 |
|
Combined Plaque Radiotherapy and Transpupillary Thermotherapy for Choroidal Melanoma
Tumor Control and Treatment Complications in 270 Consecutive Patients
Carol L. Shields, MD;
Jacqueline Cater, PhD;
Jerry A. Shields, MD;
Aning Chao, MD;
Hatem Krema, MD;
Miguel Materin, MD;
Luther W. Brady, MD
Arch Ophthalmol. 2002;120:933-940.
ABSTRACT
| |
Objective To evaluate tumor control and treatment complications following plaque
radiotherapy combined with transpupillary thermotherapy for choroidal melanoma.
Design Prospective noncomparative interventional case series.
Intervention All patients received treatment for choroidal melanoma using plaque
radiotherapy followed by 3 sessions of transpupillary thermotherapy provided
at plaque removal and at 4-month intervals.
Participants Two hundred seventy patients with newly diagnosed choroidal melanoma.
Main Outcome Measures The 2 main outcome measures included local tumor recurrence and treatment-related
complications. The clinical data regarding patient features, tumor features,
radiotherapy and thermotherapy parameters were analyzed for their effect on
the 2 main outcomes using Cox proportional hazards regression models.
Results Prior to treatment, the median base of the tumor was 11 mm (range, 4-21
mm) and the median thickness was 4 mm (range, 2-9 mm). Most tumors were located
in the posterior pole with a median proximity of 2 mm to the foveola and 2
mm to the optic disc. The median radiotherapy dose to the tumor apex was 9000
rad. Transpupillary thermotherapy was applied in 3 sessions at 4-month intervals
for a median of 700 mW. The tumor decreased in thickness to a median of 2.3
mm by 1 year and 2.1 mm by 2 years' follow-up with stable findings thereafter.
Using Kaplan-Meier estimates, tumor recurrence was 2% at 2 years and 3% at
5 years. Risk factors for tumor recurrence included macular location of the
tumor epicenter (P = .03), diffuse tumor configuration
(P = .005), and tumor margin extending underneath
the foveola (P = .001). Using Kaplan-Meier estimates,
treatment-related complications at 5 years included maculopathy in 18% of
the participants, papillopathy in 38%, macular retinal vascular obstruction
in 18%, vitreous hemorrhage in 18%, rhegmatogenous retinal detachment in 2%,
cataract in 6%, and neovascular glaucoma in 7%. Enucleation for radiation
complications was necessary in 3 cases (1%).
Conclusion Plaque radiotherapy combined with transpupillary thermotherapy provides
excellent local tumor control with only 3% recurrence at 5 years' follow-up.
INTRODUCTION
PLAQUE RADIOTHERAPY has assumed a major role in the management of posterior
uveal melanoma.1-12
Plaque radiotherapy is a form of brachytherapy in which a radiation implant
is designed and placed surgically on the sclera directly over an intraocular
tumor to provide maximal radiation dose to the tumor, while minimizing the
dose to normal tissues.4 The method of brachytherapy
was first introduced for uveal melanoma in the late 1920s using radon seed
insertion directly into intraocular melanoma.5
Later revisions on the technique allowed transscleral delivery of radiotherapy
via a tagged cobalt 60 implant or plaque sutured onto the episclera.6 Since then, several radioisotopes have been used,
including ruthenium 106, iridium 192, iodine 125, and palladium 103.3 Presently, 125I is the most commonly used
isotope for plaque radiotherapy of choroidal melanoma.
Plaque radiotherapy is designed as an eye-conserving treatment for intraocular
cancers and it is generally tolerated by the ocular structures. A review of
1300 patients with uveal melanoma treated with this method revealed local
ocular irradiation complications such as nonproliferative retinopathy in 42%
of those treated and proliferative retinopathy in 8% of those treated at 5
years' follow-up.7 These complications, combined
with the presence of an intraocular mass and frequent associated serous retinal
detachment, led to ultimate poor visual acuity (20/200 or worse) in 34% of
the patients at 5 years' and 68% of the patients at 10 years' follow-up.8 Thus, despite successful treatment of the uveal melanoma
and preservation of the eye, visual acuity is reduced in most patients.
