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.

Recurrence of iris melanoma after proton beam therapy.

BACKGROUND/AIMS: A retrospective service evaluation to report on recurrence of iris melanoma after proton beam therapy (PBT). METHODS: The cohort comprised 150 consecutive eyes with iris melanoma treated with proton beam radiotherapy. Treatment consisted of 53.1 Gy of proton beam irradiation delivered in four fractions over four consecutive days. Main outcome measures were local tumour control and tumour-related mortality. RESULTS: A total of 150 patients were treated. The median follow-up time was 66 months (range, 12-108 months). The tumour ultrasound thickness ranged from 1.1 mm to 4.9 mm, with a median of 2.4 mm. The tumours in these patients had a median largest basal diameter of 6.7 mm (range, 2.9-8.4 mm), involving more than two clock hours of iris or angle in five patients. The ciliary body was involved in three patients. Eight patients (5.3%) presented with local recurrence, diagnosed after a median follow-up of 24 months (range, 12-84 months). The recurrence was focal in two patients and diffuse in six. Six eyes were enucleated whereas one eye underwent iridocyclectomy and one received a second course of PBT. CONCLUSIONS: PBT provides excellent local tumour control and ocular preservation with good retention of vision. Most recurrences occur because the extent of the tumour is clinically underestimated but some tumours are radioresistant. Recurrence can occur several years after treatment. These findings indicate the need for wide safety margins and even radiotherapy of the entire anterior segment in patients with diffuse disease. Surveillance after treatment needs to be lifelong.

Whole anterior segment proton beam radiotherapy for diffuse iris melanoma.

AIM: To report the results of whole anterior segment proton beam radiotherapy (PBR) for diffuse iris melanoma. METHODS: Between 2000 and 2011, 12 patients with iris melanoma received PBR to the entire iris and ciliary body. RESULTS: Patients had a mean age of 57 years and a median follow-up of 3.5 years (range 1-11.6 years). Tumour iris involvement was 1-4 h in five patients, 5-8 h in four and 9-12 h in three. Angle involvement was 6-8 h in five patients and 9-12 h in seven. The visual acuity (VA) before treatment was 6/5-6/6 in six patients, 6/8-6/9 in three and 6/18-6/38 in three. No tumour recurrence occurred during the follow-up period. Glaucoma treatment was required in 11 of 12 patients. The visual acuity at the last follow-up was 6/5-6/9 in five patients, 6/18-6/24 in three, 6/60-1/60 in two and no light perception in two. Four patients developed varying non-severe degrees of limbal stem cell deficiency, which was treatable with conservative measures. CONCLUSIONS: Whole anterior segment PBR is a useful alternative to enucleation for diffuse iris melanoma. Most patients will need treatment for glaucoma and some may require treatment for tear-film instability and/or stem cell failure.

Proton beam radiotherapy of iris melanoma.

PURPOSE: To report on outcomes after proton beam radiotherapy of iris melanoma. METHODS AND MATERIALS: Between 1993 and 2004, 88 patients with iris melanoma received proton beam radiotherapy, with 53.1 Gy in 4 fractions. RESULTS: The patients had a mean age of 52 years and a median follow-up of 2.7 years. The tumors had a median diameter of 4.3 mm, involving more than 2 clock hours of iris in 32% of patients and more than 2 hours of angle in 27%. The ciliary body was involved in 20%. Cataract was present in 13 patients before treatment and subsequently developed in another 18. Cataract had a 4-year rate of 63% and by Cox analysis was related to age (p = 0.05), initial visual loss (p < 0.0001), iris involvement (p < 0.0001), and tumor thickness (p < 0.0001). Glaucoma was present before treatment in 13 patients and developed after treatment in another 3. Three eyes were enucleated, all because of recurrence, which had an actuarial 4-year rate of 3.3% (95% CI 0-8.0%). CONCLUSIONS: Proton beam radiotherapy of iris melanoma is well tolerated, the main problems being radiation-cataract, which was treatable, and preexisting glaucoma, which in several patients was difficult to control.

Proton beam radiotherapy of choroidal melanoma: the Liverpool-Clatterbridge experience.

