Proton beam radiotherapy of diffuse iris melanoma in 54 patients

Proton Therapy for 166 Patients with Iris Melanoma: Side Effects and Oncologic Outcomes

OBJECTIVE

To investigate the oncologic and functional outcomes of a large cohort of patients with a favorable stage of circumscribed and diffuse iris melanoma who underwent primary proton treatment and the risk factors related to initial tumor characteristics and the treatment field architecture.

DESIGN

Retrospective, single-center, case study.

PARTICIPANTS

We reviewed 225 patients with iris melanoma who were consecutively treated with proton beam therapy at our institution between 1998 and 2020.

METHODS

We performed Kaplan-Meier time-to-event analyses and multivariate Cox proportional hazard analyses to identify the impacts of tumor characteristics and target volumes on oncologic and functional outcomes.

MAIN OUTCOME MEASURES

We measured local tumor control, eye preservation rates, metastasis-free survival, cataract and glaucoma-directed surgery, intraocular pressure, and changes in visual acuity.

RESULTS

Of the 192 patients with tumors confined to the iris (T1a-c) who underwent proton therapy as primary treatment, a total of 166 patients (mean age, 58.4 years; 88 women) with a minimum follow-up of 6 months were included. Multifocal or diffuse tumor spread was present in 77 (46.4%) patients. The median follow-up time was 54.0 (interquartile range, 27.4-91.8 months) months. Local recurrence occurred in 2 patients (1.2%) with circumscribed iris melanoma. Enucleation was a rare event (n = 5, 3%) and no patient developed metastatic disease. A large-treatment field (full aperture, involving > 10 clock hours) was identified as a risk factor for the development of secondary glaucoma (hazard ratio [HR], 6.3; P < 0.001) and subsequent surgical interventions (HR, 10.85; P < 0.001). The large-treatment field group showed a significant decline in visual acuity (logarithm of the minimum angle of resolution > 0.3; log-rank P < 0.0001), which was associated with secondary glaucoma (HR, 3.40; P = 0.002).

CONCLUSIONS

Proton therapy provides an effective, noninvasive treatment option for patients with a favorable stage of iris melanoma. Irradiation of the anterior segment for up to 10 clock hours is associated with a low risk of the development of secondary glaucoma and vision loss.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Proton beam radiation for iris melanoma: case series and review of literature

Objective

Purpose of this study is to analyse the visual outcomes, the complication and eye retention rate as well as tumour control data of patients treated with proton beam radiation therapy (PBRT) for iris melanoma.

Methods

Retrospective case series and review based on patients’ records. All tumours were categorised according to the American Joint Committee of Cancer staging criteria for primary iris melanoma und underwent either sectorial or whole anterior segment PBRT.

Results

Thirteen cases were identified of which five received PBRT of the whole anterior segment and eight received sectorial PBRT. Local tumour control after a mean follow-up of 25 months was 92%. Complications after PBRT included cataract (46%), secondary glaucoma (31%), superficial keratitis (15%) and madarosis (8%). Complications were more common in patients necessitating irradiation of the entire anterior segment than in patients which received sectorial irradiation. Eye retention was achieved in all cases. No statistically significant difference in the mean best corrected visual acuity (BCVA) and intraocular pressure (IOP) was found before and after treatment. Comparison of mean BCVA and IOP between different treatment groups (complete anterior segment vs sectorial irradiation) at the last follow-up visit were also not significantly different. No patient developed metastatic disease during follow-up.

Conclusion

PBRT is a safe and vision preserving therapeutic modality for iris melanoma. Complete irradiation of the anterior segment is associated with higher complication rates.

Clinical outcomes of Modified Collaborative Ocular Melanoma Study IRIS plaques for treatment of iris, iridociliary, and ciliary body melanoma

BACKGROUND/OBJECTIVES

To report clinical outcomes of modified Collaborative Ocular Melanoma Study IRIS (COMS IRIS) plaques for treatment of iris, iridociliary, and ciliary body melanoma.

