Сombined Treatment of Juxtaand Parapapillary Choroidal Melanoma

Purpose. Estimation the local efficacy of the combined treatment — brachytherapy (BT) with laser coagulation (LC) in choroidal melanomas of juxta and parapapillary localization in the long-term follow-up.
Patients and Methods. In 2009–2013, 50 patients with choroidal melanoma of juxta and parapapillary localization were examined and treated, 32 women and 18 men aged from 32 to 76 years old (average — 53.8 ± 9.6 years). The averaged tumor height was 3.8 ± 1.3 mm, basal diameter — 11.2 ± 2.4 mm. The combined organ-preserving treatment included a LC from the optic disc with subsequent BT was performed. The indications for this method were choroidal melanomas of juxta and parapapillary localization (the distance between the optic disc and the central border of the tumor was no more than 1.5 pd), with the absence of subretinal exudate and retinal detachment in this zone. The follow-up period after the combined treatment ranged from 18 to 102 months (Me = 60 months).
Results. Complete tumor resorption was achieved in the majority — 38 (76.0 %) of cases, partial — in 11 (22.0 %) patients, stabilization of the process — only in one (2.0 %) patient, continued growth was not observed in any patient. The initial size of melanoma in patients with complete and partial tumor resorption showed similar averaged values, amounting to 3.8 ± 1.3 mm and 3.6 ± 1.1 mm (p > 0.05), respectively, basal diameter — 11.1 ± 2.4 mm and 11.4 ± 2.4 mm (p > 0.05), respectively. According to the duplex scanning, an increase in the distribution density of bloodflow in the projection of the tumor focus was noted compared with the initial data. In the spectral Doppler flow analysis study, an increase in the linear characteristics of the blood flow in the tumor’s own vessels after LC was recorded. Complications included optic neuropathy (88 %), hemorrhage (36 %) and secondary glaucoma (6 %).
Conclusions. The combined treatment allowed to achieve high therapeutic results — 76.0 % of the total resorption of choroidal melanomas, which have unfavorable localization for BT. Given the main focus of local treatment of the choroidal melanoma on its destruction, this technique can be used to increase the effectiveness of the BT of choroidal melanomas of juxta and parapapillary localization.

1. Shields C.L. The hunt for the secrets of uveal melanoma. Clin Exp Ophthalmol. 2008;36(3):277–280. DOI: 10.1111/j.1442-9071.2008.01717.x

2. Stöckel E., Eichmann M., Flühs D., Sommer H., Biewald E., Bornfeld N., Spaan B., Sauerwein W. Dose distributions and treatment margins in ocular brachytherapy with 106Ru eye Plaques. Ocul Oncol Pathol. 2018;4(2):122–128. DOI: 10.1159/000479558

3. Бровкина А.Ф., Зарубей Г.Д., Вальский В.В. Критерии оценки эффективности брахитерапии увеальных меланом, осложнения, их профилактика. Вестник офтальмологии. 1997;3:14–16. [Brovkina A.F., Zarubej G.D., Val’skij V.V. Criteria of uveal melanoma brachytherapy effectiveness, complications and prevention. Annals of ophthalmology = Vestnik oftal’mologii. 1997;3:14–16 (In Russ.)].

4. Бровкина А.Ф., Зарубей Г.Д., Фишкин Ю.Г. Обоснованность использования брахитерапии при увеальных меланомах юкстапапиллярной локализации. Вестник офтальмологии. 1991;6:41–44. [Brovkina A.F., Zarubej G.D., Fishkin Yu.G. Feasibility of juxtapapillary uveal melanoma brachytherapy. Annals of ophthalmology = Vestnik oftal’mologii. 1991;6:41–44 (In Russ.)].

5. Бровкина А.Ф. Органосохранное лечение увеальных меланом: границы безопасности. Вестник Российской академии медицинских наук. 2007;8:42–45. [Brovkina A.F. Organ-sparing treatment of uveal melanomas: safety borders. Annals of the Russian academy of medical sciences = Vestnik Rossijskoj akademii medicinskih nauk. 2007;8:42–45 (In Russ.)].

6. Finger P.T. Finger’s “slotted” eye plaque for radiation therapy: treatment of juxtapapillary and circumpapillary intraocular tumours. Br J Ophthalmol. 2007;91(7):891–894. DOI: 10.1136/bjo.2007.114082

7. Ярмоненко С.П. Основные физические параметры взаимодействия физических излучений с биологическими объектами. Медицинская радиология и радиационная безопасность. 2010;55(2):71–76. [Jarmonenko S.P. Basic physical parameters of the ionizing radiation interaction with biological objects. Medical radiology and radiation safety = Medicinskaja radiologija i radiacionnaja bezopasnost’. 2010;55(2):71–76 (In Russ.)].

8. Lommatzsch P.K., Lommatzsch R. Treatment of juxtapapillary melanomas. Br J Ophthalmol. 1991;75(12):715–717.

9. Sagoo M.S., Shields C.L., Emrich J., Mashayekhi A., Komarnicky L., Shields J.A. Plaque radiotherapy for juxtapapillary choroidal melanoma: treatment complications and visual outcomes in 650 consecutive cases. JAMA Ophthalmol. 2014;132(6):697–702. DOI: 10.1001/jamaophthalmol.2014.111

10. Damato B.E. Treatment selection for uveal melanoma. Dev Ophthalmol. 2012;49:16–26. DOI: 10.1159/000328251

11. Lane A.M., Kim I.K., Gragoudas E.S. Proton irradiation for peripapillary and parapapillary melanomas. Arch Ophthalmol. 2011;129(9):1127–1130. DOI: 10.1001/ archophthalmol.2011.228

12. Seregard S., Landau I. Transpupillary thermotherapy as an adjunct to ruthenium plaque radiotherapy for choroidal melanoma. Acta Ophthalmol Scand. 2001;79(1):19–22. DOI: 10.1034/j.1600-0420.2001.079001019.x

13. Shields C.L., Shields J.A., Perez N., Singh A.D., Cater J. Primary transpupillary thermotherapy for small choroidal melanoma in 256 consecutive cases: outcomes and limitations. Ophthalmology. 2002;109(2):225–234. DOI: 10.1016/s0161-6420(01)00902-2

14. Tarmann L., Wackernagel W., Avian A., Mayer C., Schneider M., Winkler P., Langmann G. Ruthenium-106 plaque brachytherapy for uveal melanoma. Br J Ophthalmol. 2015; 99(12):1644–1649. DOI: 10.1136/bjophthalmol-2015-306666