Plaque Radiotherapy Research Articles

Hemorrhagic occlusive retinal vasculitis leading to the diagnosis of ciliary body melanoma

Hemorrhagic occlusive retinal vasculitis (HORV) is a condition associated with intraocular vancomycin during surgical intervention, most frequently following bilateral sequential cataract surgery. Because of the high rate of ophthalmic vascular complications in this condition, gonioscopic evaluation for identification of neovascularization of the angle and iris is essential. Careful examination can reveal previously asymptomatic and unassociated lesions of the iris or ciliary body. We present the case of a 71-year-old female who was diagnosed with a ciliary body melanoma secondary to complete ophthalmic examination associated with HORV. She reported decreased vision to light perception in the left eye (OS) following sequential, bilateral cataract surgery. Fundus examination OS demonstrated diffuse retinal vasculitis, retinal ischemia, and extensive hemorrhage. Evaluation included inflammatory and coagulopathy laboratory evaluation, carotid ultrasonography and magnetic resonance imaging (MRI) of the brain and orbits, all of which proved unrevealing, except for an enhancing mass OS on MRI. Further evaluation revealed a pigmented mass with features of melanoma in the anterior chamber angle extending into the ciliary body. Fine needle aspiration biopsy revealed high risk cytogenetic characteristics, and plaque radiotherapy was successfully employed.

Complications and status quo of plaque radiotherapy for uveal melanoma

Radiation treatment, including episcleral plaque radiotherapy, stereotactic radiosurgery, proton beam therapy and so on, is the primary eye-conserving choice for uveal melanoma. But the complications resulted from radiotherapy's nonselective kill to tumor cells can be visual-threatening and eventually result in the enucleation of eyeball. This review summarizes current radiation strategies for uveal melanoma and how these complications occur, develop and present, in the hope that it could provide insights for the radiation interventions and diagnosis of radiative complications. (Chin J Ophthalmol, 2018, 54: 707-711).

Retinal perfusion changes in radiation retinopathy.

To investigate retinal blood flow and oxygen saturation changes in patients diagnosed with retinopathy following plaque radiation treatment to treat choroidal melanoma. Eight patients (mean age 55.75years, SD 12.58years) who have developed unilateral ischaemic radiation-related retinopathy as confirmed by wide-field fluorescein angiography were recruited for the study. The fellow eye with no other ocular or retinal pathology was used as control. Both eyes underwent measurement of total retinal blood flow (TRBF) and retinal blood oxygen saturation using prototype methodologies of Doppler Spectral Domain Optical Coherence Tomography (OCT) and Hyperspectral Retinal Camera, respectively. The average TRBF in the retinopathy eye was significantly lower compared to the fellow eye (33.48±12.73μl/min versus 50.37±15.26μl/min; p=0.013). The arteriolar oxygen saturation (SaO2 ) and venular oxygen saturation (SvO2 ) were higher in the retinopathy eye compared to the fellow eye (101.11±4.26%, versus 94.45±5.79%; p=0.008) and (62.96±11.05% versus 51.24±6.88%, p=0.051), respectively. The ionizing radiation seems to have an impact on the TRBF, SaO2 and SvO2 , clinically presenting similar to a rapidly developing diabetic retinopathy. The results show an altered retinal vascular physiology in patients with radiation-related retinopathy.

Gamma Knife radiosurgery for locally recurrent choroidal melanoma following plaque radiotherapy

BackgroundFor the majority of eyes with choroidal melanoma, radiation therapy is the treatment of choice. Local recurrence after radiation therapy can occur, however, and when it does, salvaging the globe with useful vision is atypical.Case presentationWe report a case of late, local failure 7 years following previous brachytherapy successfully managed with Gamma Knife radiosurgery (GKR). With 3 years of follow up after GKR, the visual acuity is 20/20 and there is no evidence of systemic metastases.ConclusionTo our knowledge, this is the first report of successful salvage GKR therapy after brachytherapy failure in an eye with choroidal melanoma. GKR is an option for select cases of local recurrence after radiation plaque brachytherapy.

