ruthenium-106 plaques by Lommatzsch in East Germany, and by Packer, Rotman, and Sealy, who originally used iodine-125 plaques.79,81
In 1985, the COMS chose to use iodine-125 seeds in standardized gold alloy plaques as the alternative treatment versus enucleation in the medium-sized CM trial. This decision made iodine-125 a clinical standard in North America for more than 16 years. In 1990, Finger realized that the lower-energy photons emitted from palladium-103 seeds would result in less irradiation of most normal ocular structures (and a greater likelihood of vision and eye preservation).81,82
Since that time, select
centers have adopted palladium-103 plaque therapy. At The New York Eye Cancer Center, we suggest pre-operative comparative dosimetry (iodine-125, palladium-103, ruthenium-106) to monitor doses to critical intraocular structures (fovea, optic nerve, lens, opposite eye wall), prior to radionuclide selection for each plaque.17
It is important to note that iodine-125 and palladium-103 plaques deliver photons that can extend deeply into the eye. In contrast, ruthenium-106 plaques emit beta-particles that can only extend far enough to treat 5 mm high tumors reliably.22,25
Like proton therapy, low-energy plaque
Anti-Vascular Endothelial Growth Factor Therapy Prior to the advent of bevacizumab and ranibizumab (Avastin® or Lucentis®, Roche-Genentech, South San Francisco, California, US), more than 50 % of patients were reported to have less than 20/200 vision five years after CM radiation therapy (see Table 1). Though this was all-cause visual morbidity, the most common causes of severe irreversible loss of vision were radiation maculopathy and radiation optic neuropathy. In 1997, Finger reported on short-term findings of reductions in retinal and optic nerve edema, as well as decreased retinal hemorrhage, associated with periodic intravitreal injections of bevacizumab. Later reports, and those of others, have supported these findings.84–86
It has been Finger’s impression that
higher radiation doses to fovea and optic nerve are harder to overcome with this method.
Conclusion Furthermore, the dose to the tumor base and
tumor margin can be four times higher in treatment of the same 5 mm-tall CM using iodine-125 versus ruthenium-106. The high base dose will cause earlier chorioretinal atrophy.17,77,83
irradiation of larger tumors has been associated with more radiation complications. However dry eye, eyelash loss and neovascular glaucoma are relatively uncommon (see Table 1).17
The most frequent low-energy plaque-related complications are radiation retinopathy, radiation optic neuropathy, and cataract.17,68–70
At The New
York Eye Cancer Center, the largest CM basal dimension treated with ophthalmic plaque is 22 mm and the tallest has been 16 mm. Dr Finger’s slotted plaques successfully control tumors that encircle the optic nerve (circumpapillary).71
Therefore, few patients cannot be treated with eye- and vision-conserving ophthalmic plaque radiation therapy.
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2. Bove R, Char DH, Nondiagnosed uveal melanomas, Ophthalmology, 2004;111:554–7.
3. Chin K, Finger PT, Autofluorescence characteristics of suspicious choroidal nevi, Optometry, 2009;80:126–30.
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10. Finger PT, Chin K, Iacob CE, 18-Fluorine-labelled 2-deoxy-2- fluoro-D-glucose positron emission tomography/computed tomography standardised uptake values: a non-invasive biomarker for the risk of metastasis from choroidal melanoma. Br J Ophthalmol 2006;90:1263–6.
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The primary goal of CM treatment is to destroy or remove the malignancy to prevent metastasis. Though enucleation and surgical resection are available, most patients are currently treated with plaque radiation therapy. The most widely used sources are iodine-125 and ruthenium-106 plaques, with a few referral centers using proton beam and palladium-103. Cyberknife and stereotactic radiosurgery are most exotic forms of EBRT and should be considered investigational. We know that all methods of radiation therapy can destroy a CM. However, evidence now exists that radiation dose to fovea, lens, and optic nerve can be used to predict rates of complications.81,82
Therefore, it is reasonable to
compare the available radiation modalities, perform computer-aided simulations, calculate doses to critical structures, and choose the ‘best’ method prior to treatment.
Ophthalmic oncology has progressed from primary enucleation to modern and exotic methods of eye- and vision-sparing radiation therapy. Thankfully, in the modern era, fewer patients have to lose their eye due to the presence of CM. n
12. Finger PT, Kurli M, Reddy S, et al., Whole body PET/CT for initial staging of choroidal melanoma, Br J Ophthalmol, 2005;89:1270–4.
13. Freudenberg LS, Schueler AO, Beyer T, et al., Whole-body fluorine-18 fluordeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in staging of advanced uveal melanoma, Surv Ophthalmol, 2004;49:537–40.
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18. Dendale R, Lumbroso-Le Rouic L, Noel G, et al., Proton beam radiotherapy for uveal melanoma: results of Curie Institut-Orsay proton therapy center (ICPO), Int J Radiat Oncol Biol Phys, 2006;65:780–7.
19. Henderson MA, Shirazi H, Lo SS, et al., Stereotactic radiosurgery and fractionated stereotactic radiotherapy in the treatment of uveal melanoma, Technol Cancer Res Treat, 2006;5:411–9.
20. Collaborative Ocular Melanoma Study Group, Factors predictive of growth and treatment of small choroidal melanoma: COMS Report No. 5, Arch Ophthalmol, 1997;115:1537–44.
21. Margo CE, The Collaborative Ocular Melanoma Study: an overview, Cancer Control, 2004;11:304–9.
22. Damato B, Detection of uveal melanoma by optometrists in the United Kingdom, Ophthalmic Physiol Opt, 2001;21:268–71.
23. Radcliffe NM, Finger PT, Eye cancer related glaucoma: current concepts, Surv Ophthalmol, 2009;54:47–73.
24. Shields CL, Furuta M, Berman EL, et al., Choroidal nevus transformation into melanoma: analysis of 2514 consecutive cases, Arch Ophthalmol, 2009;127:981–7.
25. Damato B, Developments in the management of uveal melanoma, Clin Experiment Ophthalmol, 2004;32:639–47.
26. Accuracy of diagnosis of choroidal melanomas in the Collaborative Ocular Melanoma Study. COMS report no. 1, Arch Ophthalmol, 1990;108:1268–73.
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28. Shields CL, Bianciotto C, Pirondini C, et al., Autofluorescence of choroidal melanoma in 51 cases, Br J Ophthalmol 2008;92:617–22.
29. Shields CL, Mashayekhi A, Materin MA, et al., Optical coherence tomography of choroidal nevus in 120 patients, Retina, 2005;25:243–52.
30. Boldt HC, Byrne SF, Gilson MM, et al., Baseline echographic characteristics of tumors in eyes of patients enrolled in the Collaborative Ocular Melanoma Study: COMS report no. 29, Ophthalmology, 2008;115:1390–7, 1397 e1–2.
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