Melanoma: Finger PT

Nag S, Quivey JM, Earle JD, Followill D, Fontanesi J, Finger PT, Anonymous00040. · Department of Radiation Oncology, Ohio State University, Columbus, OH 43210, USA. · Int J Radiat Oncol Biol Phys. · Pubmed #12738332 No free full text.

Abstract: PURPOSE: This article presents the American Brachytherapy Society (ABS) guidelines for the use of brachytherapy for patients with choroidal melanomas. METHODS: Members of the ABS with expertise in choroidal melanoma formulated brachytherapy guidelines based upon their clinical experience and a review of the literature. The Board of Directors of the ABS approved the final report. RESULTS: Episcleral plaque brachytherapy is a complex procedure and should only be undertaken in specialized medical centers with expertise in this sophisticated treatment program. Recommendations were made for patient selection, techniques, dose rates, and dosages. Most patients with very small uveal melanomas (<2.5 mm height and <10 mm in largest basal dimension) should be observed for tumor growth before treatment. Patients with a clinical diagnosis of medium-sized choroidal melanoma (between 2.5 and 10 mm in height and <16 mm basal diameter) are candidates for episcleral plaques if the patient is otherwise healthy and without metastatic disease. A histopathologic verification is not required. Small melanomas may be candidates if there is documented growth; some patients with large melanomas (>10 mm height or >16 mm basal diameter) may also be candidates. Patients with large tumors or with tumors at peripapillary and macular locations have a poorer visual outcome and lower local control that must be taken into account in the patient decision-making process. Patients with gross extrascleral extension, ring melanoma, and tumor involvement of more than half of the ciliary body are not suitable for plaque therapy. For plaque fabrication, the ophthalmologist must provide the tumor size (including basal diameters and tumor height) and a detailed fundus diagram. The ABS recommends a minimum tumor (125)I dose of 85 Gy at a dose rate of 0.60-1.05 Gy/h using AAPM TG-43 formalism for the calculation of dose. NRC or state licensing guidelines regarding procedures for handling of radioisotopes must be followed. CONCLUSIONS: Brachytherapy represents an effective means of treating patients with choroidal melanomas. Guidelines are established for the use of brachytherapy in the treatment of choroidal melanomas. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose reporting policies. These guidelines will be modified as further clinical results become available.

Rosenberg C, Finger PT. · The New York Eye Cancer Center, New York, NY 10065, USA. · Surv Ophthalmol. · Pubmed #18501266 No free full text.

Abstract: The incidence of malignant cutaneous melanoma is increasing faster than any other cancer. Thus, it will become an increasingly common source of metastatic disease to the eye, lids, and orbit. Herein, we have performed a systematic review of previously published cases including patient characteristics, clinical presentation, diagnostic techniques, current treatments, and outcomes. At the time of ocular diagnosis, nearly all reported patients had a known history of cutaneous melanoma and synchronous non-ocular metastases. Several aspects help in differentiating the tumors from primary uveal melanomas such as the presence of symptoms, rapidly growing multifocal tumors, vitreous seeding, and histopathological findings. Intraocular metastases (uvea, vitreous, retina, and anterior-segment) are more common and occur in younger patients than extraocular metastases (eyelids, orbit, and extraocular muscles). Palliative radiation therapy is often used for intraocular disease. Orbital metastases from cutaneous melanoma commonly involve the extraocular muscles resulting in diplopia and exophthalmos. The mainstays of extraocular treatment are surgical resection and radiation therapy. Unfortunately, there are few good options for systemic treatment of diffusely metastatic melanoma. Therefore, patients with ocular metastasis should be managed to prevent loss of vision or loss of the eye, and to maximize their quality of life.

Kurli M, Finger PT. · The New York Eye Cancer Center, The New York Eye and Ear Infirmary, New York University School of Medicine, 115 East 61st Street, New York, NY 10021, USA. · Ophthalmol Clin North Am. · Pubmed #15763188 No free full text.

Abstract: Melanocytic conjunctival tumors include a wide range of lesions that vary in their clinical and histopathologic features. Their management depends on numerous factors, including their location, focality, tumor dimensions (including depth), histopathologic characteristics, recurrences, growth, and the presence of metastasis.

Moshfeghi DM, Moshfeghi AA, Finger PT. · The New York Eye Cancer Center and the Ocular Tumor Service, New York Eye and Ear Infirmary, New York, USA. · Surv Ophthalmol. · Pubmed #10667436 No free full text.