An Unusual Cause of Isolated Fundal Gastric Varix

Choroidal melanoma is a rare and deadly ocular cancer. We report a case of metastatic choroidal melanoma presenting as isolated gastric varices (IGV1). A 69-year old female with a history of choroidal melanoma treated with plaque radiotherapy presented with a 3 month history of epigastric pain, especially after spicy meals. EGD revealed isolated gastric varices. Initial right upper quadrant ultrasound was negative as was a liver biopsy. CT Abdomen and Pelvis with intravenous contrast revealed a right hepatic lobe mass which repeat biopsy confirmed was metastatic melanoma. The patient eventually chose palliative care with hospice. Additional imaging revealed brain metastasis. To our knowledge, this is the first reported case of choroidal melanoma presenting as isolated gastric varices.

Regression patterns of choroidal melanoma: After palladium-103 (103Pd) plaque brachytherapy.

Purpose:To describe the patterns of regression of choroidal melanoma after treatment with plaque brachytherapy.Methods:Retrospective interventional case series including 170 consecutive patients treated with 103Pd eye plaque radiation for choroidal melanoma. Outcome measures were changes in tumor thickness, surface characteristics, tumor vascularity, ultrasonography, fluorescein angiography, optical coherence tomography, and histopathology.Results:The mean initial tumor thickness was 3.9 mm (median 2.8 mm; range 2–11.3 mm) that decreased to 1.7 mm (median 1.2 mm; range 0–7.1 mm) after plaque brachytherapy. On imaging, tumors were pigmented in 51% (n = 86/170), amelanotic in 10% (n = 17/170), and variably pigmented in 39% (n = 67/170). Tumor pigmentation increased in 64% (n = 106/166), decreased in 18% (n = 30/166), and was unchanged in 18% (n = 30/166). Of the 120 that demonstrated intrinsic vascularity, 10% (n = 12/120) had decreased tumor-related vascularity and 90% (n = 108/120) showed complete resolution. Subretinal fluid was present in 34% (n = 58/170) of eyes at presentation. Of them, 15% (9; n = 9/58) had persistent SRF at last follow-up. On ultrasound imaging, 88% (n = 149/170) tumors presented with low to moderate internal reflectivity of which 61% (n = 91/149) showed increased reflectivity on regression. We noted a crescendo–decrescendo fluctuation in the presence of orange pigment lipofuscin along with complete resolution of drusenoid retinal pigment epithelial detachments. In the entire series of 170 patients, there was 0.5% (1) failure of local control, 2% (4) secondary enucleations, and 6% (10) patients developing metastasis.Conclusion:Findings related to choroidal melanoma regression after 103Pd plaque brachytherapy included decreased intrinsic tumor vascularity, decreased tumor-related subretinal fluid, increased pigmentation, specific changes in orange pigment lipofuscin and resolution of drusenoid retinal pigment epithelial detachments, as well as decreased tumor thickness with an increase in internal reflectivity on ultrasound.

Evaluation of vascular changes with optical coherence tomography angiography after ruthenium-106 brachytherapy of circumscribed choroidal hemangioma.

To describe the vascular changes of circumscribed choroidal hemangioma (CCH) after ruthenium-106 brachytherapy using optical coherence tomography angiography (angio-OCT). Seven eyes of 7 patients diagnosed with symptomatic CCH who underwent ruthenium-106 plaque radiotherapy were included in the study. Patients underwent complete ophthalmic examination, bulbar echography and angio-OCT. The same protocol was applied 1 year after ruthenium-106 brachytherapy. At baseline, the mean best-corrected visual acuity (BCVA) in affected eyes was 0.67 ± 0.14 logMAR, and the mean tumor thickness was 4.46 ± 0.91 mm measured by standardized A-scan echography. After ruthenium-106 plaque treatment, the mean BCVA increased to 0.17 ± 0.10 logMAR (p = 0.001) and the mean tumor thickness to 2.29 ± 0.71 mm (p = 0.003). Moreover, there was a significant reduction of the tumor basal diameter (p= 0.009). Intra-tumor angio-OCT measurements revealed a statistically significant reduction of the vessel and flow areas (p = 0.006 and p = 0.002, respectively) 1 year after brachytherapy. Angio-OCT is a non-invasive reliable method with which to evaluate the vascular features of CCH and consequently to monitor changes after conservative treatment.

