Clinicopathologic findings inchoroidal melanomas after failedtranspupillary thermotherapy

doi:10.1016/S0002-9394(02)02171-2

American Journal of Ophthalmology

Volume 135, Issue 5, May 2003, Pages 657-663

https://doi.org/10.1016/S0002-9394(02)02171-2 Get rights and content

Abstract

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.

Section snippets

Methods

The Institutional Review Board of Emory University approved the study, including a retrospective chart review and correlation with histopathologic findings. A review of the diagnoses in the L.F. Montgomery Ophthalmic Pathology Laboratory between 1998 and 2002 revealed seven eyes of seven patients that were enucleated after failed TTT without any other therapy to the choroidal melanoma. A chart review of the cases was used to summarize and record clinical visits and findings, including visual

Results

The clinical and pathologic findings are summarized in TABLE 1, TABLE 2 , respectively. There were six men and one woman, ranging in age from 36 to 65 years. This represented seven of 84 (8%) patients treated with TTT for choroidal melanoma during the period studied.

A summary of the clinical findings is as follows. All patients who were enucleated had progressively decreasing vision or continued tumor growth, or both, in one or more planes (basal diameter, height, and scleral extension), as

Case reports

The following are illustrative summaries of representative cases.

Discussion

There has been a decrease in the number of enucleations performed for melanoma over the past several decades from approximately 71% in 1971 to 21% in 1991.21, 22, 23 This has been due largely to eye salvaging therapies for melanoma control. Eye salvaging therapies include radioactive plaque therapy, radiotherapy with charged particles, laser photocoagulation, TTT, local resection, and combined treatments.3, 4, 5, 6, 7, 8 The popularity of TTT has increased because of a reduction in tumor