Abstract: The three most common indications for enucleation are intraocular malignancy, trauma, and a blind, painful eye. Recommending enucleation is one of the most difficult therapeutic decisions in ophthalmology. In some cases of malignancy, cryotherapy, laser photocoagulation, diathermy, chemotherapy, and radiation therapy may be viable alternatives to surgery. When surgery is chosen, evisceration or exenteration may be alternatives to enucleation. Once the decision is made to perform enucleation or evisceration, the surgeon must choose from several types of implants and wrapping materials. These devices can be synthetic, autologous, or eye-banked tissues. With certain implants, the surgeon must decide when and if to drill for subsequent peg placement. In this review, the authors discuss choices, techniques, complications, and patient consent and follow-up before, during, and after enucleation. Controversies and results of the Controlled Ocular Melanoma Study are summarized.

Finger PT, Chin KJ, Duvall G, Anonymous00055. · The New York Eye Cancer Center, New York, New York 10065, USA. · Ophthalmology. · Pubmed #19243829 No free full text.

Abstract: PURPOSE: To describe 18 years of experience with palladium-103 ((103)Pd) ophthalmic plaque brachytherapy. DESIGN: Retrospective case series. PARTICIPANTS: From 1990 to 2007, 400 patients were diagnosed with uveal melanoma, found negative for metastatic disease, and treated. Episcleral (103)Pd radiation was delivered to a mean apical radiation dose of 73.3 Gy over 5 to 7 continuous days. INTERVENTION: Palladium-103 ophthalmic plaque brachytherapy. MAIN OUTCOME MEASURES: Patients were evaluated for local tumor control, visual acuity, radiation damage (retinopathy, optic neuropathy, cataract), and metastatic disease. RESULTS: A total of 272 tumors (68%) were located at or posterior to the equator. There were 186 (46.5%) T1 tumors, 156 (39%) T2 tumors, 50 (12.5%) T3 tumors, and 8 (2%) T4 tumors. Patients were followed for a maximum of 205 months (mean, 51.1 months). Fourteen patients required secondary enucleation (5 for tumor growth and 9 for glaucoma pain control). The local control rate was 96.7%. Life table analysis of patients with 20/200 or better before treatment (n = 357) suggests that 79% and 69% are expected to retain that acuity for 5 and 10 years, respectively. Life table analysis demonstrates a probability that 92.7% and 86.6% of patients will be free of metastatic disease at 5 and 10 years, respectively. CONCLUSIONS: In a nonrandomized phase I clinical evaluation, (103)Pd ophthalmic plaque radiotherapy was used to treat 400 patients with uveal melanoma. In this series, results after (103)Pd ophthalmic plaque radiotherapy were superior to those reported for alternative forms of radiation.

Finger PT. · The New York Eye Cancer Center, New York, NY 10065, USA. · Int J Radiat Oncol Biol Phys. · Pubmed #18313522 No free full text.

Abstract: PURPOSE: To report on bevacizumab treatment for radiation retinopathy affecting the macula. PATIENTS AND METHODS: Twenty-one patients with radiation retinopathy (edema, hemorrhages, capillary dropout, and neovascularization) and a subjective or objective loss of vision were treated. Treatment involved intravitreal injection of bevacizumab (1.25 mg in 0.05 mL) every 6-12 weeks. Treatment was discontinued at patient request or if there was no measurable response to therapy. Main outcome measures included best corrected visual acuity, ophthalmic examination, retinal photography, and angiography. RESULTS: Bevacizumab treatment was followed by reductions in retinal hemorrhage, exudation, and edema. Visual acuities were stable or improved in 86% (n=18). Three patients discontinued therapy. Each was legally blind before treatment (n=1), experienced little to no subjective improvement (n=2), or was poorly compliant (n=2). Three patients (14%) regained 2 or more lines of visual acuity. No ocular or systemic bevacizumab-related side effects were observed. CONCLUSIONS: Intravitreal bevacizumab can be used to treat radiation retinopathy. In most cases treatment was associated with decreased vascular leakage, stabilization, or improved vision. An anti-vascular endothelial growth factor strategy may reduce tissue damage associated with radiation vasculopathy and neuropathy.