An important goal of plaque radiotherapy for uveal melanoma is to achieve
local control of the melanoma.9-12
Karlsson et al9 found the 5-year local relapse
following 60Coplaque radiotherapy to be 12%. Lommatzsch et al12 reported a higher cumulative relapse rate of 37%
at 15 years following 106Ru plaque radiotherapy. Wilson and Hungerford11 analyzed a large group of patients with choroidal
melanoma treated with various radiotherapy methods and found that local tumor
recurrence at 5 years' follow-up was 4% with 125I plaque radiotherapy,
11% with 106Ru plaque radiotherapy, and 5% with proton beam radiotherapy.
Their comparative analysis of the 3 treatment methods showed that 125I and proton beam radiotherapy provided greater local tumor control
than 106Ru.
We have been using plaque radiotherapy for almost 30 years in the management
of posterior uveal melanoma. Although we used 60Co, 192Ir,
and 106Ru radioisotopes in the first few years, we currently use 125I almost exclusively. More recently we have used a combination of
plaque radiotherapy combined with argon laser photocoagulation or transpupillary
thermotherapy to secure better local tumor control, especially with those
tumors located near the optic disc and foveola. Transpupillary thermotherapy
using infrared laser is more penetrating and destructive to melanoma than
argon laser photocoagulation and is our preferred adjunctive treatment.13-16 In
this article, we analyze local tumor control and complications using custom-designed 125I plaque radiotherapy combined with transpupillary thermotherapy.
PATIENTS AND METHODS
PATIENT DATA
Data from all patients with the diagnosis of uveal melanoma treated
with 125I plaque radiotherapy combined with subsequent planned
transpupillary thermotherapy on the Ocular Oncology Service, Wills Eye Hospital,
Philadelphia, Pa, between January 1, 1995, and January 1, 2000, were prospectively
collected. Data included features of the patient and tumor as well as irradiation
parameters. Clinical data were then analyzed for the outcomes of tumor recurrence
and treatment-related complications.
Data included patient features at initial examination such as age, race
(African American, Hispanic, Asian, or white), sex
(female or male), medical problems (none, diabetes mellitus, hypertension, or hypercholesterolemia), and
previous or present use of chemotherapy. The best-corrected Snellen visual
acuity was measured at 20 ft (20/20, 20/25, 20/30, 20/40, 20/50, 20/60, 20/70,
20/80, 20/100, 20/200, 20/400, counting fingers, hand motions, light perception,
and no light perception). Reference categories that were used in subsequent
statistical analyses are italicized.
The tumor data included anatomical location (ciliary body, ciliochoroidal,
or choroidal), meridian location of tumor epicenter
(superior, superotemporal, temporal, inferotemporal, inferior, inferonasal, nasal, superonasal, or macula), proximity to optic nerve
and foveola (in millimeters), location of anterior and posterior tumor margins
(iris, ora serrata, between ora serrata and equator, or posterior to equator), largest basal dimension (based on ophthalmoscopy
in millimeters), largest thickness (based on ultrasonography in millimeters),
shape (dome, mushroom, diffuse, or plateau), pigmentation
(amelanotic or melanotic), and subretinal fluid (absent or present).
The 125I radiation plaque data included plaque shape (round, notched, curvilinear, or rectangular), plaque size,
hours of radiation exposure, and total radiation dose (in rad) and radiation
dose rate (rad per hour) to the tumor apex, tumor base, optic disc, foveola,
and lens. The target apex dose was 8000 to 10 000 rad with radiation
design and parameters as previously published.1, 3
Parameters regarding adjuvant treatment with transpupillary thermotherapy
were recorded regarding power setting (milliwatts), spot size (1.2 mm, 2.0
mm, or 3.0 mm), delivery method (indirect ophthalmoscope adapter, slitlamp
adapter), number of treatment spots, total duration of treatment (in minutes),
and tumor uptake (none, light, or heavy). The first session of thermotherapy
was applied at the time of plaque removal in the operating room and the second
and third planned sessions at 4-month intervals were provided in the office
setting at the slitlamp unit using previously published techniques.14-15
Follow-up examinations were generally made at 4-month intervals up to
5 years and 6- to 12-month intervals thereafter. Data regarding tumor recurrence
and treatment-related complications were recorded. Tumor recurrence was defined
as documented tumor growth in thickness of at least 0.4 mm or base of at least
0.2 mm as detected by ophthalmoscopy, fundus photography, or ultrasonography.
