Small Choroidal Melanoma Research Articles

Visual Outcomes after Proton Beam Irradiation for Choroidal Melanomas Involving the Fovea

To report visual outcomes in patients undergoing proton beam irradiation of tumors located within 1 disc diameter of the fovea. Retrospective review. Patients with choroidal melanoma involving the fovea treated with proton beam therapy between 1975 and2009. Three hundred fifty-one patients with choroidal melanomas located 1 disc diameter (DD) or less from the fovea and more than 1 DD away from the optic nerve were included in this study. In a subgroup of 203 of the patients with small and medium choroidal melanomas, the effect of a reduced dose of radiation, 50 Gy (relative biological effectiveness [RBE]) versus 70 Gy (RBE), on visual outcomes was analyzed. The Kaplan-Meier method and Cox regression analysis were performed to calculate cumulative rates of vision loss and to assess risk factors for vision loss, respectively. Visual acuity and radiation complications, which included radiation maculopathy, papillopathy, retinal detachment, and rubeosis, were assessed. Three hundred fifty-one patients were included in this study with a mean follow-up time of 68.7 months. More than one-third of patients (35.5%) retained 20/200 or better vision 5 years after proton beam irradiation. For those patients with a baseline visual acuity of 20/40 or better, 16.2% of patients retained this level of vision 5 years after proton beam irradiation. Tumor height less than 5 mm and baseline visual acuity 20/40 or better were associated significantly with a better visual outcome (P < 0.001). More than two-thirds (70.4%) of patients receiving 50 Gy (RBE) and nearly half (45.1%) of patients receiving 70 Gy (RBE) retained 20/200 or better vision 5 years after treatment, but this difference was not significant. Approximately 20% of patients with these smaller macular tumors retained 20/40 vision or better 5 years after irradiation. The results of this retrospective analysis demonstrate that despite receiving a full dose of radiation to the fovea, many patients with choroidal melanoma with foveal involvement maintain useful vision. A radiation dose reduction from 70 to 50 Gy (RBE) did not seem to increase the proportion of patients who retain usable vision.

This issue of ACTA, printed and electronic

This issue of ACTA, printed and electronic

Review of spectral domain enhanced depth imaging optical coherence tomography of tumors of the choroid.

Background:Spectral domain enhanced depth imaging optical coherence tomography (EDI-OCT) can provide anatomic localization of intraocular tumors.Aims:The aim was to identify topographical and intrinsic patterns of choroidal tumors on EDI-OCT.Settings and Design:Retrospective review.Materials and Methods:Analysis of published reports and personal observations using office based EDI-OCT.Results:Using EDI-OCT, choroidal nevus displayed a smooth, dome-shaped topography with overlying retinal pigment epithelium alterations, drusen, and occasional subretinal cleft demonstrating photoreceptor loss. Small choroidal melanoma showed smooth, moderately dome-shaped topography, commonly with overlying shallow subretinal fluid that often depicted “shaggy” photoreceptors. Choroidal metastasis showed a minimally “lumpy, bumpy” surface topography and with overlying subretinal fluid and shaggy photoreceptors. Choroidal hemangioma showed a smooth, dome-shaped topography, with expansion of the affected small, medium, and large choroidal vessels. Choroidal lymphoma showed varying topography with increasing tumor thickness as “flat, rippled, or undulating (seasick)” surface. Choroidal osteoma displayed a smooth undulating surface with visible intralesional horizontal lines suggestive of bone lamellae and occasional horizontal and vertical tubules with intralesional “spongy” flecks. Choroidal melanocytosis appeared as uniformly thickened choroid with increased stromal density surrounding the normal choroidal vascular structures.Conclusions:Enhanced depth imaging-OCT can depict characteristic patterns that are suggestive of various choroidal tumors.

Primary Transpupillary Thermotherapy for Choroidal Melanoma in 391 Cases: Importance of Risk Factors in Tumor Control

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.