RUTHENIUM-106 BRACHYTHERAPY IN THE TREATMENT OF CIRCUMSCRIBED CHOROIDAL HEMANGIOMA.

To examine the efficacy and safety of Ruthenium-106 plaque radiotherapy in the treatment of circumscribed choroidal hemangioma. Twenty-one eyes of 21 patients diagnosed with symptomatic circumscribed choroidal hemangioma who underwent Ruthenium-106 plaque radiotherapy were included in the study. Clinical response, ancillary tests finding improvement, and major side effects were evaluated. From the initial to the 1-year follow-up visits, vision improved in 12 eyes (57%), was stable in 7 eyes (33%), and became worse in 2 eyes (10%). Based on fluorescein angiography and optical coherence tomography, subretinal fluid and cystoid macular edema resolved in all patients. Changes in logarithm of minimum angle of resolution visual acuity (P = 0.038); tumor thickness (P = 0.0001) and largest diameter (P = 0.007) on ultrasonography; and subfoveal thickness on optical coherence tomography (P < 0.0001), were statistically significant between the initial and the 1-year follow-up visits. Side effects as observed during the follow-up period included: radiation-related retinopathy in 5 (24%) eyes, radiation-related papillopathy in 1 eye (5%), and subretinal fibrosis in 2 eyes (10%). Subretinal fibrosis was the only permanent radiation-related side effect. Ruthenium-106 plaque radiotherapy is an effective and safe method of treatment for symptomatic circumscribed choroidal hemangiomas. The incidence of permanent visual loss is low with prompt treatment of complications.

A 12-Year Study of Slotted Palladium-103 Plaque Radiation Therapy for Choroidal Melanoma: Near, Touching, or Surrounding the Optic Nerve

To present our 12-year experience with low-energy-photon, slotted eye plaque radiation therapy. Retrospective interventional case series. Setting: The New York Eye Cancer Center. Fifty-two consecutive patients with uveal melanomas near, touching, or surrounding the optic disc. Slotted eye plaque radiation therapy. Change in visual acuity, local tumor control, radiation side effects, eye salvage, and systemic metastases. Tumors were peripapillary within 1.5mm of the optic disc (n= 8, 15%), juxtapapillary touching ≤180 degrees (n= 23, 44%), or circumpapillary >180 degrees and encircling the disc (n= 21, 41%). Mean follow-up was 47months (median 34months, range 6-146months). Radiation induced a mean 41.2% reduction in tumor thickness. Life table analysis showed that 69% of patients retained their visual acuities ≥ 20/40 and had a vision loss-free survival 84months after treatment. Also, 90% of patients retained their visual acuity between 20/50 and 20/200 and had a vision loss-free survival 36months after treatment. Slotted plaque brachytherapy was associated with 4% secondary cataract, 11% neovascular glaucoma, and no dry eye or eyelash loss. Local tumor control (no recurrence) was achieved in 98.1% of patients. Life table analysis showed an overall enucleation-free survival of 93% and metastasis-free survival of 94%. Slotted plaque radiation therapy provided a normalized plaque-tumor position, such that the entire choroidal melanoma plus a 2- to 3-mm free margin of normal-appearing tissue was included in the targeted zone. At 12 years, slotted plaque radiation therapy resulted in high rates of local tumor control and vision and eye retention.

