year all-cause mortality for large- and medium-size choroidal melanomas with COMS-designated treatments. Preoperative radiation for large choroidal melanomas does not improve survival. The accuracy of the clinical diagnosis of choroidal melanoma is excellent.

CONCLUSIONS

Data from the trials are still being collected and analyzed, but primary outcomes will unlikely change significantly in the future. Similar rates of mortality after treatment with enucleation and brachytherapy shift the emphasis of selection of therapy to secondary outcomes such as preservation of vision. The findings highlight the need to better understand the biological mechanisms and timing of hematogenous dissemination to achieve an appreciable impact on choroidal melanoma survival.

Atypical Presentation: Metastatic Uveal Melanoma in a Young Patient without Visual Complaints

BACKGROUND

Uveal melanoma is a rare and aggressive subtype of melanoma, with singular characteristics that separate it from the most famous cutaneous melanoma. This uncommon condition becomes even rarer if we look at young population. Common chemotherapy regimens does not work with this aggressive disease in its metastatic scenario, and the new armament like targeted and immunotherapies are still looking for more robust evidence.

CASE PRESENTATION

We report a rare case of uveal melanoma in a patient younger than 20 years, with abdominal pain as his initial complaint. He did not present the typical visual symptoms of the primary site because of an auto accident suffered 4 months before the presentation, letting him blind of the eye affected by the tumor development.

CONCLUSION

There is always a possibility of the diagnosis of uveal melanoma in cases with associated isolated hepatic metastases, even in a young population, where this hypothesis is often rejected by the epidemiological frequency of other tumors. This rare case is a useful example.

Ruthenium-106 brachytherapy for thick uveal melanoma: reappraisal of apex and base dose radiation and dose rate

Purpose

To evaluate the outcomes of ruthenium-106 (¹⁰⁶Ru) brachytherapy in terms of radiation parameters in patients with thick uveal melanomas.

Material and methods

Medical records of 51 patients with thick (thickness ≥ 7 mm and < 11 mm) uveal melanoma treated with ¹⁰⁶Ru brachytherapy during a ten-year period were reviewed. Radiation parameters, tumor regression, best corrected visual acuity (BCVA), and treatment-related complications were assessed.

Results

Fifty one eyes of 51 consecutive patients including 25 men and 26 women with a mean age of 50.5 ± 15.2 years were enrolled. Patients were followed for 36.1 ± 26.5 months (mean ± SD). Mean radiation dose to tumor apex and to sclera were 71 (± 19.2) Gy and 1269 (± 168.2) Gy. Radiation dose rates to tumor apex and to sclera were 0.37 (± 0.14) Gy/h and 6.44 (± 1.50) Gy/h. Globe preservation was achieved in 82.4%. Preoperative mean tumor thickness of 8.1 (± 0.9) mm decreased to 4.5 (± 1.6) mm, 3.4 (± 1.4) mm, and 3.0 (± 1.46) mm at 12, 24, and 48 months after brachytherapy (p = 0.03). Four eyes that did not show regression after 6 months of brachytherapy were enucleated. Secondary enucleation was performed in 5 eyes because of tumor recurrence or neovascular glaucoma. Tumor recurrence was evident in 6 (11.8%) patients. Mean Log MAR (magnification requirement) visual acuity declined from 0.75 (± 0.63) to 0.94 (± 0.5) (p = 0.04). Best corrected visual acuity of 20/200 or worse was recorded in 37% of the patients at the time of diagnosis and 61.7% of the patients at last exam (p = 0.04). Non-proliferative and proliferative radiation-induced retinopathy was observed in 20 and 7 eyes.

Conclusions

Thick uveal melanomas are amenable to ¹⁰⁶Ru brachytherapy with less than recommended apex radiation dose and dose rates.

Treatment of Uveal Melanoma

Uveal melanoma (UM) comprises approximately 5 % of all melanoma diagnoses in the USA each year. Approximately half of patients with UM eventually develop metastases, most commonly involving the liver. Historically, prognosis for these patients has been poor, with death occurring 6-12 months from the time of metastases. Multiple trials of cytotoxic treatments largely extrapolated from cutaneous melanoma have been ineffective in metastatic UM. Trials of regional hepatic-directed therapy have led to high response rates, but these have yet to be translated into a survival benefit. Recently, it was discovered that the majority of UMs harbor activating mutations in genes encoding one of two G-alpha protein subunits, GNAQ and GNA11. This knowledge has led to the rational development of clinical trials specifically for UM utilizing targeted inhibitors of the activated signaling pathways such as mitogen-activated protein kinase, Akt, and protein kinase C. A recent trial of the oral MEK inhibitor selumetinib was the first to show clinical benefit for any systemic therapy in a randomized fashion. This increasing understanding of the biology of UM offers hope that novel treatments will continue to benefit patients with metastatic disease.

Long-term followup comparing two treatment dosing strategies of (125) I plaque radiotherapy in the management of small/medium posterior uveal melanoma

Objective. To investigate the efficacy of two different dosing strategies of radioactive iodine-125 (¹²⁵I) in the management of small- and medium-sized posterior uveal melanoma. Patients and Methods. The medical records of consecutive patients with choroidal melanomas between 1.5 and 5.0 mm in apical height treated initially with ¹²⁵I plaque radiotherapy were reviewed. Patients were treated with one of the following two treatment dosing strategies: (1) 85 Gy to the apical height of the tumor (group 1) or (2) 85 Gy to a prescription point of 5.0 mm (group 2). Results. Of 95 patients, 55 patients were treated to the apical height of the tumor, and 40 were treated to a prescription point of 5.0 mm. Comparative analysis of the incidence rates of specific complications between the two groups demonstrates that group 2 had a significantly higher incidence of radiation retinopathy, radiation optic neuropathy, and/or visually significant cataract formation than group 1 (P = 0.028). Conclusion. Treatment of choroidal melanomas less than 5 mm in apical height with ¹²⁵I brachytherapy to the true apical height is equally effective when compared to treatment with 85 Gy to 5.0 mm. Treatment to the apical height of the tumor may result in lower incidence of radiation-related complications.

