|
|
| (8 intermediate revisions by 2 users not shown) |
| Line 1: |
Line 1: |
| __NOTOC__ | | __NOTOC__ |
| {{Uveal melanoma}} | | {{Uveal melanoma}} |
| {{CMG}}{{AE}}{{Simrat}}{{Fs}} | | {{CMG}}{{AE}}{{Fs}}, {{Simrat}} |
| ==Overview== | | ==Overview== |
| The optimal therapy for uveal melanoma depends on the size of the [[tumor]]. The various treatment modalities for uveal melanoma include [[enucleation]], plaque [[brachytherapy]], external beam [[proton therapy]], transupillary [[thermotherapy]], [[Gamma Knife]] [[stereotactic radiosurgery]], and resection of the [[tumor]].
| | Pharmacologic medical therapy is recommended among [[Patient|patients]] with [[Metastasis|metastatic]] [[disease]] and include [[chemotherapy]], [[immunotherapy]], and [[targeted therapy]]. |
| | |
| ==Medical Therapy== | | ==Medical Therapy== |
| *The treatment protocol for uveal melanoma has been directed by many clinical studies, the most important being "The Collaborative Ocular Melanoma Study" (COMS). The treatment of uveal melanoma varies according to location, size of the eye melanoma, and the overall health of the patient. However, chief among them is the size of the tumor.
| | Pharmacologic medical [[therapy]] is recommended among [[Patient|patients]] with [[Metastasis|metastatic]] disease:<ref name="pmid29497459">{{cite journal |vauthors=Yang J, Manson DK, Marr BP, Carvajal RD |title=Treatment of uveal melanoma: where are we now? |journal=Ther Adv Med Oncol |volume=10 |issue= |pages=1758834018757175 |date=2018 |pmid=29497459 |pmc=5824910 |doi=10.1177/1758834018757175 |url=}}</ref><ref name="pmid26601868">{{cite journal |vauthors=Shoushtari AN, Carvajal RD |title=Treatment of Uveal Melanoma |journal=Cancer Treat. Res. |volume=167 |issue= |pages=281–93 |date=2016 |pmid=26601868 |doi=10.1007/978-3-319-22539-5_12 |url=}}</ref> |
| *Primary treatment can involve removal of the affected eye (enucleation); however, this is now reserved for cases of extreme tumor burden or other secondary problems.
| |
| *Advances in [[radiation]] therapies have significantly decreased the number of patients treated by [[enucleation]] in developed countries. The most common radiation treatment is plaque [[brachytherapy]], in which a small disc-shaped shield (plaque) encasing radioactive seeds (most often Iodine-125, though Ruthenium-106 and Palladium-103 are also used) is attached to the outside surface of the eye, overlying the tumor. The plaque is left in place for a few days and then removed. The risk of metastasis after plaque [[radiotherapy]] is the same as that of [[enucleation]], suggesting that micrometastatic spread occurs prior to treatment of the primary tumor.
| |
| *Other modalities of treatment include transpupillary [[thermotherapy]], external beam proton therapy, resection of the tumor, [[Gamma Knife]] stereotactic [[radiosurgery]] or a combination of different modalities. Different surgical resection techniques can include trans-scleral partial choroidectomy, and transretinal endoresection.<ref name="wiki"> Uveal melanoma. Wikipedia(2015) https://en.wikipedia.org/wiki/Uveal_melanoma Accessed on October, 27 2015</ref>
| |
| ===Standard treatment options for iris melanoma=== | |
| *Observation with careful follow-up
| |
| :In asymptomatic patients with stable lesions; follow-up includes serial photography.
| |
| *Local resection
| |
| :When progressive and pronounced growth is documented.
| |
| *[[Enucleation]]
| |
| :If the [[tumor]] is not amenable to local resection (diffuse involvement of the iris, involvement of more than 50% of the iris and anterior chamber angle, intractable [[glaucoma]], and extraocular extension).