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Long-term Outcomes of Small Pigmented Choroidal Melanoma Treated with Primary Photodynamic Therapy
2021, Ophthalmology Retina
Citation Excerpt :
In a series of 357 consecutive patients receiving primary TTT for choroidal melanoma, 10 patients (2.8%) eventually required enucleation. Compared with cases of choroidal melanoma undergoing primary enucleation, those who are enucleated after failed primarily treatment with TTT have a higher incidence of extrascleral extension (8%45 vs. 40%–71%,44,46 respectively). It remains unclear whether or not this risk holds true for patients undergoing primary treatment with PDT given the small cumulative number of cases requiring enucleation reported in the literature.
To report the long-term outcomes of patients with small, pigmented, posteriorly located choroidal melanoma undergoing primary treatment using photodynamic therapy (PDT) with verteporfin at the London Ocular Oncology Service.
Retrospective, interventional, consecutive case series.
All patients undergoing primary treatment using PDT with verteporfin from April 2014 to December 2015 and followed until December 2019.
This is a long-term follow-up study of the same cohort of patients previously reported by our group in 2017 and 2018.
Local tumor control, visual outcomes, and metastasis-free survival.
Twenty-six patients were included with a mean (± standard deviation) age and tumor thickness of 62 ± 14 years and 1.3 ± 0.5 mm, respectively. Tumors were posteriorly located (mean distance to optic nerve and fovea = 2.0 ± 2.2 mm and 1.6 ± 1.5 mm, respectively), and the majority were fully pigmented (73%). Overall, patients were followed for a median (interquartile range [IQR], range) of 49.5 (15.3, 7.0–66.0) months from first PDT to last follow-up. Over the course of this study, 14 of 26 (54%) have developed a local recurrence at a median of 20.0 months (20.5, 4.7–60.9 months). The most common pattern of recurrence was an isolated increase in basal dimensions (9/14; 64%). Median (IQR) final logarithm of the minimum angle of resolution visual acuity of the whole cohort was 0.2 (0.5). The only statistically significant difference in baseline and outcome characteristics between treatment failures and nonfailures was the distance to the fovea (median [IQR], 0.5 [1.3] vs. 2.5 [2.8]; P = 0.002) and final logarithm of the minimum angle of resolution visual acuity (median [IQR], 0.50 [0.80] vs. 0.00 [0.14]; P = 0.002), respectively.
Although treatment of small pigmented posterior choroidal melanoma with PDT effectively preserves visual acuity, 5-year treatment-success calculated by Kaplan–Meier analysis was only 38.4%. Recurrences after PDT tend to occur along the tumor edges, often with minimal increase in thickness. Given the substantial risk of treatment failure, primary PDT with vertepofrin is recommended in exceptional cases of choroidal melanoma, for which other treatments with greater tumor control are not a feasible option.
Primary transpupillary thermotherapy for choroidal melanoma in 391 cases: Importance of risk factors in tumor control
2015, Ophthalmology
Citation Excerpt :
The presence of residual intrascleral melanoma after TTT was first reported by Journée-de Korver et al2 and later by several other investigators.7,8,13,19 Similarly, development of extraocular tumor extension, usually along the emissarial canals, has been reported.7–9,19,26 In a review of the literature published as an editorial in 2008, Singh et al14 found that 7% of the tumor recurrences after TTT for choroidal melanoma were extrascleral, compared with 5% in this study (Table 3).
To report the long-term outcome of primary transpupillary thermotherapy (TTT) for choroidal melanoma.
Retrospective review of medical records.
We included 391 patients with choroidal melanoma treated between 1995 and 2012 at the Oncology Service, Wills Eye Hospital, Philadelphia.
We delivered TTT with an infrared diode laser.
Local tumor recurrence, Snellen visual acuity after TTT, and distant metastasis.
Of 391 patients, 311 (80%) were treated from 1995 to 2000 and 80 (20%) from 2001 to 2012. Tumors in the 2001 to 2012 group were ultrasonographically thinner (2.2 vs. 2.7 mm), more distant from the optic disc (3.2 vs. 2.5 mm) and foveola (4.0 vs. 2.0 mm), were less often located in the macular area (14% vs. 40%), and had lower rates of acoustic hollowness on B-scan ultrasonography (63% vs. 84%), subretinal fluid (58% vs. 90%), and orange pigment (50% vs. 70%). Kaplan–Meier estimates for tumor recurrence in the 1995 to 2000 group were 29% at 5 years and 42% at 10 years, whereas estimates for tumor recurrence in the 2001–2012 group were 11% at 5 years and 15% at 10 years. Of 108 recurrent tumors 20 were controlled with additional TTT and 62 required plaque radiation (n = 60) or proton beam radiation (n = 2), with enucleation necessary in 26 patients. Tumor recurrence correlated with the number of high-risk tumor features: 10-year recurrence was 18% in those with 1 or 2 risk factors, 35% in those with 3 to 5 factors, and 55% in those with 6 or 7 factors. On multivariate analysis, features predictive of tumor recurrence were presence of symptoms (P < 0.001), shorter distance between the tumor and the optic disc (P = 0.026), subretinal fluid (P = 0.035), thickness of residual tumor scar (P < 0.001), and elevation of residual tumor scar (P < 0.001). The only factor predictive of extraocular tumor extension was intraocular tumor recurrence after TTT treated with additional TTT (P = 0.007). Presence of orange pigment before TTT (P = 0.019), tumor recurrence (P = 0.002), and extraocular tumor extension (P = 0.017) were predictive of distant metastasis.
This study shows a direct correlation between a larger number of high-risk tumor features and higher rates of tumor recurrence after primary TTT of (small) choroidal melanoma. We advise that, when possible, small choroidal melanomas with multiple risk factors be treated with methods other than TTT.
Primary transpupillary thermotherapy for choroidal indeterminate melanocytic lesions
2014, Canadian Journal of Ophthalmology
Citation Excerpt :
The heat from TTT dissipates within the choroid just beyond the tumour margins, where occult tumour cells may survive treatment. In addition, TTT is not effective in eradicating intrascleral cells, which may be present in up to 55.7% of uveal melanomas.16 Complications of TTT included retinal neovascularization in 2 patients and TTT-induced severe visual loss in 2 patients with a lesion close to the optic disc or to the fovea.
This study aimed to assess the ocular and metastatic outcomes of patients with choroidal indeterminate melanocytic lesions treated by primary transpupillary thermotherapy (TTT).
Retrospective case series.
Eight patients presenting choroidal indeterminate melanocytic lesions treated by primary TTT.
