Long-Term Follow-Up of Iodine-125 Brachytherapy for Choroidal Melanomas. Part I: Anatomical Results and Life Expectancy

We report a prospective study of 19 choroidal melanomas treated with iodine-125 plaque from 1984 to 1989. The mean tumor height was 5.8 mm, base diameter 11.6 mm, and tumor volume 80 to 510 mm3. The mean radiation dose to tumor apex was 70 Gy and scleral contact dose 355 Gy; tumor base was surrounded by contiguous laser or cryopexy lesions. Follow-up was 27 to 84 months (mean 60 months). All tumors regressed at least 50% in volume with no tumor regrowth within 27 months to 60 months. Late tumor regrowth, localized in the center, occurred in one eye after 65 and another after 69 months. One tumor was successfully replaqued; the other was not re-treated because the patient had had a recent heart attack. In 17 eyes radiation retinopathy developed after 1½ years, the earliest in a diabetic eye. Despite primary recovery of preoperative vision, there was severe deterioration of visual acuity after 4½ years in all the eyes. During follow-up, two patients died due to metastases after 28 and 71 months; one patient is alive with metastases after 17 months. None of the eyes had to be enucleated. There was no incidence of madaurosis, Symblepharon, or dry eye.

Transpalpebral proton beam radiotherapy of choroidal melanoma

BACKGROUND

Collateral damage to upper eyelid margin during proton beam radiotherapy (PBR) for choroidal melanoma may cause squamous metaplasia of the tarsal conjunctiva with keratinisation, corneal irritation, discomfort and, rarely, corneal perforation. We evaluated transpalpebral PBR as a means of avoiding collateral damage to the upper eyelid margin without increasing the risk of failure of local tumour control.

METHODS

Retrospective study of consecutive patients who underwent PBR for choroidal melanoma between 1992 and 2007 at the Royal Liverpool University Hospital and the Douglas Cyclotron at Clatterbridge Cancer Centre, UK.

RESULTS

Sixty-three patients were included in this study. Mean basal tumour diameter and tumour thickness were 11.8 mm and 3.6 mm, respectively. PBR mean beam range and modulation were 26.5 mm and 16.9 mm respectively. The eyelid margin was included in the radiation field in 15 (24%) eyes. The median follow-up was 2.5 years. Local tumour recurrence developed in 2 (3.2%) patients. In these two cases that developed tumour recurrence the transpalpebral treatment did not involve the eyelid margin. Six (9.5%) patients died of metastatic disease. No eyelid or ocular surface problems developed in any of the 48 patients who were treated without eyelid rim involvement, while 7 of the 15 patients with unavoidable irradiation of the eyelid rim developed some degree of madarosis. These seven patients all received more than 26.55 proton Gy to the eyelid margin. Symptoms, such as grittiness occurred in 12% of 48 patients without eyelid margin irradiation as compared with 53% of 15 patients whose lid margin was irradiated.

CONCLUSIONS

Transpalpebral PBR of choroidal melanoma avoids eyelid and ocular surface complications without increasing failure of local tumour control.

Age, survival predictors, and metastatic death in patients with choroidal melanoma: tentative evidence of a therapeutic effect on survival

OBJECTIVE

To determine whether treatment of choroidal melanoma influences survival by correlating age at death, cause of death, age at treatment, and survival predictors.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study performed at the Liverpool Ocular Oncology Centre, a supraregional, tertiary referral service in England. We included 3072 patients treated for choroidal melanoma from January 15, 1993, through November 23, 2012, and who reside in the mainland United Kingdom.

EXPOSURES

A diagnosis of choroidal melanoma (ie, any uveal melanoma involving the choroid).

MAIN OUTCOMES AND MEASURES

Largest basal tumor diameter, tumor thickness, TNM stage, ciliary body involvement, extraocular spread, melanoma cytomorphological findings, closed connective tissue loops, mitotic count, chromosome 3 loss, chromosome 6p gain, chromosome 8q gain, age at treatment, age at death, and cause of death.

RESULTS

The largest basal tumor diameter correlated with all survival predictors except for chromosome 6p gain. Older age at treatment correlated with ciliary body involvement, extraocular spread, largest basal tumor diameter, tumor thickness, TNM stage, epithelioid cells, chromosome 3 loss, and chromosome 8q gain. A total of 1005 patients had died by the close of the study. The cause of death was metastatic disease due to uveal melanoma in 561 patients. Among the 561 patients, survival time after treatment correlated with sex, basal tumor diameter, ciliary body involvement, extraocular spread, TNM stage, closed loops, and mitotic count. In this group of patients, none of the survival predictors correlated with age at death except for mitotic count, which showed a weak correlation. All survival predictors correlated with an increased likelihood of metastatic melanoma as the cause of death.

CONCLUSIONS AND RELEVANCE

Patients who are younger at the time of treatment tend to have a smaller, less extensive tumor with a lower degree of malignancy. A tentative explanation for these findings is that ocular treatment prevents tumor growth, dedifferentiation, and metastatic disease in some patients, especially those with a smaller tumor.

[Survival rates for large choroidal melanomas]

Choosing the treatment method for patients with large choroidal melanomas remains a subject of debate. No literature data can be found on survival of such patients after either eye-preserving surgery or enucleation that takes into account the initial tumor size. The purpose of the study was to analyze the five-year survival rates for large choroidal melanomas (by J.A. Shields) in respect of the provided treatment.

MATERIAL AND METHODS

Medical records of 103 patients who had undergone treatment for choroidal melanoma (initial prominence 5.0-10.2 mm, initial diameter 7.3-20 mm) were studied. Eye-preserving surgery was performed on 60 patients, of whom 46 patients received brachytherapy (single session in 37 cases) and the other 14 patients--brachytherapy in combination with transpupillary thermotherapy (with subsequent endoresection of the tumor in one case). A total of 16 patients from this group required secondary enucleation. Primary enucleation was performed on 63 patients. Histopathological results confirming choroidal melanoma were analyzed in all 79 cases.

RESULTS AND DISCUSSION

The 5-year melanoma-specific cumulative survival rate in the group of eye-preserving surgery was 0.8146, while in the group of primary enucleation it reached 0.8951. The 8-year rate was 0.6921 and 0.7558 correspondingly. However, according to Gehan-Wilcoxon test, the differences were statistically insignificant (p = 0.11). The five-year survival of large choroidal melanoma patients who underwent eye-preserving surgery and no enucleation was 0.7708, 9-year - 0.6175.

CONCLUSION

Since the five-year melanoma-specific survival rate after primary enucleation is higher than that after eye-preserving surgery and secondary enucleation (though the difference is statistically insignificant), treatment options for large choroidal melanomas have to be chosen individually, taking into account the age and attitude of the patient as well as the size of the tumor.

The Collaborative Ocular Melanoma Study, mortality by therapeutic approach, age and tumor size

OBJECTIVES

Determine the mortality ratios and excess deaths associated with the two therapeutic options for both the small and the large tumor groups and for subsets of age and tumor size within each group as presented in the Collaborative Ocular Melanoma Study (COMS).

METHODS

Mortality ratios and excess deaths are determined using standard mortality methodology. Expectant mortality is determined from appropriate general population life mortality tables.

RESULTS

The smaller tumor group comparing brachytherpy to enucleation revealed similar mortality ratios (MR) of 134% and 137% for each treatment approach and respective Total Excess Deaths per Thousand (Total ED/K) of 131 and 128. The larger tumor group comparing results of pre-enucleation radiation therapy (PERT) followed by enucleation to enucleatic alone revealed respective mortality ratios of 291% and 305% and Total ED/K of 520 and 547. Those over 60 years of age having a maximum basal tumor diameter (MBTD) < or = 11 mm had MR = 101% and Total ED/K = 26, the best mortality experience in the study. Those over 60 years of age had better relative mortality, depending on the MBTD, when compared to the younger group.

CONCLUSIONS

Mortality associated with ocular melanoma does not vary according to whether brachytherapy (smaller melanomas) or PERT followed by enucleation (larger melanomas) is used vs simple enucleation. Mortality increases as the MBTD increases.

