McCannel TA
Fine-needle aspiration biopsy in the management of choroidal melanoma.
Curr Opin Ophthalmol. 2013; 24(3):262-6 [PubMed]

PURPOSE OF REVIEW: Fine-needle aspiration biopsy of choroidal melanoma offers an opportunity to determine the prognosis for metastasis and provide tissue resources for further study to develop molecular-based targeted therapies. Patients increasingly desire as much information as possible about their cancer so that they may plan their lives and investigate new treatments. Physicians who treat choroidal melanoma must become skilled in the technique so that even the smallest tumors, in patients who might benefit most from early treatment, may be safely biopsied. Individualized molecular therapies of the future will be predicated on the results of a patient's fine-needle biopsy.
RECENT FINDINGS: Fine-needle aspiration biopsy for metastatic prognostication was first performed in North America at the Jules Stein Eye Institute, the University of California, Los Angeles in 2004. Subsequent reports from the major ophthalmic oncology centers have since evaluated several platforms for prognostication using mainly DNA-based approaches. Monosomy 3 of the primary tumor is the cytogenetic abnormality most strongly associated with the development of metastasis. The longest clinical follow-up of a cohort of patients at the Jules Stein Eye Institute who underwent biopsy for prognostication reported in 2012 revealed no increase in ocular morbidity or metastatic risk.
SUMMARY: Fine-needle aspiration biopsy for prognostication in choroidal melanoma is the current standard of care because of new molecular knowledge and a more patient-centered approach to healthcare. Future targeted molecular therapies and metastatic surveillance in patients with choroidal melanoma may be directed by the results of fine-needle aspiration biopsy of the primary tumor.

Chen X, He D, Dong XD, et al.
MicroRNA-124a is epigenetically regulated and acts as a tumor suppressor by controlling multiple targets in uveal melanoma.
Invest Ophthalmol Vis Sci. 2013; 54(3):2248-56 [PubMed]

PURPOSE: MicroRNA-124a (miR-124a), an abundant microRNA in the central neuron system, has been linked to tumor progression. Here, we investigated the role of miR-124a in uveal melanoma development.
METHODS: Expression of miR-124a in uveal melanoma cells was examined using real time RT-PCR. The effect of miR-124a on cell proliferation, migration, and invasion was analyzed using MTS assay, flow cytometry, and transwell experiments. The ability of miR-124a to repress tumor growth was tested in vivo. Target genes of miR-124a were first predicted by bioinformatics, confirmed using a luciferase assay, and their expression determined by Western blotting. DNA methylation and histone modification of miR-124a was analyzed by methylation-specific PCR and ChIP assay. Finally, epigenetic drugs were used to alter the expression of miR-124a.
RESULTS: miR-124a expression was downregulated in both uveal melanoma cells and clinical specimens. Transient transfection of miR-124a into uveal melanoma cells inhibited cell growth, migration, and invasion. Moreover, introduction of miR-124a suppressed in vivo growth of tumor. Potential targets of miR-124a were found to include CDK4, CDK6, cyclin D2, and EZH2. Knockdown of EZH2 by siRNA resulted in inhibition of uveal melanoma cell migration and invasion. In addition, miR-124a expression was found to be regulated via epigenetic mechanisms, with its expression restored when cells were treated with a DNA hypomethylating agent, 5-aza-2'-deoxycytidine, and a histone deacetylase inhibitor, trichostatin A.
CONCLUSIONS: Our results demonstrated that miR-124a could function as a potent tumor suppressor by regulation of multiple targets, and was epigenetically silenced in the development of uveal melanoma.

Horwath-Winter J, Schneider MR, Wackernagel W, et al.
Influence of single-fraction Gamma-Knife radiosurgery on ocular surface and tear function in choroidal melanoma patients.
Br J Ophthalmol. 2013; 97(4):466-70 [PubMed]

AIM: To evaluate ocular surface and tear function in patients with choroidal melanoma treated with single-fraction radiosurgery.
METHODS: 36 patients (median age 62 years; range 26-84 years) were enrolled between 2001 and 2006 at a single institution. They were treated with the Leksell Gamma Knife in one fraction with a median dose of 30 Gy (range 25-35 Gy). In both eyes of all patients treated subjective symptom score (visual analogue scale) was evaluated, central corneal sensitivity testing, Schirmer test without local anaesthesia, and corneal and conjunctival staining were performed before therapy and 3, 6, 12, 24 and 36 months thereafter. The respective untreated fellow eye served as control.
RESULTS: Three months after radiosurgery, the subjective dry eye symptom score and lissamine green staining score of the ocular surface were significantly higher in the treated eyes compared with the fellow eyes (p<0.001, p=0.028, respectively). After 12 months, a significant difference between the treated and the fellow eyes in corneal sensitivity (p=0.041) and corneal fluorescein staining (p=0.002) was found when compared with pretreatment values. After 24 months Schirmer test values without local anaesthesia were significantly reduced in the treated eyes vis-à-vis untreated fellow eyes and pretreatment values (p=0.004). The dose applied to the lacrimal gland was significantly correlated to ocular surface staining scores (p=0.001) and Schirmer test values (p=0.026) at 24 months after irradiation.
CONCLUSIONS: Stereotactic single-fraction Gamma-Knife radiotherapy of choroidal melanoma with a median dose of 30 Gy significantly affected ocular surface and tear function and increased dry eye symptoms and signs.