Treatment-related complications including radiotherapy- or thermotherapy-induced
retinopathy, maculopathy, papillopathy, macular and extramacular retinal vascular
obstruction, surface wrinkling retinopathy, rhegmatogeneous retinal detachment,
vitreous hemorrhage, cataract, and neovascular glaucoma were recorded. Radiation
retinopathy and maculopathy were defined as retinal capillary bed changes
(nonperfusion, dilation, microaneurysm, or hemorrhage), retinal exudation,
retinal edema, nerve fiber layer infarction, or vascular sheathing.7 Radiation papillopathy was defined as peripapillary
exudation, hemorrhage, or edema, as well as optic disc edema.
STATISTICAL ANALYSIS
The 2 main outcomes in this article were local tumor recurrence and
treatment-related complications. The effect of individual clinical variables
on the development of tumor recurrence was analyzed by a series of univariate
Cox proportional hazards regressions.17 The
correlation among the variables was determined by using Pearson product moment
correlations. All variables were analyzed as discrete variables except for
patient age, intraocular pressure, tumor base, tumor thickness, proximity
to the optic disc, proximity to the foveola, percentage of tumor overhanging
the optic disc, radiation dose, radiation rate, thermotherapy power, and duration
of thermotherapy, which were analyzed as continuous variables and by grouping
into categories. Multivariable analysis was not feasible owing to the few
recurrences. The Kaplan-Meier method was used to estimate local tumor recurrence
and treatment-related complications as a function of time.18
RESULTS
The general information regarding patient demographics is listed in Table 1. The visual acuity at presentation
was 20/20 to 20/50 in 206 eyes (76%), 20/60 to 20/100 in 36 eyes (13%), and
20/200 to no light perception in 28 eyes (10%). Data regarding tumor characteristics
are listed in Table 2. There were
200 melanomas (74%) that were 3 mm or less from the optic disc and 95 melanomas
(35%) that were touching the optic disc. There were 205 melanomas (76%) that
were 3 mm or less from the foveola and 65 melanomas (24%) that were underneath
the foveola. The radiotherapy and thermotherapy parameters are listed in Table 3.
|
|
|
|
Table 1. Plaque Radiotherapy Combined With Transpupillary Thermotherapy
for Choroidal Melanoma in 270 Cases: Patient Demographics*
|
|
|
|
|
|
|
Table 2. Plaque Radiotherapy Combined With Transpupillary Thermotherapy
for Choroidal Melanoma in 270 Cases: Tumor Characteristics
|
|
|
|
|
|
|
Table 3. Plaque Radiotherapy Combined With Transpupillary Thermotherapy
for Choroidal Melanoma in 270 Cases: Treatment Parameters
|
|
|
The patients were followed up for a median of 29 months (mean, 32 months;
range, 5-79 months) from the initiation of plaque radiotherapy and thermotherapy.
The interquartile range (25%-75%) was 17 to 43 months. The final visual acuity
was 20/20 to 20/50 in 101 eyes (37%), 20/60 to 20/100 in 44 eyes (16%), and
20/200 to no light perception (including enucleation) in 125 eyes (46%). The
2 outcomes of local tumor recurrence and treatment-related complications are
summarized in Table 4. Only 5
in the entire group of 270 patients developed local tumor recurrence. The
recurrence was predominantly located on the posterior margin in all 5 cases.
The recurrence was detected at a median interval of 24 months (mean, 21 months;
range, 8-27 months) following plaque radiotherapy and at the time of detection,
the recurrence was less than 1 mm in base in 1 case and 2 mm or greater in
base in 4 cases. Treatment of the recurrence involved further thermotherapy
in 1 case and enucleation in 4 cases. Using Kaplan-Meier estimates, local
tumor recurrence was less than 1% at 1 year's, 2% at 2 years', 3% at 3 years',
and 3% at 5 years' follow-up (Table 4) (Figure 1). By univariable analysis,
factors at the initial examination and treatment predictive of local tumor
recurrence are noted in Table 5
and included tumor epicenter location in the macula (P
= .03), diffuse tumor shape (P = .005), and tumor
extending underneath the foveola (P = .001). Multivariable
analysis was infeasible owing to the few recurrences. Of the 270 patients,
there were 95 tumors (35%) that touched the optic disc and were classified
as juxtapapillary choroidal melanoma. Of these 95 juxtapapillary tumors treated
with plaque radiotherapy combined with transpupillary thermotherapy, 2.5%
(95% confidence interval [CI] = 0.0%-3.2%) recurred by 5 years' follow-up.
