What is the diagnosis and treatment for choroidal melanoma (uveal melanoma)?

From the Guidelines

Choroidal melanoma patients with metastatic disease should be considered for treatment with selumetinib, as it has shown improved progression-free survival (PFS) compared to traditional chemotherapy, although overall survival (OS) benefits are still unclear. When considering treatment options for choroidal melanoma, it's essential to weigh the potential benefits and risks of each approach. According to the ASCO guideline on systemic therapy for melanoma 1, selumetinib has demonstrated improved PFS in patients with metastatic uveal melanoma, with a hazard ratio (HR) of 0.46 (95% CI, 0.30 to 0.71) compared to temozolomide or dacarbazine. However, this improvement in PFS did not translate to a significant difference in OS (HR, 0.66; 95% CI, 0.41 to 1.06).

Some key points to consider when treating choroidal melanoma include:

• The importance of early detection and regular monitoring for local recurrence and distant metastasis
• The potential benefits and risks of different treatment options, including radiation therapy, laser therapy, and enucleation
• The need for lifelong monitoring of liver function and imaging studies to detect potential metastasis
• The consideration of systemic therapies, such as selumetinib, for patients with metastatic disease

It's also important to note that the EORTC 18021 trial found significantly greater PFS with hepatic intra-arterial (HIA) delivery of fotemustine compared to intravenous delivery in patients with uveal melanoma and liver metastases (HR, 0.62; 95% CI, 0.45 to 0.84) 1. However, this did not result in a significant difference in OS (HR, 1.09; 95% CI, 0.79 to 1.50). Overall, the treatment of choroidal melanoma requires a comprehensive and individualized approach, taking into account the size and location of the tumor, as well as the patient's overall health and preferences.

From the Research

Choroidal Melanoma Overview

• Choroidal melanoma is a rare malignant tumor and the most common primary intra-ocular neoplasm 2
• Clinical presentation can be non-specific, including photopsia, floaters, progressive visual field loss, and blurry vision 2

Treatment Options

• Ruthenium-106 (Ru-106) plaque brachytherapy is a common eye-preserving treatment for medium-sized choroidal melanomas 3, 4, 5, 6
• Ru-106 brachytherapy provides excellent rates of local control and eye preservation, with 5-year actuarial local control of 96% and 5-year overall and metastases-free survival rates of 79.6% and 76.5%, respectively 3
• Iodine-125 (125I) plaque brachytherapy is also used, with comparable disease-specific and relative 10-year survival rates to Ru-106 for thicker tumors 4

Treatment Outcomes

• Visual acuity outcomes after Ru-106 brachytherapy vary, with 53.8% and 64.2% of patients maintaining best corrected visual acuity ≥20/70 at 12 and 24 months post-irradiation, respectively 5
• Long-term visual outcomes show that 54.2% of patients maintain a visual acuity of ≤0.3 logMAR (Snellen equivalent 6/12) after Ru-106 brachytherapy 6
• Radiation-induced side effects are common, with 20.6% and 42.6% of patients experiencing early and late complications, respectively 6

Prognostic Factors

• Tumor size, location, and patient age affect prognosis, with smaller basal diameter and peripheral location associated with better metastasis-free survival 3
• Older age, lipofuscin, proximity to fovea, final tumor elevation, and radiation maculopathy predict visual loss ≥5 Snellen lines 6