Visual outcomes of macular melanocytic lesions after early or delayed proton beam therapy

PURPOSE

During their initial management, some macular melanocytic lesions can be closely monitored to wait for a documented growth before advocating a treatment by irradiation. However, the visual outcomes of this strategy have not yet been assessed. This study compares the visual outcomes of macular melanocytic lesions that underwent delayed proton beam therapy (PBT) after an initial observation to those treated early.

METHODS

A total of 162 patients with suspicious melanocytic lesions whose margins were located within 3 mm of the fovea were recruited from two French ocular oncology centers.

RESULTS

Overall, 82 patients treated with PBT within 4 months after the initial visit (early PBT group) were compared to 24 patients treated with delayed PBT (delayed PBT group) and 56 patients not treated with PBT (observation group). Visual acuity was not significantly different between baseline and last visit in the observation group (p = 0.325). Between baseline and last visit, the median [IQR] loss in visual acuity was significant in both the early (0.7 [0.2; 1.8], p < 0.001) and the delayed (0.5 [0.2; 1.5], p < 0.001) PBT groups. After irradiation, there was no significant difference between the early and delayed PBT groups for visual loss (p = 0.575), diameter reduction (p = 0.190), and thickness lowering (p = 0.892). In multivariate analysis, history of diabetes mellitus and Bruch's membrane rupture remained significantly associated with greater visual loss (p = 0.036 and p = 0.002, respectively).

CONCLUSION

For small lesions in which there is no clear diagnosis of malignant melanoma, an initial close monitoring to document tumor growth does not impact visual prognosis, despite the potential complications associated with the untreated tumor. However, the survival should remain the main outcome of the treatment of these lesions.

Combination of Brachytherapy and Intravitreal Chemotherapy in the Treatment of Retinoblastoma with Vitreous Seeding

Purpose

The aim of this study was to report the efficacy of combined intravitreal chemotherapy (IVC) and ruthenium-106 brachytherapy in retinoblastoma, either as first-line or second-line treatment, following systemic chemoreduction or intra-arterial chemotherapy.

Methods

Retrospective data of 18 eyes from 18 patients treated with IVC and brachytherapy from August 2014 to December 2019 were collected.

Results

The method described was our first-line therapy in 6 patients, whereas it was used as second-line treatment after chemoreduction in the remaining 12 patients. The eyes showed the following classification at initial presentation: 2 group B eyes, 3 group C eyes, and 13 group D eyes. The mean follow-up was 19.5 months (range 2-53 months). The mean patient age at brachytherapy was 34.0 months (range 15-83 months). The median prescribed dose at the tumour base and apex was 574.5 ± 306.7 Gy and 88.5 ± 12.2 Gy, respectively. The ocular retention rate was 66.7%. Six eyes had to be enucleated due to uncontrollable subretinal and recurrent vitreous seeding, tumour relapse, recurrence of a solid tumour elsewhere in the eye, and persistent vitreous bleeding with loss of tumour control. The mean number of intravitreal injections of melphalan was 5.0. Two patients received a simultaneous injection of topotecan for insufficient therapeutic response. With regard to radiogenic complications, we could observe temporary retinal and vitreous bleeding (27.8%), serous retinal detachment (44.4%), and radiogenic maculopathy and retinopathy (11.1%). None of the children showed metastatic disease during follow-up.

Conclusion

Ruthenium-106 plaque therapy in combination with IVC is an effective local therapy with good tumour control rates even in advanced eyes. Overall, the analysed therapeutic approach shows an acceptable side-effect profile, especially when considering that external-beam radiation therapy and systemic polychemotherapy or at least the number of cycles needed, with their increased incidence of adverse events, can thus be avoided.

Evaluation of radiation maculopathy after treatment of choroidal melanoma with ruthenium-106 using optical coherence tomography angiography

BACKGROUND

To assess the impact of brachytherapy on macular microvasculature utilizing optical coherence tomography angiography (OCTA) in treated choroidal melanoma.

METHODS

In this retrospective observational case series, we reviewed the recorded data of the patients with unilateral extramacular choroidal melanoma treated with ruthenium - 106 (¹⁰⁶Ru) plaque radiotherapy with a follow-up period of more than 6 months. Automatically measured OCTA retinal parameters were analysed after image processing.