[Choroidal melanoma stage T2 higher than 6.0 mm: organ-preserving treatment with brachytherapy and transpupillary thermotherapy vs enucleation? Survival analysis]

The aim of the study was to compare survival rates of patients with stage T2 choroidal melanoma (CM) with prominence more than 6.0 mm after eye-preserving treatment using Ru-106 brachytherapy (BT) combined with transpupillary thermotherapy (TTT) and after primary enucleation. The main group included patients treated with BT alone or combined with simultaneous TTT. Patients with CM after primary enucleation served as control. The groups were standardized in terms of age (p = 0.063), mean prominence (p > 0.149), mean maximal base diameter (p > 0.85), number of unfavorable localized tumors (juxtapapillary and ciliochoroidal) (p = 0.246), follow-up duration (p > 0.23). Kaplan-Meier analysis showed 5 year level of metastasing after eye-preserving treatment as high as 16%, after enucleation--13% (p > 0.96). Eye-preserving treatment using BT combined with TTT in patients with CM with prominence less than 10.0 mm (T2N0M0) allows to preserve eye as an organ and to save some degree of useful visual acuity. This treatment strategy can be considered an appropriate option.

[Results of 10-year use of complex treatment of choroidal melanoma stage T2 with brachytherapy and transpupillary thermotherapy]

We studied the results of complex treatment of choroidal melanoma (CM) using Ru-106+Rh- 106 brachytherapy (BT) combined with transpupillary thermotherapy (TTT). 70 patients (70 eyes) with CM prominence ranged from 2.5 till 10.8 mm (mean 6.5+0.24 mm) were enrolled into the study. Follow-up was 6-120 months, median 47 months. TTT (810 microm) was carried out 24-48 hours later ophthalmic applicator suturing. Absolute or partial regression was achieved in 69 patients (99%) from 6.4+0.24 mm till 2.4+1.9 mm. In 1 case treatment was not effective. In 1 patient enucleation was performed due to secondary glaucoma. Dissemination with liver metastases was observed in 3 patients. Kaplan-Meier analysis showed 5 year eye preservation as high as 99%, absence of metastases--94%, survival rate without recurrence--91%, total efficacy (patients without negative results)--89%. Thus complex treatment (BT + TTT) of CM compared with monotherapy BT showed to have better local outcomes (including eye preservation) and it does not reduce survival rate even in patients with stage T2 (less than 10 mm).

Nucleolar size in choroidal and ciliary body melanomas and corresponding hepatic metastases

PURPOSE

This study aimed to investigate the relationship between hepatic metastasis and the mean diameter of the 10 largest nucleoli (MLN) in uveal melanoma.

METHODS

A cross-sectional histopathological analysis of 37 metastases (13 surgical or needle biopsies, 24 autopsies) and corresponding primary choroidal and ciliary body melanomas was conducted, using statistical tests appropriate for paired data. The largest nucleoli were measured from digital photographs of silver-stained sections along a 5-mm-wide linear field. Confounders considered were presence of epithelioid cells and microvascular density (MVD), counted as the number of discrete elements labelled by monoclonal antibody QBEND/10 to the CD34 epitope.

RESULTS

Hepatic metastases had more frequent epithelioid cells (p = 0.0047) and a higher MVD (median difference, 7.5 counts/0.313 mm(2) more; p = 0.044) than their corresponding primary tumours. Hepatic metastases, especially in autopsy specimens rather than surgical biopsies, tended to have a smaller MLN (median 3.6 mum) than the corresponding primary tumour (median difference, 0.55 mum; p = 0.066). The MLN in hepatic metastases was not associated with presence of epithelioid cells and MVD. Overall survival after diagnosis of metastasis was comparable whether hepatic metastases had a large or small MLN (p = 0.95), whereas a high MVD tended to be associated with shorter survival (p = 0.096) among the 13 patients with known survival.

CONCLUSIONS

The results suggest that MLN is not a useful marker for assessing prognosis after diagnosis of hepatic metastasis from uveal melanoma.

Comparison of Survival Among Eligible Patients not Enrolled Versus Enrolled in the Collaborative Ocular Melanoma Study (COMS) Randomized Trial of Pre-Enucleation Radiation of Large Choroidal Melanoma

PURPOSE

To compare survival between patients enrolled in the Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation therapy (PERT) for large choroidal melanoma and eligible patients who did not enroll.

METHODS

COMS clinical center personnel prospectively reported to the COMS Coordinating Center all patients with choroidal melanoma examined between November 1986 and December 1994. Deaths of enrolled patients were reported prospectively by clinical center personnel. In a COMS ancillary study, we retrospectively searched medical records of participating clinical centers, the Social Security Death Index, and the National Death Index to determine vital status of eligible patients not enrolled. Cox proportional hazards analysis was used to compare survival within 10 years of baseline reporting and before July 31, 2000, of enrolled patients versus eligible patients not enrolled.

RESULTS

Clinical centers that received local institutional review board approval to participate in this ancillary study prospectively reported on 129 of 299 eligible patients not enrolled in the COMS PERT trial. The baseline characteristics of the 129 patients included in this ancillary study were similar to those of the 170 patients not included; 73 patients were reported as deceased. Previously identified prognostic covariates, i.e., age and longest tumor diameter, were confirmed to predict survival in both enrolled patients and eligible patients not enrolled; trial enrollment was not predictive. After adjusting for prognostic covariates and stratifying by clinical center, the estimated hazard ratio (enrolled vs. not-enrolled) was 1.12 (95% confidence interval: 0.83 to 1.51).

CONCLUSIONS

The results of the COMS PERT trial should be generalizable to all patients with choroidal melanoma meeting the eligibility criteria for that trial. While the methods we used may not be generalizable to all clinical trials because of unique features of the COMS, other researchers may be able to use similar methods to determine the generalizability of their trial results.

KI-67 Immunopositivity in Choroidal and Ciliary Body Melanoma with Respect to Nucleolar Diameter and Other Prognostic Factors

PURPOSE

To study the association of cell proliferation in uveal melanoma with the mean of the 10 largest nucleoli (MLN), microvascular prognostic factors, and survival.

METHODS

Population-based, retrospective cohort study of 167 choroidal and ciliary body melanomas enucleated from 1972 to 1981. Mouse monoclonal antibody Ki-67 (clone 7B11) was used to identify proliferating cells. MLN was measured from silver stained slides. Kaplan-Meier and Cox regression analysis were performed.

RESULTS

The median number of Ki-67 immunopositive cells was 8 per tumor cross-section (range, 0-272) corresponding to a median of 0.30 cells/mm2. The percentage of immunopositive cells was 0.02% of all cells (range, 0-3.2). Tumors with epithelioid cells tended to have a higher percentage of immunopositive cells (p = 0.089). Ki-67 immunoreactivity, MLN, and presence of extravascular loops and networks were independent predictors of melanoma-related mortality, whereas Ki-67 immunoreactivity was not an independent predictor of mortality when presence of epithelioid cells was in the model.

CONCLUSIONS

Taken together with previous data, the results of this population-based study support the theory that high cell proliferation index is associated with presence of epithelioid cells and that presence of a high cell proliferation index is associated with a higher risk of metastatic death independent of MLN, microvascular density, and presence extravascular loops and networks.

Palladium-103 ophthalmic plaque radiation therapy for choroidal melanoma: 400 treated patients

PURPOSE

To describe 18 years of experience with palladium-103 ((103)Pd) ophthalmic plaque brachytherapy.

DESIGN

Retrospective case series.

PARTICIPANTS

From 1990 to 2007, 400 patients were diagnosed with uveal melanoma, found negative for metastatic disease, and treated. Episcleral (103)Pd radiation was delivered to a mean apical radiation dose of 73.3 Gy over 5 to 7 continuous days.

INTERVENTION

Palladium-103 ophthalmic plaque brachytherapy.

MAIN OUTCOME MEASURES

Patients were evaluated for local tumor control, visual acuity, radiation damage (retinopathy, optic neuropathy, cataract), and metastatic disease.

RESULTS

A total of 272 tumors (68%) were located at or posterior to the equator. There were 186 (46.5%) T1 tumors, 156 (39%) T2 tumors, 50 (12.5%) T3 tumors, and 8 (2%) T4 tumors. Patients were followed for a maximum of 205 months (mean, 51.1 months). Fourteen patients required secondary enucleation (5 for tumor growth and 9 for glaucoma pain control). The local control rate was 96.7%. Life table analysis of patients with 20/200 or better before treatment (n = 357) suggests that 79% and 69% are expected to retain that acuity for 5 and 10 years, respectively. Life table analysis demonstrates a probability that 92.7% and 86.6% of patients will be free of metastatic disease at 5 and 10 years, respectively.