Thirty-three of the 95 juxtapapillary tumors hung over the optic disc. When
overhanging the optic disc, the tumor obscured a median of 50% (mean, 47%;
range, 2%-100%) of the optic disc. Only 5% of the patients with tumor overhanging
the optic disc showed tumor recurrence following treatment at 5 years. Of
the 270 patients, there were 65 patients (24%) with tumors underneath the
foveola and 5% showed recurrence at 5 years' follow-up.
|
|
|
|
Table 4. Plaque Radiotherapy Combined With Transpupillary Thermotherapy
for Choroidal Melanoma in 270 Cases: Summary of Outcomes (Tumor Recurrence
and Main Treatment-Related Complications)*
|
|
|
|
|
|
|
Figure 1. Plaque radiotherapy combined with
transpupillary thermotherapy for choroidal melanoma in 270 cases: Kaplan-Meier
estimates of patients free of local tumor recurrence.
|
|
|
|
|
|
|
Table 5. Plaque Radiotherapy Combined With Transpupillary Thermotherapy
for Choroidal Melanoma in 270 Cases: Factors at Initial Presentation Predictive
of Tumor Recurrence
|
|
|
Using Kaplan-Meier estimates, the main treatment-related complications
are summarized in Table 4 and Figure 2. The most common complications at
5 years following treatment included retinopathy in 39% and papillopathy in
38%. Those patients who developed papillopathy generally had tumors within
3 mm of the optic disc (P<.001; relative risk,
1.40; 95% CI, 1.15-1.70).
|
|
|
|
Figure 2. Plaque radiotherapy combined with
transpupillary thermotherapy for choroidal melanoma in 270 cases: Kaplan-Meier
estimates of patients free of radiation retinopathy (A), radiation maculopathy
(B), radiation papillopathy (C), extramacular branch retinal vein obstruction
or branch retinal artery obstruction (D), macular branch retinal vein obstruction
or branch retinal artery obstruction (E), surface wrinkling retinopathy (F),
rhegmatogenous retinal detachment (G), vitreous hemorrhage (H), radiation
cataract (I), neovascular glaucoma (J), and metastasis (K).
|
|
|
Melanoma metastasis developed in 13 patients at 10 years' follow-up.
Kaplan-Meier estimates of the rate of metastasis was 3% at 2 years and 12%
at 5 years (Figure 2K). Twelve of
the 13 patients showed no local tumor recurrence and 1 patient had demonstrated
previous local recurrence.
COMMENT
Several reports have addressed the issue of local tumor recurrence following
radiotherapy of uveal melanoma. In 1989, Karlsson et al9
reported 12% local tumor recurrence at 5 years following 60Co plaque
radiotherapy in 277 patients. They found that the predictors for recurrence
included increasing largest linear tumor dimension and increasing nearness
of the tumor margin to the optic disc. Thus, juxtapapillary melanoma with
large dimension was at greatest risk for recurrence following 60Co
plaque radiotherapy. Later, Lommatszch et al12
published results of long-term tumor control with 106Ru plaque
radiotherapy in 141 eyes with choroidal melanoma managed over 12 years, with
a median follow-up of 17 years. They found cumulative 15-year local tumor
recurrence in 37% and confirmed that greater tumor diameter was the main factor
associated with recurrence. In 1999, Wilson and Hungerford11
reported their experience with plaque radiotherapy using either 125I
or 106Ru applicators as well as proton beam radiotherapy. They
found tumor recurrence at 5 years was 4% with 125I, 11% with 106Ru, and 5% with proton beam radiotherapy. They indicated that 125I provided statistically significant better tumor control than 106Ru. Proton beam radiotherapy showed no significant improvement in
control over 106Ru according to their analysis.