SUBJECTS/METHODS

Retrospective, single-centre cohort study of iris melanoma treated with COMS IRIS plaque radiotherapy from July 26, 2010 to October 15, 2018. Medical records were reviewed for demographics, tumour features, treatment parameters, and clinical outcomes.

RESULTS

There were 22 cases, diagnosed at mean age of 59 years (median 65, range 21-85 years) with female sex in 14 (64%). Presenting tumour features included Snellen visual acuity (VA) ≥ 20/40 in 18 (82%) cases, mean largest tumour basal diameter 4.7 mm (median 3.9, range 2.3-13.8 mm) and thickness 1.7 mm (median 1.6 mm, range 0.8-3.9 mm), iris stromal seeding in 3 (14%) cases, angle seeding in 16 (73%), and ciliary body involvement in 13 (59%). After mean follow-up of 51 months (median 44, range 4-113 months), Snellen VA was ≥20/40 in 14 (64%) cases, with local tumour recurrence in 2 (9%), and enucleation in 2 (9%). The 3-year Kaplan-Meier estimated risk of local tumour recurrence was 7%. The most common radiation side effects were cataract in 17 (77%) patients and dry eye in 5 (23%). Systemic metastasis occurred in no cases, and 1 (5%) non-melanoma-related death due to natural causes was observed at last follow-up.

CONCLUSIONS

COMS IRIS plaques are effective for treatment of iris, iridociliary, and ciliary body melanoma with modest VA outcomes and low frequency of local tumour recurrence, enucleation, radiation side effects, and systemic metastasis.

Brachytherapy or enucleation in ring melanoma patients: which is better? Preliminary results of the authors' own experiences

Purpose

A retrospective evaluation of effectiveness of brachytherapy or enucleation in treatment of rare form of uveal melanoma: ring melanoma.

Material and methods

Analysis comprised 49 patients treated from 2000 to 2019 for ring melanoma involving ciliary body. In 15 patients, primary treatment consisted of brachytherapy (¹⁰⁶Ru or ¹²⁵I), whereas in 34 patients, eyeballs were enucleated. The evaluation concerned differences between analyzed groups relating to the clinical and histopathological features as well as overall survival, cancer-specific overall survival, and disease-free survival.

Results

No significant differences between the analyzed groups were found with regards to clinical and histopathological features, apart from intra-ocular pressure (increased in the enucleation group). Kaplan-Meier analysis did not reveal any significant differences between the group treated with enucleation and the group undergoing brachytherapy, both with regards to overall survival (p = 0.325) and cancer-specific overall survival (p = 0.477). A significant difference was observed in disease-free survival (p = 0.009), which was significantly shorter in the group undergoing brachytherapy. In the analysis of parameters of the applied brachytherapy, no significant differences between patients with and without local recurrence were found. Mean observation period was 350.8 weeks (range, 24-996 weeks, SD = 231.6). A local recurrence occurred in 11 (22.4%) patients, including 3 (6.1%) in enucleation and 8 (16.3%) after brachytherapy groups. Metastasis developed in 11 (22.4%) cases after a mean follow-up of 133 weeks (33.25 months), range 3-655 weeks.

Conclusions

Preliminary observations may suggest that brachytherapy in this rare form of uveal melanoma, such as ring melanoma involving the ciliary body, may be taken into consideration as a useful alternative to enucleation. However, the confirmation of such an approach requires a larger patients’ group to be gathered, and also a longer follow-up period. This is especially important in patients with a good baseline visual acuity in the affected eye, or when the neoplasm is present in the remaining eye with vision.