Iris Melanoma Outcomes Based on the American Joint Committee on Cancer Classification (Eighth Edition) in 432 Patients

The American Joint Committee on Cancer (AJCC) classification was updated to the eighth edition in January 2017, providing staging for iris melanoma. This study evaluated outcomes of iris melanoma per the AJCC classification, eighth edition. Retrospective case series. Four hundred thirty-two patients with iris melanoma. Management including tumor resection, plaque radiotherapy, or enucleation. Local tumor recurrence, melanoma-related systemic metastasis, and melanoma-related death. Of 432 patients with iris melanoma, AJCC classification was category T1 (n= 324 [75%]), T2 (n= 83 [19%]), T3 (n= 2 [<1%]), and T4 (n= 23 [5%]). There was no difference in age, race, gender, eye, or iris color among T categories. Overall, Kaplan-Meier analysis of outcomes (at 5 and 10 years) revealed visual acuity reduction by 3 lines or more (42% and 54%, respectively), secondary glaucoma (29% and 33%, respectively), local recurrence (8% and 17%, respectively), secondary enucleation (12% and 19%, respectively), lymph node metastasis (1% and 1%, respectively), melanoma-related systemic metastasis (5% and 10%, respectively), and melanoma-related death (3% and 4%, respectively). Compared with T1 category, the hazard ratio (HR) for local recurrence in nonenucleated eyes was 1.31 for T2, not evaluable (NE) for T3 (because of small cohort), and 6.61 for T4; the HR for metastasis was 3.41 for T2, NE for T3 (because of small cohort), and 25.6 for T4; the HR for death was 7.51 for T2, NE for T3 (because of small cohort), and 26.5 for T4; and the odds ratio for enucleation was 1.23 for T2, 3.63 for T3, and 4.72 for T4. Features predictive of melanoma-related metastasis (multivariate analysis) included secondary glaucoma (P < 0.001; HR, 4.51), T2 category (vs. T1; P= 0.01; HR, 4.09), and T4 category (vs. T1; P < 0.001; HR, 30.8). Features predictive of melanoma-related death (multivariate analysis) included older age (P= 0.008; HR, 2.16 per 10-year increase), T2 category (vs. T1; P= 0.005; HR, 8.07), and T4category (vs. T1; P < 0.001; HR, 20.3). The AJCC eighth edition classification provides prognostic stratification of iris melanoma. By multivariate analysis, the ratio for melanoma-related metastasis was 4 times greater in category T2 and 31 times greater in T4 compared with T1. The ratio for melanoma-related death was 8 times greater in category T2 and 20 times greater in T4 compared with T1. The cohort size for T3 was too small to provide useful information.

Analysis of Long-term Outcomes of Radiotherapy and Verteporfin Photodynamic Therapy for Circumscribed Choroidal Hemangioma

