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BACKGROUND: In the past few decades, the primary management for uveal melanoma has evolved from enucleation to eye-preserving treatments. However, despite achieving a high rate of local tumour control, complications following eye-preserving treatments still occur and are partly responsible for functional loss and secondary enucleation. METHODS: A literature review by a broad international panel. RESULTS: We summarised the current literature on utilizing vitreoretinal (VR) surgery for managing the complications of uveal melanoma. We also provided insights from the authors' personal experience and practical recommendations for clinical care. CONCLUSIONS: With the advancement of VR instruments and surgical techniques and the combination of VR and ocular oncology knowledge ("Onco-VR"), it is now possible to manage or even prevent complications such as vitreous haemorrhage, retinal detachment, and toxic tumour syndrome.

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PURPOSE: To evaluate the anatomical and functional outcomes of endoresection and adjuvant ruthenium (Ru)-106 brachytherapy for uveal melanoma (UM). METHODS: Retrospective case series of 15 UM patients (15 eyes) treated at our center (Careggi University Hospital, Florence). RESULTS: Six patients (40%) were male and nine were female (60%). The mean age of patients at the time of treatment was 61.6 years (±19.41). The mean BCVA at baseline was 20/50. In all cases UM originated from the choroid. The mean tumor thickness at baseline was 7.14 mm (±2.05), and the mean largest basal diameter was 11.2 mm (±1.92). A concurrent retinal detachment was diagnosed in 11 patients (73.3%). Two patients (13.3%) showed vitreous seeding at baseline. Eleven patients (73.3%) were treated with primary endoresection, while four patients (26.7%) were treated with a "salvage endoresection" after primary treatment failure (previous radiation treatment). The mean follow-up time was 28.9 months (±10.6). Thirteen out of fifteen patients were alive and showed no evidence of local recurrence or distance metastasis at the last follow-up visit. The treatment achieved local control of the disease in 14 out of 15 cases (93.3%). In one case, the patient underwent enucleation for disease recurrence. The overall survival rate at the end of the follow-up was 93.3%. The mean BCVA at last follow-up visit was 20/40. Treatment was well tolerated, without significant complications. CONCLUSIONS: Endoresection and adjuvant Ru-106 brachytherapy is a valuable conservative option for selected UM patients and can be used both as a primary treatment and as a salvage therapy. It can control melanoma and avoid enucleation, reduce radiation-related complications, and provide tumor tissue for chromosomal analysis and prognostic testing.

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The main objective of this prospective observational study was the characterization of the feasibility and early outcome of image-guided (IG) volumetric modulated arc (VMAT) radiosurgery (SRS) followed by resection for patients with large intraocular melanoma. Our study included consecutive patients with unfavorable-risk melanoma, enrolled in an ophthalmic oncology center. IG-VMAT-SRS was applied by high-resolution 4D image guidance and monitoring. Current stereotactic technique parameters were evaluated for comparison. Side effects and eye function, based on a 5-point CTC assessment score, were quantified. In patients with tumors located more than 0.7-1 mm apart from the optic nerve, partial to complete volume-sparing of the optic nerve head could be achieved. In 95.5% of this subgroup, the vitality of the optic nerve and vision could be preserved by the multimodality-treatment approach (mean follow-up: 18 months (7.5-36 months)). The advanced technology of stereotactic radiotherapy demonstrated the achievability of steep dose gradients around the high-dose volume, with 4D-IG-VMAT dose application. These results enforce IG-VMAT-SRS followed by resection as one of the major therapeutic options for patients with large intraocular melanoma. The combination of 4D-IG high-precision SRS and resection provides an effective treatment for large intraocular melanoma, with few side effects, and enables an eye bulb and even vision preserving modus operandi.