Combination of bevacizumab and irradiation on uveal melanoma: an in vitro and in vivo preclinical study

BACKGROUND

Radiotherapy (RT) is the standard treatment for uveal melanoma. However it can cause damage to the retina and optic nerve. This study examined the in vitro and in vivo effects of the anti-VEGF monoclonal antibody bevacizumab associated with radiotherapy (RT) on tumor growth and tumor proliferation and vasculature on OCM-1 human uveal melanoma cell line.

METHODS

The anti-proliferative effects of bevacizumab, RT and their combination were tested both in vitro (OCM-1 cells co-cultured with HUVEC cells in Transwell plates) and in vivo (OCM-1 tumor xenografts in nude mice). In addition, treatment effects in vitro on VEGF secretion, as well as treatment effects in vivo on tumor proliferation (Ki67 labelling), tumor vasculature (VEGFR2 labelling) and VEGF tumoral concentration were analyzed.

RESULTS

Bevacizumab given alone had a significant impact on tumor growth in vivo (and moderate effects in vitro). The bevacizumab-RT combination had additive effects in vitro (tumor cell proliferation) and in vivo (tumor growth), which translated into a significant decrease in Ki67 expression, VEGFR2 labelling and VEGF tumoral content.

CONCLUSIONS

The bevacizumab-RT combination could be a promising clinical option to explore for the management of human uveal melanoma, since it may allow RT dose reduction without loss of antitumor efficacy.

Metastasis rates and sites after treatment for choroidal melanoma by proton beam irradiation or by enucleation

Purpose

To investigate tumor thickness and location, the interval of time between treatment for choroidal melanoma (proton beam irradiation or enucleation) and diagnosis of metastatic disease, and rates and sites of metastasis.

Design

Retrospective, interventional, noncomparative case series.

Methods

Follow-up of 152 patients with primary choroidal melanoma, between 1992 and 2006 (14 years). One hundred and twenty-one patients were treated with proton beam irradiation and 31 patients were treated with enucleation. Baseline and annual or semiannual ophthalmic examination, B-scan ultrasonography, systemic and laboratory evaluations (liver enzymes, chest X-ray, ultrasonography or magnetic resonance imaging of the liver) were performed according to a standard protocol.

Results

Nineteen patients (12.5%) were diagnosed with metastasis during follow-up time after treatment for choroidal melanoma. Thirteen patients (10.7%) of the irradiation group and 6 patients (19.3%) of the enucleation group were diagnosed with metastasis. Eight patients (6.6%) of the irradiation group and 5 patients (16.1%) of the enucleation group were diagnosed with liver metastasis. Ocular complications after proton beam irradiation were recorded. Fifty-nine patients (48.7%) of the irradiation group presented with cataract. Other complications were retinal detachment, retinopathy, vitreous haemorrhage, iris neovascularization, neovascular glaucoma, optic neuropathy, and corneal opacification.

Conclusions

In our series, 10.7% of the irradiation group and 19.3% of the enucleation group were diagnosed with metastasis. The liver was the most common site of metastasis in both groups. Cataract was the most common complication in the irradiation group.

Development of a streamlined, non-invasive robotic radiosurgery method for treatment of uveal melanoma

To analyze the feasibility and safety of frameless, image-guided robotic radiosurgery against uveal melanoma, we developed a streamlined procedure that is completed within 3 hours under retrobulbar anesthesia without immobilization. Twenty patients (10 men and 10 women) with medium (3-5-mm prominence) and large (>5-mm prominence) unilateral uveal melanomas were treated with a frameless robotic radiosurgery system. Median age was 61 years (range 32-78 years). All patients underwent a single-session procedure beginning with retrobulbar anaesthesia, followed by computerized tomography (CT) scanning that was used in the generation of a treatment plan, and then the delivery of a radiosurgical tumor dose between 18 and 22 Gy to the 70% isodose line. Three-dimensional treatment planning was aimed at securing the optical lens and the optic disc as much as possible. Follow-up occurred at 3, 6, 12, and 18 months after the radiosurgery with clinical, ultrasound, and CT studies. We were able to treat all patients in the frameless setup within 3 hours. In five patients with lateral and dorsal tumors, the dose to the optic lens could be kept below 2 Gy. The clinical response was evaluated for the first seven patients treated with a follow-up of at least 6 months. No local recurrences occurred with any of the clinically evaluated patients for a mean 13-month follow-up (range 6-22 months). Maximum median apical tumor height according to standardized A-scan ultrasound evaluations decreased from 7.7 to 5.6 mm (p < 0.1). The median reflectivity increased from 41% to 70% (p < 0.01). None of the patients developed a secondary glaucoma during the short-term follow-up period. Frameless, single-session, image-guided robotic radiosurgery is a feasible, safe and comfortable treatment option for patients with uveal melanoma. Longer follow-up and analysis of a larger patient series is required for definitive clinical recommendations.

Treatment of medium-sized juxtapapillary melanoma with external Co-60 photon therapy

Twenty-six patients with medium-sized juxtapapillary choroidal melanomas were irradiated using D-shaped Co-60 beams. The overall 5-year actuarial survival was 86% with a trend towards better 5-year local control with 70 vs. 60 Gy (100 vs. 75%). Of patients with pre-treatment > or =20/200 visual acuity, 37% had functional vision at 5 years.