CONCLUSIONS

In a nonrandomized phase I clinical evaluation, (103)Pd ophthalmic plaque radiotherapy was used to treat 400 patients with uveal melanoma. In this series, results after (103)Pd ophthalmic plaque radiotherapy were superior to those reported for alternative forms of radiation.

LONG-TERM SURGICAL OUTCOME OF POSTERIOR CHOROIDAL MELANOMA TREATED BY ENDORESECTION

PURPOSE

To report the visual acuity, enucleation rates, and initial mortality after transvitreal endoresection of posterior uveal melanoma.

METHODS

Twenty consecutive patients with medium-sized posterior choroidal melanomas were treated. Vitrectomy was performed, followed by posterior hyaloid dissection, retinotomy, melanoma removal with a vitrectomy probe, retinal reattachment with perfluorocarbon liquid, and silicone oil or gas exchange.

RESULTS

Twenty patients (13 men [65%] and 7 women [35%]) were included in the study. The mean patient age +/- SD was 47.1 +/- 16 years (range, 22-70 years). Tumor thickness and tumor diameter ranged from 5.5 mm to 11 mm and 8.0 mm to 15.7 mm, respectively. Preoperative visual acuity ranged from hand motion to 20/40, and postoperative visual acuity ranged from no light perception to 20/30. Two eyes (10%) were enucleated during tumor resection due to severe bleeding. Enucleation was performed on 3 eyes (15%) during follow-up due to tumor recurrence at the edge of surgical coloboma in 1 patient, new focus of tumor in another sector distant from surgical coloboma in 1 patient, and painful blind eye in 1 patient. Fifteen eyes (75%) were saved. One patient (5%) died of metastasis to the liver. The mean follow-up period +/- SD was 89.55 +/- 38.4 months (range, 24-132 months.

CONCLUSION

These data suggest that transvitreal endoresection of posterior uveal melanoma is an acceptable management option to conserve the globe and functional vision in selected patients. Distant metastasis is an infrequent event in this modality of treatment.

Incidence of cataract and outcomes after cataract surgery in the first 5 years after iodine 125 brachytherapy in the Collaborative Ocular Melanoma Study: COMS Report No. 27

PURPOSE

To evaluate the effect of the radiation dose to the lens on cataract formation and effect of cataract surgery on visual acuity (VA) among patients with choroidal melanoma treated with iodine 125 (I125) brachytherapy.

DESIGN

Prospective study of patients enrolled in one arm of a randomized clinical trial.

PARTICIPANTS

Patients enrolled in the Collaborative Ocular Melanoma Study (COMS) who received I125 brachytherapy as randomly assigned and also were phakic, with no history of cataract in the study eye at the time of enrollment (n = 532).

METHODS

Each follow-up examination included an interim ocular history and full ophthalmic examination. Lens status (phakic, pseudophakic, or aphakic) and best-corrected VA were recorded. For the purpose of this analysis, the date of the first examination at which an eye was reported to be aphakic or pseudophakic, to have vision-limiting lenticular opacities, or to have had cataract surgery was defined as the observed time of cataract development. Date of cataract surgery was defined as the date of the first follow-up examination at which cataract surgery was reported.

MAIN OUTCOME MEASURES

Incidence of cataract and outcomes after cataract surgery.

RESULTS

During the first 5 years of follow-up, cataracts developed in 362 (68%) of the 532 study eyes, including 49 (9%) that had had cataract surgery. By 5 years, 83% of study eyes were reported to have a cataract (95% confidence interval [CI], 79%-87%), and 12% had undergone cataract surgery (CI, 9%-15%) in the study eye. Eighteen percent of eyes that received a dose of 24 Gy or higher to the lens underwent cataract surgery, whereas only 4% of patients with <12 Gy to the lens underwent cataract surgery. Median VAs were 20/125 before cataract surgery and 20/50 after cataract surgery. After cataract surgery, VA improved by 2 lines or more in 32 (66%) patients and remained stable in 13 (26%) patients. The most common cause of lack of visual improvement after cataract surgery was presence of radiation retinopathy.

CONCLUSION

Although cataract surgery was infrequent among COMS patients, VA remained stable or improved in the majority of these eyes after cataract surgery.

Hochdosisbrachytherapie des malignen Aderhaut- und Ziliarkörpermelanoms mit 106Ruthenium

BACKGROUND

The purpose of this study was to report the multifactorial results of high-dose (106)Ruthenium plaque brachytherapy for (cilio-)choroidal melanoma and to confirm them by histological examinations.

PATIENTS AND METHODS

100 patients with choroidal or ciliochoroidal melanoma treated by high-dose 106Ruthenium plaque brachytherapy were followed-up for 5 years. 12 secondary enucleated eyes were compared to a non-irradiated matched group by light microscopy.

RESULTS

The 5-year local tumour control rate was 93%, the 5-year survival rate 91%. Late radiogenic side effects occured as a retinopathy in 13%, as an optic neuropathy in 5% and as a secondary glaucoma in 3% of the patients. 14% had to be enucleated, 10% developed metastases. The histopathologic examination revealed significantly higher degrees of necrosis (p=0,041), balloon cell degeneration (p=0,025) and fibrosis (p<0,001) in the irradiated melanomas than in the control tumours.

CONCLUSION

High-dose 106Ruthenium plaque brachytherapy turned out to be an effective treatment procedure for posterior uveal melanoma (not exceeding a prominence of 5,5 mm) with a high rate of local tumour control and a low rate of side effects.

An alternative hypothesis for observed mortality rates due to metastasis after treatment of choroidal melanomas of different sizes

PURPOSE

To propose an alternative hypothesis for the observed differential survival of patients with small, medium, and large choroidal melanomas based on recently uncovered cytogenetic evidence about melanocytic choroidal tumors.

METHODS

Review and analysis of published data.

RESULTS

Recent evidence has shown that recurring nonrandom cytogenetic abnormalities are present within virtually all cytomorphologically malignant cells that compose choroidal melanomas and that certain individual cytogenetic abnormalities and combinations of these abnormalities are important prognostic factors for metastasis and metastatic death. Although these cytogenetic abnormalities are strongly correlated with recognized clinical prognostic factors (tumor size, intraocular tumor location) and histomorphologic prognostic factors (melanoma cell type, vascular mimicry pattern) for metastasis, most laboratories have found these cytogenetic abnormalities to be much more robust indicators that metastasis will or will not develop than these clinical and histopathologic factors. In most series of uveal melanomas evaluated by current cytogenetic methods, approximately 30% to 60% of the tumors have cytogenetic abnormalities indicative of high likelihood of metastasis posttreatment. Evidence suggests that these abnormalities are more frequent in larger tumors than in smaller ones. Survival analyses of uveal melanoma patients whose tumors have been evaluated cytogenetically have shown rates of metastasis that approach 100% for patients with a tumor exhibiting monosomy 3 or a class 2 gene expression profile but are very low for those with a tumor that did not exhibit these cytogenetic abnormalities.

CONCLUSION

The better prognosis of patients with smaller choroidal melanomas is likely to be attributable to a lower probability of cytogenetic abnormalities indicative of metastatic capability among smaller tumors and not to effectiveness of treatment at preventing metastasis.

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma: V. Twelve-year mortality rates and prognostic factors: COMS report No. 28

OBJECTIVES

To report refined rates of death and related outcomes by treatment arm through 12 years after primary treatment of choroidal melanoma and to evaluate characteristics of patients and tumors as predictors of relative treatment effectiveness and time to death.

DESIGN

Randomized multicenter clinical trial of iodine 125 ((125)I) brachytherapy vs enucleation conducted as part of the Collaborative Ocular Melanoma Study. Eligible patients were free of metastasis and other cancers at enrollment. All patients were followed up for 5 to 15 years at scheduled examinations for metastasis or another cancer or until death. Decedents were classified by the independent Mortality Coding Committee as having histopathologically confirmed melanoma metastasis, suspected melanoma metastasis without histopathologic confirmation, another cancer but not melanoma metastasis, or no malignancy.

MAIN OUTCOME MEASURES

Deaths from all causes and deaths with histopathologically confirmed melanoma metastasis.

