Changes in height of choroidal melanomas after plaque therapy

Radiological and clinical findings in uveal melanoma treated by plaque interventional radiotherapy (brachytherapy): Visual atlas and literature review on response assessment

Uveal melanoma (UM) is the most common intra-ocular tumor in Caucasian adults and may derive from melanocytes. Historically, the first therapeutic approach to treat UM has been surgical removal of the eye, with obvious consequences in terms of function, cosmesis, and psychological impact on patients. Collaborative Ocular Melanoma Study (COMS) introduced the first uniform approach to perform interventional radiotherapy (IRT - brachytherapy) procedure in a standardized way that allowed to demonstrate equivalence of IRT with enucleation in terms of overall survival. Since this milestone, several international guidelines have been issued with regard to several technical aspects of this procedure, which has become the mainstream therapy worldwide. However, nowadays, there is still a lack of consensus about the criteria to definitively assess UM response after IRT. We present a collection of paradigmatic cases treated in our institution, and then discuss in detail the latest available evidence on the topic.

Regression of posterior uveal melanoma following iodine-125 plaque radiotherapy based on pre-treatment tumor apical height

PURPOSE

The aim of this study was to analyze regression rates and local control of uveal melanoma patients treated with iodine-125 ( 125I) brachytherapy based on initial tumor apical height.

MATERIAL AND METHODS

Patients treated in a single institution from January 1st, 1996 to 2019 with 125I plaques (ROPES and COMS) for uveal melanoma were included in this study. Patients treated with brachytherapy for iris and those treated with transpupillary thermotherapy prior to brachytherapy were excluded. The sample was classified into 4 categories depending on initial apical tumor height (h0), i.e., h0 ≤ 2.5 (small), 2.5 < h0 ≤ 6.25 (small-medium), 6.25 < h0 ≤ 10 (medium-large), and h0 > 10 mm (large). Percentage of original tumor apical height (Δh) was collected during follow-ups. Patterns of regression were evaluated using linear least squares adjustments. Multivariable Cox regression were performed.

RESULTS

In total, 305 patients met the inclusion criteria, and 27, 166, 100, and 13 were considered for small, small-medium, medium-large, and large categories, respectively. Median follow-up was 82.4, 56.8, 76.1, 89.1, and 100.1 months for the entire cohort and each sub-group, respectively. Pattern of decrease when h0 ≤ 2.5 mm was not detectable. For the rest sub-groups, changes in height could be fitted using functional form: Δh (T) = ae-bT + c, R 2 ≥ 0.97. Multivariate Cox analysis factors predictive of local control failure revealed a hazard ratio (HR) of 6.1 (95% CI: 0.7-58.2%, p = 0.05) for patients who remained similar sized after treatment for small-medium tumors. For the rest sub-groups, Cox analysis did not indicate statistical significance in any single variable.

CONCLUSIONS

Height changes can be modeled by a negative exponential function for the first 7 years after treatment depending on the initial height, except for those less than 2.5 mm. Non-responding small-medium tumors multiply by 6 the probability of failure in local control.

Regression patterns of uveal melanoma after iodine-125 plaque brachytherapy

Background

Tumor regression of uveal melanomas (UMs) after radiotherapy has been reported as a valuable prognostic factor for metastasis and metastatic death. But its effect on prognosis is questionable. The purpose of this study was to summarize the regression features of uveal melanoma after iodine-125 plaque brachytherapy and the relationship with prognosis.

Methods

Adult uveal melanoma patients who only received iodine-125 plaque brachytherapy between December 2009 and March 2018 at the Beijing Tongren Hospital, Capital Medical University were enrolled in this study. The regression rate was calculated as the percent change in tumor height, and each eye was classified for four main regression patterns: Decrease (D), Stable (S), Others (O), and Increase (I), according to the trend of height change. Statistical analysis was performed using one-way ANOVA and chi-square test, univariate and multivariate logistic regression, and Kaplan-Meier analysis.

