Early Results of Stereotactic Radiosurgery in Uveal Melanoma and Risk Factors for Radiation Retinopathy

Safety and Efficacy of Intracameral Methotrexate and Targeted Radiotherapy for Subconjunctival Ocular Granulocytic Sarcoma: A Case Report

A 28-year-old male patient with a history of acute myeloid leukemia, who was in complete remission for 18 months after allogeneic peripheral blood stem cell transplantation (PBSCT), developed a salmon-pink nodular lesion of the upper bulbar conjunctiva with conjunctival vascular engorgement of the right eye, accompanied by severe anterior uveitis and hypopyon. Ocular granulocytic sarcoma (OGS) was diagnosed based on immunohistochemistry analysis of the tissue sample and flow cytometry analysis of the aqueous humour, representing a local recurrence of acute myeloid leukemia. Systemic and central nervous system infiltration was excluded. Targeted radiotherapy of the right eye (24 Gy/12 cycles) and a series of 12 intracameral injections of methotrexate (400 μg/0.1 ml) were implemented with no impact on the endothelial cell count or corneal morphology. Complete macroscopic and cytometric remission of the lesion was achieved without leaving any permanent visual defects.

Efficacy and safety of robotic Cyberknife radiotherapy in uveal melanoma: a systematic review and meta-analysis

OBJECTIVES

This systematic review is aimed to evaluate the efficacy and safety of robotic Cyberknife radiotherapy (CKRT) in the treatment of uveal melanoma (UM).

METHODS

Clinical studies published in English that assessed the efficacy and safety of robotic CKRT in UM were systematically searched in PubMed, Web of Science, Cochrane and Embase from inception to July 2023. Studies reporting extraocular tumours or other radiosurgery approaches were excluded. Outcomes measured were tumour size, reflectivity, local tumour control rate, eye retention rate, survival rate, complication rate, recurrence rate, and metastasis rate.

RESULTS

Ten eligible articles involving 2370 patients with 2372 UMs were included in evidence synthesis. Meta-analysis showed 811 of 912 patients (0.89, 95% Cl: 0.86, 0.92) maintained local control for three years, and 1448 of 1724 patients (0.84, 95% Cl: 0.81, 0.88) preserved the eye in three years. During follow-up, 91% (0.91, 95% Cl: 0.85, 0.97) patients survived and 351 of 1720 patients (0.23, 95% Cl: 0.09, 0.37) involving 1722 eyes had tumour recurrence. In addition, 1376 patients (0.79, 95% Cl: 0.77, 0.82) preserved the eyeball in five years. Following treatment, approximately 20% of patients had radiation retinopathy (95% Cl: 0.13, 0.28), 19% developed glaucoma (95% Cl: 0.11, 0.28), and 22% experienced retinal detachment (95% Cl: 0.07, 0.36).

CONCLUSIONS

CKRT is a viable, noninvasive RT for UM. The rate of local tumour control following treatment is comparable to that of other RT approaches, providing additional options based on the patient's condition.

Impact of tumour volume and treatment delay on the outcome after linear accelerator-based fractionated stereotactic radiosurgery of uveal melanoma

BACKGROUND/AIMS

Primary radiation therapy is used to treat malignant uveal melanoma (UM). We report our single-centre experience with fractionated radiosurgery (fSRS) with a linear accelerator (LINAC) after specific adaptation for small target volumes with HybridArc.

METHODS

From October 2014 to January 2020, 101 patients referred to Dessau City Hospital with unilateral UM underwent fSRS with 50 Gy given in five fractions on five consecutive days. Primary endpoints were local tumour control, globe preservation, metastasis and death. Potential prognostic features were analysed. Kaplan-Meier analysis, Cox proportional hazards model and linear models were used for calculations.

RESULTS

The median baseline tumour diameter was 10.0 mm (range, 3.0-20.0 mm), median tumour thickness 5.0 mm (range, 0.9-15.5 mm) and median gross tumour volume (GTV) 0.4 cm³ (range, 0.2-2.6 cm³). After a median follow-up of 32.0 months (range, 2.5-76.0 months), 7 patients (6.9%) underwent enucleation: 4 (4.0%) due to local recurrence and 3 (3.0%) due to radiation toxicities, and 6 patients (5.9%) revealed tumour persistence with a GTV exceeding 1.0 cm³. Of 20 patients (19.8%) who died, 8 (7.9%) were tumour-related deaths. Twelve patients (11.9%) suffered from distant metastasis. GTV showed an impact on all endpoints, and treatment delay was associated with reduced odds of eye preservation.