RESULTS

Thirty-one eyes of 31 patients with the mean age of 51.1 years were recruited. Six eyes had no radiation maculopathy (RM). From 25 eyes with RM, nine eyes (36%) revealed a burnout macular microvasculature with imperceptible vascular details. Twenty-one non-irradiated fellow eyes from the enrolled patients were considered as the control group. Foveal and optic disc radiation dose had the highest value to predict the burnout pattern (ROC, AUC: 0.763, 0.727). Superficial and deep foveal avascular zone (FAZ) were larger in irradiated eyes in comparison to non-irradiated fellow eyes (1629 μm² vs. 428 μm², P = 0.005; 1837 μm² vs 268 μm², P = 0.021; respectively). Foveal and parafoveal vascular area density (VAD) and vascular skeleton density (VSD) in both superficial and deep capillary plexus (SCP and DCP) were decreased in all irradiated eyes in comparison with non-irradiated fellow eyes (P < 0.001). Compared with non-irradiated fellow eyes, irradiated eyes without RM had significantly lower VAD and VSD at foveal and parafoveal DCP (all P < 0.02). However, these differences at SCP were not statistically significant.

CONCLUSION

The OCTA is a valuable tool for evaluating RM. Initial subclinical microvascular insult after ¹⁰⁶Ru brachytherapy is more likely to occur in DCP. The deep FAZ area was identified as a more critical biomarker of BCVA than superficial FAZ in these patients.

Short-term outcomes following treatment of recalcitrant cystoid macular edema secondary to radiation maculopathy using intravitreal brolucizumab

Purpose

To assess the efficacy of intravitreal brolucizumab (Beovu®, Novartis Pharmaceuticals) in a case of recalcitrant cystoid macular edema associated with radiation maculopathy secondary to retinoblastoma which was suboptimally responsive to other intravitreal anti-vascular endothelial growth factor (VEGF) therapies.

Observations

A 42-year old patient with a history of radiation maculopathy complicated by cystoid macular edema after chemoreduction treatment and radiation therapy for retinoblastoma was treated with intravitreal brolucizumab. Best-corrected visual acuity and central macular thickness assessed by optical coherence tomography were used to assess the clinical outcomes. The treated eye was also assessed for evidence of intraocular inflammation following injection. Cystoid macular edema showed marked reduction and near resolution two weeks after injection and improvement in best-corrected visual acuity which was maintained for 2 months of follow-up. No ocular inflammatory reactions or other adverse events were reported.

Conclusions and Importance

This case of radiation maculopathy refractory to other intravitreal anti-VEGF treatments showed good treatment response to brolucizumab therapy.

Treatment of radiation-induced maculopathy with fluocinolone acetonide

PURPOSE

Chronic macular oedema is a well-known presentation of radiation-induced maculopathy (RM) following external beam photon therapy, plaque radiotherapy and proton beam radiotherapy for choroidal tumours. Current therapies vary in respect of efficacy and clinical benefit. The potential of fluocinolone acetonide (FAc) slow-release implants is unknown. We hypothesised that local continuous delivery of low-dose corticosteroids might improve symptoms of RM.

METHODS

Five-two male and three female-patients from 37 to 68 years presented with RM following ¹⁰⁶Ru-plaque brachytherapy or stereotactic radiation therapy (STx) with photons using a hypofractionated schedule of 5 × 10 Gy. All were treated with triamcinolone injections in first line and proofed to be refractory to steroids. In addition, two patients had received Ozurdex® implants as a second-line treatment, though without any clinical benefit. FAc slow-release implants were injected, and patients were followed up to monitor clinical improvement.

RESULTS

All patients responded to therapy by means of a decrease in macular oedema. In four of five (80%) patients, visual acuity improved, and one patient showed stable visual acuity. No toxic effects or complications were observed.

CONCLUSION

Slow-release implants of FAc are a promising therapeutic potent steroid treatment option to benefit anatomical structures of the fovea and visual function. Slow-release implants with FAc reduce the frequency of intravitreal injections and the therapeutic burden.

Intravitreal aflibercept for the treatment of radiation-induced macular edema after ruthenium 106 plaque radiotherapy for choroidal melanoma

PURPOSE

To assess the efficacy of intravitreal aflibercept in patients suffering from post-radiation macular edema following plaque radiotherapy for choroidal melanoma.

METHODS

This prospective, interventional case series included patients affected by radiation maculopathy (RM) with macular edema secondary to ruthenium-106 plaque brachytherapy for choroidal melanoma. The effect of intravitreal aflibercept on best-corrected visual acuity (BCVA), central foveal thickness (CFT) detected by spectral domain optical coherence tomography (sd-OCT), and Horgan's grading scale of RM was evaluated throughout the 24-month follow-up. Intraocular pressure (IOP) and possible complications were also recorded.

