Histopathological changes in malignant melanomas of the choroid after cobalt plaque therapy.

A series of 23 eyes removed after cobalt plaque therapy for malignant melanoma of the choroid is presented, and the histological changes are described with particular reference to the presence or absence of necrosis in the tumours. In 17 of the 23 eyes no evidence of tumour necrosis was found, though all showed evidence of radiation changes in the adjacent tissues. Necrosis was found in 6 cases but was prominent in only 2, one of which was the only example of a mixed-cell tumour, the other 22 being spindle-cell tumours. Enucleation became necessary on average at about 32 months after treatment (23 out of 100 treated eyes) because of obvious failure of treatment with evidence of continued growth, or because of radiational complications leading to a painful blind eye. The 5-year survival rate was 86% compared with about 50% when the treatment is enculeation.     

Transpupillary thermotherapy versus plaque radiotherapy for suspected choroidal melanomas

PURPOSE: To examine the outcomes and complications of transpupillary thermotherapy for treatment of small choroidal melanomas. DESIGN: Retrospective case-matched comparative study and retrospective observational study. PARTICIPANTS: The case-matched study consisted of 36 patients treated with either transpupillary thermotherapy or plaque radiotherapy (18 patients per group). The observational study consisted of 21 patients treated with transpupillary thermotherapy alone (primary transpupillary thermotherapy) and 9 patients treated with transpupillary thermotherapy plus plaque radiotherapy (adjuvant transpupillary thermotherapy). MAIN OUTCOME MEASURES: Visual acuity, local tumor control, and metastasis. RESULTS: The case-matched groups did not differ significantly with respect to age, gender, initial visual acuity, tumor location, or length of follow-up (mean, 33 months for transpupillary thermotherapy vs. 40 months for plaque radiotherapy). There was no significant difference in final visual acuity (P = 0.810) or postoperative visual acuity change (P = 0.919) between the 2 groups. In the observational study, the mean follow-up was 32 months (range, 4-58 months). Indications for primary transpupillary thermotherapy included documented growth (10 patients) and the presence of >/=3 risk factors for growth (11 patients). Retinal complications occurred in 16 patients (76%). The mean posttreatment visual acuity change was minus 2 lines (range, minus 9 to plus 7 lines). Local failure occurred in 6 patients (29%). Local failure was associated with an increased number of transpupillary thermotherapy spots per session (P = 0.023) and decreased tumor pigmentation (P = 0.001). Indications for adjuvant transpupillary thermotherapy included tumor radioresistance (6 patients) and the presence of risk factors for local failure (3 patients). All 9 tumors that received adjuvant transpupillary thermotherapy regressed rapidly, with no local failures. The mean postoperative visual acuity change was -1.9 lines (range, -9 to +5 lines). No patient in either study developed metastasis. CONCLUSIONS: The recent interest in transpupillary thermotherapy as primary therapy for choroidal melanoma is based largely on the assumption that transpupillary thermotherapy may provide better visual outcomes than plaque radiotherapy. However, this study found no significant difference in visual outcomes between transpupillary thermotherapy and plaque radiotherapy. Further, the local failure rate with transpupillary thermotherapy was substantially higher than with plaque radiotherapy. The most promising role for transpupillary thermotherapy seems to be as an adjunct to plaque radiotherapy. The appropriate indications for transpupillary thermotherapy in the management of choroidal melanoma need to be re-evaluated.     

兔脉络膜黑色素瘤光动力学治疗的研究

目的 评价第二代光敏物质（benzoporphyrin derivative,BPD)在兔脉络膜色素性黑色素瘤光动力学治疗中的疗效。方法 对44只新英格兰大白兔眼,建立脉络膜色素性黑色素瘤模型,每日注射环孢素A行免疫抑制治疗。当黑色素瘤生长厚度达2.0-4.6mm时,将44只兔分成3组,治疗I组（14只兔）及治疗Ⅱ（20只兔）,静脉给予BPI1mg/kg,通过氩离子－染料激光进行光动力学治疗,长为692nm,照射剂量为60－150J /cm^2,对照组（10只兔）中的6只兔仅给予激光照射,4只兔为空白对照。治疗后4－6周外死兔,取其眼球观察脉络膜黑色素瘤光动力学治疗效果。结果 34只脉络膜黑色素瘤兔经光动力学治疗后,治疗I组肿瘤厚度为＜3mm,激光照射剂量60－80J/cm^2,与对照组比较,差异有非常显著意义（P＜0．001）;治疗Ⅱ组肿瘤厚度为3.0-4.6mm,激光照射剂量为＞80J/cm^2,与对照组比较,差异有非常显著意义（P＜0．001）。对照组兔眼肿瘤在2－3周时充满整个玻璃体腔。结论 光动力学治疗可能成为一种选择性治疗脉络膜色素性黑色素瘤的方法。     

Primary choroidal and cutaneous melanomas, bilateral choroidal melanomas, and familial occurrence of melanomas.