Finger PT, Chin K. · The New York Eye Cancer Center, 115 E 61st St, New York, NY 10021, USA. · Arch Ophthalmol. · Pubmed #17562985 links to  free full text

Abstract: OBJECTIVE: To evaluate intravitreal bevacizumab for radiation retinopathy. METHODS: After plaque radiation therapy, 6 patients developed radiation retinopathy (retinal edema, hemorrhages, microangiopathy, and neovascularization). Intravitreal bevacizumab (1.25 mg in 0.05 mL) was periodically injected (every 6-8 weeks). Ophthalmic evaluations included visual acuity, ophthalmic examination, fundus photography, fluorescein angiography, and optical coherence tomography/scanning laser ophthalmoscopy (OCT/SLO) imaging. RESULTS: No bevacizumab-related ocular or systemic adverse effects have occurred within the first 8 months of therapy. Progressive reductions in retinal hemorrhages, exudates, cotton-wool spots, and microangiopathy were documented by photography, angiography, and OCT/SLO imaging. Decreased macular edema was the most common finding. Improvement or stabilization of visual acuity was noted in all cases. CONCLUSIONS: Intravitreal bevacizumab was tolerated, improved or maintained vision, and reduced hemorrhage and retinal edema (angiographic leakage). This study should lead to additional and longer-term studies of humanized monoclonal anti-vascular endothelial growth factor antibody therapy for radiation retinopathy.

Kurli M, Reddy S, Tena LB, Pavlick AC, Finger PT. · The New York Eye Cancer Center, New York 10021, USA. · Am J Ophthalmol. · Pubmed #15992753 No free full text.

Abstract: PURPOSE: To evaluate whole-body positron emission tomography (PET)/computed tomography in staging of patients with metastatic choroidal melanoma. DESIGN: Interventional non-randomized clinical study. METHODS: Twenty patients were referred for whole-body 18-fluoro-2-deoxy-D-glucose (FDG) PET/computed tomography imaging because of suspected metastatic choroidal melanoma. PET/computed tomography images were studied for the presence and distribution of metastatic melanoma. Subsequent biopsies were performed to confirm the presence of metastatic disease. RESULTS: Twenty patients underwent PET/computed tomography. Eighteen were imaged because of abnormal clinical, hematologic, or radiographic screening studies during the course of their follow-up after plaque brachytherapy or enucleation. Two were imaged before treatment of their primary tumor. PET/computed tomography revealed or confirmed metastatic melanoma in eight (40%) of these 20 patients. The mean time from initial diagnosis to metastasis was 47 months (range 0 to 154). The most common sites for metastases were the liver (100%), bone (50%), lung (25%), lymph nodes (25%), and subcutaneous tissue (25%). Cardiac, brain, thyroid, and posterior abdominal wall lesions (12.5%) were also noted. Six patients (75%) had multiple organ involvement. No false positives were noted. PET/computed tomography imaging also detected benign lesions of the bone and lymph nodes in three patients (15%). All patients had hepatic metastases and liver enzyme assays were abnormal in only one (12.5%) of eight patients. CONCLUSIONS: PET/computed tomography imaging is a sensitive tool for the detection and localization of hepatic and extra-hepatic (particularly osseous) metastatic choroidal melanoma.

Jampol LM, Moy CS, Murray TG, Reynolds SM, Albert DM, Schachat AP, Diddie KR, Engstrom RE, Finger PT, Hovland KR, Joffe L, Olsen KR, Wells CG, Anonymous00158. · Department of Ophthalmology, Northwestern University Medical School, Chicago, Illinois, USA. · Ophthalmology. · Pubmed #12466159 No free full text.

