Treatment/Prognosis

Question 1

In order of importance, what are the 3 main goals of Tx in the management of ocular melanoma?

Answer 1

Main goals of ocular melanoma Tx (in order of importance):

Preserve life
Preserve eye
Preserve vision

Question 2

What is the preferred management approach for COMS category small uveal melanomas?

Answer 2

Observation or local therapy (transpupillary thermotherapy, photodynamic laser photocoagulation, local resection)

Question 3

When is RT employed in the management of COMS category small uveal melanomas?

Answer 3

RT is employed when there is progression after conservative management (i.e., observation or other local Tx).

Question 4

As per ABS 2014 guidelines, what are the eligibility criteria for observing uveal melanomas?

Answer 4

AJCC T1 tumor in the absence of: thickness ≥2 mm, subretinal exudative fluid, and superficial orange pigment lipofuscin. Tx should be initiated when growth is detected.

Question 5

If resection is employed for small melanomas, for what ocular location is it generally reserved?

Answer 5

Resection is utilized for lesions of the iris or ciliary body. It is not usually recommended for uveal lesions d/t impact on vision.

Question 6

In the COMS trials, pts with small uveal melanomas were observed with close f/u. What % of pts progressed after 5 yrs?

Answer 6

∼33% of pts with small melanomas progressed. (COMS No. 4, JAMA Ophthalmol 1997)

Question 7

What features of small uveal melanomas were found to be associated with growth after observation?

Answer 7

Orange pigmentation (6.4 times), no drusen and no adjacent retinal pigmentary changes (4.2 times), >2 mm thickness (4.4 times), >12-mm BD (5.2 times)

Question 8

What are the Tx options for COMS medium melanomas?

Answer 8

Enucleation, plaque brachytherapy, or charged particle/proton RT

Question 9

When is enucleation a preferred approach for the management of uveal melanoma?

Answer 9

Pt choice, as salvage therapy, tumor involving >40% of intraocular volume, tumor in a nonfunctional eye, symptomatic pt (pain), eye with marked neovascularization, and extrascleral extension

Question 10

What are the indications for the use of plaque brachytherapy?

Answer 10

Plaque brachytherapy is used for organ preservation for COMS medium lesions and small progressive tumors after observation.

Question 11

What are the max AH and BD sizes allowed for plaque brachytherapy?

Answer 11

For plaque brachytherapy, max allowed sizes are ≤10-mm (3–8 mm optimal) AH and 16-mm BD.

Question 12

What tumor features are deemed unsuitable for plaque brachytherapy as per the ABS 2014 guidelines?

Answer 12

Tumors with T4e extraocular extension, BDs that exceed the limits of brachytherapy, blind painful eyes, and those with no light perception vision are not suitable for plaque therapy.

Question 13

Under what circumstances should notched plaques be used?

Answer 13

Notched plaques are typically used for peripapillary tumors.

Question 14

What is the most common isotope used in plaque brachytherapy? What is the dose rate?

Answer 14

I-125, at a dose rate of 0.7–1 Gy/hr (Tx times vary from 4–7 days)

Question 15

What other isotope can be used for small-to medium-sized tumors? Why might it be preferred over I-125?

Answer 15

Ruthenium-106 (β-emitter). Ru-106 has limited dose penetration relative to I-125, so it results in less toxicity and is also easier to insert.

Question 16

How is the dose prescribed with plaque brachytherapy?

Answer 16

85 Gy to the tumor apex (or 5 mm from the internal surface of the sclera if the height is <5 mm), with a 2-mm margin around the tumor (or a plaque size equal to 4 mm + greatest BD)

Question 17

What advantages do proton/charged particle therapy confer over brachytherapy in the Tx of uveal melanoma?

Answer 17

Proton/charged particle therapy beam is preferable for larger tumor thickness, tumors near the optic nerve/disc or macula, and tumors under the orbital muscles.

Question 18

How is proton beam RT prescribed in the Tx of uveal melanoma?

Answer 18

70 cobalt gray equivalents (CGE) in 5 fx over 7–10 days

Question 19

What is the long-term LC rate of proton beam compared to plaque brachytherapy?

Answer 19

Proton beam: 95%

Plaque brachytherapy: 92%–94%

Question 20

What is the 5-yr DM rate of ocular melanoma after Tx with either protons or brachytherapy?

Answer 20

The 5-yr DM rate after local RT is 16%–20%.

Question 21

Which randomized phase III study compared the efficacy of enucleation vs. plaque brachytherapy for medium-sized uveal melanomas?

Answer 21

COMS study (Report No. 28, Arch Ophthalmol 2006): 1,317 pts. There was no difference in all-cause mortality and melanoma-specific mortality. 12-yr OS was 17%–21%.

Question 22

In the COMS medium trial, what is the 5-yr secondary enucleation rate after plaque brachytherapy? What were the most common reasons?

Answer 22

The 5-yr secondary enucleation rate is 12.5% d/t Tx failure or ocular pain from brachytherapy complications. (COMS No. 19, Ophthalmol 2002)

Question 23

What is the standard management for large uveal melanomas?

Answer 23

Enucleation. Heavy particle/proton therapy can also be used.

Question 24

What % of pts present with large uveal melanomas?

Answer 24

30% of pts present with large uveal melanomas.

Question 25

Per the COMS trial, does preop EBRT improve outcomes over enucleation alone for COMS large tumors?

Answer 25

No. In the COMS trial, there was no OS or DFS difference b/t the 2 groups. (COMS No. 24, Am J Ophthalmol 2004)

Question 26

Per the Ophthalmic Oncology Task Force, how does LR affect the risk of developing mets?

Answer 26

LR increased risk of DM by an HR of 6.28; LR detected up to 9.8 yrs after Tx and associated with extrascleral extension but not T-stage. (Ophthalmic Oncology Task Force, Ophthalmol 2016)