The medical history of a patient with a familial atypical multiple more melanoma syndrome revealed a combination of rare findings: occurrence of a melanoma in both eyes, development of 3 separate skin melanomas, and occurrence of other malignancies in the family. Another patient developed a choroidal and a skin melanoma, but there were no known malignancies in the family. A third patient with a choroidal melanoma had a mother with an ethmoidal melanoma.     

Histopathological findings in human choroidal melanomas after transpupillary thermotherapy

AIMS—The effect of transpupillary thermotherapy (TTT) on human choroidal melanomas was investigated by means of histopathology.
METHODS—Before enucleation TTT was performed in 11 eyes with a xenon arc photocoagulator with a red filter or a diode laser at 810 nm. The exposure time was 1 minute; the estimated temperature at the top of the tumour was about 65°C.
RESULTS—Seven of 11 tumours developed necrosis to a maximum depth of 3.9 mm with a sharp demarcation between the necrotic and the viable part of the tumour. The depth correlated with penetration of heat into the tumour. Scattered small haemorrhages in the transitional zone between the necrotic and the viable part of the tumour were observed in three eyes but large haemorrhages were absent. Ocular media were not affected owing to the low rate of absorption of radiation at 810 nm. TTT did not cause significant scleral damage. Intrascleral tumour cells with a viable appearance were observed in one eye, where the tumour was almost totally necrotic.
CONCLUSION—Results show that TTT has potential as a conservative therapeutic treatment for choroidal melanomas.

     

Clinicopathologic findings in choroidal melanomas after failed transpupillary thermotherapy

PURPOSE: To review the clinicopathologic features of eyes enucleated after failed transpupillary thermotherapy. DESIGN: Retrospective review. METHODS: Pathology reports in the L.F. Montgomery Laboratory between 1998 and 2002 were searched for enucleated eyes with choroidal melanoma that had been treated only by transpupillary thermotherapy (TTT) prior to enucleation. The clinical features of the patients, including ultrasonography examination, were reviewed and compared with the pathologic findings. RESULTS: Seven eyes from seven patients had been enucleated, representing 8% of eyes treated with TTT at our institute during the period studied. The primary indication for enucleation was tumor growth. The melanomas tended to grow laterally, with minimal if any increase in thickness. Five of the seven eyes histologically demonstrated extrascleral extension, which was detected by ultrasonography prior to enucleation in only one of those eyes. CONCLUSIONS: Choroidal melanoma may continue to grow along a path of least resistance after TTT. The melanoma may extend laterally in the choroid and through emissary canals. Early extrascleral extension may be difficult to detect by ultrasonography.     

Radioactive plaque therapy for metastatic choroidal carcinoma

PURPOSE: To describe the outcome of radioactive episcleral plaque therapy for treatment of metastatic carcinoma to the choroid. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Five patients (six eyes) with carcinoma metastatic to the choroid. METHODS: Retrospective review of the clinical records of five patients (six eyes) who underwent radioactive episcleral plaque therapy for choroidal metastases. MAIN OUTCOME MEASURES: Tumor height, visual acuity, radiation optic neuropathy, and radiation retinopathy. RESULTS: Radioactive episcleral plaque therapy resulted in shrinkage of the treated tumors and resolution of subretinal fluid in all eyes. After plaque treatment, best-corrected visual acuity was maintained within two lines of initial visual acuity for two eyes, decreased more than two lines for one eye, and improved more than two lines in three eyes. The treatment was well tolerated and there was no acute toxicity. Late complications included optic nerve atrophy (at 2 years) with proliferative radiation retinopathy (at 3 years) in one eye and optic atrophy (at 6 months) in another eye that had received prior external beam therapy. CONCLUSIONS: In carefully selected cases, radioactive episcleral plaque therapy appears to be an effective and reasonable treatment for carcinoma metastatic to the choroid.     

Ruthenium plaque radiation therapy for iris and iridociliary melanomas

Purpose: To determine the long‐term effects of ruthenium‐106 plaque radiation therapy for iris and iridociliary melanomas in terms of tumour regression and complications. Methods: Between 1 November 1997 and 31 December 2007, 36 patients with an iris or iridociliary melanoma were treated with Ruthenium‐106 (Ru‐106) ophthalmic plaque radiation therapy. The median follow‐up was 6.5 years with a range of 2–11 years. The mean tumour apex dose was 151.5 Gy. Main outcome measures were local tumour control and radiation‐related ocular complications. Results: The mean age of the patients at the time of treatment was 54 years (range 14–82). The tumours had a median largest basal dimension of 4.8 mm (range 3–11) and a prominence of 2.3 mm (range 0.8–5), with a median involvement of three clock hours (range 1–6). The tumours were confined to the iris in 14 patients (39%), extended into the anterior ciliary body in 12 (33%), while the anterior ciliary body tumour extended into the iris in ten patients (28%). Tumours regressed in all patients (100%) with a mean regression of 80% of the original tumour size at 7 years of follow‐up. Radiation‐related complications included corneal erosions on the first postoperative day in nine patients (25%), cataract in four of 11 patients free of cataract before treatment (36%) and postradiation glaucoma in one patient (3%). Visual acuity of 20/200 or worse was present in one of 20 patients (5%) at 6 years of follow‐up. Local recurrences occurred in two patients (5%), 2 and 5 years after the radiation therapy respectively, and both underwent enucleation. Distant metastases occurred in one of these enucleated patients (3%) 2 years after treatment. Conclusion: Ru‐106 plaque radiation therapy for iris and iridociliary melanoma resulted in good local tumour control and preservation of visual acuity with few and treatable side‐effects.     