Mierzwa-Dobranowska M, Romanowska-Dixon B
Assessment of the influence of one's education on early diagnosis of multiple primary cancer in patients with uveal melanoma.
Klin Oczna. 2012; 114(2):111-4 [PubMed]

PURPOSE: This study will show a comparison of two groups of patients with uveal melanoma; one group with multiple primary cancer, and a second group with no identifiable second cancer, in terms of education and occupation.
MATERIAL AND METHODS: Study concerns 240 patients, who were isolated from patients being treated with uveal melanoma at the Department of Ophthalmology and Ocular Oncology Jagiellonian University Medical College in the period from 1998 to 2007. On the basis of medical history and medical records 97 patients were diagnosed with the one or more independent primary cancers. These patients were subjected to comparative analysis with a group of 143 patients with uveal melanoma as a control group.
RESULTS: Analyzing the impact of education on the recognition of multiple primary cancer, there were significantly more frequent diagnoses of second primary cancers among patients with secondary and higher education than among those who had primary and vocational education. Among the obtained data on patients in the study group, the largest occupational group (according to the ISCO-88 (COM)) constituted "professionals". In the control group prevailed "craft and related trades workers".
CONCLUSIONS: The results suggest the great importance of knowledge about risk factors for the development of cancer among patients with uveal melanoma and the ensuing more scrupulous search for succesive primary neoplasm and indicate the neccesity of organizing broad prophylactic actions. uveal melanoma, multiple primary cancer.

Mierzwa-Dobranowska M, Romanowska-Dixon B
One's location of residence as an important factor related to the occurrence of multiple primary cancer among patients with uveal melanoma.
Klin Oczna. 2012; 114(2):107-10 [PubMed]

PURPOSE: This study has attempted to analyze the impact of where one lives related to the incidence of multiple primary cancer among patients with uveal melanoma.
MATERIAL AND METHODS: The group that was studied consisted of 240 patients. They were separated from other patients who had been diagnosed and treated with uveal melanoma at the Department of Ophthalmology and Ocular Oncology at Jagiellonian University Medical College in the period between January 1998 to December 2007. Ninety seven patients, diagnosed with another primary cancer, was defined as a test group. The remaining 143 patients constituted the control group.
RESULTS: In the test group individuals were mostly residents of large cities, most often with population of more than 500 thousand inhabitants. The control group represented residents of small towns, each having less than 10000 persons population.
CONCLUSIONS: The findings of this study are pointing to the dependence of the detectability of multiple primary cancer among patients with uveal melanoma on the availability of modern diagnostic methods. uveal melanoma, multiple primary cancer.

Krema H, Heydarian M, Beiki-Ardakani A, et al.
A comparison between ¹²⁵Iodine brachytherapy and stereotactic radiotherapy in the management of juxtapapillary choroidal melanoma.
Br J Ophthalmol. 2013; 97(3):327-32 [PubMed]

AIMS: To compare the treatment efficacy and radiation complications between (125)Iodine brachytherapy and stereotactic radiotherapy in the management of juxtapapillary choroidal melanoma.
METHODS: Consecutive juxtapapillary melanoma patients treated with radiotherapy were included. Patients were divided into two cohorts: patients treated with (125)Iodine brachytherapy and patients with stereotactic radiotherapy. Comparison included the rates postradiotherapy local recurrence, secondary enucleation, metastasis and radiotherapy complications. Kaplan-Meier estimates were used to determine the actuarial rates, and logrank test to compare between the estimates.
RESULTS: We included 94 patients with juxtapapillary melanoma treated with radiotherapy. The brachytherapy cohort included 30 patients and stereotactic radiotherapy was 64. The median follow-up was 46 months in both cohorts. No statistically significant differences existed between the two cohorts on comparing pretreatment clinical data and tumour characteristics. On comparing treatment efficacy, the actuarial rates at 50 months for tumour recurrence were 11% and 7% (p=0.61), secondary enucleation was 11% and 21% (p=0.30) and for metastasis were 4% and 16% (p=0.11), respectively. On comparing treatment complications, the actuarial rates at 50 months for cataracts were 62% and 75% (p=0.1), for neovascular glaucoma 8% and 47% (p=0.002), for radiation retinopathy 59% and 89% (p=0.0001), and for radiation papillopathy 39% and 74% (p=0.003), respectively.
CONCLUSIONS: Both (125)Iodine brachytherapy and stereotactic radiotherapy demonstrate comparable efficacy in the management of juxtapapillary choroidal melanoma. However, stereotactic radiotherapy shows statistically significant higher radiation-induced ocular morbidities at 4 years postradiotherapy.

Harbour JW, Roberson ED, Anbunathan H, et al.
Recurrent mutations at codon 625 of the splicing factor SF3B1 in uveal melanoma.
Nat Genet. 2013; 45(2):133-5 [PubMed]

Uveal melanoma is the most common primary cancer of the eye and often results in fatal metastasis. Here, we describe mutations occurring exclusively at codon 625 of the SF3B1 gene, encoding splicing factor 3B subunit 1, in low-grade uveal melanomas with good prognosis. Thus, uveal melanoma is among a small group of cancers associated with SF3B1 mutations, and these mutations denote a distinct molecular subset of uveal melanomas.

Wen JC, Sai V, Straatsma BR, McCannel TA
Radiation-related cancer risk associated with surveillance imaging for metastasis from choroidal melanoma.
JAMA Ophthalmol. 2013; 131(1):56-61 [PubMed]

OBJECTIVE: To estimate the lifetime attributable risk of cancer associated with whole-body positron emission tomography (PET)/computed tomography (CT) and with CT of the chest, abdomen, and pelvis if performed at various frequencies and for different durations for surveillance of patients with primary choroidal or ciliary body melanoma for distant metastasis.
METHODS: Effective radiation doses for whole-body CT and for CT of the chest, abdomen, and pelvis were calculated using Monte Carlo simulation studies. The effective dose of the PET scan was estimated by multiplying fludeoxyglucose F18 radioactivity with dose coefficients. Lifetime attributable risks of cancer were calculated using the approach described in the Biological Effects of Ionizing Radiation VII report.
RESULTS: For a 50-year-old patient, an annual CT of the chest, abdomen, and pelvis for 10 years carries an estimated lifetime attributable risk of cancer of 0.9% for male patients and 1.3% for female patients, whereas an annual PET/CT each year for 10 years carries an estimated lifetime attributable risk of cancer of 1.6% for male patients and 1.9% for female patients. Lifetime risk was found to be higher in younger, female patients. The lifetime attributable risk of cancer was estimated to be as high as 7.9% for a 20-year-old female patient receiving a PET/CT scan every 6 months for 10 years.
CONCLUSIONS: Aggressive surveillance protocols incorporating CT scanning or PET/CT scanning for detection of metastasis from primary choroidal or ciliary body melanoma appear to confer a significant substantial risk of a secondary malignant tumor in patients who do not succumb to metastatic melanoma within the first few posttreatment years.