An aggressive small choroidal melanoma

AbstractPurpose To describe a small non diffuse choroidal melanoma with extraocular extension.Methods Case‐reportResults We describe the case of a 50year‐old patient presenting with visual loss and metamorphopsia. Fundus examination revealed a suprapapillary trilobular choroidal mass with inhomogenous pigmentation and lipofuscin. The optic nerve was slightly oedematous. On fluorescein angiography, the lesion revealed pin‐points and exsudation. Ultrasound sonography (20Mhz) showed a peripapillary lesion of 3mm thickness. MRI was performed and confirmed the diagnosis of choroidal melanoma. No extraocular extension was seen on MRI or ultrasound imaging. Because of optic nerve oedema we decided to perform an enucleation. On pathology, the lesion measured 9mm diameter and 3mm thickness. It was mostly composed of epithelioïd cells and it showed scleral, perineural , optic nerve and periocular soft tissue invasion. Complementary orbital radiotherapy was performed. Until now, after one year follow‐up, the patient has shown no metastasis or local recurrence.Conclusion Extraocular invasion in a small thickness non diffuse choroidal melanoma is rare. In times of eye‐sparing choroidal melanoma treatment, the ophthalmologist should not forget the possibility of extra‐ocular involvement, even in small tumors.

Diagnostic contribution of ocular imaging techniques in a multimodal diagnostic approach of small pigmented choroidal tumors

AbstractPurpose The differential diagnosis of small pigmented choroidal tumors is based on the evaluation of the tumor diameter, thickness, retinal detachment, pigment epithelium changes, and possible associated symptoms.Methods The diagnostic contribution of color fundus photography, fluorescein angiography (FA), indocyanine green angiography (ICGA), fundus autofluorescence (FAF) and optical coherence tomography (OCT), was analyzed in 85 eyes with a small pigmented choroidal tumors, measuring 2‐10 mm in diameter and 0.8‐2.5 mm in thickness. The presumed diagnosis was a large choroidal nevus in 60 cases (71%), and a small choroidal melanoma in 25 cases (29%). The identification of the tumor border, the presence of any retinal detachment on the tumor surface or outside the tumor borders, the presence of orange pigment, drusen, pigment epithelium changes and/or pin points were analyzed on each imaging technique.Results The highest identification score for the tumor margins was reached by color fundus photography. An associated retinal detachment was best identified on OCT. Orange pigment was best detected on fundus color photography and then by FAF. Drusen identification reached the same score on fundus color photography and FA. The appearance of pin points was exclusively seen on FA. Pigment epithelium changes showed the best score on FAF.Conclusion The majority of the investigated ocular imaging techniques played an important role in the identification of diagnostic elements that contribute to the distinction between a small choroidal melanoma and a large nevus. Multimodal imaging techniques have to be used in order to obtain a higher efficacy in differentiating small pigmented choroidal tumors.

Small metastasizing choroidal melanomas.

Small choroidal melanomas have a better prognosis than large tumours. However, these small tumours can spread, often late in their course. The aim of the study was to analyse survival and tumour characteristics of six cases of late metastatic diseases after conservative treatment. A retrospective study was conducted at the Croix-Rousse University Hospital of Lyon among 523 patients treated between 1991 and 2010 by proton beam therapy (508) or brachytherapy with 106 (Ru/Rh) (15) for uveal melanomas. We have selected patients with small choroidal melanoma (thickness≤3 mm and diameter≤9 mm) (59 patients), who have developed hepatic metastases (six of 59). At the time of diagnosis, median age was 57 years (range, 37-82 years). The mean tumour thickness was 2.9 mm (range 2.5-3 mm), and the mean diameter was 7 mm (5-8 mm). Orange pigment was observed in four cases, subretinal fluid was observed in two cases, and one tumour touched the optic disc. Five patients had proton beam therapy. One patient had beta brachytherapy (106 Ru/106 Rh). Average follow-up was 8.3 years (range 4.2-11.8 years). None of the six patients developed local tumour recurrence. The mean survival time after diagnosis of melanoma was 9.8 years (range, 4.9-14.6 years). The average time from treatment of primary tumour to detection of liver metastasis was 7 years (range 3.9-12 years). The mean survival time from the diagnosis of metastasis was 35.2 months (range 9-101 months). Small melanoma-related death was 0% at 3 years, 1.7% at 5 years, 5.1% at 10 years and 10.2% at 15 years in our series. Despite a small tumoral size and an early and effective local treatment, six of 59 small choroidal melanomas have developed metastasis after local treatment. Small tumours represent a significant risk of metastasis.