Results

A total of 139 patients was included in the study. The median follow-up was 35 months. Regression patterns status was pattern D in 65 tumors (46.8%), pattern S in 50 tumors (36.0%), pattern O in 6 tumors (4.3%), and pattern I in 18 tumors (12.9%). Reductions of tumor mean height for each follow-up visit were 5.26% (3 months), 10.66% (6 months), 9.37% (12 months), and 14.68% (18 months). A comparison (D vs. S vs. O vs. I) revealed the preoperative height of pattern I was significantly lower than the pattern D, S and O (mean: 7.24 vs. 7.30 vs. 6.77 vs. 5.09 mm, respectively; P = 0.037). LBD (largest basal diameter) was strongly associated with the metastasis (P = 0.03). However, an association between the tumor regression and subsequent melanoma-related metastasis and mortality could not be confirmed (P = 0.66 and P = 0.27, respectively). The tumor regression rate increased with increasing tumor height (P = 0.04) and decreased with increasing of LBD (P = 0.01).

Conclusion

Our study showed a lack of association between the prognosis and the regression of uveal melanomas following I-125 plaque radiotherapy. The LBD and original height of the tumor have predictive value in tumor regression rate, and LBD was positively associated with metastasis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01898-3.

Ultrasound Biomicroscopy Documented Anterior Uveal Melanoma Regression after Ruthenium-106 Plaque Therapy

Introduction

Ultrasound biomicroscopy (UBM) is the only widely used method for the evaluation of anterior uveal melanoma (AUM).

Objective

Documentation of regression of AUM treated with ruthenium-106 (Ru-106) plaque types CCB and CCC using UBM.

Methods

This single institution-based retrospective case series involved 10 Caucasian patients with AUM followed after brachytherapy with UBM from January 2014 until February 2019. The largest prominence of the tumor perpendicular to the sclera or the cornea (including scleral/corneal thickness) (D) and the largest basal dimension (B) were measured in millimeters with UBM for all patients prior to the brachytherapy and at 4-month interval follow-up. Tumor regression was calculated as a percentage of decrease in the initial D and B values.

Results

The study involved 10 patients with a mean age of 64.4 years (yr) (range 46-80 yr). D ranged from 1.82 to 5.5 mm (median 2.99 mm) and B from 2.32 to 12.38 mm (median 4.18 mm). The apical radiation dose in all patients was 100 Gy. The median follow-up was 42.02 months. Regression for D was 21.11 ± 13.66%, 31.09 ± 14.66%, and 34.92 ± 19.86% at 1st, 2nd, and 3rd year of the follow-up, respectively, while for B it was 21.58 ± 16.05%, 28.98 ± 17.71%, and 32.06 ± 18.96%, respectively. Tumor recurrence was documented in 2/10 patients.

Conclusion

The major regression of AUM, treated with Ru-106 plaque types CCB and CCC, was documented in the first 2 years after brachytherapy in our study group. In the following years, only minimal regression was documented that warns of the need for close monitoring and active search for local recurrences.

Comparison of Iodide-125 and Ruthenium-106 Brachytherapy in the Treatment of Choroidal Melanomas

Background

To compare iodine-125 (¹²⁵I) with ruthenium-106 (¹⁰⁶Ru) episcleral plaque radiation therapy in terms of the effectiveness and non-inferiority for choroidal melanoma treatment.

Objective

To report the non-inferiority of new made iodine-125 (¹²⁵I) compared with ruthenium-106 (¹⁰⁶Ru) episcleral plaque radiation.

Patients and Methods

A retrospective, non-randomized comparative case series. In this series the patients treated with ¹²⁵I and ¹⁰⁶Ru episcleral plaques for choroidal melanoma between September 2013 and August 2017 at Farabi Hospital are compared. Local control of choroidal melanomas after ¹²⁵I and ¹⁰⁶Ru plaques implantation and vision changes are the main outcome measures.