Locally Invasive Diffuse Iris Ring Melanoma Presenting as Unilateral Severe Glaucoma: Case Report and Review of Molecular Genetics

We report the clinical history and histopathological findings in a case of diffuse iris ring melanoma (DIM) and review the most recent literature and modern molecular genetics of this entity. An 85-year-old Hispanic man presented with severe unilateral glaucoma, managed at an outside institution for 2 years prior to presentation. Diffuse pigmentation was noted in the angle, on the intraocular lens implant, and in the vitreous without clear demonstration of a mass on ultrasound biomicroscopy. Workup for metastatic cutaneous melanoma was negative. Histopathological examination of the enucleated eye revealed a mixed cell type iris ring melanoma with diffuse intraocular involvement. Gene expression profiling (GEP) revealed a class 2 molecular signature indicating a very high risk for metastases. Unilateral glaucoma presenting with marked pigmentation in the anterior chamber angle should be managed as melanoma until proven otherwise. Iris ring melanomas are known to have an aggressive clinical course, and recent molecular analyses indicate that they are likely primarily GEP class 2 with a very poor prognosis, similar to the majority of ciliary body melanomas.

Robotic assisted CyberKnife radiosurgery for the treatment of iris melanoma

Iris melanoma is a rare form of uveal melanoma with potential metastic spread. Treatment options include surgical resection, enucleation or irradiation. We analysed visual outcome, complication appearance and management in eight patients with iris melanoma following robotic-assisted CyberKnife treatment. Consecutive patients from the Department of Ophthalmology at University of Munich were included in the study if they had an iris melanoma that was treated with CyberKnife and had a minimum follow-up of 12 months. We evaluated tumor thickness, largest diameter, visual acuity and complications. 8 patients were included in this report. The median age was 74 years (range: 53-86 years). The median follow-up was 23 months (range 12-48 months). Tumor thickness decreased from 2.1 to 1.4 mm on average. Four out of eight patients showed stable or increased visual acuity compared to visual acuity at first visit. We did not find a correlation of applied radiation volume or radiation dose on visual outcome. Radiation keratopathy was the most common complication in five patients. No recurrences were noted. Robotic-assisted radiosurgery following CyberKnife is a promising non-invasive, single session treatment option for iris melanoma with comparable results regarding recurrence rate or complications to brachytherapy and proton beam therapy. All included patients showed good visual outcome.

Iris Melanoma: Management and Prognosis

Iris melanomas represent 2–5% of uveal melanomas. Iris melanomas vary in their size, shape, degree of pigmentation and clinical behavior. The main local clinical complications of iris melanomas are tumor vascularization, ectropion uvea, pupillary distortion, pigment dispersion, sector cataract, chronic uveitis, hyphema and glaucoma with irreversible optic nerve damage. The most effective treatment for iris nevus and melanoma remains debatable; treatment modalities have been proposed depending on the local status as well as the age and general condition of the patient. A melanocytic iris nevus is usually observed until documented progression is identified. In this case, radiotherapy or surgical resection is generally performed. Cataract, glaucoma and limbal stem cell deficiency are usually secondary to radiotherapy, while incomplete tumor excisions, which could lead to recurrence, hemorrhage, vitreous loss, dislocated lens, iridocyclitis, macular edema, retinal detachment, glaucoma and cataract, are related to surgical resection. In some cases, a combination of radiotherapy and surgery is used. Conservative treatment is an efficient alternative to enucleation and allows good local tumor control.

Palladium-103 plaque therapy for multifocal iris melanoma: Radiation of the entire anterior segment of the eye

PURPOSE

To investigate the safety and tolerability of total anterior segment palladium-103 (¹⁰³Pd) eye plaque brachytherapy for multifocal iris melanoma.

METHODS

Interventional case series of 11 patients with multifocal iris melanomas. Anterior segment ultrasound revealed tumor size, location, and intraocular margins. Epicorneal amniotic membrane grafts protected the cornea and decreased pain during total anterior segment 103-Pd ophthalmic plaque brachytherapy.

