Robertson Dennis M
Department of Ophtalmology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Am J Ophthalmol. 2003 Jul;136(1):161-70. doi: 10.1016/s0002-9394(03)00265-4.
To review emerging information related to changing concepts in the management of choroidal melanoma.
This perspective reviews and discusses selected studies from the past two decades that have influenced management strategies for large, medium, and small-size choroidal melanomas.
Large choroidal tumors continue to be managed primarily by enucleation. The large tumor trial of the Collaborative Ocular Melanoma Study (COMS) demonstrated neither a positive nor negative effect on 5- and 8-year mortality rates among more than 1000 patients whose eyes containing large choroidal melanomas were randomized to treatment between enucleation alone or enucleation preceded by external radiation. The medium-size tumor trial of the COMS randomized more than 1300 patients between iodine-125 brachytherapy and enucleation. Mortality rates following brachytherapy did not differ from mortality rates following enucleation for up to 12 years after treatment. Iodine-125 has become the most commonly used isotope for brachytherapy in North America. Ten-year follow-up of eyes treated with helium ion and 20 years of experience with proton beam confirm the relative safety and efficacy of these modalities for treatment of choroidal melanoma. Although there is a trend toward earlier treatment of small melanomas, controversy exists regarding the indications for treatment as well as the choice of specific therapy. Recurrences of melanoma after eye-sparing treatment appear to be associated with an increased rate of metastatic disease. Effective adjunctive therapy to prevent or treat melanoma metastasis is lacking.
Choroidal melanoma is a lethal tumor. Although evidence suggests that patients with untreated choroidal melanomas have a poorer prognosis than patients who receive treatment, our current treatments are unable to prevent tumor-related deaths for many patients. The use of preoperative external radiation as an adjunct to enucleation for large choroidal melanomas is unsupported by data from the COMS trial. The use of radiation with either brachytherapy or charged particles for the management of medium-size choroidal melanomas is well supported on the basis of long-term follow-up studies. There is a trend toward treatment of smaller choroidal melanomas. Treatment of melanomas should be directed toward minimizing the potential for recurrences as recurrent melanomas are associated with an increased rate of metastatic disease. Gains in our ability to manage choroidal melanoma will likely be modest at best until effective systemic therapies can be identified.
回顾与脉络膜黑色素瘤管理理念转变相关的新信息。
本观点性文章回顾并讨论了过去二十年中影响大、中、小尺寸脉络膜黑色素瘤管理策略的部分研究。
大型脉络膜肿瘤仍主要通过眼球摘除术进行治疗。协作性眼黑色素瘤研究（COMS）的大型肿瘤试验表明，在1000多名患有大型脉络膜黑色素瘤的患者中，将含肿瘤的眼睛随机分为单纯眼球摘除术组或术前进行外照射后再行眼球摘除术组，在5年和8年死亡率方面，两组既无正面影响也无负面影响。COMS的中型肿瘤试验将1300多名患者随机分为碘 - 125近距离放疗组和眼球摘除术组。治疗后长达12年，近距离放疗后的死亡率与眼球摘除术后的死亡率无差异。碘 - 125已成为北美最常用的近距离放疗同位素。对接受氦离子治疗的眼睛进行的十年随访以及质子束治疗的20年经验证实了这些治疗方式在治疗脉络膜黑色素瘤方面的相对安全性和有效性。尽管有对小黑色素瘤进行早期治疗的趋势，但在治疗指征以及具体治疗方法的选择上仍存在争议。保留眼球治疗后黑色素瘤的复发似乎与转移疾病发生率的增加有关。缺乏有效的辅助治疗来预防或治疗黑色素瘤转移。
脉络膜黑色素瘤是一种致命肿瘤。尽管有证据表明，未经治疗的脉络膜黑色素瘤患者的预后比接受治疗的患者更差，但我们目前的治疗方法无法防止许多患者因肿瘤相关原因死亡。COMS试验的数据不支持将术前外照射作为大型脉络膜黑色素瘤眼球摘除术的辅助治疗方法。基于长期随访研究，使用近距离放疗或带电粒子放疗来治疗中型脉络膜黑色素瘤有充分的依据。存在对较小脉络膜黑色素瘤进行治疗的趋势。黑色素瘤的治疗应旨在尽量减少复发的可能性，因为复发性黑色素瘤与转移疾病发生率的增加有关。在确定有效的全身治疗方法之前，我们管理脉络膜黑色素瘤的能力提升可能最多只能是适度的。