The issue of tumor control is important for conservation of the eye
and visual acuity. More importantly, local tumor recurrence influences the
overall patient survival. Karlsson et al9 found
that patients who displayed local tumor recurrence within the eye were at
greater risk for distant, life-threatening tumor metastasis. Of those with
local recurrence, 42% developed metastasis at 5 years compared with 18% metastasis
in those patients without local recurrence. These results were further confirmed
by Vrabec et al,19 who evaluated survival of
62 patients with local relapse compared with a matched group. They found that
the local relapse group showed metastasis in 42% compared with 13% for those
without local relapse. They speculated that local tumor relapse indicated
greater malignant potential of uveal melanoma.
The technique of combining plaque radiotherapy with thermotherapy was
conceived with the idea of minimizing local recurrence and improving overall
survival. In this study, we found improved local tumor control with 97% at
5 years' follow-up using 125I plaque radiotherapy combined with
thermotherapy (Figure 1), compared
with previous observations of 88% local tumor control using 60Co
applicators. Such control could be owing to many factors including refined
accuracy with localization of the tumor and placement of the plaque, advances
in the adaptation of plaque design for unusual locations such as notched-plaque
design for tumors at or overhanging the optic disc (Figure 3 and Figure 4), improvements in the ability to customize a radioactive plaque for each patient
using an array of 125I seeds rather than the noncustomized approach
with the fixed, standard 60Co applicators, and perhaps the addition
of adjuvant transpupillary thermotherapy.2-4
Thus, the combination of these factors may have allowed for exceptional local
control and likewise preservation of the eye in 99% cases.
|
|
|
|
Figure 3. Documented enlarging juxtapapillary
choroidal melanoma. A, Before treatment, the pigmented tumor abuts the optic
disc and displays orange pigment and associated subretinal fluid. B, Following
plaque radiotherapy combined with thermotherapy, the tumor completely regressed
and, at 3 years' follow-up, the visual acuity remains 20/25.
|
|
|
|
|
|
|
Figure 4. Juxtapapillary choroidal melanoma
overhanging the optic disc. A, Before treatment, the pigmented tumor overhung
the optic disc and measured 4.9 mm in thickness. B, Seven years following
plaque radiotherapy combined with thermotherapy, the tumor completely regressed
to only 1.1-mm thickness. C, At 7 years' follow-up, the visual acuity decreased
to hand motions from radiation papillopathy and maculopathy.
|
|
|
Plaque radiotherapy can be used for uveal melanoma at almost any site
within the eye.20-22
In particular, plaque radiotherapy has been adapted for choroidal melanoma
in technically difficult sites such as juxtapapillary and macular melanomas.
We previously reported local tumor recurrence in 19% of plaque-irradiated
juxtapapillary choroidal melanomas23 and 9%
of plaque-irradiated macular choroidal melanomas24
at 5 years' follow-up. However, when those patients were treated, notched
plaques and thermotherapy were unavailable; thus they were treated with a
standard round plaque. In contrast, in the present study, custom notched plaques
and adjuvant thermotherapy were used in all 95 patients with juxtapapillary
choroidal melanoma (Figure 3 and Figure 4) and we found improved tumor control,
with only 2.5% of patients showing local tumor relapse at 5 years. Of the
33 patients in our group with more advanced juxtapapillary choroidal melanoma
overhanging the optic disc (Figure 4),
recurrence was found in only 5% at 5 years. In these more advanced cases,
a special plaque design with a deeply notched posterior aspect and radioactive
seeds along the margin of the notch provides adequate radiation dose and rate
to the entire tumor, especially the prepapillary portion of the melanoma.
For macular choroidal melanoma, there were 65 patients with tumor extending
underneath the foveola in our present group, and 5% showed recurrence at 5
years, which is an improvement over the previously published recurrence rate
of 9%.24
Tumor control with 125I plaque radiotherapy is equivalent
to that found with proton beam radiotherapy as reported by Wilson and Hungerford11 and now implied in our results using the addition
of supplemental thermotherapy. Gragoudas et al25
found 3% tumor recurrence at 5 years following proton beam radiotherapy of
uveal melanoma. In their report, they included only recurrences that measured
1 mm or larger and excluded those smaller than 1 mm. In our study, all clinically
visible recurrences were included, regardless of size, even as small as 0.2
mm increase in base. Even with the inclusion of all recurrences, our results
are comparable with only 3% relapse at 5 years. If we only included tumor
recurrences of 1 mm or larger, our local relapse rate would have been even
less. This information suggests that plaque radiotherapy and proton beam radiotherapy
performed at experienced centers for ocular oncology provide excellent local
tumor control of choroidal melanoma.
