Bertil Damato

Genotypic Profiling of 452 Choroidal Melanomas with Multiplex Ligation-Dependent Probe Amplification

Purpose: Metastasis from uveal melanoma occurs almost exclusively with tumors showing chromosome 3 loss. We used multiplex ligation-dependent probe amplification (MLPA) to detect chromosome 1p, 3, 6p, 6q, 8p, and 8q abnormalities in uveal melanomas. The purpose of this study was to correlate our MLPA results with other risk factors and metastatic death. Experimental Design: Patients were included if they had a uveal melanoma involving choroid. Correlations between baseline risk factors were analyzed using the chi-square test (without Yatess adjustment) and the Mann–Whitney test, with log-rank analysis for associations with 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. MLPA abnormalities occurred in a wide variety of combinations. Ten-year disease-specific mortality was 0% in 133 tumors with no chromosome 3 loss, 55% in tumors with chromosome 3 loss but no chromosome 8q gain, and 71% in 168 tumors showing combined chromosome 3 loss and 8q gain. In tumors with both these abnormalities, epithelioid melanoma cytomorphology, closed loops, and high mitotic rate correlated with poor survival as did lack of chromosome 6p gain. Conclusions: These results support the use of MLPA for routine clinical prognostication, especially if the genetic data are considered together with clinical and histologic risk factors. We showed a wide variety of MLPA results, which suggests that chromosomal abnormalities in uveal melanoma accumulate in a variable sequence.

Senile atrophy of the human lacrimal gland: the contribution of chronic inflammatory disease.

Histological examination of 99 human lacrimal glands showed a relationship between atrophy of the secretory acini and secretory duct obstruction, ascending periductal fibrosis, and obliteration of the adjacent blood vessels caused by lymphocytic and polymorphonuclear inflammation. Investigation of the subgroups of the B lymphocytic series by immunohistochemistry did not show any statistical change with age, sex, fibrosis, or lymphocytic inflammation. The concept of senile atrophy occurring as a result of senescent involution of the lacrimal gland is challenged on the basis of the histological findings.

Understanding intraocular lymphomas

The purpose of this review is to describe the clinical features, pathology and molecular biology of intraocular lymphomas, which represent a heterogenous group of malignant neoplasms; to propose an anatomical classification of these tumours according to whether they occur in the retina or uvea; and to overview laboratory investigations and highlight factors required for successful biopsy. Recent findings show that retinal lymphomas are high‐grade (i.e. aggressive), B‐cell malignancies and are associated with a poor prognosis, with most patients dying of central nervous system disease. Immunophenotyping and somatic mutation analyses indicate that these lymphomas are probably derived from early post‐germinal centre cells. Primary choroidal lymphomas are typically low‐grade (i.e. indolent), B‐cell tumours with morphological, immunophenotypical and genotypic features similar to extranodal marginal zone B‐cell lymphomas (EMZL) elsewhere in the body. The putative cell of origin is the post‐germinal centre (memory) B cell. Primary iridal lymphomas are very rare, with an equal distribution of B‐ and T‐cell types and with a variable clinical course, most patients succumbing to their disease as a result of systemic dissemination. Primary lymphomas limited to the ciliary body are exceptionally rare. Secondary uveal lymphomas/leukaemias occur in patients with advanced systemic lymphoma or leukaemia, respectively. In summary, the term ‘primary intraocular lymphoma (PIOL)’ is imprecise. It would be preferable to refer to the various forms of intraocular lymphoma according to whether they are retinal, choroidal, ciliary or iridal and whether they are primary or secondary in these locations.

