Psychological reactions and quality of life in patients with posterior uveal melanoma treated with ruthenium plaque therapy or enucleation: a one year follow-up study.

PURPOSE: To investigate psychological reactions and quality of life among patients with posterior uveal melanoma. METHODS: Consecutive patients with uveal malignant melanoma (99/106), referred to St Erik's Eye Hospital 1995-1996, treated with rutheniuim plaque radiotherapy (n = 50) or enucleation (n = 49), were included in this non-randomised prospective comparative study. Questionnaires were completed before treatment (Hospital Anxiety and Depression Scale, HAD scale) and 2 and 12 months after diagnosis including the HAD scale, the Impact of Event Scale and the EORTC QLQ-C30. A disease-specific questionnaire was included 12 months after diagnosis. Between-group differences were analysed by chi-square, Student's t-test and ANOVA. RESULTS: A majority of the patients reported reduced 'Quality of Life' (72-85%), 'Emotional functioning' (60-74%) and 'Cognitive functioning' (51-61%). 'Fatigue' was the most frequently reported symptom (61-72%) followed by 'Insomnia' (43-58%). Anxiety and depressive symptoms were relatively frequent up to 1 year after treatment, but the levels of anxiety decreased during the first year after treatment. Disease and treatment-related problems were reported in both treatment groups 1 year after diagnosis. Enucleated patients had more problems with appearance and judging distances, whereas those treated with radiotherapy reported vision impairment to a higher extent. CONCLUSIONS: Enucleated patients reported high levels of emotional distress, problems with appearance and judging distances during the first year after treatment. Patients treated with radiotherapy reported similar levels of quality of life and emotional problems, but more problems with visual impairment. These differences in impact on disease-related functioning should be taken into account when treatment options are discussed.

Tumour cell proliferation after failed ruthenium plaque radiotherapy for posterior uveal melanoma.

Enucleation following ruthenium plaque radiotherapy for posterior uveal melanoma indicates failure of treatment. This study focused on the histopathological findings and remaining tumour cell growth fraction in 42 of 46 patients with failed ruthenium plaque treatment (of 266 patients treated) for melanoma of the choroid or ciliary body. The cause for enucleation was clinically detected tumour regrowth in 27 (64%) patients, treatment-related ocular side effects in 12 (29%) cases and the patient's personal preference in three (7%) cases. The median time elapsing from plaque radiotherapy to enucleation was not significantly different for patients with recurrent tumour growth (23 months) compared to those enucleated without clinical signs of regrowth (19 months). While all tumours showed some regressive features by histopathological examination, only five melanomas were completely necrotic and viable-appearing tumours cells were present in all of the remaining 37 (88%) irradiated tumours. Microwave processed PC-10 immunostainings increased the sensitivity to detect cycling cells compared to the sole use of mitotic cell counts. By the former technique, proliferating tumour cells were detected in 17 of 23 (74%) studied melanomas of eyes enucleated for tumour regrowth following brachytherapy. Also, the number of cycling melanoma cells was similar to that of non-irradiated controls managed solely by enucleation. In contrast, the proliferative compartments of irradiated, but non-recurrent, posterior uveal melanomas were significantly reduced compared to those of matched controls. Still, cycling tumour cells were present in four of 13 (31%) irradiated melanomas, clinically assumed to be successfully treated.

[A study of children with retinoblastoma. Diagnosis is often delayed]. / Studie av barn med retinoblastom. Ofta fördröjd diagnos.

Retinoblastoma is an uncommon but highly malignant ocular tumour of the early childhood. The delay in diagnosis following presentation at a health care facility was studied for 22 consecutive cases derived from the National Retinoblastoma Center in Sweden. Four of the children were regularly examined owing to a family history of retinoblastoma, but among the remaining 18 children the delay in diagnosis exceeded one month in five cases (including all children presenting with squint). However, there was no appreciable delay once appropriate fundus examination had been performed, thus stressing the need of early ophthalmological assessment in all cases of children manifesting signs consistent with retinoblastoma.

Prevalence of primary acquired melanosis and nevi of the conjunctiva and uvea in the dysplastic nevus syndrome. A case-control study.

PURPOSE: To investigate whether conjunctival and uveal nevi and primary acquired melanosis are more common in individuals with the dysplastic nevus syndrome than in control subjects derived from the general population. METHODS: Power calculations were used to determine the sample size. After invitation, 162 individuals with the dysplastic nevus syndrome and 119 control subjects, matched for sex and age but otherwise randomized from the Stockholm county census file, were entered into the study. All individuals were examined in a masked fashion by the same ophthalmologist, and the presence of conjunctival and uveal melanocytic lesions and the iris color, skin type, and hair color of each individual were recorded. Contingency tables and odds ratios were used for statistical evaluation. RESULTS: The proportions of individuals with the dysplastic nevus syndrome featuring primary acquired melanosis of the conjunctiva, or nevi of the iris and choroid were not significantly different from those of control subjects. However, individuals with the dysplastic nevus syndrome appeared to have a more sun-sensitive skin type and a reddish or blond hair color more often than control subjects. CONCLUSION: In contrast to previous reports, this study suggests that ocular melanocytic lesions are no more common in individuals with the dysplastic nevus syndrome than in the general population. Therefore, this work does not provide support that periodic ophthalmic surveillance of individuals with the dysplastic nevus syndrome for the purpose of detecting conjunctival or uveal melanomas, or their precursors, is meaningful.