RESULTS

Nine eyes of 9 patients were included. A mean of 4.4 ± 1.2 injections were given over the 24 months. At the end of follow-up, mean BCVA was significantly improved, from 0.9 ± 0.19 logMAR at baseline to 0.56 ± 0.3 logMAR (P = 0.028), and mean CFT was significantly decreased, from 546 ± 123 μm at baseline to 223 ± 34 μm (P < 0.001). Intravitreal aflibercept lowered baseline maculopathy stage as well. No significant change in IOP values and no complications, such as endophthalmitis, was recorded.

CONCLUSION

Intravitreal aflibercept is an effective treatment for patients with radiation-induced macular edema, allowing functional and anatomical improvements to be achieved with a relatively low number of injections.

Ruthenium brachytherapy for uveal melanomas: Factors affecting the development of radiation complications

PURPOSE

To investigate how treatment complications are related to dosimetric parameters after ruthenium-106 brachytherapy for uveal melanoma, in a large, clinically homogeneous population.

METHODS AND MATERIALS

A retrospective review was performed to evaluate patients affected by small and medium size uveal melanoma, treated with ruthenium-106 brachytherapy from December 2006 to December 2014. We excluded tumors with posterior margin within 1 mm from the edge of the optic disc and foveola. Main outcome measures were occurrence and time to radiation-related maculopathy, cataract, and optic neuropathy. Secondary end points included local recurrence and distant metastases. Kaplan-Meier analysis with log-rank test and univariate Cox proportional hazards model at 3 years were performed to identify the covariates affecting the outcome of radiation complications.

RESULTS

Two hundred thirty-nine patients, with sufficient data to evaluate the end points, were enrolled. Three years after plaque treatment, radiation maculopathy was found in 61 (25.5%) patients, cataract developed in 10 patients (4.2%) receiving a dose of 27 Gy or higher to the lens, and optic neuropathy was observed in 13 patients (5.4%) with an optic nerve dose exceeding 50 Gy and tumor proximity to optic disc of less than 4 mm. Tumor recurrences and tumor-related metastasis were found respectively in 20 (8.36%) and 14 (5.85%) patients.

CONCLUSIONS

Radiation maculopathy occurs within a median time of 31 months in 25% of cases after plaque treatment for uveal melanoma. The most significant risk factors are total dose and distance of tumor margin from the fovea. If the distance is greater than 11.22 mm, no signs of retinal damage are detected.

Intravitreal Aflibercept in Recalcitrant Radiation Maculopathy due to External Beam Radiotherapy for Nasopharyngeal Cancer: A First Case Report

PURPOSE

To present the safety and efficacy of intravitreal aflibercept (Eylea) in a patient with radiation maculopathy secondary to external beam radiotherapy for nasopharyngeal cancer unresponsive to other therapeutic options.

METHODS

A 73-year-old female presented with decreased visual acuity in both eyes 18 months after completing 47 external beam cycles of radiation for nasopharyngeal cancer. On presentation, her best corrected visual acuity was 6/60 in the right eye and counting fingers from 1 meter in the left eye. She received 5 bevacizumab injections in the right eye and 7 bevacizumab injections in the left eye over the last year without any improvement. A treatment with intravitreal injections of aflibercept was recommended in both eyes.

RESULTS

The patient received 3 intravitreal aflibercept injections (2 mg/0.05 mL) in each eye every 4 weeks. The visual acuity improved from 6/60 to 6/12 in the right eye and from counting fingers to 6/36 in the left eye. Biomicroscopy showed less exudates, hemorrhages, and microaneurysms. Optical coherence tomography revealed reduced central retinal thickness in both eyes after 1-3 intravitreal aflibercept injections.

CONCLUSION

Intravitreal aflibercept should be regarded a safe and effective treatment in patients with recalcitrant macular edema due to radiation maculopathy.

Radiation maculopathy treated with intravitreal bevacizumab

CASE REPORT

A 47 year-old woman with a choroidal melanoma developed a macular oedema secondary to radiation therapy 75 months after brachytherapy plaque. The patient received 3 intravitreal Bevacizumab injections.

DISCUSSION

The patient had a good response to bevacizumab treatment. In fact, there was a reduction in the macular oedema measured by optical coherence tomography (OCT) scan, as well as an improvement in best corrected visual acuity. There was no recurrence of macular oedema, and visual acuity remained stable after 3-years follow-up.