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PURPOSE: To report the use of short-term perfluorocarbon liquid (ST-PFCL) tamponade following choroidal melanoma endoresection. METHODS: Patients with medium to large choroidal melanomas not amenable to primary Ruthenium-106 brachytherapy underwent choroidal melanoma endoresection following gamma knife radiosurgery. During surgery, a complete vitrectomy was performed followed by PFCL injection, then a retinectomy with endoresection of the melanoma and underlying choroid was done. Complete PFCL filling was then achieved, and laser barrage surrounding the retinectomy was done. A Ruthenium-106 plaque was then inserted. Postoperatively, supine positioning was maintained for three days followed by plaque and PFCL removal with silicone oil injection. Several months later, silicone oil was removed. RESULTS: Four eyes of 4 patients underwent endoresection with ST-PFCL tamponade. Mean height of tumor was 8.6 ± 0.85 mm, while mean maximal basal diameter was 11.5 ± 1.1 mm. Mean preoperative logMAR best corrected visual acuity (BCVA) was 1.76 ± 0.18. All patients underwent preoperative gamma knife radiosurgery and postoperative brachytherapy. There were no major intraoperative or postoperative complications. All patients underwent silicone oil injection with PFCL/plaque removal after 3 days, while silicone oil was removed after 4 ± 1.2 months. Mean postoperative logMAR BCVA 3 months following oil removal was 0.89 ± 0.22 (p = 0.02). Mean follow-up duration was 17 ± 2.8 months. No patient developed local tumor recurrence, distant metastases, or vitreoretinal complications by final visit. CONCLUSION: ST-PFCL tamponade may reduce the risk of intraoperative and postoperative complications associated with choroidal melanoma endoresection.

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Surgery in intraocular tumors is done for excision/biopsy and the management of complications secondary to the treatment of these tumors. Excision/biopsy of intraocular tumors can be done via fine-needle aspiration biopsy (FNAB), transretinal biopsy (TRB), partial lamellar sclerouvectomy (PLSU), and endoresection. FNAB, TRB, and PLSU can be used in tumors that cannot be diagnosed by clinical examination and other ancillary testing methods. PLSU is employed in tumors involving the iridociliary region and choroid anterior to the equator. Excisional PLSU is performed for iridociliary and ciliary body tumors with less than 3 clock hours of iris and ciliary body involvement and choroidal tumors with a base diameter less than 15 mm. However, for biopsy, PLSU can be employed with any size tumor. Endoresection is a procedure whereby the intraocular tumor is excised using vitrectomy techniques. The rationale for performing endoresection is based on the fact that irradiated uveal melanomas may cause complications such as exudation, neovascular glaucoma, and intraocular pigment and tumor dissemination (toxic tumor syndrome), and removing the dead tumor tissue may contribute to better visual outcome. Endoresection is recommended 1-2 weeks after external radiotherapy. Pars plana vitrectomy is also used in the management of complications including vitreous hemorrhage, retinal detachment, and epiretinal membrane that can occur after treatment of posterior segment tumors using radiotherapy and transpupillary thermotherapy. It is important to make sure the intraocular tumor has been eradicated before embarking on such treatment.

Asunto(s)

Neoplasias de la Coroides , Melanoma , Neoplasias de la Úvea , Neoplasias de la Coroides/patología , Cuerpo Ciliar , Humanos , Neoplasias de la Úvea/diagnóstico , Neoplasias de la Úvea/cirugía , Vitrectomía/métodos

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AIM: To evaluate the results and complications of secondary endoresection via pars plana vitrectomy for choroidal melanoma and review the previously reported endoresection studies on the treatment of choroidal melanoma. METHODS: The medical records of 6 patients with choroidal melanoma who underwent secondary endoresection between March 2012 and March 2020 were retrospectively reviewed. The indications for secondary endoresection were progressive or recurrent tumor and severe exudative retinal detachment after previous treatment with plaque radiotherapy/Cyberknife radiosurgery/transpupillary thermotherapy (TTT). RESULTS: Before endoresection, 2 eyes had Iodine-125 plaque radiotherapy and TTT, 1 eye had Ruthenium-106 plaque radiotherapy and TTT, 1 eye had Cyberknife radiosurgery and TTT, 1 eye had Cyberknife radiosurgery, and 1 eye had TTT only. Preoperative visual acuity ranged from 20/63 to 20/1600 (Snellen) and from 0.5 to 1.9 (mean: 1.1) on the logMAR scale. The mean tumor base diameters were 9.5×8.7 mm and the mean tumor thickness was 5.4 mm. After secondary endoresection, transient vitreous hemorrhage developed in 2 (33.3%) eyes and retinal detachment in 1 (16.7%) eye. Cytopathological examination revealed epithelioid cell melanoma in 4 (66.7%) eyes and mixed cell melanoma in 1 (16.7%). Melanoma cell type was not specified in 1 (16.7%) eye. At a mean follow-up of 49.6mo (range: 16-90mo), mean visual acuity did not improve and 1 eye was enucleated due to tumor recurrence. Final visual acuity ranged from 20/63 to 20/1600 (Snellen) and from 0.5 to 1.9 (mean: 1.2) on the logMAR scale. Two patients with choroidal melanoma developed metastasis and eventually expired. CONCLUSION: Secondary endoresection seems to be an effective treatment option for globe salvage in choroidal melanoma not responsive to conventional treatment and displaying persistent exudative retinal detachment. There was no visual acuity increase among the treated eyes but globe salvage was possible in most cases in this study.