RESULTS

Eleven diffuse iris melanomas were American Joint Committee on Cancer 8th edition-classified as T1 (n = 5, 45.5%) and T2 (n = 6, 54.5%). Plaque radiation was completed to a minimum mean tumor dose of 85 Gy (mean dose rate, 58.1 cGy/h). Ultrasonographic tumor thickness regression was 41% (follow up mean 58.7, median 50, range: 8-139 months). Despite 100% local control and 100% eye retention, one patient (9.1%) developed metastatic disease. Four eyes required cataract surgery. There was no corneal stem-cell deficiency, corneal opacity, radiation maculopathy, or optic neuropathy. While visual acuity prior to treatment was 20/40 or better in 10 (91%), 9 were 20/40 or better (81.9%) at last follow-up. Four (36%) had glaucoma prior to treatment and three eyes developed glaucoma after treatment for a total of 63%.

CONCLUSION

Total anterior segment (¹⁰³Pd) plaque brachytherapy resulted in local control, good visual acuity, eye and life preservation in the treatment of multifocal iris melanoma.

Diffuse Iris Melanoma: Conservative Treatment with Proton Beam Therapy after Limbal Stem Cell Preservation or Enucleation?

Objectives

Iris melanomas represent 2-3% of uveal melanomas; the diffuse variant accounts for approximately 10% of all iris melanomas. Different treatment modalities for diffuse iris melanomas (DIM) have been proposed depending on the local status as well as the age and general condition of the patient.

Methods

This study is a single-centre retrospective case series describing the diagnosis, treatments and outcomes of DIM. Treatment consisted of enucleation or proton beam therapy (PT) of the whole anterior segment. Patients who were treated with PT benefitted from limbal stem cell preservation before irradiation.

Results

Between 1996 and 2016, a total of 14 patients with DIM presented to our institution and were included in the database. The global survival was 86%. The median follow-up was 4.6 years (range 4 months to 15 years). Only 1 patient (7%) developed metastatic disease of the DIM (gastric location). No patient developed liver metastasis. Seven patients were treated by enucleation and 7 by PT after limbal stem cell preservation. After a conservative attempt, local tumour recurrence occurred in 2 patients at 2 years, requiring enucleation. The cornea was clear after irradiation in all patients. Cataract (n = 6) and glaucoma (n = 4) were the main complications after irradiation.

Conclusions

DIM is a very rare tumour. The global survival is excellent. Conservative treatment with PT is an efficient alternative to enucleation and allows good local tumour control. Cataract and glaucoma are the main radiation-related complications, but the corneal status was excellent due to the stem cell harvest prior to radiotherapy.

[New treatment options for iridociliary tumors]

BACKGROUND

Benign iridal tumors rarely necessitate a therapeutic intervention. In contrast, malignant tumors of the iris can threaten the patient's life and eyesight and require early treatment to prevent the development of metastases.

OBJECTIVE

Presentation of current treatment options for iridal tumors with special emphasis on iridal melanoma.

METHODS

This article gives an overview of the current literature based on a PubMed search as well as own clinical experience.

RESULTS

Treatment options for iridal and ciliary body melanomas comprise radiotherapeutic and surgical (eyeball-sparing and non-sparing) approaches. The eyeball-sparing surgical procedure of choice is block excision. While local tumor control rates and metastasis rates of block excision and radiotherapy are comparable, there are distinct differences especially between the spectra of complications. New treatment procedures include immunomodulatory approaches and targeted therapies. Using checkpoint inhibitors, no convincing enhancement of overall survival could be demonstrated for metastatic iridal melanoma, as is the case for cutaneous melanoma. In contrast, tumor vaccination with the help of tumor RNA-laden patient-derived dendritic cells seems to be a promising option for a subgroup of high-risk patients. Targeted therapies aiming to suppress the MAPK and PI3K/Akt pathways could not achieve any improvement in patient survival.

CONCLUSION

For the primary treatment of iridal melanoma a surgical, eyeball-sparing approach and also when appropriate, radiotherapy can be recommended. In the future, eligible high-risk patients could profit from a tumor vaccination. To date, there is no effective systemic treatment for metastatic iridal melanoma.

