Enucleation For Choroidal Melanoma Research Articles

Patient-Reported Outcomes and Quality of Life after Treatment for Choroidal Melanoma

Background/Aims: Patients with choroidal melanoma can develop psychological morbidity because of visual disability, pain, facial deformity, and fears of metastatic disease. The aim of this study was to report on the prevalence of symptoms, moods, and well-being after radiotherapy or enucleation for choroidal melanoma and how these outcomes changed over time. Methods: Participants were mailed questionnaires approximately 6 months following treatment, then annually on every anniversary of their treatment. Results: Soon after enucleation, patients experienced visual difficulties because of loss of stereopsis and visual field and were concerned about their appearance and about metastatic disease. After radiotherapy, patients were more concerned about local tumor recurrence and more troubled by diplopia and headache. Over time, visual difficulties diminished after enucleation but increased in patients who had received radiotherapy, with concerns about metastasis, loss of health, and tumor recurrence diminishing in both groups. Anxiety tended to diminish whereas depression increased, especially after enucleation. Emotional well-being improved after both kinds of treatment, whereas functional and physical well-being diminished after enucleation but improved after radiotherapy. Self-reported quality of life diminished equally with both kinds of treatment. Conclusion: The findings of this study should help physicians understand what patients tend to feel after treatment for choroidal melanoma.

Proptosis and Anterior Dislocation as a Late Noninflammatory Complication of Failure of Tissue Integration in the Alphasphere Implant

A 57-year-old healthy female underwent enucleation for choroidal melanoma with primary implantation of a 2-hydroxyethyl methacrylate sphere (AlphaSphere, Addition Technology, Des Plaines, IL). Her course was uneventful, with successful prosthetic fitting 6 weeks postoperatively. She returned 2 years later, with anterior displacement of the implant, poor implant movement, and poor prosthetic fit. There was no defect in the conjunctiva, Tenon's layer or evidence of inflammation. Successful orbital implant exchange was performed, replacing the AlphaSphere with an eyebank-scleral wrapped acrylic implant. Intraoperative findings revealed dissolution of the scaffolding aspect of the anterior implant, with loss of extraocular muscle attachments and no fibrovascular ingrowth. This case demonstrates late AlphaSphere failure in an otherwise unremarkable course; further review of similar cases or a larger study is warranted to examine the efficacy of this relatively new implant.

Modified Enucleation for Choroidal Melanoma with Large Extrascleral Extension

Purpose: To report the technique and the outcome of modified (enlarged) enucleation via lateral orbitotomy for choroidal melanomas with massive extrascleral extension.Methods: 5 patients with choroidal malanoma with massive, circumscribed perioptic/posterior extrascleral extension underwent modified enucleation via lateral orbitotomy. After lateral orbitotomy and orbital mass exposure with direct tumor visualization, a long optic nerve stump was cut and the orbital component of the tumor was completely (macroscopically) removed along with the globe in all cases. After haemostasis and orbital reconstruction an orbital implant was then placed. Follow-up was longer than 12 months.Results: Excellent cosmetic outcome was acheived in all patients (100%) without operative or postoperative complications. At pathologic examination, tumors were completely removed in all cases (100%).Conclusions: Modified (enlarged) enucleation via lateral orbitotomy for selectd choroidal melanomas with massive, circumscribed perioptic/posterior extrascleral extension allows complete tumor removal and placement of an orbital implant, avoiding the long healing process of orbital exenteration with excellent clinical and cosmetic outcome.

Quality of Life After Iodine 125 Brachytherapy vs Enucleation for Choroidal Melanoma