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INTRODUCTION: The purpose of this study is to report a case of venous-air embolism during a vitrectomy for endoresection of choroidal melanoma. CASE DESCRIPTION: A 31-year-old man went to the clinic because of photopsias and vision loss in his right eye. On fundoscopy of the right eye, a choroidal mass with an associated retinal detachment was found near the inferotemporal vascular arcade. Multimodal imaging was performed and diagnosis of choroidal melanoma was made. Metastatic workup ruled out systemic extension. The patient underwent pars plana vitrectomy for endoresection of the lesion. During the application of laser under air, he started complaining of chest pain and dyspnea. He presented signs of supraventricular tachycardia, tachypnea, hypotension and oxygen desaturation. He was managed with orotracheal intubation, bronchodilators and vasopressor support, and stabilization was achieved. He was discharged 2 days after with no sequalae. After 1-year of follow-up, the patient has a visual acuity of counting fingers and no signs of tumor recurrence or systemic extension. CONCLUSIONS: Although rare, vitreoretinal surgeons should be aware of this potentially fatal complication and take steps to prevent it.

Asunto(s)

Neoplasias de la Coroides , Embolia Aérea , Melanoma , Desprendimiento de Retina , Adulto , Neoplasias de la Coroides/diagnóstico , Neoplasias de la Coroides/cirugía , Humanos , Masculino , Melanoma/cirugía , Recurrencia Local de Neoplasia , Vitrectomía

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Intraocular surgery is tabooed in retinoblastoma management, due to the concern of lethal extraocular spread. We reviewed the outcomes of consecutive children with intraocular retinoblastoma diagnosed at 29 Chinese centers between 2012-2014. We compared the outcomes of three categories of treatment: eye salvage including tylectomy (Group I), eye salvage without tylectomy (Group II), and primary enucleation (Group III). A total of 960 patients (1243 eyes) were diagnosed: 256 in Group I, 370 in Group II, and 293 in Group III; 41 patients abandoned treatment upfront. The estimated 5-year overall survivals (OS) were, for Group I, 94%, for Group II 89%, and for Group III 95%. The estimated 5-year disease-specific survivals (DSS) were, for Group I, 96%, for Group II 90%, and for Group III 95%. Patients in Group I had a significantly higher 5-year DSS than patients in Group II (p = 0.003) and not significantly different than patients in Group III (p = 0.367). Overall survival was not compromised by the inclusion of tylectomy in eye salvage therapy compared to eye salvage without tylectomy or primary enucleation. Disease-specific survival was better when tylectomy was included in eye salvage treatments. Tylectomy as part of multimodal treatment may contribute to the care of retinoblastoma patients with chemotherapy-resistant tumor, eyes with concomitant ocular complications, or at the risk of treatment abandonment.

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BACKGROUND: The aim of this study was to report 2 cases of pulmonary air embolism developing several hours after choroidal melanoma endoresection without the use of air infusion during the surgery, with fatality in 1 patient. METHODS: The method of this study was case report. PARTICIPANTS: Two patients with large choroidal melanomas who collapsed several hours after endoresection without air infusion as a result of pulmonary air embolism. RESULTS: A 72-year-old man collapsed 4 h and 30 min after endoresection without air infusion. Computerized tomography angiography confirmed air embolism. The patient died after 86 min of cardiopulmonary resuscitation. A 41-year-old woman collapsed 5 h and 30 min after endoresection, performed without air infusion and with close monitoring, which included right internal jugular vein catheterization intraoperatively. Transthoracic and transesophageal echography, performed preoperatively, intraoperatively, and postoperatively, revealed air embolism only after collapse occurred. Imaging showed the embolism to be biventricular because of patent foramen ovale. The patient was treated promptly with extracorporeal membrane oxygenation and mechanical ventilation, which resulted in a full recovery. CONCLUSIONS: Air embolism can develop after endoresection for choroidal melanoma, despite avoiding air infusion. Further studies are needed to understand how this occurs. Special measures are indicated to detect this complication and to treat it promptly and effectively.