Results

A total of 35 patients were identified (¹²⁵I = 15, ¹⁰⁶Ru = 20). No significant difference between two groups in visual acuity, diameter and thickness changes were observed after treatment. Multivariate linear regression (MLR) analysis showed that final diameter was only, independently and significantly, correlated with the pre-treatment diameter of the tumor (β = 0.59, 95% confidence interval [CI]: 0.29, 1.34, P = 0.003). The same MLR analysis for the final thickness and visual acuity, after adjusting for age and sex showed no significant difference between two groups. A single patient treated with ¹⁰⁶Ru had local tumor recurrence with no one in the ¹²⁵I group. No statistical difference in the rate of ocular complications was observed.

Conclusion

The treatment with our ¹²⁵I plaques is as effective as ¹⁰⁶Ru plaques in controlling choroidal melanoma tumor and preserving the vision during the two and half year of follow-up. The complication rates are alike. It means that the effectiveness of ¹²⁵I is not only comparable to ¹⁰⁶Ru but also superior when the outcome of the interest is the thickness of the tumors.

Regression rate of choroidal melanoma following iodine-125 brachytherapy is not associated with metastatic spread

Nearly half of choroidal melanomas progress to the metastatic stage at 15 years. The purpose of our study was to evaluate the prognostic value of tumour-height regression rate in medium-sized choroidal melanomas treated with iodine-125 brachytherapy. A retrospective cohort study was performed on 128 patients with medium-sized choroidal melanoma who were treated with iodine-125 brachytherapy. Tumour characteristics including tumour apical height at baseline and after irradiation, recurrence, metastasis and mortality were collected from patients' records. Regression rate was defined in mm/month or in percentage of baseline apical height. Patients were statistically stratified in three groups of regression rate at 6 months using the Ward's method and Euclidian distance (slow, medium and fast regression groups). Mean initial apical height was of 5.71±1.79 mm. At 6 months, the average regression rate was 0.02±0.12 mm/month in the slow group (n=60), 0.32±0.11 mm/month in the medium group (n=52) and 0.67±0.21 mm/month in the fast group (n=16). Cox regression analysis for the recurrence, metastasis and mortality rates according to the three groups did not show any statistically significant difference. Sensitivity analyses with the regression rates at 12 months showed similar associations. Exudative retinal detachment resolved with treatment at 5.9±4.0 months, and it was more common at presentation in the fast regression rate group. The regression rate at 6 and 12 months after iodine-125 brachytherapy is not associated with a higher metastatic rate in medium-sized choroidal melanoma.

Regression patterns of choroidal melanoma: After palladium-103 (103Pd) plaque brachytherapy

Purpose:

To describe the patterns of regression of choroidal melanoma after treatment with plaque brachytherapy.

Methods:

Retrospective interventional case series including 170 consecutive patients treated with ¹⁰³Pd eye plaque radiation for choroidal melanoma. Outcome measures were changes in tumor thickness, surface characteristics, tumor vascularity, ultrasonography, fluorescein angiography, optical coherence tomography, and histopathology.

Results:

The mean initial tumor thickness was 3.9 mm (median 2.8 mm; range 2–11.3 mm) that decreased to 1.7 mm (median 1.2 mm; range 0–7.1 mm) after plaque brachytherapy. On imaging, tumors were pigmented in 51% (n = 86/170), amelanotic in 10% (n = 17/170), and variably pigmented in 39% (n = 67/170). Tumor pigmentation increased in 64% (n = 106/166), decreased in 18% (n = 30/166), and was unchanged in 18% (n = 30/166). Of the 120 that demonstrated intrinsic vascularity, 10% (n = 12/120) had decreased tumor-related vascularity and 90% (n = 108/120) showed complete resolution. Subretinal fluid was present in 34% (n = 58/170) of eyes at presentation. Of them, 15% (9; n = 9/58) had persistent SRF at last follow-up. On ultrasound imaging, 88% (n = 149/170) tumors presented with low to moderate internal reflectivity of which 61% (n = 91/149) showed increased reflectivity on regression. We noted a crescendo–decrescendo fluctuation in the presence of orange pigment lipofuscin along with complete resolution of drusenoid retinal pigment epithelial detachments. In the entire series of 170 patients, there was 0.5% (1) failure of local control, 2% (4) secondary enucleations, and 6% (10) patients developing metastasis.