PURPOSE: To report on outcomes after proton beam radiotherapy of choroidal melanoma using a 62-MeV cyclotron in patients considered unsuitable for other forms of conservative therapy. METHODS AND MATERIALS: A total of 349 patients with choroidal melanoma referred to the Liverpool Ocular Oncology Centre underwent proton beam radiotherapy at Clatterbridge Centre for Oncology (CCO) between January 1993 and December 2003. Four daily fractions of proton beam radiotherapy were delivered, with a total dose of 53.1 proton Gy, and with lateral and distal safety margins of 2.5 mm. Outcomes measured were local tumor recurrence; ocular conservation; vision; and metastatic death according to age, gender, eye, visual acuity, location of anterior and posterior tumor margins, quadrant, longest basal tumor dimension, tumor height, extraocular extension, and retinal invasion. RESULTS: The 5-year actuarial rates were 3.5% for local tumor recurrence, 9.4% for enucleation, 79.1% for conservation of vision of counting fingers or better, 61.1% for conservation of vision of 20/200 or better, 44.8% for conservation of vision of 20/40 or better, and 10.0% for death from metastasis. CONCLUSION: Proton beam radiotherapy with a 62 MeV cyclotron achieves high rates of local tumor control and ocular conservation, with visual outcome depending on tumor size and location.

Visual acuity after Ruthenium(106) brachytherapy of choroidal melanomas.

PURPOSE: To report on conservation of visual acuity after Ruthenium(106) (Ru-106) brachytherapy of choroidal melanoma. METHODS AND MATERIALS: This study was a noncomparative interventional case series of 458 patients with choroidal melanoma treated at a single center between January 1993 and December 2001. The intervention consisted of Ru-106 brachytherapy delivering minimum scleral and apex doses of 300 Gy and 80 Gy, respectively, using a 15-mm or 20-mm plaque. For discrete, posterior tumors, the plaque was positioned eccentrically with its posterior edge aligned with the posterior tumor margin. To ensure correct plaque positioning, any overlying extraocular muscles were dis-inserted, and the locations of both tumor and plaque edges were confirmed by transillumination and indentation. The main outcome measures were conservation of vision of 20/40 or better, 20/200 or better, and Counting Fingers or better, according to baseline variables. RESULTS: The actuarial rate of conservation of 20/40 or better was 55% at 9 years, loss of such vision correlating with posterior tumor extension (p < 0.001), temporal tumor location (p = 0.001), increased tumor height (p = 0.01), and older age (p < 0.01) (Cox multivariate analysis). Similar analyses showed conservation of 20/200 or better in 57% of eyes at 9 years, loss correlating with reduced initial visual acuity (p < 0.001), posterior tumor extension (p < 0.001), and temporal tumor location (p = 0.006). Counting Fingers or better vision was conserved in 83% of patients at 9 years, loss correlating with increased tumor height (p < 0.0001). Local tumor recurrence occurred in 9 patients (actuarial rate, 3% at 9 years). CONCLUSION: Ruthenium(106) brachytherapy of posterior choroidal melanoma achieves good conservation of vision if the tumor does not extend close to the optic nerve or fovea.

Local tumor control after 106Ru brachytherapy of choroidal melanoma.

PURPOSE: To report on local tumor control after (106)Ru brachytherapy for choroidal melanoma. METHODS AND MATERIALS: A total of 458 patients with choroidal melanoma were treated at a single institution between January 1993 and December 2001. The tumors had a median longest basal dimension of 10.6 mm and a median height of 3.2 mm. The brachytherapy was administered using a 15- or 20-mm plaque. For posterior tumors, the plaque was positioned eccentrically with its posterior edge aligned with the posterior tumor margin to reduce the radiation dose to the optic disk and fovea. A minimal scleral dose sufficient to cause visible choroidal atrophy provided a permanent ophthalmoscopic record of the distribution of choroidal irradiation. If radiotherapy to the posterior tumor was uncertain, adjunctive transpupillary thermotherapy was administered 6 months postoperatively. RESULTS: The actuarial rates of tumor recurrence were 1%, 2%, and 3% at 2, 5, and 7 years, respectively. Local tumor recurrence correlated with the longest basal tumor dimension (Cox univariate analysis, p = 0.02, risk ratio 1.41, 95% confidence interval 1.06-1.88). Seven of the nine eyes with recurrent tumor were salvaged with additional conservative therapy. CONCLUSION: The low rate of local tumor recurrence suggests that ruthenium plaque radiotherapy is effective with good case selection and if special measures are taken to ensure that the plaque is positioned correctly.