DIFFUSE VERSUS NONDIFFUSE SMALL (≤3 MM THICKNESS) CHOROIDAL MELANOMA

To determine prognosis of small choroidal melanoma (≤ 3 mm thickness) comparing diffuse versus nondiffuse variants. Retrospective chart review of 1,751 patients with small choroidal melanoma classified as diffuse (thickness/base ≤ 20%) versus nondiffuse (thickness/base >20%). Of 1,751 patients with small choroidal melanoma, 297 (17%) were diffuse and 1,454 (83%) nondiffuse. Features with statistical differences (diffuse vs. nondiffuse) included mean distance to optic disk (3 vs. 4 mm), mean tumor base (12 vs. 8 mm), and mean tumor thickness (1.9 vs. 2.5 mm). Using Kaplan-Meier estimates, melanoma-related metastasis (diffuse vs. nondiffuse) was 8% versus 4% at 5 years, 16% versus 10% at 10 years, and 19% versus 16% at 15 years (P = 0.0344). Melanoma-related death was 6% versus 2% at 5 years, 11% versus 4% at 10 years, and 16% versus 6% at 15 years (P < 0.0001). In the subgroup of thin melanoma 2 mm or less in thickness, melanoma-related death was 7% versus 2% at 5 years, 10% versus 2% at 10 years, and 16% versus 4% at 15 years (P = 0.0077). By multivariate analysis, factors predictive of metastasis from diffuse melanoma included larger tumor basal dimension (P = 0.0027) and plateau/flat tumor configuration (P = 0.0257). Of 1751 patients with small (≤ 3 mm thickness) choroidal melanoma, those with diffuse tumor show higher probability of metastasis and death than those with nondiffuse tumor. This finding is evident even in the thinnest melanomas (≤ 2 mm thickness).

Palladium-103 Radiation Therapy for Small Choroidal Melanoma

To evaluate outcomes after ophthalmic plaque radiation therapy for small choroidal melanomas. Retrospective study, case series. Seventy-two patients with choroidal melanomas ≥1.5 and ≤2.4 mm apical height and ≤10 mm width treated between 2002 and 2012, with a minimum follow-up of 8 months. All patients were treated with palladium-103 plaque brachytherapy. Mean radiation dose to the tumor apex was 82.4 Gy (range, 70.0-102 Gy). Local control, radiation complications, visual acuity, and metastatic rate. Plaque radiotherapy provided 100% local tumor control and eye retention at a mean 54 months of observation (95% confidence interval, 46-63 months). The most common long-term brachytherapy-related complications were radiation maculopathy (43.1%) and radiation optic neuropathy (20.8%) developing at a mean of 27 months (range, 9-72 months) after irradiation. In this series, 94.4% of patients maintained 20/200 or better vision. There has been no small choroidal melanoma-related metastasis. Palladium-103 plaque radiation therapy offered excellent local control and visual acuity outcomes for patients with small choroidal melanoma.