Combined iodine-125 plaque irradiation and indirect ophthalmoscope laser therapy of choroidal malignant melanomas: Comparison with iodine-125 and cobalt-60 plaque radiotherapy alone

The authors studied the short-term impact of combined episcleral iodine-125 plaque radiotherapy and argon laser treatment in a series of 24 patients with choroidal malignant melanoma. All patients underwent plaque therapy prior to their initial laser session. All laser treatments were performed with an indirect ophthalmoscope argon green laser, using low-power, long-duration exposures. The endpoint of laser therapy was a well-defined atrophic circumbasal chorioretinal laser scar and complete or nearly complete nonfluorescence of the lesion on fluorescein angiography. In a case-by-case matched comparison study, the authors evaluated the relative local regression of tumors treated by combined plaque-laser therapy, iodine-125 plaque therapy alone, and cobalt-60 plaque therapy alone. The tumors treated with supplemental laser regressed substantially faster and more completely than did those treated by either type of plaque therapy alone. However, the short-term visual loss was greater in eyes treated by the combined therapy.This work was presented in part at the scientific session of the Club Jules Gonin, Vienna, Austria, 7 September 1992     

血啉甲醚光动力疗法治疗兔脉络膜黑色素瘤的实验研究

目的探讨国产新型光敏剂血啉甲醚光动力疗法（PDT）治疗兔脉络膜黑色素瘤的效果。方法选择46只新西兰白兔（46只眼）建立脉络膜黑色素瘤模型。每日注射环孢素A以抑制免疫反应,用间接检眼镜和B超观察肿瘤生长,至瘤体为1．5～4．6mm厚度时,将46只兔（46只眼）分成两组,实验组41只眼,均静脉给予血啉甲醚10mg／kg体重,3h后用波长为630nm的氦氖激光进行照射,激光能量60～150J／cm^2。对照组5只眼,其中1只眼为空白对照,2只眼为血啉甲醚对照,2只眼为激光照射对照。PDT治疗后通过间接检眼镜、B超、彩色眼底照相观察瘤体变化4～5周,实验组16只眼分别在激光照射后24h和1周时处死,摘取眼球做病理检查,以观察疗效。结果实验组中,当激光能量≥70J／cm^2时,肿瘤生长受到明显抑制,其厚度明显缩小;在激光能量为60J／cm^2照射下,仅有部分肿瘤生长受到抑制。对照组兔眼肿瘤均在2～3周内迅速增大,甚至充满整个玻璃体腔。结论国产光敏剂血啉甲醚光动力疗法对脉络膜黑色素瘤具有一定治疗作用。     

Proton irradiation of small choroidal malignant melanomas.

Five patients with choroidal malignant melanomas were treated with proton irradiation with a cyclotron. We developed an accurate method of aiming the proton beam within the eye. Four to five tantalum rings, 2 mm in diameter, were sutured to the sclera at the edges of the tumor, which is localized by indirect ophthalmoscopy and transillumination. The rings were used as markers for stereotactic radiography to align precisely the tumors with the proton beam. The patients were given a total tumor dose of 4,730 to 6,670 rads, delivered in five equal fractions, over a period of eight to nine days. All patients tolerated the treatments well without any adverse effects. The tumor response to therapy could not be evaluated at the completion of treatment since there was no immediate observable reaction of the tumor or of the surrounding retina. Although there has been no definite regression in any patient, we observed a change in the "color" of the tumor in the first two patients and resolution of two serous retinal detachments.     

A new inexpensive customized plaque for choroidal melanoma iodine-125 plaque therapy

The authors have developed a new inexpensive precious metal alloy plaque for use in customized iodine-125 plaque therapy. Each plaque is formed from two flat circular gold/palladium foils which are used in dental crown work. Using a simple manual mechanism, the two forms are stamped over a customized acrylic die shaped to the dimensions of the tumor base plus a 2-mm margin. Completed plaques consist of a back wall, a 2-mm side wall, and a 1.5-mm wide lip with holes for suture placement. Advantages include: simple construction from inexpensive components, customized shape, and iodine seeds that are readily visible on plane radiographs.