Endoresection of choroidal melanoma

AIMS The results of 52 endoresections for choroidal melanoma are reported. METHODS The current technique involves vitrectomy, retinal incision over or peripheral to the tumour, haemostasis by raising intraocular pressure and by moderate hypotensive anaesthesia, choroidal incision around tumour, endoresection with vitrector, endodiathermy to bleeding points and residual tumour, fluid-air exchange to reattach retina, endolaser to achieve retinal adhesion around the coloboma and destroy residual tumour in the sclera, silicone oil injection with removal after 12 weeks, cryotherapy to the sclerotomies, and adjunctive ruthenium plaque radiotherapy in selected cases. RESULTS Patients receiving primary endoresection had a mean age of 53 years, a mean largest basal tumour diameter of 8.2 mm, and a mean tumour thickness of 3.9 mm. 40 tumours extended to within 2 disc diameters of the optic disc, with 17 involving disc. Follow up ranged from 40 days to 7 years (median 20 months). At the last visit, 90% of eyes were retained, with vision of 6/6–6/12 (two), 6/18–6/36 (three), 6/60 to counting fingers (18), hand movements (nine), and light perception (four). The main complications were retinal detachment in 16 and cataract in 25. Secondary endoresection (11) was performed after plaque radiotherapy (four), photocoagulation (four), trans-scleral local resection (two), and proton beam radiotherapy (one), with retention of the eye in nine cases. By the close of the study, no patients developed definite local tumour recurrence but one died of metastatic disease 41 months postoperatively. CONCLUSION Depending on tumour location, endoresection may conserve central vision or temporal field when radiotherapy would be expected to cause optic neuropathy. Longer follow up is necessary to establish the efficacy of tumour control.

Estimating prognosis for survival after treatment of choroidal melanoma

Choroidal melanoma is fatal in about 50% of patients. This is because of metastatic disease, which usually involves the liver. Kaplan-Meier survival curves based only on tumor size and extent do not give a true indication of prognosis. This is because the survival prognosis of choroidal melanoma correlates not only with clinical stage but also with histologic grade, genetic type, and competing causes of death. We have developed an online tool that predicts survival using all these data also taking normal life-expectancy into account. The estimated prognosis is accurate enough to be relevant to individual patients. Such personalized prognostication improves the well-being of patients having an excellent survival probability, not least because it spares them from unnecessary screening tests. Such screening can be targeted at high-risk patients, so that metastases are detected sooner, thereby enhancing any opportunities for treatment. Concerns about psychological harm have proved exaggerated. At least in Britain, patients want to know their prognosis, even if this is poor. The ability to select patients with a high risk of metastasis improves prospects for randomised studies evaluating systemic adjuvant therapy aimed at preventing or delaying metastatic disease. Furthermore, categorization of tissue samples according to survival prognosis enables laboratory studies to be undertaken without waiting many years for survival to be measured. As a result of advances in histologic and genetic studies, biopsy techniques and statistics, prognostication has become established as a routine procedure in our clinical practice, thereby enhancing the care of patients with uveal melanoma.

Developments in the management of uveal melanoma

Uveal melanomas threaten visual loss, enucleation, and death from metastatic disease. Most patients present because of symptoms, but failures of detection and diagnosis still occur commonly. Treatments aimed at avoiding enucleation include: plaque, proton beam or stereotactic radiotherapy; trans‐scleral or trans‐retinal local resection; and transpupillary thermotherapy. Increasingly, different modalities are being used in combination. The ocular outcomes are related to tumour size, location, spread and cell type. Metastatic disease occurs in many patients and is related to factors such as tumour dimensions, ciliary body involvement, cell type, extravascular matrix patterns and cytogenetics. Abnormalities related to chromosomes 3, 6 and 8 are strongly related to tumour behaviour, for the first time enabling survival probability to be estimated with a high degree of reliability in an individual patient. This enables high‐risk individuals to be targeted for screening while providing reassurance to those with a minimal chance of developing metastatic disease. Such targeting would allow selection of patients for adjuvant systemic therapy, should a suitable treatment become available, and would also facilitate the evaluation of such treatment by increasing the statistical power of any randomized prospective study. The high mortality in patients with monosomy 3 melanoma suggests that in these patients ocular treatment is only palliative. Cytogenetic studies suggest that some melanomas may never develop any metastatic potential and if these impressions are confirmed by further studies, then in these patients the main priority of treatment would be to conserve vision.

Multiplex Ligation-Dependent Probe Amplification of Uveal Melanoma: Correlation with Metastatic Death

PURPOSE To evaluate multiplex ligation-dependent probe amplification (MLPA) of uveal melanoma as a predictive tool for metastatic death. METHODS Uveal melanoma specimens of 73 patients treated between 1998 and 2000 were included. DNA samples were analyzed with MLPA evaluating 31 loci on chromosomes 1, 3, 6 and 8, and the results were correlated with metastatic death. RESULTS The patients (27 women; 46 men) had a median age of 60.6 years and a median follow-up of 6.2 years. Metastatic death occurred in 28 patients, correlating most strongly with chromosome 3 losses and gains on 8q (Cox univariate analysis, P < 0.001). Chromosome 6, region p25, gains correlated with good survival (Cox univariate analysis, P = 0.003). Prediction of metastatic death was improved by considering equivocal chromosome 3 losses as abnormal and by taking account of multiple risk factors, such as 8q gains, tumor diameter, and histologic features indicative of high-grade malignancy. CONCLUSIONS MLPA analysis of uveal melanoma predicts metastatic death if statistically insignificant losses of chromosome 3 are considered together with gains in 8q as well as clinical stage and histologic grade of malignancy.