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Choroidal melanoma, although rare, is the most common primary intraocular malignancy among adults, with an incidence ranging from 6 to 7.5 cases per million per year globally. This tumor originates from the uveal tract's melanocytes in the eye. Melanomas usually arise from the sixth decade of age with increasing incidence with progressive age. A 60-year-old male presented with a right-sided sudden painless decrease in vision due to a grade 4 vitreous hemorrhage. B-scan ultrasonography and CT scan of the orbits revealed a mushroom-shaped choroidal mass highly suggestive of choroidal melanoma, which was managed surgically with pars plana endoresection, endodiathermy, and endolaser. Endoresection can be an effective method for the management of solitary non-metastasized choroidal tumors, especially those that have become symptomatic. Pre and post-surgical imaging are necessary, along with careful follow-up to detect any recurrence.

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Toxic tumour syndrome (TTS) is a particularly aggressive form of secondary vasculopathy occurring after radiation therapy of uveal melanoma due to the persistence of the necrotic tumour mass inside the eye. The development of TTS confers a particularly unfavourable functional and anatomical ocular prognosis, ultimately requiring enucleation in most cases if untreated. Vitreoretinal (VR) surgery has been successfully applied for treatment and prevention of TTS using both resecting and non-resecting techniques. In this systematic review, we aim to define characteristics of uveal melanomas benefiting the most from secondary VR surgery and to outline the optimal type and timing of VR intervention in such cases. Analysis of the literature reveals that endoresection should be performed within 3 months after radiotherapy to tumours thicker than 7 mm and with a largest basal diameter between 8 mm and 15 mm with post-equatorial location, especially after proton beam treatment. Alternatively, endodrainage remains a valid therapeutic option in eyes with macula-off retinal detachment, tumour diameter larger than 15 mm or ciliary body involvement. VR surgery can be successful in the management of TTS following radiotherapy for uveal melanoma when timing and indication are appropriately evaluated.

Asunto(s)

Trastornos Cerebrovasculares/prevención & control , Neoplasias de la Coroides/radioterapia , Neoplasias de la Coroides/cirugía , Melanoma/radioterapia , Melanoma/cirugía , Neoplasias de la Úvea/radioterapia , Neoplasias de la Úvea/cirugía , Cirugía Vitreorretiniana/métodos , Neoplasias de la Coroides/patología , Cuerpo Ciliar , Humanos , Melanoma/patología , Pronóstico , Terapia de Protones , Radioterapia/efectos adversos , Desprendimiento de Retina/patología , Neoplasias de la Úvea/patología , Agudeza Visual

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BACKGROUND: This study aimed to determine the efficacy and complications of intravitreal chemotherapy-assisted endoresection for refractory International Classification of Retinoblastoma (ICRB) group D retinoblastoma in monocular patients. METHODS: In this retrospective case series, intravitreal chemotherapy-assisted endoresection by pars plana vitrectomy was performed in 11 eyes with refractory ICRB group D retinoblastoma unresponsive to standard therapies in monocular patients. RESULTS: Across a mean follow-up period of 42.7 months, globe salvage was attained in all 11 eyes (100%). There were no cases of extra-ocular tumour seeding or remote metastasis. In 9 eyes (81.8%), tumour control was achieved with one pars plana vitrectomy; in 2 cases (18.2%), repeated treatment, such as laser therapy, intravitreal chemotherapy or a second pars plana vitrectomy, was needed. Retinal reattachment was achieved in all 4 eyes (100%) with previous retinal detachment. Four eyes (36.4%) required subsequent cataract surgery due to secondary cataract. Ten eyes (90.9%) had improvement in best-corrected visual acuity at the last follow-up. CONCLUSION: Intravitreal chemotherapy-assisted endoresection appears to be a safe and effective globe-salvaging method for refractory group D retinoblastoma. It is a promising alternative to enucleation and a supplementary therapeutic strategy for those unresponsive to standard therapies, especially for the monocular retinoblastoma patients.

