Conway R Max, Poothullil Antony M, Daftari Inder K, Weinberg Vivian, Chung Juliet E, O'Brien Joan M
Department of Ophthalmology, University of California, San Francisco 94143-0730, USA.
Arch Ophthalmol. 2006 Jun;124(6):838-43. doi: 10.1001/archopht.124.6.838.
To assess outcomes of proton beam radiotherapy for the treatment of extra-large uveal melanomas in patients specifically referred to the University of California, San Francisco, for ocular conservation therapy. Series patients uniformly refused enucleation both at an outside institution and again as a treatment option after extensive discussion at the University of California, San Francisco.
In a retrospective, nonrandomized cohort study, 21 patients with extra-large choroidal or ciliochoroidal melanomas measuring at least 10 mm in maximum thickness or 20 mm in maximum basal diameter or tumors located within 3 mm of the optic nerve measuring at least 8 mm in maximum thickness or 16 mm in maximum basal diameter met inclusion criteria. Main outcome measures were frequency of (1) anterior segment complications (lash loss, keratopathy, cataract, and neovascular glaucoma), (2) posterior segment complications (vitreous hemorrhage, radiation retinopathy, and radiation papillopathy), (3) treatment failure (tumor growth, enucleation, or metastases), and (4) final visual acuity.
Median follow-up was 28 months. Mean age at treatment was 58.3 years. The frequencies of hypertension and diabetes mellitus were 14.3% and 9.5%, respectively. Mean tumor thickness and mean basal diameter were 8.6 mm and 18.7 mm, respectively. Lash loss occurred in 52.4%; dry eye, in 23.8%; cataract, in 28.6%; neovascular glaucoma, in 38.1% (100% in patients with diabetes mellitus); radiation retinopathy, in 9.5%; and radiation papillopathy, in 9.5%. No patient developed radiation-associated scleral necrosis or vitreous hemorrhage. The 2-year Kaplan-Meier estimate of local tumor growth after treatment was 33%, and the rate of distant metastasis was 10%. Visual acuity of 20/200 or better was preserved in 25% of patients, including 4 patients (19%) who experienced an average of 4 lines of Snellen visual acuity improvement. Development of neovascular glaucoma was associated with tumors in close proximity to the optic nerve (P = .04), while cataract (P = .03) and lash loss (P = .02) occurred with more anteriorly located tumors. Proton beam radiotherapy provided a 67% probability of local control and 90% probability of clinically discernible metastases-free survival at 24 months after treatment.
Proton beam radiotherapy is an ocular-conserving option that may be considered for the treatment of extra-large uveal melanoma in carefully selected patients.
评估质子束放射治疗用于治疗特大葡萄膜黑色素瘤患者的疗效，这些患者专门转诊至加利福尼亚大学旧金山分校接受眼球保留治疗。系列患者在外部机构时均拒绝眼球摘除，在加利福尼亚大学旧金山分校经过广泛讨论后再次将其作为一种治疗选择予以拒绝。
在一项回顾性、非随机队列研究中，21例患有特大脉络膜或睫状体脉络膜黑色素瘤的患者符合纳入标准，这些患者的肿瘤最大厚度至少为10mm，或最大基底直径至少为20mm，或位于距视神经3mm以内且最大厚度至少为8mm或最大基底直径至少为16mm。主要结局指标为：（1）前段并发症（睫毛脱落、角膜病变、白内障和新生血管性青光眼）的发生率；（2）后段并发症（玻璃体积血、放射性视网膜病变和放射性视乳头病变）的发生率；（3）治疗失败（肿瘤生长、眼球摘除或转移）的发生率；（4）最终视力。
中位随访时间为28个月。治疗时的平均年龄为58.3岁。高血压和糖尿病的发生率分别为14.3%和9.5%。平均肿瘤厚度和平均基底直径分别为8.6mm和18.7mm。睫毛脱落的发生率为52.4%；干眼为23.8%；白内障为28.6%；新生血管性青光眼为38.1%（糖尿病患者中为100%）；放射性视网膜病变为9.5%；放射性视乳头病变为9.5%。没有患者发生与放射相关的巩膜坏死或玻璃体积血。治疗后2年局部肿瘤生长的Kaplan-Meier估计值为33%，远处转移率为10%。25%的患者视力保持在20/200或更好，其中4例患者（19%）平均视力提高了4行Snellen视力表读数。新生血管性青光眼的发生与靠近视神经的肿瘤有关（P = 0.04），而白内障（P = 0.03）和睫毛脱落（P = 0.02）与位置更靠前的肿瘤有关。质子束放射治疗在治疗后24个月时提供了67%的局部控制概率和90%的无临床可察觉转移生存率。
质子束放射治疗是一种可考虑用于精心挑选的特大葡萄膜黑色素瘤患者的眼球保留治疗选择。