RESULTS

Within 12 years after enrollment, 471 of 1317 patients died. Of 515 patients eligible for 12 years of follow-up, 231 (45%) were alive and clinically cancer free 12 years after treatment. For patients in both treatment arms, 5- and 10-year all-cause mortality rates were 19% and 35%, respectively; by 12 years, cumulative all-cause mortality was 43% among patients in the (125)I brachytherapy arm and 41% among those in the enucleation arm. Five-, 10-, and 12-year rates of death with histopathologically confirmed melanoma metastasis were 10%, 18%, and 21%, respectively, in the (125)I brachytherapy arm and 11%, 17%, and 17%, respectively, in the enucleation arm. Older age and larger maximum basal tumor diameter were the primary predictors of time to death from all causes and death with melanoma metastasis.

CONCLUSION

Longer follow-up of patients confirmed the earlier report of no survival differences between patients whose tumors were treated with (125)I brachytherapy and those treated with enucleation.

APPLICATION TO CLINICAL PRACTICE

Estimated mortality rates by baseline characteristics should facilitate counseling of patients who have choroidal melanoma of a size and in a location suitable for enucleation or (125)I brachytherapy and no evidence of metastasis or another malignancy.

Carbon-ion radiotherapy for locally advanced or unfavorably located choroidal melanoma: a Phase I/II dose-escalation study

PURPOSE

To evaluate the applicability of carbon ion beams for the treatment of choroidal melanoma with regard to normal tissue morbidity and local tumor control.

METHODS AND MATERIALS

Between January 2001 and February 2006, 59 patients with locally advanced or unfavorably located choroidal melanoma were enrolled in a Phase I/II clinical trial of carbon-ion radiotherapy at the National Institute of Radiologic Sciences. The primary endpoint of this study was normal tissue morbidity, and secondary endpoints were local tumor control and patient survival. Of the 59 subjects enrolled, 57 were followed >6 months and analyzed.

RESULTS

Twenty-three patients (40%) developed neovascular glaucoma, and three underwent enucleation for eye pain due to elevated intraocular pressure. Incidence of neovascular glaucoma was dependent on tumor size and site. Five patients had died at analysis, three of distant metastasis and two of concurrent disease. All but one patient, who developed marginal recurrence, were controlled locally. Six patients developed distant metastasis, five in the liver and one in the lung. Three-year overall survival, disease-free survival, and local control rates were 88.2%, 84.8%, and 97.4%, respectively. No apparent dose-response relationship was observed in either tumor control or normal tissue morbidity at the dose range applied.

CONCLUSION

Carbon-ion radiotherapy can be applied to choroidal melanoma with an acceptable morbidity and sufficient antitumor effect, even with tumors of unfavorable size or site.

Survival after primary enucleation for choroidal melanoma: changes induced by the introduction of conservative therapies

BACKGROUND

Most uveal melanomas are currently treated by eye-preserving radiotherapies. However, for melanomas of the largest size or with initial complications, enucleation remains the reference treatment. Enucleation is called primary when it is proposed as the only local treatment option for a melanoma. There is very little literature on the use of primary enucleation after the introduction of conservative treatments. Our main goal was to evaluate the survival of melanoma patients treated by primary enucleation since the introduction of proton-beam therapy in France in 1991.

METHODS

All melanoma patients undergoing primary enucleation in our department between 1991 and 2002 were included in this retrospective study. The 5-year melanoma-specific survival rate was calculated using the Kaplan-Meier method. The multivariate prognostic analysis was performed using the Cox proportional hazards model.

RESULTS

Forty patients, representing 8% of all patients with choroidal uveal melanoma diagnosed and followed up in our department during an 11-year period, were included in the study. No patient was lost to follow-up. The 5-year melanoma-specific survival rate was 31.45% (SE: 7.8) after primary enucleation. Significant prognosis factors in the multivariate analysis were: tumor thickness > 12 mm (p = 0.03), anterior margin of the tumor involving the iris (p = 0.018), and presence of epithelioid cells (p = 0.02).

CONCLUSIONS

The very low survival rate reported reflects the evolution of primary enucleation, which is currently indicated only for melanomas with the worst prognosis. The knowledge of current post-enucleation survival rates represents an essential achievement for both correct assessment of conservative therapies and patient counseling.

A phase II trial of arsenic trioxide in patients with metastatic melanoma

BACKGROUND

Arsenic trioxide induces growth inhibition and apoptosis in human melanoma cell lines. Therefore, a Phase II trial was conducted to evaluate the efficacy and toxicity of single-agent arsenic trioxide in patients with Stage IV melanoma.

METHODS

Twenty patients, 10 with metastatic melanoma of cutaneous origin and 10 with metastatic melanoma of choroidal origin, received arsenic trioxide 0.25 mg/kg/day for 5 days, followed by a maintenance dose of 0.35 mg/kg/day twice a week. All patients with melanoma of cutaneous origin and four patients with melanoma of choroidal origin had received prior therapy.

RESULTS

Single-agent arsenic trioxide did not induce clinical response in this patient population. Eight patients (five with melanoma of cutaneous origin, and three with melanoma of choroidal origin) had disease stabilization for at least six weeks. The median overall survival duration for patients with melanoma of cutaneous origin was 7.9 months, and that of patients with melanoma of choroidal origin has not been reached at a median follow-up duration of 11.8 months. Grade 3 toxicity included neutropenia, fatigue, abdominal pain, and arthralgia. Grade 4 toxicity did not occur.

CONCLUSIONS

Single-agent arsenic trioxide was generally well tolerated; however, no tumor regression was observed in this patient population. Future clinical trials should evaluate arsenic trioxide in combination with other anticancer drugs that may improve its clinical activity in melanoma.

Development of metastatic disease after enrollment in the COMS trials for treatment of choroidal melanoma: Collaborative Ocular Melanoma Study Group Report No. 26

OBJECTIVE

To describe the time between treatment for choroidal melanoma and first diagnosis of metastatic disease, sites of metastasis, treatments for metastasis, and time between diagnosis of metastasis and death.

DESIGN

Prospective, longitudinal follow-up of patients diagnosed with choroidal melanoma who were enrolled in 2 randomized trials conducted by the Collaborative Ocular Melanoma Study Group.

METHODS

Systemic and laboratory evaluations were performed during follow-up according to a standard protocol for 2320 patients enrolled in the Collaborative Ocular Melanoma Study trials without evidence of melanoma metastasis or other primary cancer at baseline.

RESULTS

Seven hundred thirty-nine patients were diagnosed with at least 1 site of metastasis during follow-up after treatment for choroidal melanoma. Five- and 10-year cumulative metastasis rates were 25% (95% confidence interval, 23%-27%) and 34% (95% confidence interval, 32%-37%), respectively. Liver was the most common site (89%). The death rate following the report of melanoma metastasis was 80% at 1 year (95% confidence interval, 77%-83%) and 92% at 2 years (95% confidence interval, 89%-94%). Overall survival after metastasis did not vary by baseline size of primary tumor nor treatment for metastasis (when known). Long-term survival after diagnosis of metastasis was uncommon; only 8 patients survived 5 or more years.

CONCLUSION

Metastasis rate increased significantly with increasing primary tumor dimensions at time of patient enrollment. Prognosis after metastatic disease remains poor. Effective methods are needed to prevent, diagnose, and treat metastasis from choroidal melanoma.

Monosomy 3 predicts death but not time until death in choroidal melanoma

PURPOSE

To study whether monosomy 3 can predict time until death caused by metastatic melanoma, whether life expectancy can be predicted in patients after surgical excision of a melanoma displaying monosomy 3, and to confirm the prognostic value of monosomy 3 and its correlation with tumor histology.

METHODS

Archival specimens from 71 patients who died of metastatic melanoma and 40 patients who were living or had died of other causes were identified. The number of copies of chromosome 3 was assessed by chromosome in situ hybridization, and monosomy 3 was compared with clinicopathologic features.

RESULTS

Monosomy 3 was detected in 47 of 71 metastasizing melanomas (66.1%) and was significantly associated with metastasis-related death (P < 0.0001). All 40 nonmetastasizing tumors were balanced for chromosome 3 (two copies). In 70% of cases, epithelioid cells and vascular loops in combination predicted the presence of monosomy 3 (P < 0.0001). Among the 71 patients who had died of metastasizing melanoma, there was no difference in time until death between monosomic and balanced tumors. However, a survival curve corrected for age of the patients at the time of surgery suggested that very-long-term survival with monosomy 3 is probably rare.

CONCLUSIONS

Monosomy 3 is an important predictor of death in melanoma and is in some cases predicted by histology. However, death of metastatic disease occurs in a significant number of patients without monosomy 3. There is no significant difference in time until death between metastatic melanomas, with and without monosomy 3. However, survival of patients with tumors displaying monosomy 3 is generally short.