Konstantinidis L, Roberts D, Errington RD, et al.
Whole anterior segment proton beam radiotherapy for diffuse iris melanoma.
Br J Ophthalmol. 2013; 97(4):471-4 [PubMed]

AIM: To report the results of whole anterior segment proton beam radiotherapy (PBR) for diffuse iris melanoma.
METHODS: Between 2000 and 2011, 12 patients with iris melanoma received PBR to the entire iris and ciliary body.
RESULTS: Patients had a mean age of 57 years and a median follow-up of 3.5 years (range 1-11.6 years). Tumour iris involvement was 1-4 h in five patients, 5-8 h in four and 9-12 h in three. Angle involvement was 6-8 h in five patients and 9-12 h in seven. The visual acuity (VA) before treatment was 6/5-6/6 in six patients, 6/8-6/9 in three and 6/18-6/38 in three. No tumour recurrence occurred during the follow-up period. Glaucoma treatment was required in 11 of 12 patients. The visual acuity at the last follow-up was 6/5-6/9 in five patients, 6/18-6/24 in three, 6/60-1/60 in two and no light perception in two. Four patients developed varying non-severe degrees of limbal stem cell deficiency, which was treatable with conservative measures.
CONCLUSIONS: Whole anterior segment PBR is a useful alternative to enucleation for diffuse iris melanoma. Most patients will need treatment for glaucoma and some may require treatment for tear-film instability and/or stem cell failure.

Zhao H, Yang M, Zhang X, et al.
The first case of omental metastasis from primary choroidal melanoma.
Jpn J Clin Oncol. 2013; 43(3):314-7 [PubMed]

Choroidal melanoma is the most common intraocular malignancy and can be fatal in half of the patients because of metastatic disease. Metastasis of choroidal melanoma to the omentum is extremely rare and, to our knowledge, no such case has ever been described in the literature. Here we present a 41-year-old Chinese man with an omental metastasis, 5 years after he was diagnosed with a spindle-cell-type malignant melanoma of the choroid and had his left eye enucleated. The patient demonstrated some uncommon symptoms, but the diagnosis was confirmed histopathologically. The cells were positive for S-100, HMB-45 and Melan-A proteins. He underwent a complete tumor resection and concomitantly received chemotherapy, biological treatment and traditional Chinese medicine. At 2-year follow-up, this patient continues to do well.

Dimaras H, Parulekar MV, Kwok G, et al.
Molecular testing prognostic of low risk in epithelioid uveal melanoma in a child.
Br J Ophthalmol. 2013; 97(3):323-6 [PubMed]

AIMS: To characterise a histologically unusual paediatric uveal melanoma by gene expression and karyotypic profiling and assess prognosis.
METHODS: The tumour was studied by histopathology, karyotype analysis, single nucleotide polymorphism and gene expression profile analysis for correlation with clinical outcome.
RESULTS: The tumour had predominantly epithelioid histology. Karyotype analysis showed none of the poor prognosis features normally associated with uveal melanoma. single nucleotide polymorphism analysis revealed no imbalance at chromosome 3. Gene expression profiling indicated low risk disease.
CONCLUSIONS: We report a child remaining relapse-free 6 years after diagnosis of a very rare uveal melanoma, with poor prognosis epithelioid histology, but gene expression profiling that accurately predicted low risk disease.

Perri P, Fiorica F, D'Angelo S, et al.
Ruthenium-106 eye plaque brachytherapy in the conservative treatment of uveal melanoma: a mono-institutional experience.
Eur Rev Med Pharmacol Sci. 2012; 16(14):1919-24 [PubMed]

BACKGROUND: Traditional treatment for uveal melanoma is the enucleation of the eye with outcomes cosmetically unacceptable and loss of useful vision. Plaque brachytherapy, compared to enucleation, had the advantage to preserve the eye with outcomes cosmetically acceptable and preservation of vision.
PATIENTS AND METHODS: From July 1990 to December 2009 one hundred forty-two (142) patients (51 males and 91 females) with small to medium uveal melanoma were treated with 106Ru plaque brachytherapy. The patients underwent a complete staging before brachytherapy with indirect ophthalmoscopy and ultrasounds. Mean tumour thickness was 3.26 mm (1.6-6 mm). The dose scheduled was 80-100 Gy to the apex with a maximum dose of 800 Gy to the sclera.
RESULTS: One hundred forty-two have been treated, nine patients had lost the follow-up and drop out; 133 patients were assessed. Mean follow-up was 7.7 years (6 months-18 years). The overall survival at 5, 10 and 15 years was 92%, 85% and 78% respectively. Cancer fee survival was 95%, 90% and 83%, respectively at 5, 10 and 15 year. Radiation-induced toxicity was represented in 47 patients with a 5 year actuarial survival rate free from complications of 54%.
CONCLUSIONS: 106Ru plaque brachytherapy is a valid approach for treatment of uveal melanoma. This technique is efficacy and safe, with a low toxicity profile.