To determine the long-term therapeutic outcome for different treatments of circumscribed choroidal hemangioma (CCH). Retrospective observational study. Patients with newly diagnosed CCH. Observation, verteporfin (Visudyne) photodynamic therapy (PDT), lens-sparing external beam radiotherapy (LS-EBRT), or plaque brachytherapy. Best-corrected visual acuity (BCVA) at baseline and throughout follow-up, tumor dimensions, and OCT central thickness (where available) at baseline and throughout follow-up were recorded. There were 60 treatment-naïve consecutive cases with CCH between January 2000 and June 2014; 42 (70%) received treatment. These were LS-EBRT (23/60 [38%]; mean follow-up, 45.5 months), PDT (16/60 [27%]; mean follow-up, 38 months), and plaque radiotherapy (3/60 [5%]; mean follow-up, 92 months). Macular location, mottled or orange pigment, and absence of drusen were significantly more frequent in the treatment group. In the LS-EBRT group, median thickness reduction on ultrasound B scan was 1.6 mm (mean ± standard deviation, 1.65±1.6; range,-6.5 to+0.7). The mean ± standard deviation BCVA gain was 0.22±0.34, with >3 Snellen lines in 48% of cases. Kaplan-Meier estimates were 80% for any gain and 40% for >3 Snellen lines gain at 5 years. In the PDT group, the median decrease in thickness was 0.95 mm (mean ± standard deviation, 1.0±0.8; range,-2.5 to+0.2). The mean ± standard deviation BCVA gain was at 0.3±0.51, with >3 Snellen lines in 30% of cases. Kaplan-Meier estimates were 93% for any gain and 68% for >3 Snellen lines at 5 years. Double versus single duration PDT had more favorable outcomes with a greater reduction in tumor thickness (P= 0.04), central retinal thickness (P= 0.02), and improvement in visual acuity (median, 0.33 vs-0.05). There was no difference in decrease in tumor thickness or BCVA gain between the LS-EBRT and PDT groups. With plaque brachytherapy, the mean decrease in thickness was 2.5 mm, but BCVA loss of >2 Snellen lines was noted in all 3 cases at the end of follow-up. Radiation complications developed in 10 of 23 cases (43.5%) from the LS-EBRT group and 2 of 3 cases (67%) from the plaque brachytherapy group. LS-EBRT is equivalent to PDT in CCH management for post-treatment BCVA and tumor thickness reduction. The risk of LS-EBRT and plaque brachytherapy was late radiation-related complications. Double duration PDT was more favorable than single duration.

Evaluation of Vascular Changes with Optical Coherence Tomography Angiography after Plaque Radiotherapy of Choroidal Melanoma

Aim: The purpose of this paper was to evaluate whether optical coherence tomography angiography (OCT-A) can be used to quantify the vascular changes in radiation maculopathy, and changes in the tumor vasculature in eyes treated with plaque radiotherapy for choroidal melanoma. Methods: In this prospective study, we evaluated 39 Caucasian patients with choroidal melanoma (39 eyes) treated with ruthenium-106 plaque radiotherapy. The patients underwent complete ophthalmic examination, bulbar echography, and OCT-A before and 1 year after treatment. Results: At baseline, the mean best-corrected visual acuity (BCVA) in the affected eyes was 0.35 ± 0.40 logMAR, and the mean tumor thickness was 2.68 ± 0.25 mm at A-scan echography. After treatment, the mean BCVA increased to 0.41 logMAR, the mean tumor thickness decreased to 1.66 ± 0.23 mm, and the tumor basal diameter was significantly reduced (U = 108, p = 0.001). Moreover, the capillary vessel density was significantly lower in all Early Treatment of Diabetic Retinopathy Study sectors, and both the vessel and flow areas were significantly reduced (p = 0.030 and p = 0.001, respectively). Conclusions: OCT-A is a noninvasive, reliable method with which to quantify the vessel changes in radiation maculopathy and, given the association between vascularization and malignancy, this procedure may be an aid in treatment decision-making and in monitoring the efficacy of treatment.

Cytogenetic results of choroidal nevus growth into melanoma in 55 consecutive cases

PurposeTo investigate the cytogenetic results of choroidal nevus with photographically-documented transformation into choroidal melanoma. MethodsRetrospective analysis of 55 consecutive patients who underwent fine needle aspiration biopsy (FNAB) for DNA isolation and whole genome array based assay for chromosomes 3, 6, and 8 analysis prior to plaque radiotherapy. Tumors with abnormalities in chromosomes 3 and 8 were considered high-risk for metastasis. ResultsAt diagnosis of choroidal nevus the mean patient age was 57 years (median 57, range 10–83 years). All patients were Caucasian and 36 (65%) were female. At the time of nevus diagnosis, the mean tumor basal diameter was 7.4 mm (median 6.5, range 1.5–18.0 mm) and tumor thickness was 2.2 mm (median 2.2, range 0.5–3.9 mm). The mean interval between diagnosis of choroidal nevus and transformation into choroidal melanoma was 58 months (median 42, range 3–238 months). At the time of melanoma diagnosis, the mean tumor basal diameter was 9.7 mm (median 9.0, range 5.0–19.0) and tumor thickness was 3.5 mm (median 3.4, range 1.3–8.1). Cytogenetic analysis of FNAB-isolated melanoma revealed 25 patients (45%) with high-risk and 30 (55%) with low-risk cytogenetic findings. The rate of tumor growth into melanoma was inversely related to high-risk cytogenetic profile (p = 0.03) as those with fast transformation ≤ 1 year showed high-risk in 80% compared to those with slow transformation > 1 year whoshowed high-risk profile in only 38%. Fast transformation into melanoma conferred a relative risk (RR) of 2.116 for high-risk cytogenetic profile, compared to slow transformation. ConclusionsChoroidal nevus with rapid transformation into melanoma within 1 year is significantly more likely to demonstrate high-risk cytogenetic profile, at risk for metastatic disease, compared to those with slow transformation.