The Zimmerman-McLean-Foster hypothesis: 25 years later

It is now 25 years since the publication of the landmark article by Zimmerman, McLean, and Foster, in which they cast doubts on the benefit of enucleation, which was the prevailing management of choroidal melanoma at that time. Over the past 25 years several advances have been made in the management of uveal melanoma. Research in the pathobiology of cancer metastasis in general and uveal melanoma in particular has also provided new insights. In this review, the Zimmerman-McLean-Foster hypothesis is explored in the light of current clinical, epidemiological, statistical, and experimental evidence.

Survival after proton-beam irradiation of uveal melanomas

PURPOSE

To evaluate the independent prognostic factors for survival, metastasis, local recurrence, and enucleation in patients who had undergone proton-beam therapy for posterior uveal melanomas.

DESIGN

Interventional case series.

METHODS

In this retrospective study, 224 consecutive incident cases were treated at the Biomedical Cyclotron Centre (Nice, France) from June 1991 to December 1997. Overall, metastasis-free, local recurrence-free, and enucleation-free survival rates were calculated according to the Kaplan-Meier method using the log-rank test. The multivariate prognostic analysis was performed using the Cox proportional hazards model.

RESULTS

The 5-year overall survival rate was 78.1% (SE: 3.7%). A largest basal tumor diameter (LTD) below 10 mm and female sex were independently associated with a better prognosis. The 5-year metastasis-free survival rate was 75.6% (SE: 3.6%). Only an LTD above 10 mm and ciliary body involvement were independently associated with metastasis. Ten patients (4.5%) had a local recurrence, which was correlated with the risk of metastasis (P =.045). The 5-year enucleation-free survival rate was 69.6% (SE: 4.0%). Once again, an LTD below 10 mm and female sex were predictive of a better prognosis.

CONCLUSION

Our results with proton-beam therapy correspond to those reported in the literature. This treatment strategy is safe and yields predictably good results. In addition to the two independent prognostic factors for survival and metastasis, namely LTD and ciliary body involvement, sex also had a significant impact in our case series, but the clinical relevance of this finding is unknown.

Survival, anatomic, and functional long-term results in choroidal and ciliary body melanoma after ruthenium brachytherapy (15 years' experience with beta-rays)

PURPOSE

To analyze survival, radiation-related complications, local recurrence, enucleation, and visual acuity after ruthenium-106 irradiation of malignant uveal melanoma.

DESIGN

Retrospective study.

METHODS

A total of 213 patients treated with ruthenium-106 brachytherapy between 1983 and 1995. End point rates were estimated by life tables, and prognostic factors by Cox proportional hazards regression. Main outcome measures were survival rate, radiation-related maculopathy, radiation-related vascular occlusion, local tumor recurrence, enucleation, and visual acuity (<20/100 at 3 years).

RESULTS

At 5 and 10 years, survival was 82% (standard error [SE] 2.7%) and 72% (SE 3.4%), local recurrence 21.7% (SE 3.0%) and 24.3% (SE 3.2%), and enucleation 18.0% (SE 2.7%) and 19.2% (SE 2.8%), respectively. Sixty-one patients showed maculopathy (29%), 36 retinal vascular occlusion (17%), in 33 local recurrence (16%), and 38 enucleation (18%). Age and large tumor diameter were independently associated with survival (P <.0001 and P <.0075, respectively). Age below 40 and melanoma located posteriorly were significant risk factors for maculopathy (P <.0085 and P <.0004, respectively) and vascular occlusion (P <.0415 and P <.0114, respectively). Diameter and Bruch membrane rupture were significant predictors (P <.0032 and P <.0390, respectively) of local recurrence. Visual acuity <20/100 was observed in only 26 of 97 (27%) cases of anterior but 34 of 42 (81%) of posterior tumor (P <.001).

CONCLUSION

Although percentage tumor recurrence was high, survival was comparable to series using other treatments. Radiation-related complication rates were acceptable, especially for anterior tumors. Ruthenium therapy can, therefore, be recommended for small and medium-sized tumors with anterior location.

Current trends in the treatment of ocular melanoma by radiotherapy

The Collaborative Ocular Melanoma Study (COMS) has recently confirmed once and for all that it is safe to attempt to preserve an eye with a posterior uveal melanoma by demonstrating no survival advantage of enucleation over plaque radiotherapy. While COMS has been under way, we have set out in London to define the selection criteria for conservative therapy versus enucleation for the various categories of melanoma in terms of size, location within the eye, and presence or absence of retinal detachment. The evolution of this approach has culminated in an overall ocular survival rate of 94% in 597 patients following radiation therapy combined with a mean loss of visual acuity of only 2.4 Snellen lines in the eyes preserved.

Long-term risk of local failure after proton therapy for choroidal/ciliary body melanoma

PURPOSE

To quantitate long-term risk of local treatment failure after proton irradiation of choroidal/ciliary body melanomas and to evaluate risk of metastasis-related deaths after local failure.

METHODS

We followed prospectively 1,922 patients treated at the Harvard Cyclotron between January 1975 and December 1996 for local recurrences of their tumors. Mortality surveillance was completed through June 1999. For analysis, patient follow-up continued until tumor regrowth was detected or, in patients without recurrence, until the date of the last dilated examination prior to April 1998. Actuarial methods were used to calculate rates of recurrence and metastatic deaths. Cox regression models were constructed to evaluate risk factors for these outcomes.