Bhatia S, Moon J, Margolin KA, et al.
Phase II trial of sorafenib in combination with carboplatin and paclitaxel in patients with metastatic uveal melanoma: SWOG S0512.
PLoS One. 2012; 7(11):e48787 [PubMed] Free Access to Full Article

BACKGROUND: Sorafenib, a multikinase inhibitor of cell proliferation and angiogenesis, inhibits the mitogen-activated protein kinase pathway that is activated in most uveal melanoma tumors. This phase II study was conducted by the SWOG cooperative group to evaluate the efficacy of sorafenib in combination with carboplatin and paclitaxel (CP) in metastatic uveal melanoma.
METHODS: Twenty-five patients with stage IV uveal melanoma who had received 0-1 prior systemic therapy were enrolled. Treatment included up to 6 cycles of carboplatin (AUC = 6) and paclitaxel (225 mg/m(2)) administered IV on day 1 plus sorafenib (400 mg PO twice daily), followed by sorafenib monotherapy until disease progression. The primary endpoint was objective response rate (ORR); a two-stage design was used with the study to be terminated if no confirmed responses were observed in the first 20 evaluable patients. Secondary efficacy endpoints included progression-free survival (PFS) and overall survival (OS).
RESULTS: No confirmed objective responses occurred among the 24 evaluable patients (ORR = 0% [95% CI: 0-14%]) and the study was terminated at the first stage. Minor responses (tumor regression less than 30%) were seen in eleven of 24 (45%) patients. The median PFS was 4 months [95% CI: 1-6 months] and the 6-month PFS was 29% [95% CI: 13%-48%]. The median OS was 11 months [95% CI: 7-14 months].
CONCLUSION: In this study, the overall efficacy of CP plus sorafenib in metastatic uveal melanoma did not warrant further clinical testing when assessed by ORR, although minor tumor responses and stable disease were observed in some patients.
TRIAL REGISTRATION: ClinicalTrials.govNCT00329641.

Kang DW, Lee SC, Park YG, Chang JH
Long-term results of Gamma Knife surgery for uveal melanomas.
J Neurosurg. 2012; 117 Suppl:108-14 [PubMed]

OBJECT: Gamma Knife surgery (GKS) is currently believed to be a safe and minimally invasive modality in the treatment of uveal melanomas. It could be used as an alternative treatment to enucleation, preserving the eyeball as well as visual function. The authors report their experiences with GKS for uveal melanomas for the period from February 1998 to December 2006.
METHODS: Twenty-two patients with uveal melanoma were enrolled in this study. The population consisted of 12 men and 10 women with a mean age of 53.4 years (range 24-79 years). The mean tumor volume was 877 mm(3), and the mean margin dose was 45.6 Gy. The median follow-up period was 67 months (range 3-126 months). All of the patients had received a diagnosis and referral from an ophthalmology clinic; the patients underwent a preoperative orbital examination that included MRI.
RESULTS: Tumor regression was achieved in 20 patients (90.9%), whereas tumor progression was observed in 2 patients (9.1%) 3 years after GKS. The cumulative 1-year and 2-year mean rates of tumor thickness reduction were 18.8% and 42.8%, respectively. The mean rate of tumor volume reduction was 63.7%. The rate of eye retention 5 years after radiosurgery was 77.3% (17 of 22 patients). Overall visual acuity was reduced after GKS in all patients; 14 patients (63.6%) displayed preserved visual function better than hand-movement perception. The most frequent side effect was cataract, which was detected in 9 patients (40.9%); this was followed in frequency by radiation-induced retinopathy in 5 patients (22.7%).
CONCLUSIONS: Gamma Knife surgery provides excellent local control of uveal melanomas with a decrease in volume over time. This procedure not only preserves the eyeball and its potential visual function, but also decreases the potential for hematological dissemination and achieves sufficient local tumor control with a gradual reduction in volume.

Asnaghi L, Handa JT, Merbs SL, et al.
A role for Jag2 in promoting uveal melanoma dissemination and growth.
Invest Ophthalmol Vis Sci. 2013; 54(1):295-306 [PubMed]

PURPOSE: Controlling the spread of uveal melanoma is key to improving survival of patients with this common intraocular malignancy. The Notch ligand Jag2 has been shown to be upregulated in primary tumors that metastasize, and we therefore investigated its role in promoting invasion and clonogenic growth of uveal melanoma cells.
METHODS: mRNA and protein expression of Notch pathway components were measured using qPCR and Western blot in uveal melanoma cell lines. Expression of Jag2 ligand was upregulated using Jag2-GFP-MSCV constructs or downregulated by sh-Jag2 in the uveal melanoma cell lines Mel285, Mel290, 92.1, and OMM1, and the effects on growth and invasion were assessed.
RESULTS: Jag2 was introduced into Mel285 and Mel290 cells, which have low baseline levels of both this ligand and Notch activity. Overall growth of the Jag2-expressing cultures increased somewhat, and a significant 3-fold increase in clonogenic growth in soft agar was also noted. Introduction of Jag2 increased motility in both wound-healing and transwell invasion assays. We also observed a significant increase in Jag2 and Hes1 mRNA in invasive OMM1 cells that had passed through a Matrigel-coated filter in the transwell assay when compared with noninvading cells. Loss-of-function studies performed in 92.1 and OMM1 lines using Jag2 shRNAs showed that downregulation of the ligand significantly suppressed cellular growth, invasion, and migration.
CONCLUSIONS: Our data suggest that Jag2 may play an important role in promoting Notch activity, growth, and metastasis in uveal melanoma.