It is important to understand the complications of radiotherapy and
thermotherapy to the eye (Figure 2A-J)
(Table 4).7, 15-16,24, 26
Radiation retinopathy following plaque radiotherapy has been found in 42%
of patients with the development of proliferative retinopathy in 8% at 5 years.7 Factors predictive of retinopathy in patients with
choroidal melanoma treated with 125I applicators included tumor
thickness over 5 mm and elevated tumor base dose rate exceeding 260 rad/h.7 Visual acuity loss is most profound in those patients
with thicker tumors near the optic disc and foveola.8
The vision-threatening complications are greater for patients with tumors
at posterior locations such as those near the optic disc and those in the
macula. At 5 years' follow-up of plaque radiotherapy for juxtapapillary choroidal
melanoma, radiation retinopathy was found in 95% and papillopathy in 58%,
leading to visual loss of at least 3 Snellen lines in 70%.23
Similarly, patients with macular choroidal melanoma underlying the foveola
showed vision impairing radiation maculopathy in 40% and papillopathy in 13%
at 5 years following plaque radiotherapy.24
Our group of 270 patients displayed juxtapapillary tumors in 95 cases (35%)
and subfoveal tumors in 65 cases (24%), explaining the bothersome posterior
segment complications of radiation maculopathy in 18% and papillopathy in
38% at 5 years. Thermotherapy can also lead to visually compromising complications
such as macular retinal vascular obstruction and surface wrinkling retinopathy,
found in 18% and 8% of our patients, respectively, at 5 years.15-16
Plaque radiotherapy for choroidal melanoma provides equivalent local
tumor control and similar posterior segment complications, but substantially
less anterior segment complications than charged particle irradiation using
proton beam or helium ion.10-11
Char et al10 evaluated 184 patients with choroidal
melanoma treated with plaque radiotherapy or helium ion radiotherapy and found
neovascular glaucoma in 11% of the plaque-irradiated group and in 29% of the
helium ion– treated group. Wilson and Hungerford11
found that severe radiation complications and enucleation were less following
plaque radiotherapy compared with proton beam radiotherapy for choroidal melanoma.
Eleven (6%) of 190 eyes treated with 125I plaque radiotherapy required
enucleation compared with 29 (11%) of 267 eyes treated with proton beam radiotherapy.
In our group of 270 patients treated with combined plaque radiotherapy and
thermotherapy, there were 3 patients (1%) who developed neovascular glaucoma.
Using Kaplan-Meier estimates, 7% developed neovascular glaucoma by 5 years'
follow-up. Enucleation for radiation complications was performed in 3 cases
(1%). This may be partly explained by the fact that the tumors in our series
may be slightly smaller with less subretinal fluid than those treated with
charged particle radiotherapy. However, in this series we did treat large
choroidal melanoma with tumor thickness up to 9 mm.
There are limitations that should be realized in this series of patients.
This article provides short-term 6-year results and we expect more local recurrences
with longer follow-up. First, as with any report on posterior uveal melanoma,
tumor recurrence and distant metastasis are ideally evaluated over a follow-up
period of 10 to 20 years. Second, thermotherapy is generally reserved as a
supplemental treatment to radiotherapy for choroidal melanoma posteriorly
in the eye where it is feasible to provide the heat through the dilated pupil.
It may be infeasible to provide thermotherapy to large melanomas, especially
those in the peripheral fundus or with substantial retinal detachment. This
knowledge could skew our patient selection toward those with smaller tumors,
macular or juxtapapillary location, and less subretinal fluid, which could
bias results toward a decreased metastatic rate, but possibly increased macular
and papillary complications. Third, it is difficult to compare our results
with other reports as there are different tumor parameters, treatment techniques,
definitions of recurrence, and follow-up intervals. Additionally, some authors
have used thermotherapy immediately following plaque radiotherapy while others
have delayed thermotherapy and applied it for tumor nonresponse or tumor recurrence
on follow-up.14, 27 However, it
is critical to realize that we represent a tertiary referral center for ocular
tumors so that more difficult cases might be managed by us and included in
a series such as this. Lastly, the number of tumor recurrences was small,
thus the univariable risks predictive for this event are of low power.