Autofluorescence of intraocular tumours

Fundus autofluorescence is a noninvasive technique for evaluation of intrinsic autofluorescence of the tissues within the eye. In recent years, autofluorescence has become an important diagnostic tool for the assessment of various ocular diseases such as age-related macular degeneration and retinal dystrophies. In this report, we review the recent literature on autofluorescence of intraocular tumours. The autofluorescence features of intraocular tumours range from bright hyperautofluorescence to dark hypoautofluorescence. The fundus autofluorescence generally represents the status of the overlying retinal pigment epithelium (RPE). Choroidal nevi typically have overlying hypoautofluorescence from chronic RPE atrophy as opposed to choroidal melanoma that exhibits hyperautofluorescence from overlying lipofuscin within RPE (orange pigment) and free fluorophores within fresh subretinal fluid. Choroidal metastases demonstrate overlying hyperautofluorescence that correlates to focal RPE accumulation of lipofuscin as well as subretinal fluid, particularly on the fresh advancing tumour margin. Choroidal haemangioma displays overlying hyperautofluorescence from lipofuscin within RPE and fresh subretinal fluid, but when choroidal haemangioma is chronic with resolved fluid, there is often overlying hypoautofluorescence from RPE atrophy. Congenital hypertrophy of the RPE is characterized by marked hypoautofluorescence of the RPE lesion and trace hyperautofluorescence within the lacunae. Autofluorescence is a noninvasive, valuable diagnostic tool for assessment of intraocular tumours, based primarily on the effects on the overlying RPE. Some findings are strongly characteristic of certain tumours, particularly the bright hyperautofluorescence overlying small choroidal melanoma and the dark hypoautofluorescence of congenital hypertrophy of the RPE.

Enhanced Depth Imaging Optical Coherence Tomography of Small Choroidal Melanoma

To evaluate characteristics of small choroidal melanoma using enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT). Retrospective comparative analysis. Of 37 eyes with small choroidal melanoma imaged using EDI-OCT, the mean tumor thickness was 1025 μm by EDI-OCT compared with 2300 μm by ultrasonography. By EDI-OCT, choroidal features included optical shadowing in 36 (100%) and overlying choriocapillaris thinning in 37 (100%). Outer retinal features included shaggy photoreceptors in 18 (49%), as well as absence (structural loss) of photoreceptors in 9 (24%), inner segment-outer segment junction in 24 (65%), external limiting membrane in 16 (43%), outer nuclear layer in 6 (16%), and outer plexiform layer in 4 (11%). Inner retinal features included irregularity of inner nuclear layer in 3 (8%), inner plexiform layer in 3 (8%), ganglion cell layer in 3 (8%), and nerve fiber layer in 2 (5%). Also identified were subretinal fluid in 34 (92%), subretinal lipofuscin deposition in 35 (95%), and intraretinal edema in 6 (16%). Using EDI-OCT, a comparison with similar-sized choroidal nevus revealed that small choroidal melanoma showed increased tumor thickness, subretinal fluid, subretinal lipofuscin deposition, and retinal pigment epithelium atrophy. Statistically significant EDI-OCT features for small choroidal melanoma included intraretinal edema (P=.003), shaggy photoreceptors or loss of photoreceptors (P=.005), loss of external limiting membrane (P=.008), loss of inner segment-outer segment junction (P=.02), irregularity of inner plexiform layer (P=.04), and irregularity of ganglion cell layer (P=.04) (t test and χ2 test). Shaggy photoreceptors were found overlying small choroidal melanoma in 18 (49%) but were not observed overlying choroidal nevus (P<.001). Small choroidal melanoma tumor thickness was overestimated by 55% on ultrasonography compared with EDI-OCT. The EDI-OCT features of small choroidal melanoma compared with choroidal nevus include increased tumor thickness, subretinal fluid, subretinal lipofuscin deposition, and retinal irregularities, including shaggy photoreceptors.