Vu TH, Bronkhorst IH, Versluis M, et al.
Analysis of inflammatory cells in uveal melanoma after prior irradiation.
Invest Ophthalmol Vis Sci. 2013; 54(1):360-9 [PubMed]

PURPOSE: Primary uveal melanomas with a poor prognosis contain high numbers of infiltrating macrophages, especially of the M2 phenotype, as well as lymphocytes. We wondered whether local inflammatory responses were affected by irradiation and therefore determined the presence of inflammatory cells in uveal melanomas enucleated after prior irradiation.
METHODS: We analyzed 46 uveal melanoma-containing eyes that had to be enucleated due to nonresponsiveness, tumor recurrence, or complications. Immunofluorescent staining was performed to determine the presence of CD68(+) and CD68(+)CD163(+) macrophages, and of CD4(+), CD8(+), and Foxp3(+) regulatory T lymphocytes. Outcomes were compared with clinical and histologic parameters.
RESULTS: Numbers of CD68(+) and CD68(+)CD163(+) macrophages in secondarily enucleated eyes varied widely, but did not differ from primarily enucleated eyes and were not related to the reason for enucleation. Similarly, the number of CD4(+), CD8(+), and Foxp3(+) T lymphocytes showed great variability. Tumors with epithelioid cells showed significantly more lymphocytes than spindle cell tumors. In the first 2 years after enucleation, previously irradiated tumors showed increased numbers of lymphocytes compared with primarily enucleated eyes.
CONCLUSIONS: Numbers of infiltrating T lymphocytes and macrophages varied widely between tumors, but tumors with high numbers of macrophages also contained more lymphocytes. Irradiation had no effect on the number and type of macrophages, but led to an increased amount of T lymphocytes up to 24 months postirradiation. Because the presence of infiltrating cells was related to the tumor cell type, it is conceivable that the presence of an infiltrate is especially a consequence of the primary tumor characteristics before irradiation.

Herwig MC, Bergstrom C, Wells JR, et al.
M2/M1 ratio of tumor associated macrophages and PPAR-gamma expression in uveal melanomas with class 1 and class 2 molecular profiles.
Exp Eye Res. 2013; 107:52-8 [PubMed] Article available free on PMC after 01/02/2014

Macrophages have been found to be negative predictors of outcome in patients with uveal melanoma. In particular, recent studies point toward a disease-progressing role of proangiogenic M2 macrophages in melanomas with monosomy 3. Although most studies implicate a protective effect of PPAR-gamma activation in tumors, PPAR-gamma has also been shown to promote the polarization of M1 macrophages toward the M2 phenotype. The purpose of this investigation was first, to characterize the phenotype of tumor infiltrating macrophages and second, to study PPAR-gamma expression in uveal melanomas with molecular gene expression profile as prognostic predictors for patients' outcome. Twenty specimens from patients with uveal melanoma were analyzed for clinical and histologic tumor characteristics. The molecular RNA profile (class 1 or class 2) was commercially determined. Using immunohistochemical techniques, the specimens were dual labeled for CD68 and CD163. CD68 + CD163- M1 macrophages and CD68 + CD163+ M2 macrophages were analyzed in ten high power fields sparing macrophage-poor areas and a mean value was calculated for each tumor. The tumors were immunostained for von Willebrand factor and the micro vascular density (MVD) was analyzed according to Foss. To assess the proliferative rate of each tumor, Ki67 expression was evaluated in ten high power fields followed by calculation of a mean value. Expression of PPAR-gamma was evaluated using a score from 0 (no staining) to 3 (tumor entirely stained). Statistical analysis and a respective correlation were made between histologic characteristics, molecular profile, type of tumor infiltrating macrophages (M1 vs. M2), MVD, proliferative rate, and PPAR-gamma expression. Our results showed a correlation between the ratio of M2/M1 macrophages and the molecular profile with a ratio of approximately 1 corresponding to molecular class 1 and a ratio of approximately 2 corresponding to molecular class 2 (p = 0.01). The ratio of M2/M1 macrophages was higher in tumors with extraocular extension (p = 0.01). PPAR-gamma was predominantly expressed in the cytoplasm of tumor cells. Its expression showed no association with the molecular RNA profile (p = 0.83). This study confirmed that the ratio of M2/M1 macrophages is another prognostic factor in uveal melanoma. Thus, polarization of macrophages plays an important role for patients' outcome. PPAR-gamma is expressed in uveal melanoma tumor cells and further studies are warranted to determine its role in tumor biology.

Frenkel S, Zloto O, Pe'er J, Barak V
Insulin-like growth factor-1 as a predictive biomarker for metastatic uveal melanoma in humans.
Invest Ophthalmol Vis Sci. 2013; 54(1):490-3 [PubMed]

PURPOSE: High expression levels of insulin-like growth factor-1 (IGF-1) receptor were associated with metastatic uveal melanoma (UM). The purpose of this study was to examine the potential of serum IGF-1 in early detection of liver metastasis.
METHODS: IGF-1 serum levels were analyzed using enzyme-linked immunosorbent assay for 118 subjects in three different groups: 55 disease-free (DF) UM patients who did not develop metastasis within 10 years of diagnosis; 22 metastatic patients; and 41 healthy subjects. Matched pairs univariate analysis was performed for sera of 19 metastatic patients 12 and 6 months before the diagnosis of metastasis and on the day of diagnosis, both as time groups and normalized levels per patient. IGF-1 levels were compared among groups by analysis of variance and Student t-test.
RESULTS: Mean ± SD IGF-1 serum levels for the control, DF, and metastatic groups were 152.48 ± 49.76, 119.92 ± 60.66, and 96.99 ± 56.91 ng/mL, respectively (P < 0.001). Normalized changes in IGF-1 per metastatic patient from 6 months prior to the diagnosis of metastases compared to the day of diagnosis of metastases showed a decreasing trend.
CONCLUSIONS: IGF-1 levels in 10-years' disease-free UM patients were significantly lower than those in healthy subjects and were even lower in metastatic patients. IGF-1 levels decreased toward the diagnosis of metastases. Therefore, serum IGF-1 level may be used as a predictive biomarker for metastatic UM when measured repeatedly.