Novel Eye Plaque Designs for Brachytherapy of Iris and Ciliary Body Melanoma and the First Clinical Application

Background

While traditional eye plaque brachytherapy can be used for the treatment of iris melanoma, it faces challenges of poor patient tolerability due to cornea-plaque touch caused by radius of curvature mismatch and potential dosimetric inaccuracy from incomplete coverage. We present novel plaque designs and the first clinical application of the plaques for iris melanoma.

Methods

Two dome-shaped plaques (EP2132 and EP1930) were designed to vault above the cornea to treat tumors of the iris and ciliary body. Image-based treatment planning of the first 2 clinical cases using the EP2132 plaque covered the tumor base plus a 2 mm margin and the involved ciliary body with at least 75 Gy to the tumor apex.

Results

The tumors decreased in size following treatment. The patients tolerated the treatment well. There was no adverse event associated with the traditional iris plaques, such as decreased vision, pain, corneal edema, glaucoma, or cataract.

Conclusion

The novel dome-shaped plaques for the treatment of iris melanoma provide effective dose distribution, improved surgical maneuverability, and increased tolerability for the patient. This plaque model can be used to treat iris melanoma of various sizes, configurations, and locations, including the ciliary body. The need for a customized plaque platform for each patient is minimized.

Proton Beam Therapy for Iris Melanomas in 107 Patients

PURPOSE

To report on the clinical characteristics and outcomes for patients with iris melanoma using proton therapy.

DESIGN

Retrospective study.

PARTICIPANTS

One hundred seven patients with iris melanoma from 3 regional ophthalmologic centers.

METHODS

A retrospective study was conducted for iris melanoma patients from 3 regional ophthalmologic centers referred to and treated at a single proton therapy facility between 1996 and 2015.

MAIN OUTCOME MEASURES

At each follow-up visit, examinations included measurement of best-corrected VA, slit-lamp, examination, indirect ophthalmoscopy, and ultrasound biomicroscopy.

RESULTS

With a median follow-up of 49.5 months, 5 of 107 patients experienced a local relapse within a median of 36.3 months. The cumulative incidence of relapse was 7.5% at 5 years. All 5 patients showed involvement of the iridocorneal angle (P = 0.056). Diffuse iris melanoma showed a higher risk of relapse (P = 0.044). Four patients showed out-of-field relapse and 1 showed angular relapse. Three patients were retreated with proton therapy, whereas 2 other patients, one with T1b disease and another with diffuse T3 disease, underwent secondary enucleation. None of the patients experienced metastases nor died of iris melanoma. Vision improved in 59.4% of patients (n = 60/101). However, cataracts occurred in 57.4% of the 54 patients (n = 31) without cataract or implant at diagnosis. Secondary glaucoma was reported in 7.6% of the patients (n = 8), uveitis in 4.7% (n = 5), and hyphema in 3.7% (n = 4). All but 5 cases of complications were mild, transient, and not sight limiting after treatment. Five cases of glaucoma, including 1 with uveitis, were severe and associated with visual deterioration.

CONCLUSIONS

Proton therapy showed efficacy and limited morbidity in iris melanomas.

Proton therapy of iris melanoma with 50 CGE : Influence of target volume on clinical outcome

PURPOSE

The aim of this study was to evaluate local tumour control, incidence of radiation-induced glaucoma and associated interventions of sector-based and whole anterior segment proton beam therapy (PBT) for the treatment of iris melanoma.

PATIENTS AND METHODS

We retrospectively analysed the data of 77 patients with iris melanoma who underwent PBT applied as 50 CGE in four daily fractions. Of the patients, 47 received PBT with a circular-shaped collimator and 30 with a conformal sector-shaped target volume. Local control, eye preservation and secondary glaucoma were evaluated.

