Uveal melanoma medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]
Overview
The optimal therapy for uveal melanoma depends on the size of the tumor. The various treatment modalities for uveal melanoma include enucleation, plaque brachytherapy, external beam proton therapy, transupillary thermotherapy, Gamma Knife stereotactic radiosurgery, and resection of the tumor.[1]
Medical Therapy
- The treatment protocol for uveal melanoma has been directed by many clinical studies, the most important being "The Collaborative Ocular Melanoma Study" (COMS). The treatment of uveal melanoma varies according to location, size of the eye melanoma, and the overall health of the patient. However, chief among them is the size of the tumor.
- Primary treatment can involve removal of the affected eye (enucleation); however, this is now reserved for cases of extreme tumor burden or other secondary problems.
- Advances in radiation therapies have significantly decreased the number of patients treated by enucleation in developed countries. The most common radiation treatment is plaque brachytherapy, in which a small disc-shaped shield (plaque) encasing radioactive seeds (most often Iodine-125, though Ruthenium-106 and Palladium-103 are also used) is attached to the outside surface of the eye, overlying the tumor. The plaque is left in place for a few days and then removed. The risk of metastasis after plaque radiotherapy is the same as that of enucleation, suggesting that micrometastatic spread occurs prior to treatment of the primary tumor.
- Other modalities of treatment include transpupillary thermotherapy, external beam proton therapy, resection of the tumor, Gamma Knife stereotactic radiosurgery or a combination of different modalities. Different surgical resection techniques can include trans-scleral partial choroidectomy, and transretinal endoresection.[2]
Standard treatment options for iris melanoma
- Observation with careful follow-up
- In asymptomatic patients with stable lesions; follow-up includes serial photography.
- Local resection
- When progressive and pronounced growth is documented.
- If the tumor is not amenable to local resection (diffuse involvement of the iris, involvement of more than 50% of the iris and anterior chamber angle, intractable glaucoma, and extraocular extension).
- Plaque radiation therapy
Standard treatment options for ciliary body melanoma
- Plaque radiation therapy
- Local control rates are high, but treatment is associated with a high incidence of secondary cataract.
- External-beam, charged-particle radiation therapy
- This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.
- Local tumor resection
- This option is mainly suitable for selected ciliary body or anterior choroidal tumors with smaller basal dimension and greater thickness.
- This option is generally reserved for large melanomas when there is no hope of regaining useful vision. It is also indicated in the presence of intractable secondary glaucoma and extraocular extension.[1]
Standard treatment options for small choroidal melanoma
- Observation
- This strategy is important for patients with an uncertain diagnosis or in whom tumor growth has not been documented. It is also used for asymptomatic patients with stable lesions (particularly elderly or debilitated patients), and patients with a tumor in their only useful eye.
- Plaque radiation therapy
- This treatment is used for small- or medium-sized uveal melanomas, amelanotic tumors, or tumors that touch the optic disc for greater than 3 clock-hours of optic disk circumference.
- External-beam, charged-particle radiation therapy
- This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.
- This treatment may be a feasible option for small-sized to medium-sized melanomas.
- Transpupillary thermotherapy
- As noted above, this approach has very limited use, but it can be used as a primary treatment or as an adjunctive method to plaque radiation therapy.
- Local tumor resection
- This strategy is used mainly for selected ciliary body or anterior choroidal tumors with smaller basal dimensions and greater thickness.
- Enucleation
- This approach is used when severe intraocular pressure elevation is a factor. It may also be considered with small- and medium-sized melanomas that are invading the tissues of the optic nerve.[1]
Standard treatment options for medium-sized choroidal melanomas
- Plaque radiation therapy
- External-beam, charged-particle radiation therapy
- This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.
- Local eye-wall resection
- Combined therapy, with ablative laser coagulation or transpupillary thermotherapy to supplement plaque treatment
- Enucleation
- This approach is considered primarily for diffuse melanomas or for cases in which there is extraocular extension; radiation complications or tumor recurrence may sometimes make enucleation necessary.[1]
Standard treatment option for large choroidal melanomas
Enucleation when the tumor is judged to be too large for eye-sparing approaches.
Standard therapy for extraocular extension and metastatic intraocular melanoma
Extrascleral extension confers a poor prognosis. For patients with gross tumor involvement of the orbit, treatment requires orbital exenteration. However, there is no evidence that such radical surgery will prolong life. Most patients with localized or encapsulated extraocular extension are not exenterated. No effective method of systemic treatment has been identified for patients with metastatic ocular melanoma. Available clinical trials should be considered as an option for these patients.[1]
Standrad therapy for recurrent intraocular melanoma
The prognosis for any patient with recurring or relapsing disease is poor, regardless of cell type or stage. The question and selection of further treatment depends on many factors, including the extent of the lesion, age and health of the patient, prior treatment, and site of recurrence, as well as individual patient considerations. Surgical resection of metastases diagnosed subsequent to initial management of ocular melanoma in single-center, case series of highly selected patients has been reported. The extent to which the occasional favorable outcomes are the result of strong selection factors is not clear, so this approach cannot be considered standard. Clinical trials are appropriate, and eligible patients should be advised to consider participation in them whenever possible. [1]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Uveal melanoma. National Cancer Institute(2015) http://www.cancer.gov/types/eye/patient/intraocular-melanoma-treatment-pdq Accessed on October 24 2015
- ↑ Uveal melanoma. Wikipedia(2015) https://en.wikipedia.org/wiki/Uveal_melanoma Accessed on October, 27 2015