CLINICAL AND HISTOPATHOLOGIC FINDINGS AFTER PHOTODYNAMIC THERAPY OF CHOROIDAL MELANOMA

Photodynamic therapy (PDT) has been used occasionally as an alternative treatment for uveal melanomas. The present study describes the clinical and histopathologic features of five choroidal melanomas after PDT. Three patients with pigmented choroidal melanomas were treated with PDT and intravitreal bevacizumab 1 week before undergoing biopsy and brachytherapy to minimize the risks of bleeding during the biopsy. Another two patients received PDT as a primary treatment for peripapillary amelanotic melanomas, one of them also in combination with bevacizumab. The tumors treated with PDT and bevacizumab showed a marked reduction in tumor vascularity assessed by indocyanine angiography, and the biopsies were conducted without recognizable bleeding, showing viable tumor cells. The tumors receiving PDT as a primary treatment were followed by progressive tumor growth that led to enucleation years after. The histopathology revealed overlying fibrosis with invasion of sclera and optic nerve. Photodynamic therapy and bevacizumab can induce closure of the superficial vasculature of a pigmented choroidal melanoma, but in none of our cases, there was evidence of tumor destruction from this treatment. Preoperative PDT may be useful to reduce the potential of bleeding at the time of tumor biopsy. Our cases do not support the use of a single session of PDT as a primary treatment for pigmented small choroidal melanomas.

Genetic findings in small melanocytic lesions

AbstractPurpose The management of patients with small melanocytic choroidal tumour is controversial. The aim of this presentation is to inform the current debate on patient care by reporting on histological grade of malignancy and genetic type of such tumours.Methods We reviewed our database and selected patients with: a melanocytic tumour having dimensions conforming to the TNM size category 1 (i.e., ‘small’); tumour involving choroid; and clinical and/or histological features of malignancy. Patients with such a ‘small choroidal melanoma’ were excluded if not resident in the British Isles, if the tumour was not treated at our centre between 1993 and 2010 or if they had bilateral uveal melanoma.Results 3132 patients with a choroidal melanoma were identified, of which 1001 (32.2%) were ‘small’. Chromosome 3 status was known in 102 of such small choroidal melanomas. Chromosome 3 loss was detected in 40% of these. Approximately 63% of tumours with chromosome 3 loss showed chromosome 8q gain (cf. 85% of tumours of TNM size category 4). Approximately 70% (i.e., 16 tumours) of small choroidal melanomas with both these genetic abnormalities also showed epithelioid cells. Metastatic death occurred in 4 patients, all of whom had a tumour with chromosome 3 loss, chromosome 8q gain and epithelioid cells.Conclusion Our data suggest that uveal melanomas show ‘crescendo malignancy’ with cumulative genetic abnormalities ultimately resulting in a lethal ‘double‐hit’ of chromosome 3 loss and chromosome 8q gain. We hypothesize that treatment of small choroidal melanomas showing either chromosome 3 loss or chromosome 8q gain prevents such a lethal double hit and hence the onset of metastatic spread. Delayed treatment of small choroidal melanomas may therefore be dangerous. Prognostication is greatly enhanced by multivariate analysis combining TNM staging with histological grading and genetic typing also taking account of the patient’s age and sex. There would seem to be scope for greater use of biopsy so as to provide better counselling of patients and plans for systemic screening and other aspects of care.

