N Lakotka

Proton Beam Therapy of Parapapillary Choroidal Melanoma

PURPOSE To analyze the functional outcome with regard to the development of visual acuity and radiation-induced optic neuropathy of patients with parapapillary choroidal melanoma treated with proton beam therapy. DESIGN Clinical case series, retrospective study. METHODS We evaluated 147 consecutive patients with parapapillary choroidal melanoma who received proton beam therapy as primary tumor treatment at the Helmholtz Center in Berlin from 1998 to 2005. A cumulative dose of 60 Cobalt Gray Equivalents (CGE) was delivered to the tumor and the optic disc received a minimum of 50 CGE. Kaplan-Meier analysis was used to assess ocular outcome and survival rates. For trend analysis of functional development, Wilcoxon-Mann-Whitney U test was used to compare the medians of 2 groups and Kruskal-Wallis test was used in the case of more than 2 groups. RESULTS The mean follow-up time was 6.5 years (range 0.3-11.7 years). The most common side effects were radiation-induced optic neuropathy, retinopathy, and cataract. The median visual acuity before and within the first year after therapy was 0.4 logMAR (20/50), lapsing to 1.3 logMAR (20/400) after 3 years and 1.4 logMAR (20/500) after 5 years. During follow-up, no light perception developed in 17 cases (11.6%), mostly attributed to radiation-induced retinopathy, optic neuropathy, and secondary glaucoma. Enucleation was carried out in 14 patients (9.5%) because of local recurrence or severe side effects. CONCLUSION Radiation-induced optic neuropathy is an expected issue after proton beam therapy of parapapillary choroidal melanoma, and visual impairment is common during long-term follow-up, but some useful vision can be preserved in a considerable number of patients.

Proton beam radiotherapy of diffuse iris melanoma in 54 patients

Background Treatment modalities in iris melanoma include excision, plaque radiotherapy, photon or proton beam therapy and enucleation. In extensive tumours and diffuse seeding, radiotherapy remains as an alternative to enucleation. Methods This study is a retrospective, consecutive, interventional, single-institutional case series. 54 patients with a diffuse and non-resectable iris melanoma diagnosed from September 1998 to June 2012 were included. A 68-megaelectron volt proton beam was used to treat the anterior segment with a total dose of 4×12.5 cobalt grey equivalent. The cases were evaluated for local tumour control, eye retention, functional outcome and local complications after treatment. Results During a mean follow-up of 62.7 months (median 54.8 months, range 5.5–159.6 months), local tumour control was achieved in 96.3% of the patients. Cataract and glaucoma were the main complications developing after irradiation in 42.6% and 55.6%, respectively. In 34 of 44 patients (77.3%) who underwent cataract removal, a visual acuity of 20/40 or better following surgery was preserved. Enucleation was performed in three patients. The reason was suspected tumour recurrence in one and glaucoma in two. Hepatic metastasis occurred in one patient. Conclusions As an alternative to enucleation, whole anterior segment fractionated proton beam radiotherapy offered excellent local tumour control in diffuse iris melanoma. Given the limited alternatives, the rate of complications appears acceptable and visual function could be preserved in the majority of the patients during follow-up.

Diagnostik und Therapie choroidaler Melanome

BACKGROUND Prognosis evaluation of patients with choroidal and ciliary melanoma has experienced recent progress through tumour sampling and cytogenetic analysis of metastatic risk. By allocating tumor extension, height and linear basal diameter to defined TNM stages, an estimation of prognosis can also be made without invasive tissue sampling. METHODS Therapeutic strategies of organ preserving irradiation using different sources have clearly come to the forefront. RESULTS Due to microscopic haematogenous spreading of tumour cells prior to treatment, the metastatic risk following radiation of any form is not influenced in comparison to primary enucleation. CONCLUSION However, metastatic disease still remains a fatal condition which currently may only be influenced by early detection and treatment of uveal melanomas.

Minimalinvasive Therapie der exsudativen Amotio nach Radiatio durch Vitrektomie und Endotamponade mit Laserung der Tumoroberfläche

Einleitung: Aderhautmelanome gehen oft mit einer visusbedrohenden, exsudativen Begleitablatio einher. Eine Endoresektion des Tumorgewebes ist bei zentralen Tumoren mit einer unabdingbaren Visusminderung, bei Ziliarkorpertumoren mit einer erhohten Blutungsgefahr verbunden. Diese Studie untersucht, ob die alleinige Vitrektomie mit Endodrainage und Silkonoltamponade in Kombination mit einer intraoperativen Laserung der Tumoroberflache zu einer dauerhaften Netzhautanlage fuhren kann. Methodik: Es wurden 26 Patienten mit choroidalen Melanomen (n=24 mit AHMM, n=2 mit AHZKMM) untersucht, die im Zeitraum von 2003–2011 nach Protonentherapie (N=24) oder Ruthenium (n=2) bei persistierender, exsudativer Ablatio eine PpV mit Silikonoltamponade erhalten haben. Untersucht wurden Tumorkontrolle, Visus, Netzhautanlage und Komplikationen. Ergebnisse: Follow-Up Zeit betrug im Median 17,1 Monate (4,2–95,1) Monate. Die Tumorprominenz betrug im Median 6,1mm bei einem maximalen Durchmesser von 14,4mm vor Bestrahlung. Im Follow-Up lag die Prominenz bei 3,4mm (p<0,004). Die Zeit zwischen Protonen/Ruthenium und PpV lag bei durchschnittlich 4,2 Monaten, nach durchschnittlich 7,5 Monaten wurde das Ol wieder entfernt. Die Netzhaut lag bei 11 (n=13) Patienten nach primarer Olentfernung dauerhaft an, bei den 2 Patienten nach Re-PpV und Gas auch dauerhafte Netzhautanlage. Im Follow-Up nach 17,1 Monaten ist bei 13 Patienten noch die Oltamponade vorhanden, alle Patienten mit Netzhautanlage. Der initiale Visus lag bei 0,3 nach DIN, im Follow-Up nach 17,1 Monaten bei 0,1. Eine lokale Tumorkontrolle wurde bei allen Patienten erreicht. Es wurde eine Enukleation wegen eines nicht beherrschbaren Sekundarglaukoms durchgefuhrt, weitere schwere Komplikationen traten nicht auf. Diskussion: Das „minimal invasive“ Vorgehen fuhrte bei diesem Patientenkollektiv zu einem anatomisch zufriedenstellenden Ergebnis mit guter Tumorkontrolle. Weitere Untersuchungen sollen helfen, die Patientengruppe, bei der dieses Vorgehen erfolgversprechend ist, einzugrenzen