Outcomes of iodine 125 plaque radiotherapy after initial observation of suspected small choroidal melanomas: a pilot study

PURPOSE

To determine the visual and survival outcomes for patients undergoing plaque radiotherapy of suspected small choroidal melanomas after observation for growth in a pilot study.

DESIGN

Noncomparative interventional case series.

PARTICIPANTS

Forty-five patients with suspected small choroidal melanomas who were seen at the Bascom Palmer Eye Institute between 1974 and 2001 and had iodine 125 (I125) plaque radiotherapy between 1991 and 2002.

METHODS

Patients with suspected small choroidal melanomas were monitored by clinical examination, photography, and echography. When the melanoma grew or developed orange pigment, patients were treated with I125 plaque radiotherapy. Outcomes included visual acuity, ocular complications, tumor dimensions, metastasis, and death.

MAIN OUTCOME MEASURE

Melanoma-specific mortality.

RESULTS

In our pilot study, 1 patient died from metastatic melanoma. One patient developed metastatic disease and is still alive. One patient developed marginal tumor recurrence after treatment and after enucleation was performed. Globe conservation was achieved in 97.8% of patients. In patients with tumor margins >2 mm from the optic nerve, vision was preserved with less than a doubling of the visual angle (within approximately 2 Snellen lines of preoperative acuity) in 90.6% (29/32) of patients at 1 year postoperatively, 65.6% (21/32) at 2 years, and 52.2% (12/23) in the long term (4-11 years).

CONCLUSIONS

Five-year melanoma-specific mortality after I125 plaque radiotherapy of suspected small choroidal melanomas was 3.9% (95% confidence interval, 0%-11.2%). This information can be used to counsel patients with small suspected choroidal melanomas and to compare with other treatment modalities.

New Zealand experience of I125 brachytherapy for choroidal melanoma

PURPOSE

To examine patient survival, visual function and complications in all patients with choroidal melanoma treated with I125 brachytherapy between 1995 and 2003 at the authors' institution. To compare the results from their institution with those from international series.

METHODS

Data were collected on 92 consecutive patients. Dosimetry was calculated for the lens, fovea, optic nerve and tumour apex. Follow-up status of each patient domiciled outside the treatment centre was analysed from a postal questionnaire.

RESULTS

Average pretreatment tumour dimensions were 3.9 mm (thickness) and 15.2 mm (diameter). Complete follow-up data were available on 92% of patients. Regression of tumour occurred in 88% of cases. Five enucleations were performed. There were five melanoma-related deaths. Visual acuity remained >6/12 in 35% of patients and >6/60 in 51% of patients. The most frequently observed complication was radiation retinopathy (maculopathy 23%, peripheral retinopathy 17%). Radiation cataract was seen in 11% and optic neuropathy in 10%. Dose of more than 90 Gy to the macula gave a 63% chance of developing maculopathy (P < 0.01). A tumour larger than 4 mm significantly increased the risk of developing radiation maculopathy (P = 0.003). Development of radiation cataract was dose-related; >25 Gy to the lens gave a 44% risk of cataract development (P < 0.001). For tumours less than 4 mm from the disc margin there was a 50% risk of optic neuropathy (P < 0.001).

CONCLUSIONS

Patient outcomes following brachytherapy were excellent with a high percentage of patients retaining mobility vision. Development of complications was related to the tumour location and dose to non-tumour structures.

Forecasting the Prognosis of Choroidal Melanoma with an Artificial Neural Network

PURPOSE

To develop an artificial neural network (ANN) that will forecast the 5-year mortality from choroidal melanoma.

DESIGN

Retrospective, comparative, observational cohort study.

PARTICIPANTS

One hundred fifty-three eyes of 153 consecutive patients with choroidal melanoma (age, 58.4+/-14.6 years) who were treated with ruthenium 106 brachytherapy between 1988 and 1998 at the Department of Ophthalmology, Hadassah University Hospital, Jerusalem, Israel.

METHODS

Patients were observed clinically and ultrasonographically (A- and B-mode standardized ultrasonography). Metastatic screening included liver function tests and liver imaging. Backpropagation ANNs composed of 3 or 4 layers of neurons with various types of transfer functions and training protocols were assessed for their ability to predict the 5-year mortality. The ANNs were trained on 77 randomly selected patients and tested on a different set of 76 patients. Artificial neural networks were compared based on their sensitivity, specificity, forecasting accuracy, area under the receiver operating curves, and likelihood ratios (LRs). The best ANN was compared with the results of logistic regression and the performance of an ocular oncologist.

MAIN OUTCOME

The ability of the ANNs to forecast the 5-year mortality from choroidal melanoma.

RESULTS

Thirty-one patients died during the follow-up period of metastatic choroidal melanoma. The best ANN (one hidden layer of 16 neurons) had 84% forecasting accuracy and an LR of 31.5. The number of hidden neurons significantly influenced the ANNs' performance (P<0.001). The performance of the ANNs was not significantly influenced by the training protocol, the number of hidden layers, or the type of transfer function. In comparison, logistic regression reached 86% forecasting accuracy, with a very low LR (0.8), whereas the human expert forecasting ability was <70% (LR, 1.85).

CONCLUSIONS

Artificial neural networks can be used for forecasting the prognosis of choroidal melanoma and may support decision-making in treating this malignancy.

HESA-A: new treatment for breast cancer and choroidal metastasis

BACKGROUND

Breast cancer is one of the main causes of mortality among women worldwide. This type of cancer metastasizes to different body tissues, giving rise to many problems. The effect of HESA-A, a drug of herbal-marine origin, on vision, quality of life, and survival of end-stage breast cancer patients was investigated in this study.

MATERIAL/METHODS

In a double-blind study, 24 breast cancer patients with choroidal metastasis, aged between 41 and 49 years, were divided into case and control groups, treated with 50 mg/kg/day of HESA-A and placebo, respectively. The patients were evaluated in respect to the intensity of experienced pain, by assessing their rate of narcotic analgesic use. The patients' vision scale was also evaluated.

RESULTS

Notable improvement was seen in the vision of patients treated with HESA-A. Patients receiving HESA-A used narcotics at lower doses, owing to reduced experience of pain. No changes were observed in the vision of control group patients, or their pain experience.

CONCLUSIONS

The effects of natural compounds with antioxidant and anticancer properties have been emphasized by different studies. HESA-A is a compound of natural origin, consisting of rare elements and organic materials, which in several animal and cellular studies has shown powerful anticancer effects and less toxicity on normal cells. The results of this study showed considerable improvement in the vision of breast cancer patients treated with HESA-A.

Tumor, Node, Metastasis Classification of Malignant Ciliary Body and Choroidal MelanomaEvaluation of the 6th Edition and Future Directions

PURPOSE

The tumor, node, metastasis classification of malignant uveal melanoma has been revised. We evaluated how the 6th edition (TNM6) improves on the previous one (TNM5).

DESIGN

Population-based, retrospective, cross-sectional study.

PARTICIPANTS

Two hundred eighty-nine consecutive patients who had a ciliary body and choroidal melanoma treated in the district of the Helsinki University Central Hospital, Finland, between 1962 and 1981.

METHODS

Tumor dimensions, ciliary body involvement, and extraocular extension were evaluated from histopathologic sections and pathology reports. Tumors were assigned into categories and stages according to TNM6, TNM5, and 2 previously proposed size classifications.

MAIN OUTCOME MEASURES

Proportion of tumors classified in each category and melanoma-specific survival by category and stage.

RESULTS

Of the 289 melanomas, 5% were classified as pT1, 63% as pT2, 22% as pT3, and 7% as pT4 according to TNM6. The corresponding percentages based on TNM5 were 8%, 17%, 63%, and 10%. Of pT2 tumors in TNM6, 4% came from pT1, 65% from pT3, and 4% from pT4 category of TNM5. Of 28 melanomas with extraocular growth, 29% were classified as pT2 in TNM6 rather than pT4 in TNM5. The 10-year survival estimate was 2 percentage points lower for pT1, 7 percentage points higher for pT2, 17 percentage points lower for pT3, and 13 percentage points lower for pT4 by TNM6 compared with TNM5; TNM6 (P<0.0001) and the modified alternative size classifications (P = 0.0022 and P = 0.0026) divided tumors according to prognosis better than TNM5. The 10-year survival for stage I, II, and III tumors was 2 percentage points lower, 7 points higher, and 23 points lower by TNM6, which was not better than TNM5 in separating patients according to prognosis (P = 0.47). The alternative size classifications provided more equal categories and fitted the data set better than TNM5 regarding prognosis.