RESULTS

Median ocular follow-up after irradiation was 5.2 years. Local recurrence was documented in 45 patients by ultrasound and/or sequential fundus photographs; in 17 more patients, the eye was enucleated due to suspected but unconfirmed tumor growth. Recurrences were documented between 2 months and 11.3 years after irradiation. The 5- and 10-year rates of regrowth, including suspected cases, were 3.2% (95% confidence interval [CI], 2.5%-4.2%), and 4.3% (95% CI, 3.3%-5.6%). Among the 45 documented recurrences, about one half (21) occurred at the margin, presumably due to treatment planning errors. The remaining cases represented extrascleral extensions (nine cases), ring melanomas (six cases), or uncontrolled tumor (nine cases). Recurrence of the tumor was independently related to risk of tumor-related death.

CONCLUSION

These data, based on relatively long-term follow-up, demonstrate that excellent local control is maintained after proton therapy and that patients with recurrences experience poorer survival.

Chemotherapy for eye cancer

Chemotherapy has been used to treat a multitude of eye cancers. We attempted to review the role of chemotherapy in the treatment of ocular, adnexal, and orbital malignancies by conducting an extensive search of the medical literature. Unfortunately, the published reports typically contain few patients with limited follow-up, precluding definitive recommendations. For most eye cancers, multicenter trials will offer the potential to gather the numbers of patients required to determine the clinical utility of chemotherapy.

Preliminary experience in the treatment of choroidal melanoma with gamma knife radiosurgery

Object. The authors report their early results from an ongoing experience treating patients with choroidal melanoma by using gamma knife radiosurgery (GKS).

Methods. Between September 1998 and March 2000, 11 patients were treated for choroidal melanoma. Treatment was facilitated with specialized frame placement. Eye immobilization was accomplished with supra- and infraorbital nerve block and tethering sutures to the periorbital tissue. Magnetic resonance imaging was performed to localize the tumor for treatment planning. Plugging patterns were used to steer fall-off radiation away from the fovea, optic nerve, or lens. Tumor volume, tumor location relative to critical structures, and dose to critical structures were determined using GammaPlan. Tumor response was determined using ultrasonography. Toxicity was determined by clinical assessment, visual acuity testing, and ophthalmoscopy.

All 11 patients successfully completed the treatment. In every case, 40 Gy was prescribed to the 50% isodose, which completely encompassed all visible tumor. Tumor height ranged from 2.9 to 7 mm. The tumor diameter ranged from 6 to 13 mm. The range of follow up was 2 to 19 months. No tumor has progressed. One patient had improvement in vision because of improvement in retinal detachment. Two patients experienced visual decline. One patient's visual decline was due to a vitreous hemorrhage, and the other's was due to hard exudates encroaching on the macula. One patient has developed a dry eye that is managed effectively with topical eye lubricants.

Conclusions. This preliminary experience demonstrates that GKS is a feasible treatment option for small- to medium-sized choroidal melanomas. Longer follow up and additional patients will be required to improve the assessment and the ultimate tumor control and toxicity in this ongoing series.

Iodine-I25 episcleral plaque therapy in uveal melanoma

PURPOSE

To assess the efficacy of iodine-125 (I-125) episcleral plaque therapy in the management of uveal melanoma with regard to local control, survival, globe preservation and visual outcome.

METHODS

Between January 1985 and January 1997, 50 patients with the diagnosis of uveal melanoma were treated with I-125 episcleral plaques. The mean initial tumour height was 5.5 mm (range, 2.0-9.5 mm) and basal diameter 9.5 mm (range, 4.0-14.5 mm). I-125 seeds with a mean activity of 1259.1 MBq were used. The mean apical dose was 80.5 Gy (range, 68.0-95.0 Gy). Scleral dose ranged from 225.0 to 940.0 Gy. Pretreatment visual acuity was 6/60 or better in 43 patients.

RESULTS

One patient was lost to follow up and excluded from analysis. The remaining 49 patients had a mean follow up of 39.5 months. There were seven local failures, with a mean duration to tumour progression of 16.7 months. All seven patients were successfully managed with enucleation. Five other enucleations were performed for treatment-related complications. At the time of analysis, 10 patients have died, five of metastatic melanoma. Of the patients with preserved globes, corrected visual acuity was 6/60 or better in 31 patients.

CONCLUSIONS

Good local tumour control and survival can be achieved with episcleral plaque therapy. Globe preservation with useful vision was possible in the majority of cases. Our findings are in keeping with other reported series.

Enucleation

The three most common indications for enucleation are intraocular malignancy, trauma, and a blind, painful eye. Recommending enucleation is one of the most difficult therapeutic decisions in ophthalmology. In some cases of malignancy, cryotherapy, laser photocoagulation, diathermy, chemotherapy, and radiation therapy may be viable alternatives to surgery. When surgery is chosen, evisceration or exenteration may be alternatives to enucleation. Once the decision is made to perform enucleation or evisceration, the surgeon must choose from several types of implants and wrapping materials. These devices can be synthetic, autologous, or eye-banked tissues. With certain implants, the surgeon must decide when and if to drill for subsequent peg placement. In this review, the authors discuss choices, techniques, complications, and patient consent and follow-up before, during, and after enucleation. Controversies and results of the Controlled Ocular Melanoma Study are summarized.

Radiation complications and tumor control after plaque radiotherapy of choroidal melanoma with macular involvement

PURPOSE

To determine the outcome of plaque radiotherapy in the treatment of macular choroidal melanoma and to identify the risk factors associated with the development of radiation complications, tumor recurrence, and metastasis.

METHODS

Chart analysis of 630 consecutive patients (630 eyes) with macular choroidal melanoma managed by plaque radiotherapy between July 1976 and June 1992.