Asunto(s)

Recurrencia Local de Neoplasia/epidemiología , Neoplasias de la Retina/terapia , Retinoblastoma/terapia , Terapia Recuperativa/métodos , Topotecan/administración & dosificación , Vitrectomía/métodos , Quimioterapia Adyuvante/efectos adversos , Quimioterapia Adyuvante/métodos , Niño , Preescolar , Estudios de Seguimiento , Humanos , Lactante , Inyecciones Intravítreas , Terapia Neoadyuvante/efectos adversos , Terapia Neoadyuvante/métodos , Recurrencia Local de Neoplasia/prevención & control , Siembra Neoplásica , Neoplasias de la Retina/patología , Retinoblastoma/patología , Estudios Retrospectivos , Terapia Recuperativa/efectos adversos , Topotecan/efectos adversos , Resultado del Tratamiento , Agudeza Visual , Vitrectomía/efectos adversos , Cuerpo Vítreo/efectos de los fármacos , Cuerpo Vítreo/patología , Cuerpo Vítreo/cirugía

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Objective. To report a rare presentation of solitary retinal capillary hemangioma manifesting with combined retinal detachment as initial presentation and its successful management. Methods. A 35-year-old healthy Indian male presented with combined retinal detachment associated with solitary retinal capillary hemangioma as initial presentation; a clinical entity still not reported in literature. Patient was managed with pars plana vitrectomy combined with retinectomy, endolaser, & silicon oil tamponade with good visual & anatomical recovery. Results. Patient had good clinical outcome with final best-corrected visual acuity (BCVA) of 6/ 24 and well attached retina at last follow-up. Conclusion. Solitary retinal capillary hemangiomas can rarely present with advanced vitreo-retinal complications like combined retinal detachment as initial manifestation that can be effectively managed with skilled & appropriate surgical intervention.

Asunto(s)

Angiografía con Fluoresceína/métodos , Hemangioma Capilar/diagnóstico , Desprendimiento de Retina/etiología , Neoplasias de la Retina/diagnóstico , Curvatura de la Esclerótica/métodos , Agudeza Visual , Vitrectomía/métodos , Adulto , Estudios de Seguimiento , Fondo de Ojo , Hemangioma Capilar/complicaciones , Hemangioma Capilar/cirugía , Humanos , Masculino , Retina/patología , Retina/cirugía , Desprendimiento de Retina/diagnóstico , Desprendimiento de Retina/cirugía , Neoplasias de la Retina/complicaciones , Neoplasias de la Retina/cirugía

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This study compared the cytogenetic profiles of choroidal melanoma samples retrieved before and after proton beam irradiation. Twenty-four consecutive patients who underwent both fine-needle aspiration biopsy (FNAB) during tantalum clip positioning, and endoresection within three months of irradiation, were retrospectively included. Chromosome alterations were explored by array comparative genomic hybridization. Age at diagnosis was 50 ± 14 years, tumor thickness was 8.6 ± 1.7 mm and tumor diameter was 12.4 ± 2.3 mm. Six FNAB samples were non-contributive (25%), versus one endoresection sample (4%) (p = 0.049). Among 17 cases with paired contributive samples, the profiles of chromosomes 3 and 8 were identical in all cases, except one with partial chromosome 3 loss on the FNAB sample only. Three cases presented additional discordant aberrations on chromosomes other than 3 or 8q. Overall, we identified monosomy 3 in two cases, 8q gain in six cases, and both alterations in three cases. All cases presented GNAQ or GNA11 mutations assessed by a custom next-generation sequencing panel. Among the six cases with non-contributive initial FNAB, three cases presented abnormal 3 or 8q chromosomes detected on the endoresection material. These results demonstrate the higher rentability of endoresection material for cytogenetic analysis compared to FNAB, and provide clinical evidence of tumor heterogeneity in choroidal melanoma.

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Local treatment of choroidal melanoma (CM) attracts the attention of many ophthalmology specialists, especially in recent years as the capabilities to target irradiation at small objects and possibilities of surgical interventions on the eyeball have expanded. The article discusses the medical indications for local treatment of CM. Review of literature of the last 16 years and author's own observations on CM patients who underwent almost all kinds of conventional methods of local treatment allowed thorough analysis of indications and counter-indications for their usage. Among the authors who favor local destruction and removal of large CM, the main indication is the possibility to preserve vision and anatomical structures of the eye. This led to unreasonably wide spread of local destruction (removal) of large CM, primarily the endovitreal resection method. However, such metastasis risk factors as CM size and its localization are being overlooked. Literature analysis and author's own observations helped validate the unsafety of the local treatment of large CM. The article features long-term results of contact and distant radiation therapy, and presents CM metrics for best therapeutic effect.