CONCLUSIONS

TNM6 is an improvement over TNM5 in some, but not all, respects. Areas for development include taking into account ciliary body involvement and extraocular extension in more detail and combining into each stage tumor categories with similar rather than different prognosis. An evidence-based, multicenter approach would be beneficial.

Identification of monosomy 3 in choroidal melanoma by chromosome in situ hybridisation

BACKGROUND/AIMS

In uveal melanoma monosomy 3 is emerging as a significant indicator of a poor prognosis. To date most cytogenetic studies of uveal melanoma have utilised fresh tissue or DNA extracted from tissue sections. In this study chromosome in situ hybridisation (CISH) was used to study monosomy 3 in tissue sections. The copy number of chromosome 3 was determined and related to patient survival.

METHODS

Archival glutaraldehyde or formalin fixed, paraffin embedded material was obtained from 30 metastasising and 26 non-metastasising choroidal melanomas. Hybridisations were performed using centromere specific probes to chromosomes 3 and 18. Chromosome 18 was included as a control as previous abnormalities in uveal melanoma have not been described. Chromosomal imbalance was defined on the basis of changes in both chromosome index and signal distribution.

RESULTS

CISH was successfully performed on both glutaraldehyde and formalin fixed tissue. Four cases were unsuccessful because of extensive tumour necrosis. All cases were balanced for chromosome 18. Monosomy 3 was detected in 15 of the 26 cases of metastasising melanoma; the 26 non-metastasising tumours were all balanced for chromosome 3. Monosomy 3 was significantly associated with metastases related death.

CONCLUSION

CISH can successfully identify monosomy 3 in archival glutaraldehyde or formalin fixed, paraffin embedded tissue sections. Similar to previous studies monosomy 3 is a significant predictor of metastases related death.

The Collaborative Ocular Melanoma Study (COMS) randomized trial of pre-enucleation radiation of large choroidal melanoma: IV. Ten-year mortality findings and prognostic factors. COMS report number 24

PURPOSE

To report rates of death and related outcomes through 10 years after treatment of large choroidal melanoma and to evaluate characteristics of patients and tumors as predictors of relative treatment effectiveness and time to death.

DESIGN

Randomized multicenter clinical trial of pre-enucleation radiation vs enucleation alone conducted as part of the Collaborative Ocular Melanoma Study.

METHODS

Eligible patients were free of metastasis and other cancers at enrollment. All patients were followed for 5 years or longer at scheduled examinations and contacts for metastasis, another cancer, or death. Each decedent was classified as having histopathologically confirmed melanoma metastasis, suspected melanoma metastasis without histopathologic confirmation, another cancer but not melanoma metastasis, or no malignancy.

RESULTS

Within 10 years after enrollment, 576 of 1,003 patients died. Ten-year all-cause mortality rates were 61% for patients in both treatment arms. Ten-year rates of death with histopathologically confirmed melanoma metastasis were 45% in the pre-enucleation radiation arm and 40% in the enucleation alone arm. Older age and larger maximum basal tumor diameter were the primary predictors of time to death from all causes and death with melanoma metastasis. No differences in unadjusted or adjusted mortality rates were found between treatment arms. Of 448 patients eligible for 10 years of follow-up, 145 patients (32%) were alive and clinically cancer-free 10 years after treatment.

CONCLUSIONS

Longer follow-up confirmed the earlier report of no survival advantage attributable to pre-enucleation radiation. Mortality rates by baseline characteristics should facilitate counseling of patients who have large choroidal melanoma and no evidence of metastasis or another malignancy at diagnosis.

Plaque radiotherapy for choroidal and ciliochoroidal melanomas with limited nodular extrascleral extension

BACKGROUND

Currently available clinical information regarding management of posterior uveal melanomas complicated by nodular extrascleral extension is inadequate to determine the role, if any, for plaque radiotherapy in such patients.

METHODS

The authors performed a retrospective descriptive study of eight patients with a choroidal or ciliochoroidal melanoma complicated by nodular extrascleral extension who were treated by surgical excision of the extrascleral nodule followed immediately by plaque radiotherapy of the intraocular tumour. The calculated volume of the extrascleral nodule was greater than 1 mm3 but less than 1000 mm3 in all cases, and the intraocular tumour was deemed treatable by plaque radiotherapy in all patients.

RESULTS

Four of the eight patients died during available follow-up, three from metastatic melanoma and one from a second cancer. The median length of follow-up for the four surviving patients was 10.1 years. The actuarial 5-year and 10-year all-cause death rates were 37.5% and 53.1% respectively. One of the eight patients experienced local intraocular tumour relapse following plaque therapy and underwent secondary enucleation. None of the patients experienced orbital tumour recurrence or underwent secondary orbital exenteration.

INTERPRETATION

Our results coupled with previously published results from another centre suggest that plaque radiotherapy may be an effective local treatment for selected patients with choroidal or ciliochoroidal melanoma complicated by nodular extrascleral extension. The fact that none of the patients in this series or in the previously reported series experienced orbital recurrence following plaque radiotherapy or required secondary orbital exenteration suggests that plaque therapy may be better than enucleation alone in terms of these end points. These results should not be extrapolated, of course, to patients with massive extrascleral tumour extension or a choroidal or ciliochoroidal melanoma too large for plaque radiotherapy.

Prognostic factors for survival after enucleation for choroidal and ciliary body melanomas

PURPOSE

To evaluate prognostic factors for the survival of patients treated by enucleation for choroidal and ciliary body melanomas.

METHODS

The study included 293 consecutive patients (147 men and 146 women) treated by enucleation for a choroidal or ciliary body melanoma during the period 1955-2000. The median age at treatment was 61 years (range 26-88 years). Clinical and histopathological findings, vital status at October 1st, 2002, and cause of death were registered. Prognostic factors for survival were evaluated by univariate and multivariate Cox proportional hazards analysis and by Kaplan-Meier survival analysis.

RESULTS

Follow-up was complete. The median follow-up time was 6.2 years (range 21 days to 43.4 years) and the median potential follow-up time was 25.7 years (range 1.9-47.7 years). In multivariate Cox proportional hazards analysis an increased risk of melanoma-related death was found for largest basal diameter (n = 264, p < 0.001, mortality rate ratio (RR) = 1.09 for continuous parameter in mm), anterior tumour margin at the iris/ciliary body versus choroid (p < 0.001, RR = 2.22), and non-spindle cell type versus spindle cell (p = 0.047, RR = 1.45). An increased risk of death from all causes was found for men versus women (n = 266, p = 0.02, RR = 1.41), high age (p < 0.001, RR = 1.41 for continuous parameter in 10-year age groups), largest basal diameter (p < 0.001, RR = 1.07), anterior tumour margin at the iris/ciliary body (p = 0.02, RR = 1.52), and non-spindle cell type (p = 0.04, RR = 1.34).

CONCLUSION

The risk of melanoma-related death after enucleation for a choroidal or ciliary body melanoma was high for tumours with large basal diameter, of non-spindle cell type and anterior location. Additional risk factors for death from all causes were male sex and high age.

Effectiveness of 1alpha-hydroxyvitamin D2 in inhibiting tumor growth in a murine transgenic pigmented ocular tumor model

OBJECTIVE

To study the effectiveness of the vitamin D analogue 1alpha-hydroxyvitamin D(2) (1alpha-OH-D(2)) in inhibiting ocular tumor growth in transgenic "Tyr-Tag" mice that developed pigmented ocular tumors produced with the simian virus 40 T and t antigens under the control of the mouse tyrosinase gene. These animals develop pigmented intraocular tumors primarily from the retinal pigment epithelium that closely resemble the histologic features and growth pattern of human choroidal melanoma.

METHODS

A total of 73 Tyr-Tag transgenic mice between 6 and 7 weeks old were randomly assigned by sex and litter to 3 treatment groups to receive 0.05 microg/d, 0.1 microg/d, or 0.2 microg/d of 1alpha-OH-D(2); a control group received vehicle (coconut oil). The drug was administered by oral gavage 5 times a week for 5 weeks. The animals were then euthanized and their eyes were enucleated and processed histologically. Three serial sections from each eye were examined microscopically and the mean tumor area measured using Optimus software version 6.5 (Media Cybernetics LP, Silver Spring, Md). Toxic adverse effects were assessed on the basis of mortality, weight loss, and serum calcium levels.