| |
| *Plaque [[radiation therapy]]
| |
| :Offered as an alternative for large, diffuse, surgically nonresectable lesions of the [[iris]].<ref name="NCI">Uveal melanoma. National Cancer Institute(2015) http://www.cancer.gov/types/eye/patient/intraocular-melanoma-treatment-pdq Accessed on October 24 2015</ref>
| |
| | |
| ===Standard treatment options for ciliary body melanoma===
| |
| *Plaque [[radiation therapy]]
| |
| :Local control rates are high, but treatment is associated with a high incidence of secondary [[cataract]].
| |
| *External-beam, charged-particle [[radiation therapy]]
| |
| :This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.
| |
| *Local [[tumor]] resection
| |
| :This option is mainly suitable for selected ciliary body or anterior choroidal tumors with smaller basal dimension and greater thickness.
| |
| *[[Enucleation]]
| |
| :This option is generally reserved for large melanomas when there is no hope of regaining useful vision. It is also indicated in the presence of intractable secondary [[glaucoma]] and extraocular extension.<ref name="NCI">Uveal melanoma. National Cancer Institute(2015) http://www.cancer.gov/types/eye/hp/intraocular-melanoma-treatment-pdq#section/_119 Accessed on October 26 2015</ref>
| |
| ===Standard treatment options for small choroidal melanoma===
| |
| *Observation
| |
| :This strategy is important for patients with an uncertain diagnosis or in whom tumor growth has not been documented. It is also used for asymptomatic patients with stable lesions (particularly elderly or debilitated patients), and patients with a tumor in their only useful eye.
| |
| *Plaque [[radiation therapy]]
| |
| | |
| :This treatment is used for small- or medium-sized uveal melanomas, [[Amelanotic melanoma|amelanotic]] tumors, or tumors that touch the [[optic disc]] for greater than 3 clock-hours of [[optic disk]] circumference.
| |
| *External-beam, charged-particle [[radiation therapy]]
| |
| | |
| :This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.
| |
| *[[Gamma-Knife]] [[radiation]] [[surgery]]
| |
| :This treatment may be a feasible option for small-sized to medium-sized melanomas.
| |
| *Transpupillary thermotherapy
| |
| :As noted above, this approach has very limited use, but it can be used as a primary treatment or as an adjunctive method to plaque [[radiation therapy]].
| |
| *Local tumor resection
| |
| :This strategy is used mainly for selected [[ciliary body]] or anterior choroidal tumors with smaller basal dimensions and greater thickness.
| |
| *[[Enucleation]]
| |
| | |
| :This approach is used when severe [[Intraocular pressure (IOP)|intraocular pressure]] elevation is a factor. It may also be considered with small- and medium-sized melanomas that are invading the tissues of the optic nerve.<ref name="NCI">Uveal melanoma. National Cancer Institute(2015) http://www.cancer.gov/types/eye/hp/intraocular-melanoma-treatment-pdq#section/_125 Accessed on October 26 2015</ref>
| |
| ===Standard treatment options for medium-sized choroidal melanomas=== | |
| *Plaque [[radiation therapy]]
| |
| *External-beam, charged-particle [[radiation therapy]]
| |
| :This approach is offered at specialized referral centers. It requires careful patient cooperation, with voluntary fixation of gaze.
| |
| *Local eye-wall resection
| |
| *Combined therapy, with ablative laser coagulation or transpupillary [[thermotherapy]] to supplement plaque treatment
| |
| *[[Enucleation]]
| |
| :This approach is considered primarily for diffuse melanomas or for cases in which there is extraocular extension; radiation complications or [[tumor]] recurrence may sometimes make enucleation necessary.<ref name="NCI">Uveal melanoma. National Cancer Institute(2015) http://www.cancer.gov/types/eye/hp/intraocular-melanoma-treatment-pdq#section/_125 Accessed on October 26 2015</ref>
| |
| ===Standard treatment option for large choroidal melanomas===
| |
| | |
| * [[Enucleation]] when the tumor is judged to be too large for eye-sparing approaches.