CONCLUSION

LINAC-based fSRS with static conformal beams combined with dynamic conformal arcs and discrete intensity-modulated radiotherapy results in a high tumour control rate. The tumour volume is the most robust physical prognostic marker for local control and disease progression. Avoiding treatment delay improves outcomes.

Radiation retinopathy following episcleral brachytherapy for intraocular tumors: Current treatment options

Radiation retinopathy (RR) and radiation maculopathy (RM) can occur as a result of uveal melanoma radiation treatment and after irradiation of other head and neck extraocular tumors, even with precise targeting techniques, such as stereotactic or proton beam radiotherapy. This review provides an overview of the current understanding of potential radiation damage to ocular tissues, and how recent developments in ophthalmic multimodal imaging techniques and treatment modalities have improved managing options. Several treatment strategies have been employed so far for the management of RR, including laser photocoagulation, intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents or glucocorticosteroids and surgery. The use of intravitreal anti-VEGFs or dexamethasone implants have significantly altered the final visual outcome for uveal melanoma patients. As a prophylaxis, a few different strategies were proposed, but still there is a lack of large randomized clinical trials supporting these approaches and clear clinical guidelines for daily practice. Early detection and proper treatment are crucial in preventing or reducing vision loss, and improving patients' quality of life. Close monitoring and timely intervention are essential for successful management.

Factors affecting eye conservation and metastasis in posterior uveal melanomas

PURPOSE

To determine the effect of patient and tumor features and different treatments on eye removal (enucleation or exenteration) and metastasis in posterior uveal melanoma (PUM).

METHODS

Retrospective analysis. Patient age (≤60 vs >60 years), sex (female vs male), visual acuity (VA, ≤20/40 vs >20/40), largest tumor basal diameter (LTBD), tumor thickness, tumor stage according to American Joint Committee on Cancer (AJCC) 8th edition, ciliary body involvement, distance to optic disc (OD)/fovea (≤3 mm vs >3 mm), OD involvement, and histopathology were evaluated. Primary treatment options were transpupillary thermotherapy, plaque radiotherapy, Cyberknife radiosurgery, exoresection, and eye removal. Risk factors for primary eye removal were determined using logistic regression test and those for secondary eye removal and metastasis with Cox regression analysis.

RESULTS

Of 387 cases, 153 (39.5%) underwent primary eye removal. Multivariable risk factors for primary eye removal included AJCC tumor stage (p = 0.001, OR:4.586; p < 0.001, OR:34.545; p < 0.001, OR:103.468 for stages T2, T3, and T4 vs stage T1, respectively), and VA≤20/40 (p = 0.014, OR:2.597). Multivariable risk factors for secondary eye removal were VA≤20/40 (p = 0.019, RR:2.817) and AJCC stage T3 vs T1 (p = 0.021, RR:2.666). Eye preservation rates in patients undergoing eye-conserving treatments were 80.3%, 69.6%, and 51.5% at 5, 10, and 15 years, respectively. Metastasis-free survival rates were 81.0%, 73.0%, and 56.7% at 5, 10, and 15 years, respectively. Multivariable risk factors for metastasis included eye removal as primary treatment (p = 0.005, RR:2.828) and mixed type histopathology (p < 0.001, RR:4.804).

DISCUSSION

Early diagnosis is crucial for both eye preservation and survival in PUM. Increasing AJCC tumor stage and lower VA were risk factors for eye removal in this study. Mixed type histopathology and primary eye removal were risk factors for metastasis.

