Medium and Large Choroidal Melanoma
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Enucleation remains the standard therapy for most large choroidal melanomas and melanomas that cause severe glaucoma or invade the optic nerve. One of the two clinical trials of the Collaborative Ocular Melanoma Study (COMS) compared preoperative external-beam radiation therapy plus enucleation to enucleation alone in patients with large choroidal tumors to address the concern that enucleation might precipitate tumor metastasis and shorten survival.[1] After 10 years of follow-up, the cumulative all-cause mortality rate for each treatment arm was 61%. In addition, the 10-year rates of death with histopathologically confirmed melanoma metastasis were not significantly different (45% in the pre-enucleation radiation arm and 40% in the enucleation-alone arm, P = .40).[1][Level of evidence: 1iiA]
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Episcleral radionuclide plaque brachytherapy and external-beam, charged-particle radiation therapy offer patients eye-sparing and vision-sparing alternatives to enucleation.[2,3] Both treatment approaches result in relatively slow regression of uveal melanoma during a period of 6 months to 2 years. Most tumors regress to approximately 50% of their original thickness; only occasionally does a tumor regress to a completely flat scar.[2] Local control is achieved in a large proportion of treated eyes with either technique. The probability of visual preservation and of eye retention with either method is related to tumor size and location.
Plaque brachytherapy is the most frequently used eye-sparing treatment for choroidal melanoma. Iodine 125 (125 I), gold 198 (198 Au), palladium 103 (103 Pd), and other ophthalmic plaques can be effective in the treatment of medium-sized melanomas.[4,5,6,7]125 I is the most commonly used isotope because of its good tissue penetration, accessibility, adequate shielding of the source, and lesser risk to other ocular structures and medical personnel. Methods to ensure proper plaque placement are critical to successful radiation therapy.[8,9,10,11,12]
Results from the second COMS clinical trial, which compared 125 I plaque brachytherapy to enucleation in patients with medium-sized choroidal tumors, revealed no significant difference in cumulative all-cause mortality between the two study arms at 12 years of follow-up (43% for 125 I plaque brachytherapy vs. 41% for enucleation; risk ratio = 1.04; 95% CI, 0.86-1.24).[13][Level of evidence: 1iiA] In addition, the 12-year rates of death with histopathologically confirmed melanoma metastasis did not differ significantly between the 2 study arms (21% in the 125 I brachytherapy arm and 17% in the enucleation arm, P = .62). Among the patients treated with 125 I brachytherapy, 85% retained their eye for 5 years or more, and 37% had visual acuity better than 20/200 in the irradiated eye 5 years after treatment.[14]
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