In summary, plaque radiotherapy combined with transpupillary thermotherapy
provides excellent intraocular tumor control with local tumor recurrence of
only 3% at 5 years' follow-up. Hopefully, such control will reflect long-term
improved life prognosis.
AUTHOR INFORMATION
Submitted for publication July 10, 2001; final revision received March
4, 2002; accepted March 20, 2002.
This study was supported by the Macula Foundation, New York, NY (Dr
C. L. Shields), and the Eye Tumor Research Foundation, Philadelphia, Pa (Dr
C. L. Shields), and the Paul Kayser International Award of Merit in Retina
Research, Houston, Tex (Dr J. A. Shields).
Corresponding author and reprints: Carol L. Shields, MD, Ocular Oncology
Service, Wills Eye Hospital, Thomas Jefferson University, 900 Walnut St, Philadelphia,
PA 19107 (e-mail: carol.shields{at}shieldsoncology.com).
From the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson
University (Drs C. L. Shields, Cater, J. A. Shields, Chao, Krema, and Materin);
and the Department of Radiation Oncology, Medical College of Pennsylvania,
Hahnemann University (Dr Brady), Philadelphia. The authors have no commercial,
proprietary, or financial interest in any of the products or companies described
in this article.
REFERENCES
| |
1. Shields JA, Shields CL, Donoso LA. Management of posterior uveal melanoma. Surv Ophthalmol. 1991;36:161-195.
FULL TEXT
|
ISI
| PUBMED
2. Shields JA, Shields CL. Management of posterior uveal melanoma. In: Intraocular Tumors: A Text and Atlas.
Philadelphia, Pa: WB Saunders; 1992:171-206.
3. Shields CL, Shields JA, Gunduz K, et al. Radiation therapy for uveal malignant melanoma. Ophthalmic Surg Lasers. 1998;29:397-409.
ISI
| PUBMED
4. Shields JA, Shields CL. Management of posterior uveal melanoma. In: Atlas of Intraocular Tumors. Philadelphia,
Pa: Lippincott Williams & Wilkins; 1999:113-140.
5. Moore RF. Choroidal sarcoma treated by the intraocular insertion of radon seeds. Br J Ophthalmol. 1930;14:145-152.
FREE FULL TEXT
6. Stallard HB. Malignant melanoblastoma of the choroid. Bibl Ophthalmol. 1968;75:16-38.
PUBMED
7. Gunduz K, Shields CL, Shields JA, Cater J, Freire JE, Brady LW. Radiation retinopathy following plaque radiotherapy of posterior uveal
melanoma. Arch Ophthalmol. 1999;117:609-614.
FREE FULL TEXT
8. Shields CL, Shields JA, Cater J, et al. Plaque radiotherapy for uveal melanoma: long-term visual outcome in
1106 patients. Arch Ophthalmol. 2000;118:1219-1228.
FREE FULL TEXT
9. Karlsson UL, Augsburger JJ, Shields JA, et al. Recurrence of posterior uveal melanoma after 60Co episcleral
plaque therapy. Ophthalmology. 1989;96:382-388.
ISI
| PUBMED
10. Char DH, Quivey JM, Castro JR, et al. Helium ions versus iodine 125 brachytherapy in the management of uveal
melanoma: a prospective, randomized, dyanamically balanced trial. Ophthalmology. 1993;100:1547-1554.
ISI
| PUBMED
11. Wilson MW, Hungerford JL. Comparison of episcleral plaque and proton beam radiation therapy for
the treatment of choroidal melanoma. Ophthalmology. 1999;106:1579-1587.
FULL TEXT
|
ISI
| PUBMED
12. Lommatzsch PK, Werschnik C, Schuster E. Long-term follow-up of Ru-106/ Rh-106 brachytherqapy for posterior
uveal melanoma. Graefes Arch Clin Exp Ophthalmol. 2000;238:129-137.
FULL TEXT
| PUBMED
13. Shields JA, Glazer LC, Meiler WF, Shields CL, Gottlieb MS. Comparison of xenon arc and argon laser photocoagulation in the treatment
of choroidal melanomas. Am J Ophthalmol. 1990;109:647-655.