Abstract: OBJECTIVE: To describe the frequency and predictors of local treatment failure and enucleation after iodine 125 (I(125)) brachytherapy in patients with choroidal melanoma treated and followed up in a large randomized clinical trial. DESIGN: Prospective, noncomparative, interventional case series within a randomized, multicenter clinical trial. PARTICIPANTS: Patients enrolled in the Collaborative Ocular Melanoma Study (COMS) trial of enucleation versus brachytherapy between February 1987 and July 1998; tumors measured 2.5 to 10.0 mm in apical height and no more than 16.0 mm in longest basal dimension. METHODS: I(125) brachytherapy was administered via episcleral plaque according to a standard protocol. Follow-up ophthalmic evaluations, including ophthalmic ultrasound and fundus photography, were performed according to a standard protocol at baseline, every 6 months thereafter for 5 years, and subsequently at annual intervals. Survival analysis methods were used to estimate the cumulative risk of postirradiation treatment failure and enucleation. Factors associated with treatment failure and enucleation of plaqued eyes were evaluated using Cox proportional hazards analysis. MAIN OUTCOME MEASURES: Reports of enucleation and of local treatment failure, defined as tumor growth, recurrence, or extrascleral extension, derived from clinical reports based on echographic and photographic documentation. RESULTS: As of September 30, 2000, 638 of the 650 patients randomized to brachytherapy and so treated had been followed up for 1 year or longer, and 411 had been followed up for at least 5 years. Sixty-nine eyes were enucleated during the first 5 years after brachytherapy, and treatment failure was reported for 57 eyes. The Kaplan-Meier estimate of proportion of patients undergoing enucleation by 5 years was 12.5% (95% confidence interval [CI], 10.0%-15.6%); the risk of treatment failure was 10.3% (95% CI, 8.0%-13.2%). Treatment failure was the most common reason for enucleation within 3 years of treatment; beyond 3 years, ocular pain was most common. Risk factors for enucleation were greater tumor thickness, closer proximity of the posterior tumor border to the foveal avascular zone, and poorer baseline visual acuity in the affected eye. Risk factors for treatment failure were older age, greater tumor thickness, and proximity of the tumor to the foveal avascular zone. Local treatment failure was associated weakly with reduced survival after controlling for baseline tumor and personal characteristics (adjusted risk ratio, 1.5; P = 0.08). CONCLUSIONS: Local treatment failure and enucleation were relatively infrequent events after I(125) brachytherapy within the COMS. Treatment failure typically occurred early and was associated weakly with poorer survival. The COMS randomized trial documented the absence of a clinically or statistically significant difference in survival for patients randomly assigned to enucleation versus brachytherapy. This analysis documents the efficacy of brachytherapy to achieve sustained local tumor control and to conserve the globe.

Demirci H, McCormick SA, Finger PT. · The New York Eye Cancer Center, 115 E 61st St, New York, NY 10021, USA. · Arch Ophthalmol. · Pubmed #10900099 No free full text.

Abstract: OBJECTIVES: To clinically evaluate topical mitomycin chemotherapy in patients with diffuse, multifocal, or recurrent primary acquired melanosis with atypia and/or conjunctival malignant melanoma and to histopathologically study ocular tissue samples obtained before and after treatment. METHODS: Chemotherapy with topical mitomycin, 0.04% 4 times daily, was administered for 28 days as the primary and only treatment in 7 patients (after biopsy) and for 7 days as adjuvant therapy to excision and cryotherapy in 5 patients. Mean follow-up was 38 months. Five patients developed subconjunctival recurrences, for which 2 underwent orbital exenteration and 3 were treated conservatively. Histopathologic specimens of conjunctival, adnexal, and ocular tissues obtained before and after chemotherapy were evaluated. RESULTS: Regression of tumor was observed in 11 patients with primary or adjuvant topical mitomycin chemotherapy. One patient with nodular melanoma was resistant to mitomycin chemotherapy. Histopathologic findings included regionally variable conjunctival epithelial atrophy and thinning. Dyskeratosis and focal keratinization in conjunctival epithelium were noted. Epithelial nuclei were occasionally pyknotic in areas of atrophic epithelium. Subepithelial inflammation was present and was most intense in areas with severe atrophy and/or keratosis. Two patients with primary treatment and 2 with adjuvant treatment developed subconjunctival recurrence. In patients with recurrent malignant melanoma, the deeper layers of the lamina propria were involved, with sparing of the epithelium and superficial lamina propria. Transient keratoconjunctivitis was observed in all patients during treatment. In evaluation of the exenteration specimens, corneal, scleral, episcleral, retinal, and anterior structures were within normal limits. CONCLUSIONS: Topical mitomycin chemotherapy was found to induce regression of conjunctival melanoma and primary acquired melanosis with atypia. When mitomycin chemotherapy was used as an adjuvant to excision and cryotherapy, 2 (40%) of 5 patients experienced tumor recurrence at a mean of 4.3 years' follow-up. Our histopathologic findings demonstrated a long-term mitomycin chemotherapy-related effect on the conjunctiva. The degree of chronic atrophy and inflammation was not clinically significant. The pattern of effect and location of recurrent disease suggest that this regimen of topical mitomycin chemotherapy was most effective for superficial tumors. No complications that would preclude use of our dose regimen were noted. Although subconjunctival or orbital recurrences were noted, topical mitomycin chemotherapy warrants further investigation as an alternative treatment for primary acquired melanosis with atypia and conjunctival malignant melanoma. Arch Ophthalmol. 2000;118:885-891

Finger PT, Berson A, Szechter A. · Department of Ophthalmology, The New York Eye and Ear Infirmary, New York University School of Medicine, New York 10021, USA. · Ophthalmology. · Pubmed #10080222 No free full text.