Standardized precision radiotherapy in choroidal metastases.

Metastases in the choroid of the eye are frequent in patients with disseminated malignancy. We here report the results using the precision radiotherapy technique described by Schipper et al. to treat 14 of 17 consecutive patients (21 eyes) with symptoms from such metastases. A beam defining collimator was used and a lateral field was given with the treated eye individually fixed. Varying fractionations and doses were used. The biologically effective dose for early effects (BED3) was 47 to 90 Gy and for late effects (BED10) 28 to 59 Gy. In 14 eyes (82%) the metastases regressed completely. The visual acuity was stabilized or improved in all patients and none needed local surgery. Three patients developed signs of radiation retinopathy, but only in one case the visual function was compromised. With this standardized technique no individualized dose planning was needed, the risk of radiation cataract was minimized and a dry eye avoided.

Long-term effects of radiotherapy and bromocriptine treatment in patients with previous surgery for macroprolactinomas.

The long-term effect of radiotherapy and bromocriptine treatment was retrospectively evaluated in 25 patients who had previously undergone transsphenoidal surgery for treatment of macroprolactinomas. Surgery had reduced the median serum prolactin (PRL) value from 613 micrograms/l, a reduction of 53%. Postoperative bromocriptine was administered to 21 of the 25 patients. In 14 of these patients, serum PRL values became normal or almost normal with medication. There were no radiological or ophthalmological signs of progressive tumor growth during bromocriptine treatment. Fourteen patients received postoperative radiotherapy. After withdrawal of bromocriptine in 13 of these patients an average of 7 years after radiotherapy, the median serum PRL value had further decreased by 95%. The PRL reduction was similar for all doses applied, 38 to 52 Gy. After withdrawal of bromocriptine in 8 patients not receiving radiotherapy an average of 7 years after operation, the median serum PRL level had further decreased by 75%. At follow-up, 18 additional instances of pituitary insufficiency had developed in the group receiving radiotherapy, compared with 8 cases of insufficiency in the group not receiving radiotherapy. Thus, because bromocriptine has a long-standing effect on prolactin secretion, and radiotherapy is associated with a notably high incidence of pituitary insufficiency, we propose that photon irradiation should be considered mainly for patients who are not candidates for surgical or medical treatment.

External irradiation of growth hormone producing pituitary adenomas: prolactin as a marker of hypothalamic and pituitary effects.

Fifty-six patients with acromegaly were treated with external irradiation, 50 Gy, after unsuccessful pituitary surgery. A 50% reduction of pre-irradiation growth hormone levels was obtained in 51/56 patients. This level was reached after 26 +/- 14 months in 33 patients with prolactin levels less than 25 micrograms/l at diagnosis, after 21 +/- 17 months in 18 patients with prolactin greater than or equal to 25 micrograms/l, and after 20 +/- 21 months in 12 patients with prolactin greater than 40 micrograms/l at diagnosis. A further 50% decrease of growth hormone levels was obtained in 40/51 patients 42 +/- 22 months after radiotherapy, indicating that in clearly responsive patients, the growth hormone depression after radiotherapy follows a first order reaction. Four patients did not reach a 50% reduction of growth hormone levels 48-80 months after radiotherapy. During 10 years of follow-up, the growth hormone depression tended to be more pronounced in patients with mixed secretion of growth hormone and prolactin. The reduction of growth hormone levels was not correlated with the irradiated volume or the cumulative radiation effect. Within the first year, prolactin increased within the normal range in normoprolactinemic patients and remained so during follow-up. In hyperprolactinemic patients, prolactin decreased successively but to a lesser extent than growth hormone. Pituitary insufficiencies increased over time and three patients developed GH-insufficiency. Hypothalamic damage as indicated by prolactin changes was a regular phenomenon after radiotherapy.

Growth hormone producing pituitary adenomas with concomitant hypersecretion of prolactin are particularly sensitive to photon irradiation.

The effect of photon irradiation (50 Gy with a 3-field technique in fractionated doses) on growth hormone (GH), prolactin (PRL), and somatomedin A (SMA) was studied in 25 patients with acromegaly after previous unsuccessful surgery. In patients with concomitant hypersecretion of PRL, the GH reduction was 70 +/- 22% 1 year and 88 +/- 10% 3 years after radiotherapy. The corresponding reductions in patients with isolated GH hypersecretion were 42 +/- 25% and 60 +/- 22%. The reduction of GH levels was most notable the first year after radiotherapy in 16 patients and during the second year in 7 patients. Serum PRL decreased after radiotherapy in all patients with hyperprolactinemia, whereas PRL in normoprolactinemic patients showed inconsistent changes, including PRL increments in 8/12 patients. The effect of radiotherapy on GH and PRL was not correlated to the irradiation target volume or the cumulative radiation effect. SMA levels decreased after radiotherapy, but became normal only in 3 patients, all with pretreatment GH less than 5 micrograms/l. Radiotherapy, 3 years after treatment, appeared to be equivalent to the primary surgical intervention in reducing GH and SMA in patients with acromegaly due to advanced macroadenomas. Patients with concomitant hyperprolactinemia showed increased sensitivity to radiation compared to normoprolactinemic patients with acromegaly.