Lawrence B. Tena

Initial PET/CT staging for choroidal melanoma: AJCC correlation and second nonocular primaries in 333 patients.

Purpose To report on whole body positron emission tomography/computed tomography (PET/CT) screening for metastasis at diagnosis of primary uveal melanoma. Methods Since August 2003, 333 consecutive patients were diagnosed with uveal melanoma and underwent whole body screening for metastatic disease with PET/CT along with liver function tests and physical examination. Abnormal findings prompted further biopsies, blood tests, imaging, or clinical evaluations for confirmation. The presence of metastatic disease and second cancers were evaluated. Results Using the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) 7th edition criteria, 104 tumors were classified T1 (31%), 162 T2 (49%), 37 T3 (11%), and 30 T4 (9%). Seven of 333 (2.1%; 95% confidence interval [CI] 0.8-4.3) patients had metastatic melanoma. One tumor was a T3 and 6 were T4. Thus, 3% of T3 and 20% of T4 melanomas were found to have metastases at the time of initial diagnosis. Ten patients (3.3%; 95% CI 0.9-5.5) had synchronous second cancers and 28 (8.4%) concurrent benign lesions. The most common metastatic sites were liver (7/7) and bone (2/7). Discussion This study suggests that PET/CT improves the yield of detecting both extrahepatic metastases, especially from tumors defined as AJCC-T4, and synchronous primary cancers, irrespective of the size of the uveal melanoma. With respect to liver metastases, PET/CT demonstrated high sensitivity and positive predictive values, indicating an overall better performance than conventional screening procedures.

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

OBJECTIVEnTo evaluate slotted eye plaque radiation therapy for choroidal melanomas near the optic disc.nnnDESIGNnA clinical case series.nnnPARTICIPANTSnTwenty-four consecutive patients with uveal melanomas that were near, touching, or surrounding the optic disc.nnnINTERVENTIONnSlotted eye plaque radiation therapy.nnnMAIN OUTCOME MEASURESnRecorded characteristics were related to patient, clinical, and ophthalmic imaging. Data included change in visual acuity, tumor size, recurrence, eye retention, and metastasis.nnnRESULTSnFrom 2005 to 2010, 24 consecutive patients were treated with custom-sized plaques with 8-mm-wide, variable-depth slots. Radiation doses ranged from 69.3 to 163.8 Gy (mean, 85.0 Gy) based on delivering a minimum tumor dose of 85 Gy. All treatments were continuously delivered over 5 to 7 days. Mean patient age at presentation was 57 years. Tumors were within 1.5 mm of the optic nerve (n = 3, 13%), juxtapapillary (n = 6, 25%), touching ≥180 degrees (n = 7, 29%), or circumpapillary (n = 8, 33%). Ultrasound revealed dome-shaped tumors in 79% of patients, collar-button tumors in 17% of patients, irregular tumor in 1 patient (4%), and intraneural invasion in 2 patients. Mean initial largest basal dimension was 11.0 mm (standard deviation [SD] ± 3.5 mm; median, 11.4 mm; range, 5.9-16.4 mm). Mean initial tumor thickness was 3.5 mm (SD ± 1.7 mm; median, 3.0 mm; range, 1.4-6.9 mm). Initial visual acuities were a median 20/25 (range, 20/20 to hand motions) and decreased to a median 20/40 (range, 20/20 to no light perception). At a mean follow-up of 23 months, 12 patients required periodic intravitreal bevacizumab to suppress radiation optic neuropathy (RON) or maculopathy. To date, there has been a 100% local control rate. No patients have required secondary enucleation for recurrence or neovascular glaucoma. No patients have developed metastasis.nnnCONCLUSIONSnSlotted plaque radiation therapy allows peripapillary, juxtapapilary, and circumpapillary choroidal melanomas (and a safety margin) to be included in the radiation targeted zone. Normalization of the plaque position beneath the tumor appears to increase RON and improve local control.

Electron beam radiation for conjunctival squamous carcinoma.

Purpose: To describe the authors technique and preliminary results using electron beam radiation as rescue therapy for recalcitrant squamous cell carcinoma of the conjunctiva and cornea. Methods: A retrospective review comprised of an interventional case series of patients with pathologically confirmed diagnosis of squamous cell carcinoma of the conjunctiva and cornea, who had failed multiple standard treatments and underwent electron beam radiation therapy. Outcomes, radiation-related complications, and adverse effects were documented. Mortality and local control rates were calculated by the Kaplan-Meier survival probability method. Results: Eight patients met the inclusion criteria; of these, 6 (75%) were men and 2 (25%) were women, with ages ranging from 38 to 65 years (mean 50 years). One tumor (12.5%) was classified as T2N0M0, 6 (75%) were classified as T3N0M0, and one (12.5%) was classified as T4N0M0. Follow up from electron beam radiation therapy ranged from 3 to 72 months (mean 30.25 months). The most common side effect was erythema and edema of the eyelids with diffuse transient eyelash loss, seen in all patients. Tumor local control and regression after electron beam radiation therapy were noted in 6 patients (75%); recurrence was noted in 2. There was neither metastatic spread nor tumor-related deaths. Conclusions: The authors report a small case series where local tumor control was achieved with electron beam radiation therapy for recalcitrant squamous cell carcinoma of the conjunctiva and cornea. This approach may be considered for patients who fail conventional therapy.

