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Plaque Radiotherapy for Choroidal Melanoma Encircling the Optic Disc (Circumpapillary Choroidal Melanoma)
Mandeep S. Sagoo, MB, PhD, MRCOphth;
Carol L. Shields, MD;
Arman Mashayekhi, MD;
Jorge Freire, MD;
Jacqueline Emrich, PhD;
Jay Reiff, PhD;
Lydia Komarnicky, MD;
Jerry A. Shields, MD
Arch Ophthalmol. 2007;125(9):1202-1209.
Objective To report results of plaque radiotherapy for choroidal melanoma that completely encircles the optic disc (circumpapillary melanoma).
Methods Retrospective medical record review over a 31-year period of 37 consecutive patients. The main outcome measures were treatment complications, long-term visual acuity, enucleation, tumor recurrence, metastasis, and death.
Results The median patient age at treatment was 69 years (range, 20-86 years). The presenting complaint was visual loss in 19 eyes (51%), photopsia in 5 (14%), and visual field loss in 3 (8%). All tumors touched and encircled the optic disc for 360°. The quadrantic location of the main tumor epicenter was superior in 8 eyes (22%), nasal in 10 (27%), inferior in 9 (24%), and temporal in 10 (27%). The median tumor basal diameter was 11 mm (range, 4.8-20 mm) and median tumor thickness was 3.6 mm (range, 1.8-14.8 mm). The optic disc was obscured to some extent by overhanging tumor in 19 cases (52%). The most commonly used isotope for plaque radiotherapy was iodine 125 (n = 34 cases; 92%), and a notched plaque design was used in 34 cases (92%). Planned adjunctive treatment included transpupillary thermotherapy in 17 cases (49%) and argon laser photocoagulation in 6 of 35 cases (17%) with follow-up. Of the 28 eyes with more than 5 months' follow-up (mean, 52 months; median, 46 months; range, 5-234 months), treatment complications included nonproliferative and proliferative retinopathy in 11 (39%) and 7 eyes (25%); maculopathy in 7 (25%); papillopathy in 9 eyes (32%); neovascular glaucoma in 5 (18%); and vitreous hemorrhage in 13 (46%). Pars plana vitrectomy was required in only 2 of 13 eyes (15%) with persistent vitreous hemorrhage. Long-term visual acuity of 20/200 or worse was observed in 13 eyes (62%), and 12 eyes (57%) lost more than 5 Snellen visual acuity lines, excluding 7 cases (25%) in which enucleation was necessary. Recurrence was noted in 4 cases (14%), of which 3 were treated with enucleation and 1 with transpupillary thermotherapy. Systemic metastasis occurred in 1 patient (4%) and there were no melanoma-specific deaths during the study period.
Conclusions Custom-designed plaque radiotherapy is a potential treatment for selected patients with circumpapillary choroidal melanoma. We found satisfactory local tumor control, and globe retention was achieved in 75% of eyes with more than 5 months' follow-up.
Author Affiliations: Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University (Drs Sagoo, C. L. Shields, Mashayekhi, and J. A. Shields), and the Department of Radiation Oncology, Drexel University College of Medicine, Hahnemann Hospital (Drs Freire, Emrich, Reiff, and Komarnicky), Philadelphia, Pennsylvania.
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