Zloto O, Pe'er J, Frenkel S
Gender differences in clinical presentation and prognosis of uveal melanoma.
Invest Ophthalmol Vis Sci. 2013; 54(1):652-6 [PubMed]

PURPOSE: We examined the clinical differences in manifestation and prognosis of uveal melanoma (UM) between men and women.
METHODS: We evaluated 723 UM patients (325 males) who were treated between 1988 and 2010 at a national referral center. Men and women were compared regarding differences in annual distribution, age at diagnosis, size and intraocular location of the tumor, symptoms leading to diagnosis, recurrence, development of metastases, and mortality. Statistical analysis included ANOVA, Pearson correlations, and competing risks for melanoma-related mortality.
RESULTS: Significant gender differences were not found for annual distribution, diagnosis age, tumor size, or recurrence rate. Tumors were located more frequently posterior to the equator in men than in women. However, men were less likely than women to complain of symptoms before the diagnosis (77.10% vs. 84.65%). Men suffered more metastases. In the subgroup of patients who had metastases, the time until development of metastases was shorter in men (metastases 1 and 5 years after diagnosis of UM: 26% vs. 12.96% and 84% vs. 50%, respectively). The cumulative incidence for melanoma-related mortality was higher for men, with an almost two-fold excess of male melanoma-related mortality in the first 10 years after the diagnosis of UM.
CONCLUSIONS: Men have earlier and more frequent metastases in the first decade after the diagnosis of UM, a fact that may have significant implications in planning clinical trials to test adjuvant therapies to prevent metastasis.

Caujolle JP, Paoli V, Chamorey E, et al.
Local recurrence after uveal melanoma proton beam therapy: recurrence types and prognostic consequences.
Int J Radiat Oncol Biol Phys. 2013; 85(5):1218-24 [PubMed]

PURPOSE: To study the prognosis of the different types of uveal melanoma recurrences treated by proton beam therapy (PBT).
METHODS AND MATERIALS: This retrospective study analyzed 61 cases of uveal melanoma local recurrences on a total of 1102 patients treated by PBT between June 1991 and December 2010. Survival rates have been determined by using Kaplan-Meier curves. Prognostic factors have been evaluated by using log-rank test or Cox model.
RESULTS: Our local recurrence rate was 6.1% at 5 years. These recurrences were divided into 25 patients with marginal recurrences, 18 global recurrences, 12 distant recurrences, and 6 extrascleral extensions. Five factors have been identified as statistically significant risk factors of local recurrence in the univariate analysis: large tumoral diameter, small tumoral volume, low ratio of tumoral volume over eyeball volume, iris root involvement, and safety margin inferior to 1 mm. In the local recurrence-free population, the overall survival rate was 68.7% at 10 years and the specific survival rate was 83.6% at 10 years. In the local recurrence population, the overall survival rate was 43.1% at 10 years and the specific survival rate was 55% at 10 years. The multivariate analysis of death risk factors has shown a better prognosis for marginal recurrences.
CONCLUSION: Survival rate of marginal recurrences is superior to that of the other recurrences. The type of recurrence is a clinical prognostic value to take into account. The influence of local recurrence retreatment by proton beam therapy should be evaluated by novel studies.

Edelhauser G, Schicher N, Berzaczy D, et al.
Fotemustine chemoembolization of hepatic metastases from uveal melanoma: a retrospective single-center analysis.
AJR Am J Roentgenol. 2012; 199(6):1387-92 [PubMed]

OBJECTIVE: The purpose of the current study was to retrospectively evaluate response and survival in patients with hepatic metastasis from uveal melanoma treated by palliative transarterial chemoembolization (TACE) with fotemustine.
MATERIALS AND METHODS: During the study period, 21 patients with hepatic metastases from uveal melanoma were treated by TACE. A series of TACE interventions (mean number per patient, 3.29 interventions; range, 1-6 interventions) was performed on each patient with an emulsion of fotemustine dissolved in 10 mL of saline mixed with 10 mL of an oily contrast agent. Tumor response based on the Response Evaluation Criteria in Solid Tumors was evaluated using contrast-enhanced CT scans obtained 6-10 weeks after embolization.
RESULTS: CT showed partial regression after TACE in three patients (14%). Six patients (29%) presented with stable disease but no significant change in tumor size after TACE, and 12 patients (57%) presented with progressive disease after TACE treatment. The overall response rate was 43%. The mean survival after diagnosis of hepatic metastasis was 28.7 months.
CONCLUSION: TACE of hepatic metastasis from uveal melanoma with fotemustine is well tolerated, and the survival rates in this study (mean, 28.7 months) are among the longest reported.

Dobner BC, Riechardt AI, Joussen AM, et al.
Expression of haematogenous and lymphogenous chemokine receptors and their ligands on uveal melanoma in association with liver metastasis.
Acta Ophthalmol. 2012; 90(8):e638-44 [PubMed]

PURPOSE: Chemokine receptors and their ligands are involved in a number of cell processes, including normal cell trafficking as well as metastasis in cancer. During metastasis, they are thought to play a role in determining cancer cell distribution and target organs. The aim of this study was to examine the expression of the chemokine receptors CXCR4, CCR7 and CCR10 as well as their respective chemokine ligands (CXCL12, CCL19, CCL27) in human uveal melanomas.
METHODS: Seventy formalin-fixed paraffin-embedded uveal melanoma specimens from patients treated in 1996-1997 were examined using immunohistochemistry and evaluated using an immune reactive score (IRS).
RESULTS: The chemokine receptors CXCR4, CCR7 and CCR10 were primarily expressed in the cytoplasm of uveal melanoma cells, with CXCR4 (average IRS 8.2) and CCR7 (average IRS 5.7) showing the strongest expression, respectively. The chemokine ligand CCL19 demonstrated a moderate expression (average IRS 5.3), whereas the expression of receptor CCR10 (average IRS of 3.4), ligand CCL27 (average IRS 2.5) and ligand CXCL12 (average IRS 0.6) by uveal melanoma cells was low. A significant association between liver metastases and chemokine expression was found for CCR7 expression (p = 0.037) only. Comparison of liver metastasis and choroid uveal melanoma (35.3%, n = 12 of 34) versus ciliary body involvement (72.7%, n = 8 of 11) was significant (p = 0.030).
CONCLUSION: Chemokine receptors are more strongly expressed on uveal melanoma cells than their ligands. Our results show new aspects of the metastatic process in uveal melanoma.