ISI
| PUBMED
14. Oosterhuis JA, Journee-de Korver HG, Keunen JE. Transpupillary thermotherapy: results in 50 patients with choroidal
melanoma. Arch Ophthalmol. 1998;116:157-162.
FREE FULL TEXT
15. Shields CL, Shields JA, Cater J, et al. Transpupillary thermotherapy for choroidal melanoma: tumor control
and visual results in 100 consecutive cases. Ophthalmology. 1998;105:581-590.
FULL TEXT
|
ISI
| PUBMED
16. Shields CL, Shields JA, Perez N, et al. Primary transpupillary thermotherapy for choroidal melanoma in 256
consecutive cases: outcomes and limitations. Ophthalmology. 2002;109:225-234.
FULL TEXT
|
ISI
| PUBMED
17. Lee ET. Statistical Methods for Survival Data Analysis. 2nd ed. New York, NY: John Wiley & Sons; 1992:258.
18. Kaplan E, Meier P. Nonparametric estimation from incomplete observation. J Am Stat Assoc. 1958;53:457-481.
FULL TEXT
|
ISI
19. Vrabec TR, Augsburger JJ, Gamel JW, et al. Impact of local tumor relapse on patient survival after cobalt 60 plaque
radiotherapy. Ophthalmology. 1991;98:984-988.
ISI
| PUBMED
20. Shields CL, Shields JA, De Potter P, et al. Treatment of non-resectable malignant iris tumors with custom designed
plaque radiotherapy. Br J Ophthalmol. 1995;79:306-312.
FREE FULL TEXT
21. Gunduz K, Shields CL, Shields JA, et al. Plaque radiotherapy of uveal melanoma with predominant ciliary body
involvement. Arch Ophthalmol. 1999;117:170-177.
FREE FULL TEXT
22. Gunduz K, Shields CL, Shields JA, et al. Plaque radiotherapy for management of ciliary body and choroidal melanoma
with extraocular extension. Am J Ophthalmol. 2000;130:97-102.
PUBMED
23. De Potter P, Shields CL, Shields JA, Cater JR, Brady LW. Plaque radiotherapy for juxtapapillary choroidal melanoma: visual acuity
and survival outcome. Arch Ophthalmol. 1996;114:1357-1365.
ABSTRACT
24. Gunduz K, Shields CL, Shields JA, Cater J, Freire JE, Brady LW. Radiation complications and tumor control after plaque radiotherapy
of choroidal melanoma with macular involvement. Am J Ophthalmol. 1999;127:579-589.
FULL TEXT
|
ISI
| PUBMED
25. Gragoudas ES, Egan KM, Seddon JM, Walsh SM. Intraocular recurrence of uveal melanoma after proton beam irradiation. Ophthalmology. 1992;99:760-766.
ISI
| PUBMED
26. Summanen P, Immonen I, Kivela T, Tommila P, Heikkonen J, Tarkkanen A. Radiation related complications after ruthenium plaque radiotherapy
of uveal melanoma. Br J Ophthalmol. 1996;80:732-739.
FREE FULL TEXT
27. Seregard S, Landau I. Transpupillary thermotherapy as an adjunct to ruthenium plaque radiotherapy
for choroidal melanoma. Acta Ophthalmol Scand. 2001;79:19-22.
PUBMED
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Plaque Radiotherapy for Choroidal Melanoma Encircling the Optic Disc (Circumpapillary Choroidal Melanoma)
Sagoo et al.
Arch Ophthalmol 2007;125:1202-1209.
ABSTRACT
| FULL TEXT
Extended Follow-up of Small Melanocytic Choroidal Tumors Treated With Transpupillary Thermotherapy.
Win et al.
Arch Ophthalmol 2006;124:503-506.
ABSTRACT
| FULL TEXT
Combined plaque radiotherapy and transpupillary thermotherapy in choroidal melanoma: 5 years' experience
Bartlema et al.
Br. J. Ophthalmol. 2003;87:1370-1373.
ABSTRACT
| FULL TEXT
Enucleation Following Transpupillary Thermotherapy of Choroidal Melanoma: Clinicopathologic Correlations
Singh et al.
Arch Ophthalmol 2003;121:397-400.
FULL TEXT
|