Asunto(s)

Braquiterapia , Neoplasias de la Coroides , Hipertermia Inducida , Melanoma , Neoplasias de la Coroides/terapia , Humanos , Melanoma/terapia , Pupila , Factores de Riesgo

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Uveal melanoma is the most common intraocular malignant tumor, with the choroid being the most common site. Management of choroidal melanoma has evolved greatly over the past years. In the past, the conventional method of treatment was enucleation of the affected eye with a debate regarding the effect of enucleation to promote or prevent metastasis. However, nowadays, there are many therapeutic options available including plaque radiotherapy, proton beam radiotherapy, argon laser photocoagulation, transpupillary thermotherapy, stereotactic radiotherapy using gamma knife, enucleation, and surgical resection of the tumor whether through transscleral approach "Exoresection" or less commonly through internal resection approach "Endoresection." The indications and complications of each technique are reviewed. Although radiotherapy is the primary treatment of choroidal melanoma in most ocular oncology centers, it is used as an adjuvant therapy in combination with surgical resection. Preoperative stereotactic radiotherapy before endoresection and brachytherapy to the surgical bed in both exo and endoresection can effectively decrease the recurrence rate. In this article, we will focus on surgical resection of choroidal melanoma whether endoresection or exoresection. We collected data published in indexed journals and related books.

Asunto(s)

Neoplasias de la Coroides/cirugía , Melanoma/cirugía , Procedimientos Quirúrgicos Oftalmológicos/métodos , Neoplasias de la Coroides/diagnóstico , Humanos , Melanoma/diagnóstico

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PURPOSE: To review long time treatment results in patients with small or medium sized choroidal melanoma who underwent surgical tumor endoresection as a primary treatment when plaque radiotherapy was unable and patients declined enucleation. MATERIALS AND METHODS: Patients were evaluated for best corrected visual acuity (BCVA), and underwent biomicroscopy, indirect ophthalmoscopy, retinography and ultrasound as well as the usual systemic workup. Study inclusion required the absence of scleral invasion or metastasis and an anterior margin not exceeding the pars plana or the ciliary body. Surgery consisted of a clear lens phacoemulsification with a PC-IOL, and a 23-gauge pars plana vitrectomy with anterior vitreous shave, lesional choroidal endodiathermy, followed by 23-gauge probe tumor endoresection and continuous endolaser. Patients were followed at post-operative 1 day, 1 week, 1, 3, and 6 months and then every 6 months with a complete ophthalmological exam including ultrasound biomicroscopy and systemic follow-up at 3, 6 and every 6 months thereafter. RESULTS: Fourteen patients with choroidal melanoma were included the study. Pre-operative BCVA ranged from 20/20 to hand motion (HM): 20/20 (n = 2); 20/60 (n = 1); and HM (n = 10). Pathological analysis confirmed the diagnosis of uveal melanoma in all cases. Mean follow-up was 54.5 months (45-66 months) with a final BCVA ranging from 20/60 to HM: 20/60 (n = 1); 20/60 to 20/200 (n = 10); and HM (n = 2). The eye retention rate in our study was 100%. No intraocular recurrence was observed. One patient died 12 months after surgery from metastatic disease. CONCLUSION: Endoresection appears to be an acceptable alternative to enucleation for the treatment of posteriorly-localized uveal melanoma, with excellent local control and eye salvage rates.

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PURPOSE: To evaluate the treatment of selected patients with uveal melanoma with endoresection and adjuvant ruthenium brachytherapy. METHODS: Thirty-five patients with uveal melanoma not suitable for ruthenium plaque monotherapy were treated with endoresection and adjuvant ruthenium brachytherapy between January 2001 and October 2013. Recurrence-free survival, globe retention, course of visual acuity (VA), occurrence of therapy-related complications and metastasis-free and overall survival were analysed retrospectively. RESULTS: Eight patients (22.9%) had a tumour recurrence after a median follow-up of 49.5 months (range: 21-134 months). Enucleation was necessary in eight patients. Thirty-two patients (91%) had a loss of VA with a median loss of nine lines (range: 0 to -39 lines); VA was stable in three patients and no patients had a gain in VA. Four patients (11.4%) developed radiation retinopathy. Metastases were detected in seven patients (20.0%) during follow-up. The occurrence of metastasis was significantly associated with monosomy 3 (p < 0.0001). Twenty-four patients (68.6%) were alive at the end of follow-up. Five patients (14.3%) died because of uveal melanoma (UM) metastasis. CONCLUSIONS: Endoresection with adjuvant ruthenium brachytherapy is an option for selected patients with UM who cannot be treated with brachytherapy as monotherapy. About two-thirds of eyes can be retained long term without recurrences. Visual acuity cannot be maintained in most cases, and may even decrease considerably. Radiation complications are comparatively rare and not a significant problem.