Primary transpupillary thermotherapy for small choroidal melanoma

The treatment of small choroidal melanoma is controversial. Thermal laser-induced treatment is utilized by some centers but there is still sparse literature about the subject, mainly with short-term follow-up time. The efficacy of transpupillary thermotherapy (TTT) for the treatment of small choroidal melanomas was evaluated. A prospective nonrandomized study of transpupillary thermotherapy for small (thickness ≤ 4.0mm and basal diameter ≤ 12mm) pigmented choroidal melanomas presenting either growth or risk factors for growth and metastasis. Ophthalmoscopic aspect, tumor control, visual acuity and complications were evaluated. Twenty-seven patients were treated; mean age 61years; mean tumor thickness before treatment was 2.7mm and base was 8.52mm. After a mean of three treatment sessions and 45-month follow-up, mean tumor thickness decreased significantly to 1.34mm (p < 0.001) and mean tumor base to 5.48mm (p < 0.001). Complications were observed in 12 patients (44%) and included retinal vascular occlusion, optic disc atrophy, retinal traction, vitreous hemorrhage, rhegmatogenous retinal detachment, and maculopathy. Lesions touching the optic disc were associated with a significantly higher rate of disc atrophy after treatment (60% vs. 40%, p=0.030). Visual acuity remained the same in nine eyes (33%), improved in five (19%) and decreased during the first 6months after treatment in 13 eyes (48%). Complete tumor control without recurrence was observed in 25 patients (93%). Recurrence at tumor margin was detected in two (7%). All eyes were preserved. One patient had tumor-related death. TTT is an effective treatment in the management of selected small choroidal melanoma. Decrease in visual acuity occurred early after treatment mainly associated with subfoveal and perifoveal tumors treatment and complications. Long-term randomized studies are still needed in order to better situate this treatment.

Bilateral Diffuse Uveal Melanocytic Proliferation Presenting as Small Choroidal Melanoma

Purpose. To describe a patient with Bilateral Diffuse Uveal Proliferation who presented initially with a clinical picture consistent with choroidal melanoma. Methods. Presentation of a clinical case with fundus photos, fluorescein angiography, and optical coherence tomography. Results. A 70-year-old Caucasian male with history of esophageal cancer presented with an asymptomatic pigmented choroidal lesion in his left eye initially diagnosed as choroidal nevus. This lesion enlarged over the course of a year and developed orange pigment and increased thickness. A metastatic workup was negative, and a radioactive iodine plaque was placed on the left eye. Over the next six months, the visual acuity in his left eye decreased. His clinical picture was consistent with unilateral Diffuse Uveal Proliferation. A recurrence of his esophageal carcinoma with metastasis was discovered and palliative chemotherapy was initiated. Although his visual acuity improved in the left eye, similar pigmentary changes developed in the right fundus. His visual acuity in both eyes gradually decreased to 20/200 until his death a year later. Conclusion. BDUMP should always be considered in the differential diagnosis of patients with pigmented fundus lesions and a history of nonocular tumors.

Radiation Retinopathy and Neuropathy following Plaque Therapy of Small Choroidal Melanoma

Despite yielding excellent local tumor control, the long term visual outcome following plaque radiotherapy is poor. The purpose of this study is to examine the incidence of radiation retinopathy (RR) and radiation optic neuropathy (RON) following I-125 and Ru-106 plaque therapy for the treatment of small choroidal melanomas as a function of radiation dose to the macula and optic disc.

Observation in choroidal melanomas

Abstract Purpose The management of suspected small choroidal melanomas is controversial. The purpose of the present study is to assess tumor growth, visual acuity changes, activity factors and survival on choroidal melanoma patients under observation in our Intraocular Tumors Unit. Methods Prospective, consecutive and non‐interventional case series. Patients diagnosed with choroidal melanoma from 1990 to 2010 and with observation as therapeutic option were included. Criteria for observation were small size without risk factors for growing; medium and large size: no risk factors for growing (but size), advanced age, bad general health, only eye or treatment rejection. Demographic, tumoral and follow‐up data were collected in a data base and analyzed. Results 118 out of 397 patients (29.7%) diagnosed with uveal melanoma were enrolled, with mean age of 66.4 years (SD 14.3). The mean follow‐up time was 51.1 months (SD 4.5). Regarding the size, 91 (77.1%) tumors were small and 85 (72.%) were diagnosed in a routine examination. Main reason for observation was tumor small/inactive (80,5%) followed by treatment rejection (17.7%). Mean height was 2.8mm (SD 1.9) and mean base 7.6 (SD 2.8). Along the follow‐up, 17 tumors grew; 11 were treated with brachytherapy, 5 with enucleation and one with brachytherapy and enucleation. Only 16 patients died during the follow‐up, 2 by melanoma metastasis. Conclusion In our series with more than 4 years of follow up, observation seems to be a safe therapeutic option for selected small choroidal melanomas, allowing the patients to preserve visual function.