RESULTS

The mean tumor size in the 0.1- microg/d and 0.2- microg/d dose groups was smaller than in the controls (P<.001). No significant difference was seen between the 0.05- microg/d dose group and the control group (P =.64). Survival for the 0.1- microg/d and 0.2- microg/d dose groups was lower than for the controls (95% in the controls vs 85.7% and 73.7%, respectively; P<.01).

CONCLUSION

In the Tyr-Tag transgenic mouse, 1alpha-OH-D(2) inhibits pigmented ocular tumor growth at moderate drug levels with relatively low mortality. Clinical Relevance Vitamin D analogues merit further preclinical study in the treatment of ocular melanoma.

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.

Enucleation versus preservation of blind eyes following plaque radiotherapy for choroidal melanoma

BACKGROUND

Currently available information about patients with posterior uveal melanoma treated by plaque radiotherapy is insufficient to determine what to do about eyes that become blind as a consequence of the tumour and its treatment. Should they be enucleated, or is ocular preservation just as good in terms of survival?

METHODS

We performed a retrospective survival analysis of secondary enucleation versus ocular preservation in patients with a posterior uveal melanoma treated by plaque radiotherapy whose irradiated eye became completely blind following that treatment. Of the 79 patients who fulfilled defined inclusion criteria, 25 underwent secondary enucleation of the blind eye, and 54 retained their irradiated blind eye.

RESULTS

Most of the baseline demographic and tumour-related variables evaluated were similarly distributed between the subgroups. The 5-year, 10-year and 15-year all-cause death rates in the secondary enucleation subgroup were 24.7%, 51.5% and 52.0% respectively, and those in the ocular preservation subgroup were 7.4%, 32.9% and 48.1% respectively. In spite of the apparent slight difference between the curves, the difference was not statistically significant (p = 0.41, Mantel-Haenszel test).

INTERPRETATION

Although a retrospective study of this type has several limitations, our results suggest that secondary enucleation is not likely to substantially improve survival of patients whose irradiated eye becomes totally blind following plaque radiotherapy for choroidal or ciliochoroidal melanoma.

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.

Stereotactic radiotherapy in the treatment of juxtapapillary choroidal melanoma: preliminary results

PURPOSE

To evaluate the preliminary results of stereotactic radiotherapy in the management of patients with juxtapapillary choroidal melanoma.

METHODS & MATERIALS

A retrospective, consecutive case series of 28 patients with choroidal melanoma located within 2 mm of the optic nerve who were treated with stereotactic radiotherapy at Princess Margaret Hospital, Toronto, between October 1998 and May 2001.

RESULTS

Median age was 62 years. Median tumor height was 4.6 mm and median maximum tumor diameter was 9.4 mm. The prescribed radiation dose was 70 Gy in five fractions over 10 days and median follow-up was 18.5 months. Posttreatment, 2 patients developed local tumor regrowth and 3 patients developed liver metastases. Actuarial rates of local tumor control, metastases, and survival at 18 months were 96%, 10%, and 94%, respectively. Actuarial rates of radiation-induced neovascular glaucoma, cataract, retinopathy, and optic neuropathy at 18 months were 20%, 29%, 30%, and 37%, respectively. A higher radiation dose to the lens was associated with an increased risk of cataract (p = 0.02).

CONCLUSIONS

Stereotactic radiotherapy offers a noninvasive alternative to enucleation and brachytherapy in the management of juxtapapillary choroidal melanoma. However, further efforts are needed to optimize local tumor control and minimize radiation-induced complications.

Ten-year follow-up of fellow eyes of patients enrolled in Collaborative Ocular Melanoma Study randomized trials

PURPOSE

To report findings observed in fellow eyes during prospective follow-up of patients with unilateral choroidal melanoma after treatment with standard enucleation or 1 of 2 radiotherapy methods, either iodine 125 (I(125)) brachytherapy or pre-enucleation external radiation, in order to document long-term outcomes and to identify any adverse effect of radiotherapy on the contralateral eye.

DESIGN

Two multicenter randomized trials conducted by the Collaborative Ocular Melanoma Study (COMS) Group.

PARTICIPANTS

Eligible patients assigned randomly to standard enucleation or to the radiotherapy protocol adopted for tumors of the specified size and location and treated as assigned: 994 patients of 1003 enrolled in the COMS trial of pre-enucleation radiation and 1296 patients of 1317 enrolled in the COMS trial of I(125) brachytherapy.

OUTCOMES

Changes in best-corrected visual acuity (VA), intraocular pressure, and other findings in fellow eyes from baseline to examinations conducted at 6 and 12 months after enrollment and annually thereafter.

RESULTS

Five years after enrollment, 1307 of 2290 fellow eyes were examined; 358 fellow eyes were examined 10 years after enrollment. Mean change in VA of fellow eyes from baseline to each examination was one letter (0.2 lines) or less. Cumulative 5-year incidence rates of cataract surgery and visually significant cataract in initially phakic eyes with good VA and no lenticular opacity were 8% in both trials; 10-year rates were 18% in the trial of pre-enucleation and 15% in the trial of I(125) brachytherapy. Intraocular pressures changed by less than 1 mmHg from baseline to each examination. Apart from lower rates of incident cataracts among fellow eyes of patients treated with pre-enucleation radiation, findings within each trial were similar in the 2 treatment arms.

CONCLUSIONS

Almost all surviving patients retained good VA in fellow eyes throughout 5 years of follow-up after treatment for choroidal melanoma. These findings persisted through 10 years of follow-up among patients eligible for examinations beyond 5 years. There was no evidence that fellow eyes of patients whose affected eye was treated with pre-enucleation radiation or with I(125) brachytherapy were at greater risk of loss of VA or new ophthalmic diagnoses than eyes of patients treated with enucleation alone.

Transscleral resection versus iodine brachytherapy for choroidal malignant melanomas 6 millimeters or more in thickness

OBJECTIVE

To assess differences in treatment outcome after transscleral resection (TSR) and iodine brachytherapy (IBT) of choroidal melanomas too thick for ruthenium brachytherapy.

DESIGN

Matched case-control study.

SETTING

Two national ocular oncology services.

PARTICIPANTS

Forty-nine pairs of patients with choroidal melanoma 6 mm thick or more (range = 6-14), treated within 3 years of each other by either TSR or IBT, and retrospectively matched by age, visual acuity at diagnosis, largest basal tumor diameter, and posterior extension of the tumor.

INTERVENTION

Iodine brachytherapy in Finland or TSR in United Kingdom. Prospectively collected time-to-event data were compared with parametric Weibull regression, adjusting for matching.

MAIN OUTCOME MEASURES

Tumor control, complications, and visual acuity.

RESULTS

Risk of local recurrence after IBT was smaller than that after TSR (hazard ratio [HR] = 0.02, 95% confidence interval [CI] = 0.01-0.11, P<0.001, Weibull regression adjusted for matching), but the 8-year all-cause and melanoma-specific (HR = 0.81, 95% CI = 0.30-2.22, P = 0.69) survivals did not differ. The risks of cataract (HR = 2.05, 95% CI = 1.08-3.89, P = 0.029), maculopathy (HR = 2.28, 95% CI = 0.96-5.43, P = 0.062), and vitreous hemorrhage (HR = 2.30, 95% CI = 0.95-5.57, P = 0.064) were higher after IBT. Rubeosis, neovascular glaucoma, and optic neuropathy developed only after IBT. Risk of retinal detachment, exudative after IBT and rhegmatogenous after TSR (HR = 0.84, 95% CI = 0.40-1.75, P = 0.63), and risk of losing 20/60 vision (HR = 1.37, 95% CI 0.76-2.45, P = 0.29) were comparable between the groups, but risk of losing 20/200 vision was higher after IBT (HR = 2.38, 95% CI = 1.48-3.83, P<0.001). No overall difference in quality of life was found.

CONCLUSIONS

This study suggests that TSR preserves 20/200 vision better than IBT and avoids some of its major complications, but increases the risk of local recurrence. About 350 patients would need to be randomized to prove that TRS preserves 20/60 vision better than IBT.