To describe health- and vision-targeted quality of life following treatment with iodine 125 brachytherapy vs enucleation for choroidal melanoma in a subgroup of patients who were treated and observed prospectively as part of a large randomized clinical trial. Difficulty with driving, near vision activities, and activities using stereopsis or binocularity; anxiety; and depression. Two hundred nine patients who enrolled in the Collaborative Ocular Melanoma Study trial for medium-sized tumors between March 1995 and July 1998 and gave informed consent prior to randomization to participation in an ancillary study of quality of life. Patients were interviewed by telephone by a trained interviewer from the Collaborative Ocular Melanoma Study Coordinating Center at baseline (prior to randomization), at 6 months, and on annual anniversaries of enrollment. The questionnaire battery included the Medical Outcomes Study Short Form 36, the Activities of Daily Vision Scale, the National Eye Institute Visual Function Questionnaire, and the Hospital Anxiety and Depression Scale. Additional questions concerning satisfaction with posttreatment appearance and concerns about cancer recurrence also were included in posttreatment interviews. There was a significant increase in both treatment groups in levels of reported difficulty for most vision-oriented activities, and in bodily and ocular pain, 6 months following treatment. Differences in visual function between treatment groups reported during follow-up were relatively small, but significant differences favoring brachytherapy-treated patients were observed for driving during the first year of follow-up and for peripheral vision during the first 2 years of follow-up. Anxiety levels in both groups decreased significantly following treatment, but patients treated with brachytherapy with symptoms of anxiety were less likely to report later resolution of symptoms than patients with symptoms of anxiety who were treated with enucleation. This study was unable to assess impact of treatment on satisfaction with appearance and concern about cancer recurrence during the first year after treatment, but no treatment-related differences were found on these measures at 2 years and later follow-up times. Patients treated with brachytherapy reported significantly better visual function than patients treated with enucleation with respect to driving and peripheral vision for up to 2 years following treatment. Differences between treatments in visual function diminished by 3 to 5 years posttreatment, paralleling decline in visual acuity in brachytherapy-treated eyes. Patients treated with brachytherapy were more likely to have symptoms of anxiety during follow-up than patients treated with enucleation. Given that no significant differences in survival between enucleation and brachytherapy have been found, the differences demonstrated here for driving and anxiety will allow the individual patient and physician to make informed choices regarding treatment based on personal preferences.

Late Isolated Brain Metastasis Following Enucleation for Choroidal Melanoma

Brain metastases from choroidal melanoma are rare and usually have a grave prognosis. A case of successfully treated late isolated brain metastasis from choroidal melanoma is described. A 35-year-old man presented with epileptic seizures of recent origin, 9 years following enucleation for choroidal melanoma. Imaging studies revealed a lesion of the right frontal lobe that was surgically removed. Results of pathologic examination were compatible with metastatic choroidal melanoma. The patient is asymptomatic 5 years postoperatively. Late isolated brain metastases from uveal melanoma may be treatable by local resection. Close, lifelong follow-up is required to diagnose and aggressively treat metastatic disease.

Prognostic factors for survival after enucleation for choroidal melanoma.

To evaluate the prognostic value of DNA content-ploidy, agoraphilic nucleolar organizing regions (AgNORs) and proliferating cell nuclear antigen (PCNA) for survival among patients with choroidal melanoma choroidal melanomas managed by enucleation in 55 patients with a follow-up of 5 years were studied. AgNor counts were evaluated by two examiners after sections were specifically processed. Immunohistochemistry was performed to evaluate PCNA expression. Kaplan-Meier estimation of survival curves, the log-rank test, and Cox regression analysis were used to compare survival according to the above mentioned factors. Five years after enucleation 62% of patients had died. Patients with spindle cell type melanomas had the best and those with epithelioid cell type had the worst survival (p=0.004). Patients with small tumors had better survival than those with medium or large tumors (p=0.02). Patients having tumors with aneuploid nuclear DNA content had worse survival than those having tumors with diploid DNA content (p=0.004). A high PCNA level correlated with lower survival rates (p=0.02). Patients having a high AgNor count had a worse survival than those with lower counts (p=0.02). DNA content, PCNA level, and AgNOR count each showed a clinically significant influence on patient survival. However, each of these new evaluated prognostic factors was strongly related to one or both of the classic prognostic factors. It is therefore difficult to separate the effects of the two categories of prognostic factors. Results of the Cox regression analysis suggested that these newer evaluated prognostic factors provided little additional information about patient prognosis.

A review of mortality from choroidal melanoma. I. Quality of published reports, 1966 through 1988.

The literature concerning mortality after a diagnosis of choroidal melanoma was reviewed to identify relevant articles published from 1966 through 1988 and to select those with mortality rates presented separately by tumor size for inclusion in a pooled analysis (meta-analysis) of 5-year mortality after enucleation for choroidal melanoma. The quality of the published literature for our purposes was assessed. Candidate articles were identified from a search of the MEDLINE files by an information specialist. Altogether, of 217 candidate articles, 76 (70 from the MEDLINE search and six more from our files) qualified for review. All-cause mortality rates were reported in 80% of the articles. Among six aspects of design and methods for which information was sought, eligibility criteria were reported in 52 (68%) of the 76 articles and statistical methods were cited in 38 (50%); other information was reported with intermediate frequency. Quality scores based on completeness of reporting with respect to 16 factors ranged from 13.3 to 92.3 of a possible 100.0. Findings suggest that researchers, clinicians, journal editors, and reviewers should be more attentive to the completeness of reports from clinical research studies with respect to basic information regarding design and methods.