RESULTS

The median largest basal tumor diameter was 10 mm, and the median tumor thickness was 4 mm. By means of Kaplan-Meier estimates, visually significant maculopathy developed at 5 years in 40% of the patients, cataract in 32%, papillopathy in 13%, and tumor recurrence in 9%. Vision decrease by 3 or more Snellen lines was found in 40% of the patients at 5 years. Sixty-nine eyes (11%) were enucleated because of radiation complications and recurrence. Twelve percent of the patients developed metastasis by 5 years and 22% by 10 years. Results of multivariate Cox proportional hazards analyses showed that the significant predictors for tumor recurrence were a distance of tumor margin from the optic disk of less than 2 mm (P = .003) and retinal invasion (P = .009). The significant variables that were predictive of metastasis included tumor thickness greater than 4 mm (P = .02) and largest basal tumor diameter greater than 10 mm (P = .03).

CONCLUSIONS

Plaque radiotherapy offers a 91% 5-year local tumor control rate for macular choroidal melanoma. Despite good local tumor control, the risk for metastasis is 12% at 5 years and 22% at 10 years. In 11% of the patients, enucleation eventually became necessary because of radiation complications and tumor recurrence.

The treatment of metastatic uveal melanoma

Malignant melanoma can occur in various ocular structures and accounts for 70% of all primary eye malignancies. At the time of initial diagnosis of uveal melanoma, most patients have no demonstrable evidence of metastatic disease. However, within 5 years, metastases appear in 19-35% of patients. The median relapse-free interval for these patients is 2-4 years. Unlike cutaneous melanoma, uveal melanoma most commonly metastasises to the liver. In fact, the liver is the sole site or the initial site of metastasis in more than 50% of patients. This paper reviews major studies that evaluated different treatment options for metastatic uveal melanoma, including surgery, systemic chemotherapy, intra-arterial chemotherapy, chemoembolisation and chemoimmunotherapy. Surgery and systemic chemotherapy offer minimal benefits for these patients. However, the use of intra-arterial fotemustine demonstrated a 40% response rate for patients with liver metastases of uveal melanoma. Additionally, chemoimmunotherapy with a four-drug chemotherapy regimen and interferon alfa has provided response rates of approximately 20% and may contribute to prolonged survival. Ongoing multicentre trials are expected to determine the feasibility of this regimen. The activity of immunotherapy, particularly interferon, encourages its use in combination with other active therapies, such as intra-arterial fotemustine.

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.

Brachytherapy in primary ocular tumors

Patients with primary ocular tumors are seen infrequently in the medical profession, and most of these patients are referred to specialty centers which has resulted in a good study population. In the past, ocular tumors were treated with enucleation, but the current emphasis is now on organ preservation with sparing of all or partial visual acuity. In the management of these tumors, plaque brachytherapy and particle beam therapy have been used more frequently as an alternative to enucleation. A multi-institutional study, the Collaborative Ocular Melanoma Study (COMS), is currently underway, organized by the National Eye Institute. The COMS isotope of choice is Iodine-125 (I-125). Recurrence after plaque therapy is approximately 15%, although it may be as high as 37% at 15 years for metastatic disease. In one study, nondiffuse iris melanoma has been controlled in 93% of patients by custom plaques utilizing I-125. Plaque brachytherapy also utilizes I-125 for the treatment of retinoblastoma tumors either as primary therapy or following external beam radiation. Currently, through the utilization of plaque radiation therapy, enucleation may be avoided in the majority of patients, and many patients may retrieve some visual acuity. We will review plaque brachytherapy techniques, diagnosis, staging, and some of the pertinent literature of the two most frequently encountered primary ocular tumors: choroidal melanoma, sometimes referred to as uveal melanoma, with an incidence of approximately 1,500 new cases per year in the adult population; and retinoblastoma, the most common intraocular primary malignancy found in childhood, with a frequency of approximately 250 [corrected] new cases per year.

Tumour cell proliferation after failed ruthenium plaque radiotherapy for posterior uveal melanoma

Enucleation following ruthenium plaque radiotherapy for posterior uveal melanoma indicates failure of treatment. This study focused on the histopathological findings and remaining tumour cell growth fraction in 42 of 46 patients with failed ruthenium plaque treatment (of 266 patients treated) for melanoma of the choroid or ciliary body. The cause for enucleation was clinically detected tumour regrowth in 27 (64%) patients, treatment-related ocular side effects in 12 (29%) cases and the patient's personal preference in three (7%) cases. The median time elapsing from plaque radiotherapy to enucleation was not significantly different for patients with recurrent tumour growth (23 months) compared to those enucleated without clinical signs of regrowth (19 months). While all tumours showed some regressive features by histopathological examination, only five melanomas were completely necrotic and viable-appearing tumours cells were present in all of the remaining 37 (88%) irradiated tumours. Microwave processed PC-10 immunostainings increased the sensitivity to detect cycling cells compared to the sole use of mitotic cell counts. By the former technique, proliferating tumour cells were detected in 17 of 23 (74%) studied melanomas of eyes enucleated for tumour regrowth following brachytherapy. Also, the number of cycling melanoma cells was similar to that of non-irradiated controls managed solely by enucleation. In contrast, the proliferative compartments of irradiated, but non-recurrent, posterior uveal melanomas were significantly reduced compared to those of matched controls. Still, cycling tumour cells were present in four of 13 (31%) irradiated melanomas, clinically assumed to be successfully treated.

Choroidal melanoma: a review of the experience of the Sydney Eye Hospital Professorial Unit 1979-1995

PURPOSE

This study examines 90 patients presenting with choroidal or ciliochoroidal melanoma to the Professorial Unit at the Sydney Eye Hospital. The indications for treatment, and the outcome for the eye and vision are presented together with an account of mortality and the incidence of metastases.