A retrospective chart review was conducted for patients with a newly diagnosed choroidal indeterminate melanocytic lesion treated by at least 3 TTT sessions from 2002 to 2011. Best-corrected visual acuity and lesion dimensions were measured at baseline and during follow-up. Complications were recorded including lesion growth, metastasis, melanoma-related mortality, and treatment-related complications.
Mean initial thickness was 2.0 ± 0.8 mm. Patients had an average of 3.0 ± 0.9 risk factors for lesion growing. Three patients (38%) had lesion growth. Two patients (25%) had severe visual loss (>1.0 logMAR) directly related to TTT treatment. There were no fatalities due to metastasis.
Despite careful patient selection and systematic treatment with at least 3 TTT sessions, the use of primary TTT to treat patients with choroidal indeterminate melanocytic lesions with ≥ 1 risk factor for lesion growth yielded poor local lesion control and the possibility for severe ocular complications.
Evaluation des complications oculaires et métastatiques chez des patients ayant été traités en première intention par thermothérapie transpupillaire (TTT) pour des lésions choroïdiennes mélanocytaires indéterminées.
Rétrospective d’une série de cas
Huit patients présentant des lésions mélanocytaires choroïdiennes indéterminées traités par TTT.
Une revue rétrospective des dossiers a été faite pour les patients qui, ayant un nouveau diagnostic de lésion mélanocytaire choroïdienne indéterminée, avaient reçu au moins trois sessions de TTT entre 2002 et 2011. La meilleure acuité visuelle corrigée et les dimensions des lésions ont été mesurées à la base et durant le suivi. Les complications relevées comprenaient la croissance, les métastases, la mortalité reliée au mélanome et les complications associées au traitement.
La moyenne des épaisseurs initiales était de 2,0 ± 0,8 mm. Les patients avaient une moyenne de 3,0 ± 0,9 facteurs de risque de croissance de la lésion. Trois patients (38 %) ont démontré une croissance de la lésion. Deux (25 %) des patients avaient une sévère perte visuelle (> 1,0 logMAR) reliée directement au traitement TTT. Il n'y a pas de décès directement liés aux métastases.
Malgré la sélection attentive des patients et le traitement systématique avec au moins trois sessions de TTT, l’utilisation en première intention du TTT pour traiter les patients ayant des lésions mélanocytaires choroïdiennes indéterminées avec ≥1 facteur de risque de croissance de lésion a démontré un mauvais contrôle de la lésion locale et la possibilité de sévères complications oculaires.
Laser Treatment of Choroidal Melanoma
2012, Retina Fifth Edition
Prognosis of posterior uveal melanoma
2012, Retina Fifth Edition
Transpupillary thermotherapy (TTT) - Review of the clinical indication spectrum
2010, Medical Laser Application
Citation Excerpt :
Kiratli and Bilgiç [49,50] reported pigment dispersion into the vitreous [49] as well as subretinal [50] pigment dispersion. Furthermore, there is a risk of lateral extension of the tumor [45,51] which makes close follow-up monitoring essential. Reports of pain continuing after therapy are quite common.
Transpupillary thermotherapy (TTT) is a non-invasive treatment option for malignant choroidal melanoma and choroidal neovascularization (CNV) in age-related macular degeneration (ARMD). It can be considered as a cost-saving treatment, preventing surgical intervention. Up to now the energy level for TTT in CNV has not been clearly defined. Therefore over-treatment (inducing a retinal scar) as well as undertreatment (persistence of CNV) is possible. This may be the main cause for not using TTT as a preferred treatment for wet ARMD. Over the last 2 years the use of TTT for CNV has experienced a slight revival. In some studies a sub-threshold or low-dose TTT has been applied alone or in combination with intravitreal triamcinolone acetonide (iVTA) or vascular endothelial growth factor (VEGF) inhibitors. In several studies TTT for the treatment of malignant choroidal melanoma has been shown to be safe as a unique treatment for small choroidal tumors or as an adjuvant treatment for larger choroidal tumors (‘sandwich technique’).
Bei der transpupillären Thermotherapie (TTT) handelt es sich um eine nicht-invasive Behandlungsmethode. Sie kommt sowohl zur Therapie von malignen Aderhautmelanomen als auch von chorioidalen Neovaskularisationen (CNV) in der Behandlung der altersbedingten Makuladegeneration (AMD) zur Anwendung. Die TTT ist eine günstige Behandlungsmethode und erfordert keine operativen Maßnahmen. Bis heute konnte allerdings kein exaktes Energieniveau für die Behandlung von CNV festgelegt werden. Daher kann es sowohl zu einer Überdosierung (retinale Narbe) als auch zu einer Unterbehandlung (Persistenz der CNV) kommen. Dieser Fakt könnte die Hauptursache dafür sein, dass die TTT nicht mehr als bevorzugte Behandlungsmethode für die feuchte AMD eingesetzt wird. Jedoch hat die TTT in den letzten zwei Jahren ein vorsichtiges ,,Come-back” in der Behandlung von CNV erfahren. In einigen Studien wurde die TTT in einer unterschwelligen oder niedrigen Leistungsdosierung als alleinige Therapie oder in Kombination mit Triamcinolon-Injektionen oder VEGF-Inhibitoren angewandt.
In vielen Studien konnte gezeigt werden, dass die TTT für die Behandlung von malignen Melanomen der Aderhaut eine relativ sichere Behandlungsmethode darstellt, entweder als alleinige Therapie bei kleinen chorioidalen Tumoren oder als adjuvante Therapie für größere chorioidale Tumoren (sog. ,,Sandwich-Technik”).

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^☆: Supported in part by an unrestricted department grant from Research to Prevent Blindness, Inc, New York, New York.

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Original articlesClinicopathologic findings inchoroidal melanomas after failedtranspupillary thermotherapy☆

Abstract

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Results

Case reports

Discussion

Prog Retin Eye Res

Surv Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Ophthalmology

Surv Ophthalmol

Am J Ophthalmol

Exp Eye Res

Posterior uveal melanoma

Acta Ophthalmol Scand

“Melanoma 92”. Epidemiological study of uveal melanoma in France

J Fr Ophthalmol

Transvitreal retino-choroidal biopsy of suspected malignant lesions of the choroid. Follow-up of cases over 7 years

Acta Ophthalmol Scand

New treatment modalities for uveal melanoma

Curr Opin Ophthalmol

Current management of posterior uveal melanoma

Mayo Clin Proc

The conservative management of choroidal melanoma

Aust N Z J Ophthalmol

Alternatives to enucleation in the management of choroidal melanoma

Aust N Z J Ophthalmol

Original articles
Clinicopathologic findings inchoroidal melanomas after failedtranspupillary thermotherapy☆