Clinicopathologic Study of Organic Dye: Laser in the Human Fundus

One day before enucleation for choroidal melanoma, four patients consented to experimental laser photocoagulation for the purpose of comparing the histopathologic appearance of acute chorioretinal lesions produced by various dye laser wavelengths with krypton red and argon green laser controls. Three patients had simulated “light” and “heavy” treatment of an extrafoveal choroidal neovascular membrane (CNVM) with wavelengths 577 nm (yellow), 595 nm (orange), and 600 nm (orange). One patient had simulated panretinal photocoagulation (PRP) with four different dye laser wavelengths. Extrafoveal “light” treatment with the three dye wavelengths and both controls spared the inner retina and produced similar effects in the outer retina, pigment epithelium, and choriocapillaris. Choroidal penetration was deepest with the longer wavelengths (590–647 nm) in both “light” and “heavy” treatment groups. “Heavy” treatment gave varying degrees of full-thickness retinal uptake for all dye and both control wavelengths. Both ends of the orange spectrum (590–600 nm) produced the most severe inner retinal uptake. Panretinal photocoagulation produced similar full-thickness retinal uptake for all four dye wavelengths tested. These results indicate that caution should be used when treating “heavily” with 590 and 600 nm in the extrafoveal area.

Results after beta-irradiation (106Ru/106Rh) of choroidal melanomas. Twenty years' experience.

For two decades, from 1964 to 1984, 309 patients suffering from choroidal melanoma were treated with 106Ru/106Rh applications, following confirmation of diagnosis by a variety of tests. A total of 216 patients (69.9%) were treated successfully and have been under observation for a mean period of 6.7 years after irradiation. 188 patients were followed for more than five years. Results indicate that enucleation for choroidal melanoma, especially in cases of eyes with good vision, may no longer be the standard treatment for this disease. This appears particularly true inasmuch as almost 50% of all patients with large choroidal melanomas who have enucleation die from metastases within 5 years of the operation. Therefore, conservative methods such as photocoagulation, irradiation, and microsurgical excision have been used with more or less success to destroy tumor and save a functioning eye.

Management of choroidal malignant melanoma at Iowa.

Approximately 50% of patients undergoing enucleation for choroidal melanoma will eventually die of metastases. The majority of tumor related deaths will occur within 5 years of enucleation, but late metastases may occur 20-30 years after enucleation. Long-term follow-up of patients refusing treatment has shown a 100% mortality. Although recent reports have attempted to link the performance of enucleation with the development of metastases, examination of available data suggests that metastases occur preoperatively, but are subclinical at the time of enucleation. The most important variable determining prognosis in these cases is the size of the tumor at the time of diagnosis and treatment. Patients who undergo enucleation before the tumor exceeds 7 X 7 X 2 mm have an extremely favorable prognosis. Patients whose maximum tumor diameter exceeds 12 mm have an extremely poor prognosis. Metastases and extrascleral extension have both been reported to occur in tumors which failed to demonstrate growth while being followed. For these reasons we recommend immediate enucleation be carried out in all patients whose tumors exceed 7 X 7 X 2 mm and in whom the diagnosis can be confirmed by indirect ophthalmoscopy, ultrasound, fluorescein angiography, and other tests. Follow-up of non-enucleation methods of treatment of choroidal melanomas is too short to draw meaningful conclusions. The consistent finding of persistence of some tumor mass and the histopathologic presence of viable tumor cells following these treatment modalities leaves us very concerned about the long-term results in these patients. Late metastases continue to occur decades following diagnosis of a choroidal melanoma, especially if it is small. The ophthalmologist must remain aware that the results of his decision concerning treatment of a melanoma may not become apparent for many years.

Normal intraocular pressure during enucleation for choroidal melanoma.

A simple surgical technique for maintaining normal intraocular pressure during enucleation of eyes with a malignant melanoma of the choroid consists of making an incision into the anterior chamber through clear cornea with a microvitreo-retinal blade, followed by the introduction of a No. 21-gauge scalp vein needle or a No. 23-gauge sidewall-holed needle attached to a closed system filled with balanced salt solution. Measurements of pressure fluctuations during five enucleations are given. Such a system maintains the anterior chamber and keeps fluctuations in IOP to a minimum. This may be important in preventing hematogenous dissemination of tumor cells, resulting in metastatic disease.