Choroid metastases: clinical features and treatments in 123 patients

BACKGROUND

The current study was performed to analyze the effects of radiotherapy and chemotherapy on visual improvement in patients with choroid metastases (CM), and to determine the clinical factors potentially related to the risk of death.

METHODS

One hundred twenty-three consecutive patients were diagnosed with CM at the Institut Gustave-Roussy between 1966 and 1992. Treatment failure was defined as the absence of tumor regression or choroid tumor progression documented at the time of last ophthalmologic examination. The Cox proportional hazards model was used to estimate the risk of treatment failure associated with analyzed covariates.

RESULTS

Approximately 81% of the patients were women. The most frequent primary tumors were breast carcinoma (71%) and lung carcinoma (9%). Bilateral CM were found in 25% of patients. Sequential vinca alkaloid-based chemoradiotherapy was reported to be significantly associated with a decreased rate of treatment failure compared with radiotherapy alone (relative risk [RR] = 0.3; 95% confidence interval [95% CI], 0.03-2.2). However, when considered separately, each type of treatment also decreased the risk of treatment failure (RR = 0.5 [95% CI, 0.3-0.8] for radiotherapy and RR = 0.4 [95% CI, 0.3-0.7] for chemotherapy). The total dose of radiotherapy (< 30 grays [Gy] vs. > or = 30 Gy) was not found to modify treatment results. The 2-year overall survival rate was 25% (95% CI, 17-34%). The risk of death was found to be correlated with the presence of metastases in the liver (P = 0.02) or lung pleura (P = 0.04) at the time of the diagnosis of CM.

CONCLUSIONS

Sequential combination radiotherapy and vinca alkaloid-based chemotherapy appear to be the most beneficial treatment modality. However, because treatments were not prescribed randomly, the results of the current study should be interpreted with caution.

Mortality after deferral of treatment or no treatment for choroidal melanoma

PURPOSE

To report mortality of patients who were eligible for enrollment in the Collaborative Ocular Melanoma Study (COMS) clinical trials of medium-sized choroidal melanoma or large-sized choroidal melanoma but chose to defer treatment or receive no melanoma treatment.

DESIGN

Prospective nonrandomized multicenter cohort study as an adjunct to the COMS randomized clinical trials.

METHODS

Patient follow-up procedures included examinations, correspondence, telephone contacts, and National Death Index searches. Primary outcome was patient death measured by all-cause mortality. Secondary outcomes were melanoma treatment and melanoma metastasis.

RESULTS

Of 77 patients eligible for the COMS clinical trials who chose to defer or receive no melanoma treatment, 61 were appropriate candidates and 45 (74%) enrolled in the natural history study. Forty-two patients (42 eyes) had medium melanoma, and median follow-up was 5.3 years (range, 4-10.7 years). Twenty-two patients (52%) had subsequent melanoma treatment, and 20 (48%) had no melanoma treatment. For the 42 patients, the Kaplan-Meier estimate of 5-year mortality was approximately 30% (95% confidence interval [CI], 18%-47%). For the COMS medium melanoma trial, 5-year mortality was 18% (95% CI, 16% -20%), not statistically significantly different from the natural history study patients. After adjusting for differences in age and longest basal diameter, the 5-year risk of death for natural history study patients vs COMS trial patients was 1.54 (95% CI, 0.93-2.56). Three patients had large melanoma. Melanoma metastasis was confirmed or suspected in eight (42%) of 19 deaths.

CONCLUSION

Greater mortality and higher risk of death for natural history study patients are probative but not conclusive evidence of a beneficial, life-extending effect of medium melanoma treatment.

Microphthalmia transcription factor analysis in posterior uveal melanomas

PURPOSE

The protein encoded by the Microphthalmia gene (MITF) is a transcription factor essential for the development and survival of melanocytes. It serves as a master regulator in modulating extracellular signals. Because of its central role in melanocytes survival and to assess its potential use as a histopathological marker for melanoma, MITF expression was examined in human choroidal melanomas.

METHODS

Fifty-seven paraffin-embedded sections of choroidal melanoma specimens and 1 choroidal melanoma cell line were analyzed using immunochemistry and RT-PCR. Normal choroids and normal choroidal melanocyte cells were used as control.

RESULTS

Sixty-five percent of the tumoral specimens stained positively for MITF with a predominant nuclear pattern of reactivity. MITF-M and MITF-A isoforms were detected by RT-PCR in all specimens examined. Using a chimeric protein resulting from the fusion of each Mitf protein with the GFP, Mitf-M exhibited an exclusive nuclear staining whereas Mitf-A exhibited a mixed nuclear and cytoplasmic staining. No correlation between MITF-positivity and parameters such as cell type, largest tumor diameter, sclera invasion, mitotic figures was observed. In contrast, a significant negative association was found between MITF staining and the pigmentation (p=0.02) and a positive correlation between MITF staining and the proliferative marker Ki67 was found (p=0.02).

CONCLUSION

MITF may be implicated in choroidal melanoma pigmentation and proliferation. Further analysis should provide new insights into the mechanisms underlying the molecular and cellular changes of choroidal melanomas.

Golden Jubilee Lecture. Randomised clinical trials of choroidal melanoma treatment

PURPOSE

To illustrate an approach to evidence-based medical practice by reporting the Collaborative Ocular Melanoma Study (COMS) randomised clinical trials and cohort studies of choroidal melanoma.

METHODS

COMS randomised clinical trials of Iodine-125 (I-125) brachytherapy, adjunctive cohort study of visual acuity in eyes treated with brachytherapy and adjunctive natural history study. COMS randomised clinical trial of pre-enucleation radiation.

RESULTS

The COMS I-125 brachytherapy trial (N = 1,317 patients) of medium-sized choroidal melanoma showed 5-year all-cause mortality of 18% [95% Confidence Interval (CI), 16-20%] and no statistically significant difference in mortality following I-125 brachytherapy or enucleation. Adjunctive cohort natural history study (N-42 patients) of patients eligible for the I-125 brachytherapy trial who deferred treatment or had no melanoma treatment had a 5-year all-cause mortality of 30% (95% CI, 18-47%). The COMS pre-enucleation radiation trial (N = 1,003 patients) of large-sized choroidal melanoma showed 5-year all-cause mortality of 40% (95% CI, 37-44%).

CONCLUSIONS

Evidence derived from randomised clinical trials and cohort studies shows the need for longterm (> or = 5 years) follow-up to determine the efficacy of treatment for choroidal melanoma by any modality. The rather similar 5-year mortality for treated and untreated medium melanoma patients suggests that metastatic dissemination may occur at an early stage of choroidal melanoma. To increase longterm survival, ocular treatment of choroidal melanoma must strive for diagnosis and treatment of melanoma at an early stage when metastasis is less likely and be combined with measures to detect and treat micrometastasis.

Tumor basal area and metastatic death after proton beam irradiation for choroidal melanoma

BACKGROUND

Tumor dimension is an established prognostic factor for metastasis-related death after radiotherapy for uveal melanoma.

OBJECTIVE

To compare various methods of modeling the relationship between tumor dimension and metastatic death.

PATIENTS AND METHODS

The analyses were based on a consecutive series of 1204 patients with primary choroidal melanoma treated with proton beam irradiation (70 cobalt-gray equivalent in 5 fractions) at the Harvard Cyclotron Laboratory, Boston, Mass, between January 1985 and December 1998. Largest basal diameter and largest perpendicular basal diameter were recorded at the time of surgical placement of tantalum rings used for tumor localization during proton treatment. The height of the tumor and the axial diameter of the eye were measured by ultrasonography prior to treatment. Using proportional hazards regression, we compared the prognostic influence of different indices of tumor size with estimated risk ratios and death rates according to tumor basal area and largest basal diameter. All estimates were adjusted for other established prognostic factors.

RESULTS

Patients were followed up annually through June 30, 2000. Of the 1204 patients analyzed, 193 died of melanoma metastasis. The median follow-up among survivors was 7.9 years. The 5- and 10-year metastatic death rates were 12.8% and 20.7%, respectively. Among various approaches for modeling tumor dimension, the logarithm of tumor basal area had the highest log-likelihood and performed better than other approaches in 85% of the simulations. Based on this model, the covariate-adjusted rate ratio for any doubling in tumor basal area was 1.92 (95% confidence interval, 1.62-2.28).

CONCLUSION

Tumor basal area is a better prognostic indicator than largest tumor diameter and tumor volume in the prediction of metastatic death after proton beam irradiation for uveal melanoma.