MLPA of choroidal melanoma

Abstract Purpose To determine the genotypic profiles of choroidal melanomas using multiplex ligation‐dependent probe amplification (MLPA) and to correlate findings with clinical and pathological features and metastatic death. Methods DNA samples from 452 choroidal melanomas were analyzed with MLPA evaluating 31 loci on chromosomes 1, 3, 6 and 8. The MLPA results were correlated with survival predictors and wiht metastatic death. Results The patients (194 female; 258 male) had a median age of 59.4 years and a median follow‐up of 1.89 years. Metastatic death occurred in 47 patients, correlating most strongly with concurrent chromosomes 3 losses and chromosome 8q gains (Logrank analysis, p&lt;0.001). Many small choroidal melanomas with a basal diameter of less than 10mm showed only chromosome 3 loss or chromosome 8q gain or none of these, suggesting that their tumour was 'pre‐lethal' at the time of ocular treatment. Conclusion MLPA analysis of choroidal melanoma is predictive of metastatic death and, therefore, clinically useful. The findings of this study are most consistent with evolutionary clonal abnormality, suggesting that timely treatment prevents the metastatic genotype and metastatic spread in a proportion of patients.

Eye growth transformation: uveal melanoma

The care of patients with uveal melanoma is potentially about to take another leap in the right direction. Recently, there has been extensive research into the early detection of small choroidal melanomas, features of choroidal nevi predictive of malignant transformation, cytogenetic analysis and prognosis of patients with uveal melanoma. The aim of this article is to provide a comprehensive review of benign nevi of the uveal tract, as well as uveal melanoma and its associated risk factors, clinical features and diagnosis. This article will also review the recent developments in the field that are not only addressing efforts toward earlier and more accurate diagnosis of this condition but also the overall approach to the management of local disease and metastases.

Tumorregression maligner Aderhautmelanome nach Transpupillarer Thermotherapie (TTT) versus Ruthenium-Brachytherapie und Sandwichtherapie – eine vergleichende Analyse

The aim of this study was to evaluate tumour regression in a large series of choroidal melanomas, which were treated with three different eye-sparing treatment modalities. Retrospective review of the treatment results in all eyes with malignant choroidal melanoma, which were treated in the University Eye Clinic of Mainz consecutively in the time span 1.1992 to 12.2000 with transpupillary thermotherapy (TTT, standard protocol Oosterhuis JA 1995), ruthenium brachytherapy (RB, tumor apex dose 150 Gy) or sandwich therapy (ST). One-step ST was defined as TTT followed by RB with 100 Gy tumor apex dose within 48 hours. The treatment of residual prominences with TTT secondary to RB after different time spans was called two-step ST. Follow-up was 2 years. 131 eyes with malignant choroidal melanoma (mean tumour thickness: 4.5 mm) were treated with RB (66 eyes), TTT (26 eyes) or ST (39 eyes). Preservation of the globe was achieved in 109 eyes (81 %). Local tumour control was found in small melanomas (prominence up to 3 mm) in 89 %, in large tumors (prominence 8 mm and higher) in 50 %. In a subgroup of small posterior melanomas (n = 70 eyes, prominence up to 4.5 mm, located posterior to the equator) local tumour control was noted in 91 %. The time span to reach local tumour control (Kaplan-Meier estimates) was the shortest after TTT (median: 20 weeks), compared with RB (48 weeks) and one-step ST (29 weeks). In choroidal melanomas the chance of local tumour control and preservation of the globe decreases with increase of the tumour prominence. In small choroidal melanomas with posterior location local tumour control was achieved significantly faster after TTT than after RB.