Scleral necrosis in patients with posterior uveal melanomas evaluated by transcleral fine needle aspiration biopsy and treated by 125I plaque.

To evaluate the incidence, potential correlation with transcleral fine needle aspiration biopsy, and treatment of scleral necrosis in patients with posterior uveal melanomas treated by 125I plaque radiotherapy and assessed by transcleral fine needle aspiration biopsy. We per-formed a retrospective review of posterior uveal melanoma treated by 125I plaque radiotherapy at a single academic institution between July 2006 and July 2013. Consecutive patients diagnosed with a posterior uveal melanoma during the study period that had an anterior margin at or anterior to the equator who were evaluated by transcleral fine needle aspiration biopsy prior to 125I plaque radiotherapy were included. The main outcome measure was development of scleral necrosis, and the secondary outcome was treatment of this complication. Statistical analysis included computation of conventional descriptive statistics, cross-tabulation and chi-square tests of potential factors related to the development of scleral necrosis, and summarizing of treatment approaches and results. The incidence of treatment of scleral necrosis was calculated using the Kaplan-Meier method. During the 7-year study period, 87 posterior uveal melanomas were evaluated by transcleral fine needle aspiration biopsy and treated by 125I plaque radiotherapy. The median largest basal diameter of the tumor was 13.3 mm, and the median thickness was 6.8 mm. Eight patients (9.2%) developed scleral necrosis during follow-up. Thicker tumors (> 6.5 mm) were more likely to develop scleral necrosis (n=7) than thinner tumors (p=0.05). The median interval between 125I plaque radiotherapy and detection of scleral necrosis was 19.1 months. The overall cumulative probability of scleral necrosis was 6.2% at 6 months and 14.3% at 24 months, subsequently remaining stable. For thicker tumors, the probability of scleral necrosis was 23.5% at 45.4 months. Five patients were treated by scleral patch graft (62.5%) and three by observation (37.5%). One patient underwent enucleation after two failed scleral patch attempts and recurrent scleral necrosis. The mean follow-up period for patients with scleral necrosis was 34.5 months. Thicker posterior uveal melanomas are more likely to develop scleral necrosis after 125I plaque radiotherapy and transcleral fine needle aspiration biopsy. While observation is sufficient for managing limited scleral necrosis, scleral patch graft is a viable alternative for eye preservation in extensive scleral necrosis.

Choroidal Melanoma Resection.

Uveal melanoma is the most common intraocular malignant tumor, with the choroid being the most common site. Management of choroidal melanoma has evolved greatly over the past years. In the past, the conventional method of treatment was enucleation of the affected eye with a debate regarding the effect of enucleation to promote or prevent metastasis. However, nowadays, there are many therapeutic options available including plaque radiotherapy, proton beam radiotherapy, argon laser photocoagulation, transpupillary thermotherapy, stereotactic radiotherapy using gamma knife, enucleation, and surgical resection of the tumor whether through transscleral approach “Exoresection” or less commonly through internal resection approach “Endoresection.” The indications and complications of each technique are reviewed. Although radiotherapy is the primary treatment of choroidal melanoma in most ocular oncology centers, it is used as an adjuvant therapy in combination with surgical resection. Preoperative stereotactic radiotherapy before endoresection and brachytherapy to the surgical bed in both exo and endoresection can effectively decrease the recurrence rate. In this article, we will focus on surgical resection of choroidal melanoma whether endoresection or exoresection. We collected data published in indexed journals and related books.