METHODS

A retrospective analysis of 90 choroidal melanoma patients managed by one surgeon over a 16-year period was undertaken. Initial findings, investigations performed, incidence of metastatic disease, treatment received and complication rates and mortality, where applicable, were recorded.

RESULTS

The group was followed for an average of 64 months (range, 5-172 months). Primary treatment was with either iodine125 (125I) brachytherapy, local excision or enucleation. Radiation retinopathy was prominent in 125I cases resulting in poor visual acuity when the tumour resided in the posterior pole. Local excision even of large tumours was effective particularly if peripheral. Overall metastatic disease was seen in 11% with 5-year survival rates for the metastatic group being 10%. Prognosis after diagnosis of metastases was poor.

CONCLUSIONS

Specific therapy for choroidal melanoma must relate to the size and location of the tumour at the time of diagnosis. Visual outcome relates directly to the proximity of the tumour to the optic nerve and fovea. Metastatic disease latency can be prolonged; therefore caution about prognosis is required long after therapy is given. The 5-year survival is encouraging with all forms of therapy. However, as the natural history of ocular melanoma is variable and not fully delineated it is important to monitor the effects of conservative therapy. Further long-term survival data is required to distinguish whether one form of treatment is advantageous over the others, although case-control studies are difficult for ethical and practical reasons. In this regard the Collaborative Ocular Melanoma Study (COMS) will provide further evidence for the safety and efficacy of conservative therapy with brachytherapy compared to enucleation.

Results following episcleral ruthenium plaque radiotherapy for posterior uveal melanoma. The Swedish experience

The Swedish experience of ruthenium 106 plaque radiotherapy for posterior uveal melanoma includes 266 patients treated between 1979 and 1995. The median dose delivered at the tumour apex was 100 Gy and the median follow-up after radiotherapy was 3.6 years (range = 0.5 to 12.5 years) with no patient being lost to follow-up. Visual acuity deteriorated moderately following treatment but appeared to stabilize after 5 to 6 years. Treatment failure defined as enucleation following plaque treatment occurred in 46 of the 266 (17%) studied patients. The cumulative 5-year probability of retaining the eye after radiotherapy was 82% and by univariate analysis tumour height, tumour diameter and tumour stage each predicted subsequent treatment failure, whereas in multivariate analysis no single covariate retained a predictive value. Forty-five of the 266 patients died of any cause during follow-up; 27 of these deaths were melanoma-related. The cumulative 5-year survival proportion (based on melanoma-related deaths only) was 86%. Death in metastatic disease appeared to be more common among patients that failed ruthenium plaque radiotherapy, however these patients also tended to have large tumours.

Posterior uveal melanoma. The Swedish perspective

Posterior uveal melanoma is the most common primary intraocular malignant tumour and in Sweden some 70-80 new cases present each year. While uveal melanoma is more prevalent in the setting of ocular melanocytosis and neurofibromatosis, there is little conclusive data on the aetiology. Most patients experience a progressive visual field defect and present with a grey or greyish-brown mass of the posterior choroid. Diagnostic procedures include fluorescein angiography, ultrasound and magnetic resonance imaging. In some cases, intraocular biopsy may be required to make a correct diagnosis. Posterior uveal melanomas can usually be managed by any of a number of eye-preserving options like plaque radiotherapy and charged particle irradiation, but eyes containing large tumours are often enucleated. Nearly half of patients with posterior uveal melanoma, and in particular those with large tumours, ultimately succumb to metastatic disease. While most patients with tumour dissemination are treated with systemic chemotherapy possibly combined with interferon, metastatic spread confined to the liver may potentially be managed by intraarterial perfusion chemotherapy or liver resection. However, outcome of patients with systemic disease remains extremely poor with a median survival following detectable tumour dissemination of only two to five months. There are still insufficient data on the impact of various treatments on survival, but a large prospective trial addressing this issue is in progress. The present review summarizes the state-of-the-art knowledge and current management of posterior uveal melanoma from a Swedish perspective.

125I plaque therapy for uveal melanoma. Analysis of the impact of time and dose factors on local control

BACKGROUND

125I episcleral plaque therapy has gained wide acceptance for the treatment of uveal melanoma because of its potential to preserve vision, salvage the globe, and provide good local control. A rigorous analysis of the optimum radiation dose, dose rate, and overall treatment time has not been reported with this technique.

METHODS

One hundred fifty patients with uveal melanoma treated with 125I plaques between 1982 and 1990 and included in the uveal melanoma study (UMS) database of the Wills Eye Hospital were analyzed. Mean patient age was 60.7 years (range: 17.7-84.6 years). Initial mean tumor size was 9.7 x 8.5 x 3.7 mm with a range of 4.5 to 21.5 mm in basal dimension and 1.2 to 11.8 mm in height. Mean dose to the tumor apex was 94.77 gray (Gy) (29.5-141 Gy). Mean dose rate to the tumor apex was 92.9 cGy/hr (10-292 cGy/hr); the mean dose to the base was 359 Gy (181-692 Gy); the mean dose rate to the base was 348 cGy/hr (112-893 cGy/hr); and mean duration of treatment was 124.7 hours (range: 28-333 hours)

RESULTS

With a median follow-up of 68 months, there have been 33 local failures. Mean time to local failure was 19 months (range: 6-78 months). Actuarial local control is 81% at 5 years. Multivariate analysis demonstrates significant correlation of local failure with larger tumor dimension (P = 0.0046), close proximity to the optic disc (P = 0.0029), lower radiation dose to the tumor apex (P = 0.03), lower radiation dose rate to the tumor apex and base (P = 0.01 and 0.03), and longer overall treatment time (P = < 0.0001).