Risk factors for residual and recurrent uveal melanoma after trans-scleral local resection.

AIMS: The aims of this study were to report local tumour control after trans-scleral local resection of uveal melanoma and to identify risk factors for (i) clinical residual tumour recognised immediately after surgery, and (ii) delayed tumour recurrence from subclinical microscopic deposits. METHODS: The sample included 310 patients, treated by choroidectomy (188), cyclochoroidectomy (87), or iridocyclectomy (35), with follow up ranging from 42 days to 20.9 years (median 36 months), a mean basal largest tumour diameter of 13.2 mm, and a mean tumour thickness of 7.4 mm. RESULTS: There were 24 patients with residual tumour. Forward stepwise logistic regression indicated that posterior extension to within 1 disc diameter of the optic disc or fovea was the sole best indicator of the risk of residual disease (p < 0.001). After excluding these cases, 286 patients were studied for the development of delayed local recurrence, which occurred in 57 cases. Forward stepwise multivariate analysis showed the statistically significant predictors for recurrent tumour to be epithelioid cellularity (p = 0.002), posterior tumour extension to < 1 disc diameter of disc of fovea (p = 0.002), large tumour diameter > or = 16 mm (p = 0.019) and lack of adjunctive plaque radiotherapy (p = 0.018). CONCLUSIONS: The recurrence rate at 4 years varied from 6% if no risk factors were present to 57% if there were more than two risk factors.

BRAF mutations are detectable in conjunctival but not uveal melanomas.

Activating mutations in exon 15 of BRAF have been detected in a high proportion of cutaneous melanomas. To determine whether such mutations are a feature of conjunctival or uveal melanomas, we screened DNA from these tumours. Twenty-one conjunctival and 88 uveal tumours were included in the study. Mutation analysis of BRAF exons 11 and 15 was undertaken using a combination of conformationally sensitive gel electrophoresis and direct sequencing. Mutations in exon 15 were detected in three of the conjunctival tumours (two V599E and one E585 K). None of the uveal tumours possessed a BRAF mutation in either exon 15 or 11. We conclude that uveal melanomas arise independently of oncogenic BRAF mutations, but the development of a proportion of conjunctival tumours involves mutation of this gene.

Staging of Ciliary Body and Choroidal Melanomas Based on Anatomic Extent

PURPOSE To refine the anatomic classification and staging of ciliary body and choroidal melanomas in the TNM classification. PATIENTS AND METHODS Tumor largest basal diameter and thickness of 7,369 patients were analyzed based on registry data from five ocular oncology centers. T categories were derived empirically by dividing data into blocks representing 3- × 3-mm fractions. Blocks with similar survival were grouped together so that no T category comprised a large majority of tumors, and each was uniform in survival, using randomly drawn 60% building and 40% validation data sets. Presence of ciliary body involvement (CBI) and extraocular extension (EXE) was analyzed among 5,403 patients to define T subcategories. Stages were generated by iteratively combining subcategories with similar survival. RESULTS Of the 7,369 tumors analyzed, 24% were classified as T1, 33% as T2, 31% as T3, and 12% as T4. Ten-year Kaplan-Meier survival estimates for the T categories were 89%, 77%, 58%, and 39%, respectively (P < .001). Survival of patients in four subcategories based on presence or absence of CBI and EXE differed significantly within each T category (P = .018 for T1; P < .001 for T2 to T4). EXE exceeding 5 mm in largest diameter carried a worse prognosis than smaller extensions (P < .001) and was assigned a separate subcategory. Ten-year Kaplan-Meier survival estimates for stages I, IIA to IIB, and IIIA to IIIC were 88%, 80%, 67%, 45%, 27%, 10%, respectively (P < .001). CONCLUSION This evidence-based anatomic classification provides a basis for staging ciliary body and choroidal melanomas in the seventh edition of the Cancer Staging Manual of the American Joint Committee on Cancer.