Marshall E, Romaniuk C, Ghaneh P, et al.
MRI in the detection of hepatic metastases from high-risk uveal melanoma: a prospective study in 188 patients.
Br J Ophthalmol. 2013; 97(2):159-63 [PubMed]

BACKGROUND/AIMS: To evaluate MRI in the detection of asymptomatic hepatic metastases from uveal melanoma.
METHODS: A single-arm prospective cohort study.
PARTICIPANTS: We enrolled 188 patients whose predicted 5-year mortality from uveal melanoma exceeded 50%. This prognostication was performed by multivariate analysis of clinical stage, histological grade and genetic type, using our online tool, based on Accelerated Failure Time modelling. These high-risk patients underwent a six-monthly assessment, which included history-taking, clinical examination, hepatic MRI (without contrast, unless suspicious lesions were identified) and biochemical liver function tests.
RESULTS: Ninety (48%) of the 188 patients developed detectable metastases, a median of 18 months after ocular treatment. Six-monthly MRI-detected metastases before symptoms in 83 (92%) of 90 patients developing systemic disease, with 49% of these having less than five hepatic lesions all measuring less than 2 cm in diameter. Of these 90 patients, 12 (14%) underwent hepatic resection, all surviving for at least a year afterwards.
CONCLUSIONS: Six-monthly MRI detects metastases from high-risk uveal melanoma before the onset of symptoms, enhancing any opportunities for early treatment of metastatic disease and clinical trial participation. Whether these actually result in prolongation of life, after taking lead-time bias into account, requires further investigation.

Mudhar HS, Rennie IG
Local conjunctival metastases from primary conjunctival melanoma: clinico-pathological correlation and implications.
Br J Ophthalmol. 2013; 97(1):33-9 [PubMed]

BACKGROUND/AIMS: A retrospective service evaluation identified seven patients who developed local conjunctival metastases (LCMs) of the conjunctiva after a primary diagnosis of conjunctival invasive melanoma. The study was conducted to identify the clinico-pathological characteristics and implications of these LCMs.
METHODS: Seven patients with primary conjunctival melanoma seen by the ocular oncology service were identified as having also developed LCMs. The clinical history, histopathology, tumour biology, prognostic and staging implications of LCMs were evaluated.
RESULTS: A total of 15 primary conjunctival melanomas and 19 LCMs were identified. The LCM developed 8-102 months after the first primary melanoma and, in three patients, non-conjunctival metastases developed 8-37 months after the first LCM. The LCMs showed some distinct histopathological features: they were well defined, were separated from the overlying epithelium by a Grenz zone, and were often multiple and associated with vessels and sometimes lymphocytic aggregates. Some appeared within the confines of the vascular drainage territory of the primary melanoma; others did not confine themselves to this distribution.
CONCLUSIONS: LCMs are local metastases of primary conjunctival melanoma that probably develop by dissemination through the local vessels and then becoming extavascular. Their accurate histopathological recognition is important, as it indicates a higher disease stage-indicating 'N' status within the TNM classification and may be a proxy indicator of the presence of non-conjunctival metastases, thus necessitating high-resolution radiological imaging modalities or sentinel node biopsy. LCMs may represent an under-recognised lesion and may have been mistaken for primary 'nodular' conjunctival melanomas in the past.

Mudhar HS, Smith K, Talley P, et al.
Fluorescence in situ hybridisation (FISH) in histologically challenging conjunctival melanocytic lesions.
Br J Ophthalmol. 2013; 97(1):40-6 [PubMed]

BACKGROUND: Even in experienced hands, the classification of some melanocytic lesions of the conjunctiva remains challenging. In skin pathology, the recent application of fluorescence in situ hybridisation (FISH) has been demonstrated to be of use for the analysis and diagnosis of ambiguous melanocytic neoplasms of the skin. This study set out to evaluate this method on seven prospective conjunctival cases that were histologically equivocal.
METHODS: 18 unequivocal retrospective melanocytic controls were exposed to FISH. Commercially available probes assessing copy numbers of RREB1 (6p25), MYB (6q23) and CCND1 (11q13) genes compared with CEP6 (a chromosome six centromeric reference point) were used. After control verification, seven prospective, equivocal cases were identified and exposed to FISH.
RESULTS: There was complete correlation between FISH result and the control section histopathology report. Control cases of melanoma cases were all positive for FISH and control benign lesions were negative. Of the seven equivocal cases, five were positive and classed as invasive melanoma or melanoma-in situ, one was negative and one tetraploid, classed as negative (these last two cases were classed as naevi with careful clinical observation).
CONCLUSIONS: FISH is very useful in classifying equivocal conjunctival melanocytic lesions, especially those with atypical junctional activity and naevoid melanocytic proliferations of the conjunctiva.

Wackernagel W, Holl E, Tarmann L, et al.
Visual acuity after Gamma-Knife radiosurgery of choroidal melanomas.
Br J Ophthalmol. 2013; 97(2):153-8 [PubMed]

BACKGROUND/AIMS: To report on conservation of visual acuity after Gamma-Knife radiosurgery of choroidal melanoma.
METHODS: A total of 189 patients with choroidal melanoma were treated with Gamma-Knife stereotactic single-fraction radiosurgery at a single institution between June 1992 and May 2010. The main outcome measure of our retrospective analysis was conservation of pretreatment visual acuity of 20/40 or better, 20/200 or better and counting fingers (CF) or better, over time of follow-up. Patient, tumour and treatment parameters were evaluated as potential risk factors for visual loss.
RESULTS: Five years after treatment, the actuarial probability of keeping visual acuity better than 20/40, 20/200 and CF was 13%, 14% and 36%, respectively. The majority of patients (84.7%) encountered a deterioration of vision after treatment. The most important risk factors for visual loss were tumour height, longest basal diameter, distance to the optic disk and/or foveola, and retinal detachment before treatment. Treatment dose, and patient characteristics (age, sex, concurrent systemic diseases) were less important. Local tumour control rate was 94.4% after a median follow-up of 39.5 months.
CONCLUSIONS: Visual outcome after single-fraction Gamma-Knife radiotherapy is comparable with linear accelerator (LINAC) based fractionated stereotactic radiotherapy, inferior to proton beam radiotherapy, and depends primarily on tumour size, location and pre-existing retinal detachment.