Ocular Complications of Radiotherapy in Uveal Melanoma

Uveal melanoma is the most common primary malignant intraocular tumor in adults. Radiation therapy has replaced enucleation and is now the preferred treatment in most cases. Nonetheless, around 70% of patients develop radiation-related complications, some of which are vision-threatening. The objective of this review is to present the most important complications associated with radiotherapy in the treatment of uveal melanoma and their pathogenesis, incidence, risk factors, and available preventive and therapeutic measures. The most common complications are cataracts, with a reported incidence ranging from 4% to 69%, and radiation retinopathy, reported in 5-68% of cases. Radiation-related complications are responsible for approximately half of secondary enucleations, the leading cause being neovascular glaucoma. A poor visual outcome is mainly associated with the presence of radiation retinopathy and radiation optic neuropathy. Therapeutic options are available for the majority of complications with the notable exception of optic neuropathy. However, many studies report a final visual acuity of less than 20/200 in more than 60% of treated eyes. Reducing complication rates can be achieved by lowering the dose of radiation, with the use of eccentric, customized plaques and careful planning of the irradiation delivery in order to protect structures vital to vision and by associating radiation therapy with other methods with the aim of reducing tumor volume.

Treatment of Intravitreal Ranibizumab Resistant Radiation Retinopathy with Intravitreal Dexamethasone Implant: A Case Report

A 43-year-old female patient presented with complaints of decreased vision in both eyes. Her medical history revealed the diagnosis of metastatic breast cancer. She was treated with chemotherapy, and whole-brain, manubrium sterni, and right chest wall radiation therapy. Best-corrected visual acuity (BCVA) was 20/200 and 20/160 in the right and left eye, respectively. Optical coherence tomography (OCT) confirmed the presence of cystoid macular edema (CME). OCT angiography confirmed the presence of microaneurysms, ischemia, and capillary drop-out on the macula. Fundus fluorescein angiography revealed multiple microaneurysms with surrounding ischemia and leakage. Based on these findings and medical history, a diagnosis of radiation maculopathy was considered. The patient was administered intravitreal four doses of ranibizumab injections. Laser photocoagulation was performed on the ischemic areas of the retina in both eyes. Despite the follow-up and treatment, the presence of residual CME and BCVA 20/200 in both eyes was determined; it was decided to change the treatment regimen to an intravitreal dexamethasone implant. One month after injection, BCVA was 20/80 in both eyes, and normal foveal contour and no edema as confirmed on OCT. The DEX implant showed a promising result and should be kept in mind in the treatment of radiation retinopathy.

Feasibility, Method and Early Outcome of Image-Guided Volumetric Modulated Arc Radiosurgery Followed by Resection for AJCC Stage IIA–IIIB High-Risk Large Intraocular Melanoma

Simple Summary

The aim of this trial was to define one optimal contemporary treatment procedure for large intraocular melanoma. Radiosurgery is a highly effective treatment in cancer. In this trial, all consecutive patients with large intraocular melanoma treated with multimodality treatment, comprising 4D image-guided volumetric modulated arc radiosurgery procedure followed by resection, were evaluated. In the short-term follow-up there was no clinical toxicity due to external beam radiation therapy, and no local tumor recurrence. In 98% of the cases, the eye bulb could be maintained with partial residual visual acuity in the mean follow-up of 18 months. The outcome estimates one optimal treatment procedure for high-risk, large intraocular melanoma, with excellent results in the first follow-up.

Abstract

The main objective of this prospective observational study was the characterization of the feasibility and early outcome of image-guided (IG) volumetric modulated arc (VMAT) radiosurgery (SRS) followed by resection for patients with large intraocular melanoma. Our study included consecutive patients with unfavorable-risk melanoma, enrolled in an ophthalmic oncology center. IG-VMAT-SRS was applied by high-resolution 4D image guidance and monitoring. Current stereotactic technique parameters were evaluated for comparison. Side effects and eye function, based on a 5-point CTC assessment score, were quantified. In patients with tumors located more than 0.7–1 mm apart from the optic nerve, partial to complete volume-sparing of the optic nerve head could be achieved. In 95.5% of this subgroup, the vitality of the optic nerve and vision could be preserved by the multimodality-treatment approach (mean follow-up: 18 months (7.5–36 months)). The advanced technology of stereotactic radiotherapy demonstrated the achievability of steep dose gradients around the high-dose volume, with 4D-IG-VMAT dose application. These results enforce IG-VMAT-SRS followed by resection as one of the major therapeutic options for patients with large intraocular melanoma. The combination of 4D-IG high-precision SRS and resection provides an effective treatment for large intraocular melanoma, with few side effects, and enables an eye bulb and even vision preserving modus operandi.