Conclusion:

Findings related to choroidal melanoma regression after ¹⁰³Pd plaque brachytherapy included decreased intrinsic tumor vascularity, decreased tumor-related subretinal fluid, increased pigmentation, specific changes in orange pigment lipofuscin and resolution of drusenoid retinal pigment epithelial detachments, as well as decreased tumor thickness with an increase in internal reflectivity on ultrasound.

Clinical Predictors of Regression of Choroidal Melanomas after Brachytherapy: A Growth Curve Model

PURPOSE

To build multivariate models to assess correctly and efficiently the contribution of tumor characteristics on the rate of regression of choroidal melanomas after brachytherapy in a way that adjusts for confounding and takes into account variation in tumor regression patterns.

DESIGN

Modeling of longitudinal observational data.

PARTICIPANTS

Ultrasound images from 330 of 388 consecutive choroidal melanomas (87%) irradiated from 2000 through 2008 at the Helsinki University Hospital, Helsinki, Finland, a national referral center.

METHODS

Images were obtained with a 10-MHz B-scan during 3 years of follow-up. Change in tumor thickness and cross-sectional area were modeled using a polynomial growth-curve function in a nested mixed linear regression model considering regression pattern and tumor levels. Initial tumor dimensions, tumor-node-metastasis (TNM) stage, shape, ciliary body involvement, pigmentation, isotope, plaque size, detached muscles, and radiation parameters were considered as covariates.

MAIN OUTCOME MEASURES

Covariates that independently predict tumor regression.

RESULTS

Initial tumor thickness, largest basal diameter, ciliary body involvement, TNM stage, tumor shape group, break in Bruch's membrane, having muscles detached, and radiation dose to tumor base predicted faster regression, whether considering all tumors or those that regressed in a pattern compatible with exponential decay. Dark brown pigmentation was associated with slower regression. In multivariate modeling, initial tumor thickness remained the predominant and robust predictor of tumor regression (P < 0.0001). In addition, use of ruthenium isotope as opposed to iodine isotope (P = 0.018) independently contributed to faster regression of tumor thickness. For both isotopes considered alone, initial tumor thickness was the sole clinical predictor of regression (P < 0.0001).

CONCLUSIONS

Regression of choroidal melanoma after brachytherapy was associated with several clinical tumor and treatment parameters, most of which were shown to reflect initial tumor size. An independent predictor of regression of tumor thickness was the isotope used. These 2 covariates need to be adjusted for when exploring the associations with the rate of regression of histopathologic or genetic features of the tumor. Our model allows such future analyses efficiently without matching.

Association between Tumor Regression Rate and Gene Expression Profile after Iodine 125 Plaque Radiotherapy for Uveal Melanoma

PURPOSE

Gene expression profile (GEP) testing segregates uveal melanoma (UM) into 2 main prognostic classes. It is unknown if a greater tumor regression response after iodine 125 (I¹²⁵) brachytherapy correlates with class 2 GEP status. The purpose of this study was to determine whether there is a significant relationship between the rate of UM height regression and GEP classification testing after I¹²⁵ plaque brachytherapy.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

Adult UM patients treated with I¹²⁵ plaque brachytherapy who had concurrent tumor biopsy at the time of surgery with a GEP test result from January 1, 2010 through June 30, 2014.