Extrascleral extension of choroidal melanoma: post-enucleation high-dose-rate interstitial brachytherapy of the orbit.

PURPOSEnTo investigate if orbital extension of uveal melanoma can be treated with high-dose-rate (HDR) brachytherapy.nnnMETHODS AND MATERIALSnThis study is a retrospective analysis of the results of a clinical case series was performed on 10 patients. Each underwent primary enucleation for uveal melanoma, was discovered to have orbital extension, and consented for HDR brachytherapy. By American Joint Committee on Cancer (AJCC) initial tumor grading, there was one each (T1c, T2c, T2d, and T3d, three T4c, and two T4d-staged uveal melanomas. One was AJCC-staged R2 due to orbital recurrence presenting 16xa0months after enucleation. (192)Ir HDR brachytherapy involved transcutaneous circumferential orbital incisions allowing for evenly spaced brachytherapy catheters into the orbit. A target dose of 32.85xa0Gy (range, 32.85-34xa0Gy) was delivered in 9-10 twice-daily fractions (range, 3.4-3.65xa0Gy per fraction) over 5 consecutive days. Data analysis included but was not limited to radiation therapy methods, local tumor control, side effects, and metastatic rate.nnnRESULTSnIn the 9 patients who tolerated treatment, there has been no orbital recurrence at a median follow-up of 18xa0months (range, 1-62xa0months). Four patients died of metastatic disease (one presented with a treated solitary liver metastasis before brachytherapy). There was no significant eyelash or eyebrow loss. There was no radiation-induced eyelid erythema, orbital infection, or contracted sockets. All orbits accepted and maintained ocular prostheses.nnnCONCLUSIONSnBrachytherapy was used as an alternative to external beam radiation treatment for postenucleation orbital melanoma. This series reports complete local control, few side effects, and excellent cosmetic results.

Eyelid-Sparing Adjuvant Radiation Therapy for Renal Cell Carcinoma

Purpose: To describe the use of debulking surgery with adjuvant external beam irradiation as an eyelid-sparing treatment for renal cell carcinoma. Design: Interven tional case report. Methods: A 63-year-old male presented with a right upper lid tumor. He had a history of renal cell carcinoma and pulmonary metastasis treated with surgery and systemic chemotherapy. The eyelid tumor was biopsied, followed by debulking surgery and external beam radiation therapy to treat this metastatic tumor. Results: Histopathological evaluation of the excised tumor revealed a metastatic renal cell carcinoma, clear cell type. At 4 months’ follow-up, he had no evidence of recurrence or radiation oculopathy. He was pleased with his cosmetic result. Conclusions: Meta static renal cell carcinoma presenting in the eye and orbit can be the initial manifestation of the primary tumor. It is important to include this tumor in the differential diagnosis of recurrent eyelid lesions. Debulking surgery followed by external beam radiation therapy can be used to control the tumor with an eyelid-sparing cosmetic result.

Palladium-103 plaque radiation therapy for ciliary body melanoma through a functioning glaucoma filtering bleb:

Purpose: To provide a clinical description of the long-term outcome of a 103Pd plaque-irradiated ciliary body melanoma with extrascleral extension while attempting to preserve a subadjacent glaucoma filtering bleb. Methods: A 75-year-old woman with pseudoexfoliative glaucoma for 17 years, 16 years status post argon laser trabeculoplasty, and 15 years status post trabeculectomy in the left eye, was diagnosed with an ipsilateral ciliary body melanoma with visible extrascleral extension. Treatment involved insertion of a 103Pd radioactive plaque over the functioning trabeculectomy, with removal 7 days later. At plaque insertion, amniotic membrane grafts were used to cover the plaque and protect the filtering site. Results: The tumor was successfully treated without clinical evidence of harm to the filtering bleb, with resultant stable intraocular pressure. However, the patient developed blebitis 1.5 years later. Though it resolved with topical antibiotic therapy, the bleb became less succulent. Two years postoperatively, she developed a spontaneous hyphema that resolved after one injection of transscleral bevacizumab 1.25 mg. Her tumor continually regressed in thickness. Without additional glaucoma surgery, her intraocular pressure remained well-controlled on topical medications for 6 years. Conclusions: Ciliary body melanoma with minimal extrascleral extension beneath a functioning filtering bleb can be treated using radioactive plaque therapy. In this case, we were able to achieve both tumor regression and glaucoma control by covering the plaque with an amniotic membrane graft.