Outcomes of primary endoresection for choroidal melanoma

PurposeTo review long time treatment results in patients with small or medium sized choroidal melanoma who underwent surgical tumor endoresection as a primary treatment when plaque radiotherapy was unable and patients declined enucleation.Materials and methodsPatients were evaluated for best corrected visual acuity (BCVA), and underwent biomicroscopy, indirect ophthalmoscopy, retinography and ultrasound as well as the usual systemic workup. Study inclusion required the absence of scleral invasion or metastasis and an anterior margin not exceeding the pars plana or the ciliary body. Surgery consisted of a clear lens phacoemulsification with a PC-IOL, and a 23-gauge pars plana vitrectomy with anterior vitreous shave, lesional choroidal endodiathermy, followed by 23-gauge probe tumor endoresection and continuous endolaser. Patients were followed at post-operative 1 day, 1 week, 1, 3, and 6 months and then every 6 months with a complete ophthalmological exam including ultrasound biomicroscopy and systemic follow-up at 3, 6 and every 6 months thereafter.ResultsFourteen patients with choroidal melanoma were included the study. Pre-operative BCVA ranged from 20/20 to hand motion (HM): 20/20 (n = 2); 20/60 (n = 1); and HM (n = 10). Pathological analysis confirmed the diagnosis of uveal melanoma in all cases. Mean follow-up was 54.5 months (45–66 months) with a final BCVA ranging from 20/60 to HM: 20/60 (n = 1); 20/60 to 20/200 (n = 10); and HM (n = 2). The eye retention rate in our study was 100%. No intraocular recurrence was observed. One patient died 12 months after surgery from metastatic disease.ConclusionEndoresection appears to be an acceptable alternative to enucleation for the treatment of posteriorly-localized uveal melanoma, with excellent local control and eye salvage rates.

Current Therapies in Superficial Malignant Tumors

This article is a review of diagnostic and therapeutic possibilities in common epibulbar malignant tumors, such as basal cell carcinoma, conjunctival lymphoma, squamous cell carcinoma and conjunctival melanoma. Most importantly, for every tumor patient there is a detailed anamnesis, split lamp examination and photo documentation. Further regular controls after therapy are required due to the risk of recurrences.Basal cell carcinoma is the most common tumor of the periocular skin, divided into three subtypes (nodular, superficial and morphea). The treatment consists of total excision with a sufficient safety margin.The most common tumor of the orbital and ocular adnexa are lymphoma. They can appear primary or secondary, as lymphatic system disease. The gold standard therapy is a percutaneous irradiation.Squamous cell carcinoma and its precancerous stages (CIN I - III) are frequently diagnosed on the conjunctiva. A complete tumor excision is required, but sometimes it is not possible due to large tumor growth. Therefore, an adjuvant therapy with mitomycin C eyedrops, brachytherapy with ruthenium plaque or proton radiotherapy is required.Conjunctival melanoma is a rare, but life-threatening disease. Melanosis with atypia has a high risk for degeneration and requires further treatment with mitomycin C eyedrops. In cases of malignant tumor growth, an excision with a non-touch technique and adjuvant therapy with brachy or proton irradiation should be applied.

IMAGE QUALITY AND ARTIFACTS ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY: Comparison of Pathologic and Paired Fellow Eyes in 65 Patients With Unilateral Choroidal Melanoma Treated With Plaque Radiotherapy.