METHODS

Baseline clinical data and GEP class assignments were obtained. The ultrasonographic tumor height was recorded at baseline and at 3, 6, 9, and 12 months and at the most recent final follow-up visits. Subanalysis of paired cases based on pretreatment ultrasound height was performed. Statistical analysis was performed using Wilcoxon rank-sum tests, the Fisher exact test, and Kaplan-Meier analysis.

MAIN OUTCOME MEASURES

Percentage change in tumor height from baseline.

RESULTS

A total of 353 patients were included in the study. Median follow-up was 2.1 years (range, 0.5-5.3 years). Gene expression profile status was class 1 in 247 tumors (70%) and class 2 in 106 tumors (30%). Increased patient age, larger tumor dimensions, and greater tumor thickness were associated with class 2 GEP status (P = 0.006, P < 0.001, and P < 0.001, respectively). The percentage reduction in tumor height from baseline was significantly greater in class 1 than class 2 tumors at 3 months (17.5% vs. 11.8%; P = 0.007) and 6 months (26.8% vs. 17.1%; P = 0.007), respectively, but there was no significant difference in reduction between class 1 and 2 tumors at 9 months (P = 0.26) and 12 months (P = 0.57) after treatment. Class 1A and 1B tumors showed similar reduction compared with class 2 tumors (P < 0.05).

CONCLUSIONS

Class 1 UM tumors tend to regress more rapidly than class 2 tumors in the first 6 months after plaque radiotherapy. Class 1A and 1B tumors regress at similar rates after plaque radiotherapy.

CAVERNOUS HEMANGIOMALIKE CHANGES IN A CHOROIDAL MELANOMA AFTER BRACHYTHERAPY

PURPOSE

To describe a degenerative vascular change in a treated choroidal melanoma that clinically simulated late treatment failure.

METHODS

Observational case report.

RESULTS

A 79-year-old man with choroidal melanoma treated 15 years earlier with iodine-125 brachytherapy demonstrated substantial increase in size of this once stable tumor. The eye was removed because of concern of late treatment failure. Histologically, the tumor consisted of melanocytes with no mitotic activity and virtually no Ki-67 expression. Roughly half the lesion was composed of cavernous blood-filled spaces lined by bland CD34+ and CD31+ endothelial cells.

CONCLUSION

Late degenerative changes in the vasculature of treated uveal melanoma can result in tumor enlargement, which may raise clinical concerns over treatment failure and neoplastic potential.

Intravitreal bevacizumab combined with plaque brachytherapy reduces melanoma tumor volume and enhances resolution of exudative detachment

Background

The purpose of this study was to evaluate intravitreal bevacizumab as an adjuvant treatment to plaque brachytherapy in the treatment of choroidal melanoma.

Methods

This was a retrospective, consecutive study of 124 patients treated from 2007 to 2009 for choroidal melanoma with plaque brachytherapy. Patients were treated with I-125 plaque brachytherapy with 2 mm margins and 85 Gy to the tumor apex. Consecutive patients were injected intravitreally with 2.5 mg/0.1 mL bevacizumab at a site away from the primary tumor and immediately following plaque removal. Choroidal melanomas were observed using indirect ophthalmoscopy, wide-angle photography, and ultrasound. The main outcome measures were tumor volume, resolution of exudative retinal detachment, and visual acuity.

Results

One hundred and twenty-four patients met our inclusion criteria and were included in the analysis. The mean patient age was 65.7 years, and the mean apical tumor height was 4.0 ± 2.7 mm and basal diameter was 12.7 ± 3.0 mm. Mean follow-up was 24 months. Prior to treatment, 100% of tumors had exudative retinal detachment, and pretreatment visual acuity was 20/55 (median 20/40). Tumor control was 100%, metastasis was 0% at last follow-up, and 89.8% had complete resolution of exudative retinal detachment, with a mean time to resolution of 3.36 months. At one month, 43% had complete resolution of exudative retinal detachment, which increased to 73% at 4 months. Visual acuity was 20/62 (median 20/40) at 4 months, with stabilization to 20/57 (median 20/40) at 8 months, 20/56 (median 20/30) at 12 months, and 20/68 (median 20/50) at 24 months. Tumor volume following combined therapy was shown to be reduced by 22.2% at 3 months, 28.9% at 6 months, 39.3% at 12 months, and 52.2% at 24 months (all P < 0.001). All patients tolerated the procedure well without systemic side effects.