| |
| ===Standard therapy for extraocular extension and metastatic intraocular melanoma===
| |
|
| |
|
| * Extrascleral extension confers a poor prognosis. For patients with gross [[tumor]] involvement of the orbit, treatment requires orbital exenteration. However, there is no evidence that such radical surgery will prolong life. Most patients with localized or encapsulated extraocular extension are not exenterated. No effective method of systemic treatment has been identified for patients with metastatic ocular melanoma. Available clinical trials should be considered as an option for these patients.<ref name="NCI">Uveal melanoma. National Cancer Institute(2015) http://www.cancer.gov/types/eye/hp/intraocular-melanoma-treatment-pdq#section/_146 Accessed on October 26 2015</ref> | | *'''[[Chemotherapy]]''' |
| ===Standrad therapy for recurrent intraocular melanoma===
| | **[[Dacarbazine]] |
| | **[[Temozolomide]] |
| | **[[Cisplatin]] |
| | **[[Treosulfan]] |
| | **[[Fotemustine]] |
| | *'''[[Immunotherapy]]''' |
| | ** Checkpoint blockade |
| | ***[[Pembrolizumab]] |
| | ***[[Ipilimumab]] + [[nivolumab]] |
| | ***[[Ipilimumab]] + [[nivolumab]] |
| | ***[[Ipilimumab]] + radioembolization |
| | ***[[Ipilimumab]] + [[nivolumab]] +radioembolization |
| | ** TILs (tumor-infiltrating lymphocytes) |
| | **[[T cell]] redirection |
| | **[[Antibody]]–[[drug]] conjugate |
| | *** Glembatumumab vedotin |
| | *[[Targeted therapy|'''Targeted therapy''']] |
| | **[[Protein kinase C|PKC]] ([[protein kinase C]])/ MEK |
| | *** AEB071 + BYL719 |
| | *** Intermittent selumetinib |
| | *** Selumetinib +/– [[paclitaxel]] |
| | ***[[Binimetinib]] + AEB071 |
| | ** Multi-kinase inhibition |
| | ***[[Sorafenib]] (STREAM) |
| | ***[[Cabozantinib]] versus [[temozolomide]]/ [[dacarbazine]] |
| | ** Epigenetic therapy |
| | ***[[Histone deacetylase 2|HDAC]] ([[histone deacetylase]]) inhibition |
| | ****[[Vorinostat]] |
| | ****[[Pembrolizumab]] + entinostat (PEMDAC) |
| | *** BET (bromodomain and extra-terminal motif) inhibition |
| | ** Liver-directed therapy |
| | *** IHP (isolated [[hepatic]] perfusion) |
| | *** PHP (percutaneous isolated hepatic perfusion) with melphalan<br /> |
|
| |
|
| * The prognosis for any patient with the recurring or relapsing disease is poor, regardless of cell type or stage. The question and selection of further treatment depend on many factors, including the extent of the [[lesion]], age and health of the patient, prior treatment, and site of recurrence, as well as individual patient considerations.
| |
| * Surgical resection of [[metastases]] diagnosed subsequent to initial management of [[ocular]] [[melanoma]] in single-center, case series of highly selected patients has been reported. The extent to which the occasional favorable outcomes are the result of strong selection factors is not clear, so this approach cannot be considered standard. Clinical trials are appropriate, and eligible patients should be advised to consider participation in them whenever possible. <ref name="NCI">Uveal melanoma. National Cancer Institute(2015) http://www.cancer.gov/types/eye/hp/intraocular-melanoma-treatment-pdq#section/_69 Accessed on October 26 2015</ref>
| |
| == References == | | == References == |
| {{reflist|2}} | | {{reflist|2}} |
| Line 69: |
Line 48: |
| [[Category:Medicine]] | | [[Category:Medicine]] |
| [[Category:Oncology]] | | [[Category:Oncology]] |
| [[Category:Up-To-Date]] | | [[Category:Up-To-Date]] |
| [[Category:Primary care]]
| |
| [[Category:Surgery]] | | [[Category:Surgery]] |