Asunto(s)

Braquiterapia/métodos , Melanoma/terapia , Radioisótopos de Rutenio/uso terapéutico , Neoplasias de la Úvea/terapia , Anciano , Anciano de 80 o más Años , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Alemania/epidemiología , Humanos , Masculino , Melanoma/diagnóstico , Melanoma/mortalidad , Persona de Mediana Edad , Procedimientos Quirúrgicos Oftalmológicos , Radioterapia Adyuvante , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento , Neoplasias de la Úvea/diagnóstico , Neoplasias de la Úvea/mortalidad , Agudeza Visual

RESUMEN

OBJECTIVE The use of Gamma Knife radiosurgery (GKRS) as monotherapy in the treatment of uveal melanoma (UM) allows clinicians to achieve high local tumor control with low recurrence but does not prevent secondary enucleation due to glaucoma in cases of large tumors. The authors analyzed indications for tumor endoresection (ER), the time interval between irradiation and surgery, and the features and results of performing ER for UM after GKRS. METHODS Thirty-seven patients between 28 and 78 years of age (16 male and 11 female patients) with UM underwent GKRS with a dose of 70 to 80 Gy that was applied to the center of the tumor with complete immobilization of the eye during the procedure. Tumor resection with histological investigation was performed in 24 eyes (transscleral resection was performed in 3 eyes, and ER was performed in 21 eyes) at 3 to 97 days after GKRS, mainly during the first 2 or 3 weeks. As a rule, ER (21 eyes) was performed to treat large, centrally localized, or equatorial UMs with exudative macula-on retinal detachment that reduced vision. The average tumor height was 8.9 mm, and the average width was 13.7 mm at the base. ER for UM included phacoemulsification, microinvasive vitrectomy with transretinal tumor resection, laser photocoagulation, and application of a temporary silicone oil tamponade. Seven patients received intraocular injections of inhibitors of angiogenesis for the prevention and treatment of radiation neuroretinopathy. The follow-up period ranged from 8 to 41 months. RESULTS Preservation of the eyes without tumor recurrence was achieved in all 37 patients after GKRS (monotherapy and combined therapy). One patient died of liver metastases at 21 months after GKRS. In the ER group (21 eyes), drug-resistant glaucoma with low visual acuity appeared in 4 eyes (19%) with long-existing total exudative retinal detachment and delayed operations. Severe radiation neuroretinopathy with macular edema occurred in 4 of 21 cases (19%). Intraocular injections of inhibitors of angiogenesis significantly decreased retinal edema. Residual rhegmatogenous retinal detachment was revealed in 1 eye (4.8%). The conservation of the patient's primary vision or its improvement were observed in 11 eyes (52.4%). Useful vision more than 0.1 was achieved in 12 cases (57%), and more than 0.3 was achieved in 8 cases (38%). CONCLUSIONS As a result of this research, ER for UM after GKRS proved to be an effective method of combined eye-conserving treatment for large centrally localized or equatorial tumors at high risk of the emergence and development of toxic tumor syndrome. Perfect eye immobilization, timely ER, and multiple intraocular injections of inhibitors of angiogenesis saved not only the eye in all cases, but also useful vision in many cases. Close cooperation among radiosurgeons, ophthalmologists, and vitreoretinal surgeons is the key to effective treatment.

Asunto(s)

Melanoma/patología , Melanoma/radioterapia , Radiocirugia , Neoplasias de la Úvea/patología , Neoplasias de la Úvea/radioterapia , Adulto , Anciano , Terapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Invasividad Neoplásica

RESUMEN

This article explores the range of tumor specimens that may be submitted to ophthalmic pathology. The handling of complex enucleation and exenteration is described along with smaller eyelid, conjunctival and corneal specimens. The importance of a good understanding of the unique anatomy of the ocular region and detailed clinical information is emphasized as this results in the taking of appropriate blocks for histology and consequently clinically helpful reports. Recommendations for handling specimens where further tissue is required for molecular studies is discussed.

Asunto(s)

Neoplasias del Ojo/patología , Ojo/patología , Patología/métodos , Biopsia , Enucleación del Ojo , Humanos , Evisceración Orbitaria