Conclusion

Intravitreal bevacizumab may be used as an adjuvant agent following plaque brachytherapy. Treated choroidal melanomas show reduction in tumor volume as well as resolution of exudative retinal detachments.

Combined plaque radiotherapy and transpupillary thermotherapy in choroidal melanoma: 5 years' experience

AIM

To evaluate the results of combined plaque radiotherapy and transpupillary thermotherapy (TTT) in 50 consecutive patients 5 years after treatment.

METHODS

50 adult patients with choroidal melanoma were treated with ruthenium-106 ((106)Ru) plaque radiotherapy combined with TTT. A flat scar was the preferred end point of treatment. The mean tumour thickness was 3.9 mm (range 1.5-8.0 mm), the mean tumour diameter was 11.3 mm (range 5.8-15.0 mm). TTT was performed with an infrared diode laser at 810 nm, a beam diameter of 2-3 mm, and 1 minute exposures. Tumours >5 mm thick received an episcleral contact dose of 800 Gy (106)Ru; tumours <or=5 mm thick received a contact dose of 600 Gy (106)Ru. TTT was repeated in case of incomplete tumour regression after combined therapy.

RESULTS

Complete tumour regression was obtained in 45 patients. It required one, two, or three TTT sessions in 32, 11, and two patients, respectively. In tumours <or=3 mm thick complete flattening was achieved significantly faster than in tumours >3 mm thick (log rank test p = 0.01). Eight melanomas were amelanotic, seven of which required multiple TTT sessions. In one patient the tumour recurred at the central margin of the treated area; this eye was enucleated. In one patient the tumour failed to regress 6 months after treatment and enucleation was performed at the patient's request. Three eyes developed severe proliferative retinopathy. Radiation maculopathy caused a loss of the best corrected visual acuity: before treatment 31 patients had a best corrected visual acuity of 20/60 or better but in only 12 patients did it remain in this range 5 years after treatment. Three patients developed distant metastasis to the liver.

CONCLUSION

The 5 year results for combined plaque radiotherapy and TTT as treatment for choroidal melanoma are favourable in terms of complete tumour regression and low rate of recurrences; however, there was considerable loss of visual acuity as a result of radiation maculopathy.

Thermotherapy in the management of choroidal melanoma

During the past 20 years of enucleation, which was the standard treatment for choroidal melanoma over more than a century, has largely been replaced by eye salvaging therapies such as radiotherapy or local resection. In 1995 transpupillary thermotherapy (TTT) using an infrared diode laser was introduced as a new conservative therapy for patients with choroidal melanoma. TTT can be defined as a heat treatment modality, which is delivered through a dilated pupil to the tumour surface. The technique uses a wide diode laser beam diameter with a low irradiance and a long exposure time. TTT induces tumour necrosis at sub-photocoagulation levels by a direct cell destructive effect with only a few ocular complications. TTT can be performed as sole therapy or combined with plaque radiotherapy, thus permitting a lower radiation dose. For amelanotic tumours dye-enhanced TTT with indocyanine green can be used. In this paper we review the role of sole or combined TTT, related to the current other treatment modalities for choroidal melanoma.

Amelanotic choroidal nevus and melanoma: cytology, tumor size, and pigmentation as prognostic indicators

BACKGROUND

Choroidal nevi are fairly common lesions of the posterior pole that can sometimes transform into melanoma, and it is thought that most choroidal melanomas arise from preexisting nevi. Occasionally, these lesions present as nonpigmented or amelanotic variations of their pigmented counterparts. Recent studies suggest a relationship between tumor pigmentation and risk of growth and metastasis, with a better prognosis for lightly pigmented or amelanotic lesions.