CONCLUSIONS

This retrospective analysis reinforces the importance of dose rate, minimum tumor dose, overall treatment time, maximum tumor basal dimension, and proximity to the optic nerve in the treatment of uveal melanoma.

Long term visual outcome of radiated uveal melanomas in eyes eligible for randomisation to enucleation versus brachytherapy

AIMS

To determine the long term visual outcome of patients who were eligible for randomisation to enucleation versus brachytherapy in a US collaborative ocular melanoma study (COMS) but were treated with either helium ion or 125I radioactive plaque therapy.

METHOD

A retrospective analysis was performed of 426 ciliochoroidal melanomas that met COMS inclusion criteria for randomisation to enucleation versus radioactive plaque but were treated with either helium ions or 125I brachytherapy.

RESULTS

At 3 years 36.0% of eyes had 6/12 or better visual acuity. The length of visual retention was most dependent on tumour thickness, tumour location with respect to the optic nerve, fovea, or ciliary body, and patient age. In addition to these factors, the retention of 6/12 visual acuity and the time to 6/120 visual acuity were dependent on the preoperative visual acuity. The risk of visual loss was greatest immediately after treatment and decreased with time. The 5 year actuarial metastatic rate was approximately 13%. Patients at the greatest risk of post-radiation visual loss had significantly greater risk of tumour related mortality.

CONCLUSIONS

Some patients who would have been eligible for randomisation to either enucleation or radioactive plaque therapy can be irradiated with retention of excellent vision.

Cytogenetics of twelve cases of uveal melanoma and patterns of nonrandom anomalies and isochromosome formation

We present cytogenetic data of 12 new cases of uveal melanoma. One case showed a hypotetraploid chromosome number; the others were near-diploid. Underrepresentation or monosomy of chromosome 3 as well as multiplication of chromosomes 8, 8q, or regions of 8q was found in five cases. Both anomalies were observed in three cases. In two of these, multiplication of 8q resulted from isochromosome formation. The smallest multiplicated region seemed to be 8q23-24-->qter. Chromosome 6 anomalies were found in five cases without monosomy 3. Aberrations of chromosome 21 were seen in five cases and found to be the only cytogenetic change in two of them. These anomalies may define a subgroup of uveal melanoma. An anomaly of chromosome 1 was found in three cases. Anomalies of other chromosomes were detected in at most two cases each. Nonclonal centromeric or telomeric associations were seen in one case and different nonclonal ring chromosomes in another. Underrepresentation of chromosome 3 was seen exclusively in tumors with ciliary body involvement, while anomalies of chromosome 6 were detected only in pure choroideal melanomas. A review of the published cytogenetic data of untreated uveal melanoma supports our finding that monosomy 3 is frequently associated with multiplication of 8q but rarely with anomalies of chromosome 6, whereas the opposite is true for tumors with disomy 3, and that isochromosomes are closely associated with monosomy 3. Thus, cells with monosomy 3 seem to predispose to isochromosome formation.

Rates of local control, metastasis, and overall survival in patients with posterior uveal melanomas treated with ruthenium-106 plaques

The prognostic importance of clinically assessed tumor variables, patient variables, and treatment variables of 184 patients treated with ruthenium-106 eye plaques for uveal melanoma was studied using crude survival, metastatic disease and local tumor control as the endpoints. Using the multivariate Cox proportional hazards model, tumor diameter, age and sex were identified as the strongest variables predicting survival. Risk of metastasis was found to be dependent on tumor size (diameter) only and the metastasis was generally observed within 6 years after the end of treatment (96%). Clinically diagnosed local tumor control was predicted by tumor T-stage, treatment time, and total dose to the sclera. No correlation between metastatic disease and local failure was detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Cataractogenesis after Cobalt-60 eye plaque radiotherapy

PURPOSE

This study was designed to estimate the actuarial incidence of typical postirradiation cataracts and to identify prognostic factors related to their development in melanoma-containing eyes treated by Cobalt-60 plaque radiotherapy. Our special interest was the impact of calculated radiation dose and dose-rate to the lens.

METHODS AND MATERIAL

The authors evaluated the actuarial occurrence of post-irradiation cataract in 365 patients with primary posterior uveal melanoma treated by Cobalt-60 plaque radiotherapy between 1976 and 1986.

RESULTS

Only 22% (S.E. = 4.6%) of the patients who received a total dose of 6 to 20 Gy at the center of the lens developed a visually significant cataract attributable to the radiation within 5 years after treatment. Using multivariate Cox proportional hazards modeling, the authors identified thickness of the tumor, location of the tumor's anterior margin relative to the equator and the ora serrata, and diameter of the eye plaque used as the best combination of covariables for predicting length of time until development of cataract. Surprisingly, the dose of radiation delivered to the lens, which was strongly correlated to all of these covariables, was not a significant predictive factor in multivariate analysis.

CONCLUSION

The results suggest that success of efforts to decrease the occurrence rate of post-irradiation cataracts by better treatment planning might be limited in patients with posterior uveal melanoma.

Seed strength determination for eye plaque therapy

Standardized radioactive plaques have been used in the irradiation of intraocular tumors. These plaques have defined slots to accommodate 125I seeds and hence produce predictable isodose distributions. The seed strength has to be adjusted to deliver 100 Gy to the prescription point, which varies with the tumor size. The purpose of this work is to develop lookup tables that relate the seed strength to different prescription distances. Dose rates were determined for a set of standardized eye plaques. Using these dose rates and the source strength decaying expression, the seed strengths were determined as a function of distance along a line through the plaque. Two seed-strength tables were created based on four-day and five-day treatment times delivering a 100 Gy to the prescription distance.