Yonekawa Y, Kim IK
Epidemiology and management of uveal melanoma.
Hematol Oncol Clin North Am. 2012; 26(6):1169-84 [PubMed]

Uveal melanoma is the most common primary intraocular malignancy in adults. The disease overwhelmingly affects white populations. Other risk factors include fair skin, light iris color, ancestry from northern latitudes, and ocular/oculodermal melanocytosis. Historically, enucleation was the definitive treatment of uveal melanoma, but brachytherapy and proton beam irradiation are now the most commonly used treatment methods. However, there are still no effective therapies against metastatic uveal melanoma, which is almost always fatal. Continued advances in understanding of the molecular mechanisms of uveal melanoma will facilitate the identification of prognostic markers and therapeutic targets.

el Filali M, Ly LV, Luyten GP, et al.
Bevacizumab and intraocular tumors: an intriguing paradox.
Mol Vis. 2012; 18:2454-67 [PubMed] Article available free on PMC after 01/02/2014

PURPOSE: Bevacizumab, a humanized monoclonal antibody to vascular endothelial growth factor-A (VEGF-A), was originally developed as an anti-tumor treatment. In ocular oncology, it is being used to treat macular edema due to radiation retinopathy, but it may also be useful for the treatment of primary uveal melanoma (UM) or its metastases. We determined the effect of bevacizumab on the growth of B16F10 cells inside the eye and on B16F10 and UM cells cultured in vitro.
METHODS: B16F10 melanoma cells were placed into the anterior chamber of the eye of C57Bl/6 mice and tumor growth was monitored after injection of different doses of bevacizumab or mock injection. In addition, the effect of bevacizumab on in vitro growth of B16F10 and human UM cells and on the expression of VEGF-A, GLUT-1, and HIF-1α was evaluated.
RESULTS: Following intraocular injection of bevacizumab into murine B16 tumor-containing eyes, an acceleration of tumor growth was observed, with the occurrence of anterior chamber hemorrhages. Bevacizumab did not affect proliferation of B16F10 cells in vitro, while it inhibited UM cell proliferation. Expression analysis demonstrated that addition of bevacizumab under hypoxic conditions induced VEGF-A, GLUT-1 and HIF-1α in B16F10 cells as well as in UM cell lines and two of four primary UM tumor cultures.
CONCLUSIONS: In contrast with expectations, intraocular injection of bevacizumab stimulated B16F10 melanoma growth in murine eyes. In vitro exposure of B16 and human UM cells to bevacizumab led to paradoxical VEGF-A upregulation. The use of VEGF inhibitors for treatment of macular edema (due to radiation retinopathy) after irradiation of UM should be considered carefully, because of the possible adverse effects on residual UM cells.

Khan AM, Kagan DB, Gupta N, et al.
Ciliary body lymphangiogenesis in uveal melanoma with and without extraocular extension.
Ophthalmology. 2013; 120(2):306-10 [PubMed]

PURPOSE: To determine whether peritumoral ciliary body lymphatics are found in uveal melanoma in the absence of extraocular extension.
DESIGN: Consecutive case series from 1999 to 2005.
PARTICIPANTS: Thirty-two uveal melanoma cases involving the ciliary body from the Ophthalmic Pathology Laboratory, University of Toronto, of which 23 showed no extraocular extension.
METHODS: All immunofluorescence studies and quantitative analyses were performed in a masked fashion. Sections were immunostained for the presence of lymphatic endothelium using podoplanin (D2-40 antibody) and blood vessel endothelium using CD34.
MAIN OUTCOME MEASURES: Identification and quantification of D2-40-positive lymphatic vessels in the ciliary body.
RESULTS: In every case (n = 32), D2-40-positive lymphatics were detected in the peritumoral ciliary body. Lymphatic signal was significantly increased in the peritumoral ciliary body compared with the nonperitumoral ciliary body (P < 0.0001). There was no difference in lymphatic signal between cases with and without extraocular extension (P > 0.05). Lymphatics were not detected within the tumors.
CONCLUSIONS: Peritumoral lymphangiogenesis was present in the ciliary body in uveal melanomas with and without extraocular extension, and as such, the presence of peritumoral lymphatics is not recommended as a prognostic marker in uveal melanoma.

Kim EC, Kim MS, Kang NY
Excision with corneoscleral lamellar keratoplasty and amniotic membrane transplantation of a corneal displaced recurrent conjunctival melanoma.
Korean J Ophthalmol. 2012; 26(5):383-7 [PubMed] Article available free on PMC after 01/02/2014

An 81-year-old woman with a raised pigmented nodule over her left cornea for 7 months duration was examined. Dark conjunctival pigmentation was observed in the upper bulbar fornix conjunctiva. She had previously undergone primary surgical excision of a malignant conjunctival melanoma four years earlier. The tumor separated easily from the corneal surface, but remained slightly attached to the corneoscleral surface. A corneoscleral lamellar dissection of 3 mm in width and 2 mm in depth as well as a corneoscleral lamellar keratoplasty for the reconstruction of the corneoscleral defect were performed. The wide upper bulbar and fornix conjunctiva were excised, and an amniotic membrane transplantation was performed. Biopsy revealed an invasive melanoma with a depth of 1 mm. Left, right, and inferior tumor margins of the corneoscleral lesion and the pigmentary lesion in the conjunctiva were free of the tumor. After surgery, 0.04% mitomycin was administered topically 4 times daily for 4 weeks. There was no recurrence 2 years after surgery, and systemic evaluation revealed no metastasis.