To study image quality and artifacts seen on optical coherence tomography angiography (OCTA). Sixty-five consecutive patients with unilateral posterior uveal melanoma treated with plaque radiotherapy had OCTA during follow-up. Optical coherence tomography angiography was performed on both the affected and fellow eye. Signal strength and frequency of image artifacts on en face images were compared between affected and fellow eyes. A total of 130 eyes in 65 patients were analyzed, the mean age at time of OCTA was 55 years (median: 56, range: 12-81 years), and 39 (39/65, 60%) were female. Majority of tumors were located in the choroid (62/65, 95%) and extramacular (55/65, 85%). The mean distance to the foveola was 4 mm (median: 3, range: 0-18 mm) and optic nerve was 4 mm (median: 4, range: 0-16 mm). Optical coherence tomography angiography was performed at a mean 46 months after plaque radiotherapy. Most patients had a history of radiation maculopathy or papillopathy in the treated eye at the time of OCTA (46/65, 71%). Overall, 95 eyes (95/130, 73%) had at least one significant artifact on OCTA. The most common major artifacts were loss of focus (71/130, 55%), broad (>5 pixels width and >4 lines) blink lines (48/130, 37%), motion artifact (34/130, 26%), specular dot (33/130, 25%), and edge duplication (10/130, 8%). Statistically, eyes treated with plaque radiotherapy (affected vs. fellow eye) were more likely to have at least one major OCTA artifact (92 vs. 54%, P < 0.001) and, specifically, loss of focus was more frequent (78 vs. 31%, P < 0.001). Multivariate analysis found decreased visual acuity significantly associated with higher incidence of broad blink lines (P = 0.0166) and loss of signal (P < 0.0001), whereas male sex was associated with increased loss of signal (P = 0.0015), and distance to the foveola was related to edge duplication (P = 0.0119). Image artifacts on OCTA are commonly encountered and appear to be more frequent in eyes with pathology and poor visual acuity. Recognition of these artifacts might help improve image interpretation and decision making.

TWENTY-FIVE-GAUGE CANNULA-ASSISTED FINE-NEEDLE ASPIRATION BIOPSY OF CHOROIDAL MELANOMA: Cytopathological Analysis.

To report cytopathological observations on the cells retrieved from the 25-G cannula used during prognostic transvitreal fine-needle aspiration biopsy of choroidal melanoma. Transvitreal fine-needle aspiration biopsy of choroidal melanoma was performed through a 25-G valved cannula. Twenty samples from 20 consecutive patients were obtained. Most tumors were treated with plaque radiation therapy (16/20, 80%) following standard clinical guidelines. Four enucleated globes (4/20, 20%) were subjected to a similar transvitreal biopsy before enucleation. Cytopathological analysis of the cells retrieved from the cannula revealed the absence of any cells in 4 of 20 samples (20%). In the remaining 16 samples, definite melanoma cells and atypical cells (probable melanoma cells) were observed in 2 samples each (total 4, 25%). Histiocytes (4/16, 25%) and lymphocytes (1/16, 6%) were also observed. Thirteen samples (13/16, 81%) contained conjunctival epithelial epithelium. Prognostication could be performed on all fine-needle aspiration biopsy samples (20, 100%). Use of a 25-G valved cannula offers potential advantages by isolating the needle tract and by allowing retrieval of the contaminating cells without affecting the prognostic yield of the fine-needle aspiration biopsy sample.

Uveal melanoma: millimeters, personalized prognosis, and new therapies

SummaryThe management of uveal melanoma is going through tremendous transition into the realm of early detection, personalized prognostication and potentially new systemic and local therapies. In this Keynote Lecture, we will discuss four topics relevant to current melanoma management including (1) the importance of detection of small melanoma where thickness is approximately 3 mm or less, (2) optical coherence tomography angiography (OCTA) of melanoma before and after plaque radiotherapy, (3) DNA analysis of &gt;1000 cases of uveal melanoma and the ability to personally prognosticate each patient based on cytogenetic profile, and (4) new systemic and local therapies.