CASE REPORTS

A case of an amelanotic choroidal nevus and melanoma are presented. In Case 1, a 26-year-old white female was found to have a large amelanotic nevus in the right eye. After 7 years of periodic observation, the lesion has not changed. In Case 2, a 51-year-old white male was diagnosed with a large amelanotic melanoma in the left eye. Due to extensive involvement of the optic nerve, the patient underwent enucleation. Histological evaluation confirmed the lesion as a mixed-cell type malignant amelanotic melanoma.

CONCLUSION

Management of choroidal nevi generally consists of periodic observation, and the most widely accepted management of choroidal melanoma is observation, radiotherapy, and transpupillary thermotherapy or enucleation. The therapeutic modality of choice for melanoma will vary depending on the size, growth, and location of the lesion. In addition, recent studies suggest an association between heavy tumor pigmentation, tumor size, cell type, and risk of metastasis. Although many variables will influence the final treatment option, pigmentation of the lesion should also be considered.

Risk factors for metastatic uveal melanoma after trans-scleral local resection

AIMS

This study reports the metastatic death rate after trans-scleral local resection of uveal melanoma and identifies relevant risk factors.

METHODS

Local resection was performed in 332 patients (mean age 51 years), with follow up ranging to 20.9 years (median for living patients 33 months). The tumours had a mean largest basal diameter of 13.1 mm and mean thickness of 7.5 mm, with 135 containing epithelioid cells. Risk factors were identified by Cox analysis and metastatic rates demonstrated using Kaplan-Meier curves.

RESULTS

There were 52 deaths from metastatic melanoma. The significant risk factors were (i) age more than 60 years at treatment (p = 0.001), (ii) mixed/epithelioid tumours (p = 0.003), (iii) superior location of mixed/epithelioid tumours (over and above (ii)) (p = 0.001), (iv) largest basal tumour diameter of 16 mm or more (p < 0.001), (v) lack of adjunctive radiotherapy (p = 0.031), (vi) secondary enucleation for bulky residual/recurrent tumour (p = 0.002), and (vii) secondary enucleation for small residual/recurrent tumour extraocularly (p = 0.019). Metastatic death was not significantly associated with (i) incomplete tumour excision (p = 0.163), and (ii) small residual/recurrent tumour treated by enucleation (p = 0.855).

CONCLUSIONS

Survival diminished from 92% at 15 years if less than two risk factors were present to less than 30% in 3.5 years if more than three risk factors were present.

Helium ions versus iodine 125 brachytherapy in the management of uveal melanoma. A prospective, randomized, dynamically balanced trial

PURPOSE

Optimal radiation therapy for uveal melanoma is uncertain, and the relative efficacies of radioactive plaques and charged particles are unclear.

METHODS

The authors prospectively studied helium-ion irradiation and iodine 125 (125I) brachytherapy in a randomized, dynamically balanced trial. Of the 184 patients who met the eligibility criteria, 86 were treated with helium ions and 98 with 125I brachytherapy.

RESULTS

No patients with uveal melanoma had a history of systemic malignancy. Tumors were less than 15 mm in maximum diameter and less than 10 mm in thickness. A minimum tumor dose of 70 GyE was delivered to the tumor apex. There was a significantly higher local recurrence rate after 125I brachytherapy than after helium-ion irradiation. Enucleations occurred more frequently after brachytherapy (relative risk = 1.99; 95% confidence interval, 0.78-5.78). More anterior segment complications occurred after helium-ion irradiation. To date, there has been no measurable impact on survival.

CONCLUSIONS

Most uveal melanomas can be managed with radiation with retention of the eye. There was better tumor control with helium-ion irradiation; however, there were more anterior segment complications.

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)