Uveal melanoma: therapeutic consequences of doubling times and irradiation results; a review

Thirty-six of 39 published calculated doubling times (Td's) of uveal melanomas appeared to be longer than 60 days. Metastatic death occurs 35-40 Td's after dissemination. The shortest interval between dissemination and metastatic death in individual patients may, therefore, be calculated as 35 x 60 days = 6 years; the interval may extend to 80 years. This suggests, that local therapy cannot influence the survival data within the first 7 post-therapeutic years, because almost all metastatic deaths within these 7 years are due to pretreatment dissemination. For that reason, the published comparative survival analyses after various therapies have within this period failed to show statistically significant death rates differences. Microscopically viable melanoma tissue has been noted in 215 of 231 histopathologically studied irradiated uveal melanomas. Observed mitotic figures 4-6 years after irradiation indicate retained reproductive integrity. This constitutes a--by enucleation avoidable--incremental risk for post-irradiation exponential growth and dissemination. The risk cannot become statistically manifest before a greater than or equal to 10-year follow-up period. Retained, generally poor, visual acuity in a small percentage of patients cannot balance the incremental risk/benefit ratio of irradiation. A few, at present justifiable, indications for radiotherapy on uveal melanomas are enumerated.

Phototherapy of posterior uveal melanomas

The results of phototherapy on a small series of 19 patients with uveal melanomas are presented. Laser radiation at a wavelength of 620 to 630 nm was used in conjunction with a 5 to 7.5 mg/kg dose of haematoporphyrin derivative administered 24 hours before treatment, with total doses/treatment averaging 960 J/cm2. Eleven patients received two treatments, and one received a third. The longest duration of tumour control to 30 September 1990 was 31 months. Of the 19 patients treated six had complete regression of the tumour, while another five had minor to significant regression. A strong correlation between degree of regression and degree of tumour pigmentation was found, the lighter tumours responding much better than darker tumours. There were also strong indications that if a tumour did not respond to the initial phototherapy it was very unlikely that subsequent phototherapy would provide any further benefit.

Impact of local tumor relapse on patient survival after cobalt 60 plaque radiotherapy

The authors investigated the impact of local intraocular tumor relapse on survival in a matched-group comparison study of patients with primary choroidal or ciliary body melanoma managed with cobalt 60 plaque radiotherapy. Sixty-two patients with local relapse were matched with an equal number of relapse-free patients in terms of known clinical prognostic factors for both melanoma-specific mortality (largest linear tumor dimension, location of anterior tumor margin, age) and local tumor relapse (location of posterior tumor margin). The follow-up of every relapse-free patient equaled or exceeded the interval to relapse for each matched patient with local relapse. The estimated 5-year survival (Kaplan-Meier) in the relapse-free patients was 87% (standard error = 4%), while that in the local relapse group was 58% (standard error = 6%). This difference is statistically significant (P less than 0.0001, log rank test). These results support the hypothesis that local tumor relapse after cobalt 60 plaque radiotherapy is an important post-treatment clinical indicator of the tumor's greater malignant potential and the patient's increased risk of melanoma-specific mortality.

Clinical prognostic factors in patients with posterior uveal malignant melanoma

The authors evaluated the prognostic value of clinically assessed variables for predicting length of survival until death from metastatic disease in 237 patient with a primary choroidal or ciliary body melanoma. Using multivariate Cox proportional hazards modeling, the authors identified the largest linear basal tumor diameter (mm), estimated by indirect ophthalmoscopy and fundus drawing, the location of the anterior margin of the tumor relative to the ocular equator and ora serrata, and the age of the patient at the time of treatment as the best combination of the clinically assessed variables for predicting survival. For each patient in this group, the authors computed a prognostic index based on the best multivariate Cox model. They showed that patients with low, intermediate, and high values of prognostic index had low, intermediate, and high melanoma-related mortality rates, respectively, during the first 5 to 8 posttreatment years. These results suggest that: (1) clinically assessed variables evaluated according to a standardized protocol are useful for predicting the survival of treated patients with posterior uveal melanoma and (2) ophthalmologists who assess potential clinical prognostic variables consistently may identify subgroups of patients with comparable mortality risk on the basis of noninvasive testing.

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.

Relative survival rates after alternative therapies for uveal melanoma

Survival in a group of 556 patients with uveal melanoma treated by proton beam irradiation with a median follow-up of 5.3 years was compared with that of 238 patients enucleated during the same 10-year period as irradiated patients (July 1975 to December 1984) with a median follow-up of 8.8 years, and 257 patients enucleated during the preceding 10 years (January 1965 to June 1975) with a median follow-up of 17.0 years. Adjustments were made for known prognostic factors including age, tumor location, tumor height, and clinical estimate of tumor diameter (for enucleated patients this was estimated in a regression equation relating histologic to clinical measurement). The overall rate ratio for all cause mortality was 1.2 (95% confidence interval, 0.9-1.6) for the concurrent enucleation series versus proton beam, and 1.6 (95% confidence interval, 1.2-2.1) for the earlier enucleation series versus proton beam. Relative rates of metastatic death, cancer death, and all cause mortality comparing alternative treatments were found to vary with time after treatment. Interval-specific rate ratios were evaluated using proportional hazards models fitted to separate time intervals after treatment. For all three outcomes, rate ratios were over two and statistically significant for the first 2 years after treatment and closer to one and nonsignificant after year 6 comparing the two enucleation groups with proton beam. Results suggest that treatment choice has little overall influence on survival in patients with uveal melanoma.