RESULTS

Median follow-up time was 54.9 months. Local tumour control was 100% in patients receiving whole anterior segment irradiation. Two patients developed pigment dispersion in the non-irradiated area after sector-based PBT and received whole anterior segment salvage PBT. The mean volume of ciliary body irradiated was 89.0% and 34.9% for whole anterior segment and lesion-based irradiation, respectively. At the end of follow-up, secondary glaucoma was found in 74.3% of the patients with whole anterior segment irradiation and in 19.2% with sector-based irradiation. Patients with sector-based PBT had a stable visual acuity of logMAR 0.1, while it declined from logMAR 0.1 to 0.4 after whole anterior segment irradiation.

CONCLUSION

We found a significant reduction in radiation-induced secondary glaucoma and glaucoma-associated surgical interventions and stable visual acuity after sector-based irradiation compared with whole anterior segment irradiation. Sector-based irradiation revealed a higher risk for local recurrence, but selected patients with well-circumscribed iris melanoma benefit from applying a lesion-based target volume when treated with sector-based PBT.

Use of Ruthenium-106 Brachytherapy for Iris Melanoma: The Scottish Experience

PURPOSE

To analyse long-term outcomes of ruthenium-106 (¹⁰⁶Ru) plaque brachytherapy for the treatment of iris melanoma.

METHODS

We retrospectively reviewed medical records of 19 consecutive patients with pure iris melanoma treated with ¹⁰⁶Ru plaque brachytherapy between 1998 and 2016 at the Scottish Ophthalmic Oncology Service, Glasgow. The iris melanoma was treated with a ruthenium plaque placed on the corneal surface to deliver a surface dose of 555 Gy. We analysed vision preservation, local tumour control, radiation-related complications, eye retention rates, symptomatic metastasis and melanoma-related mortality.

RESULTS

The mean largest basal diameter of the lesions was 3.50±1.42 mm (range 1.6-6.5 mm), and the mean maximum height was 1.47±0.65 mm (range 0.7-2.8 mm). The tumour control and eye retention were 100% at a mean follow-up of 62 months (range 6-195 months). A 62% reduction in tumour height was observed on ultrasonography. Complications included cataract (68%), dry eye (47%), uveitis (37%) and scleral thinning (5%). At the final follow-up visit, the mean loss of Snellen visual acuity was 1.11±2.90 lines and vision of 6/9 or better was maintained in 53% of patients. None of the patients had evidence of symptomatic metastasis (non-imaged) or melanoma-related mortality.

CONCLUSIONS

¹⁰⁶Ru plaque treatment for iris melanoma was highly effective a high tumour control, no tumour recurrences and a relatively a low complication rate.

Trabeculectomy in patients with uveal melanoma after proton beam therapy

BACKGROUND

Retrospective evaluation of intraocular pressure, use of topical and systemic anti-glaucoma medication, secondary complications, local tumor control and survival in patients treated with trabeculectomy for the regulation of the intraocular pressure (IOP) after proton beam therapy for uveal melanoma.

METHODS

In this retrospective clinical case series we evaluated the follow-up of 15 patients receiving a trabeculectomy as surgical treatment if the IOP could not be lowered adequately by medications or laser surgery. All patients had received proton beam therapy for uveal melanoma at the Helmholtz-Zentrum Berlin between 1998 and 2010.

RESULTS

The median IOP decreased significantly from 35 mmHg ± 8.8 before TE to 16 mmHg ± 8.2 (=52.3 %) six months after TE (Wilcoxon-Mann-Whitney-U Test, p<0.01). None of the patients needed any glaucoma medication six months after trabeculectomy. Two patients developed local recurrence during follow-up, which were independent of the trabeculectomy. One patient had to be enucleated due to intractable pain and suspected remaining tumor activity. One patient died due to metastasis.

CONCLUSIONS

Trabeculectomy is an option in intractable glaucoma in patients with uveal melanoma after proton beam therapy in single cases. Secondary interventions are common. Inoculation metastases are possible. Secure local tumor control must be a prerequisite for filtrating operations.