Abstract: OBJECTIVE: To describe the first clinical experience with palladium-103 (103Pd) ophthalmic plaque radiotherapy for choroidal melanoma. DESIGN: Phase-I (nonrandomized) clinical trial. PARTICIPANTS: Eighty patients with uveal melanomas were diagnosed by clinical examination, found to be negative for metastatic disease, and offered 103Pd radioactive plaque treatment. Nine patients were concurrently treated with microwave hyperthermia. INTERVENTION: Palladium-103 ophthalmic plaque radiotherapy was employed for each patient. Eye plaques were sewn to the episclera to cover the base of the intraocular tumor, radiation was continuously delivered over 5 to 7 days, and then the plaques were removed. A mean apical dose of 81 Gy was delivered. MAIN OUTCOME MEASURES: The authors evaluated the ease of use of 103Pd seeds within standard gold eye plaques. Patient-related outcomes were control of tumor growth, change in visual acuity, the development of radiation damage (retinopathy, optic neuropathy, and cataract), and metastatic disease. RESULTS: From September 1990 to December 1997, 80 patients were treated with 103Pd and followed for an average of 38 months. Two patients were lost to follow-up. During this time, the authors found that 103Pd seeds were equivalent to iodine-125 (125I) with respect to plaque manufacture and ease of dosimetric calculations. Two patients in this series were treated for tumor recurrence after 125I plaque radiotherapy. They both failed secondary 103Pd treatment and were enucleated. When 103Pd was used as a primary treatment, it controlled the growth of 75 of 78 tumors (96%). Overall, there have been six enucleations: three failures of primary treatment, two failures of retreatment, and one for neovascular glaucoma. Visual acuity evaluations at the 36-month follow-up visit (including the enucleated patients) revealed that 38% of eyes had decreased 3 or more lines of vision, and 77% were 20/200 or better. CONCLUSION: Palladium-103 plaque radiotherapy can be used to treat uveal melanomas. Compared with 125I, computerized dosimetry suggests a more favorable dose distribution with 103Pd. Treatment of most patients resulted in tumor shrinkage and preservation of functional vision. The authors have noted no complications that might preclude the use of 103Pd ophthalmic plaque radiotherapy for choroidal melanoma.

Finger PT, Iezzi R, Romero JM, Rosen RB, Szechter A, Hegde H. · Department of Ophthalmology, The New York Eye and Ear Infirmary, New York 10003, USA. · Arch Ophthalmol. · Pubmed #10037561 No free full text.

Abstract: OBJECTIVE: To evaluate the usefulness of plaque-mounted diode-light transillumination (DLT) for the localization of episcleral plaques around intraocular tumors. METHODS: A clinical case series was performed to create, evaluate, and modify diode-light plaque construction, application, and imaging. Eight patients with choroidal melanoma were offered DLT as an additional method of ophthalmic plaque localization. Plaques were constructed by affixing non-heat-producing, light-emitting diodes with their apertures flush with the episcleral outer surface of the rim of the plaque. A bioimplantable epoxy was used to encapsulate the electronic components. Radioactive DLT eye plaques were sewn to the episclera to cover the base of the intraocular tumors; then diode lights were illuminated, viewed, and recorded. Thus, DLT was used to photographically document the relative position of the eye plaque covering the tumor base. The use of DLT also permitted a subjective evaluation of the contact (plaque contact) of each light with the sclera. RESULTS: Still and video images of plaque-mounted diode retro-transillumination were obtained, and no evidence of toxic effects of diode light were noted. CONCLUSIONS: Small posterior melanomas are difficult to visualize with standard transillumination techniques and are associated with poor local control. To improve and document plaque placement, we developed plaque-mounted diode lights for retrobulbar transillumination. This technique provides unique photographic documentation of episcleral plaque localization beneath intraocular tumors.

Shulman JP, Latkany P, Chin KJ, Finger PT. · The New York Eye Cancer Center, New York, New York 10065, USA. · Ocul Immunol Inflamm. · Pubmed #19412870 No free full text.

Abstract: PURPOSE: To describe whole-body 18-fluorodeoxyglucose (FDG) positron emission tomography/computed radiographic tomography (PET-CT) imaging of ophthalmic patients with systemic sarcoidosis. METHODS: Four systemic sarcoidosis patients were evaluated with PET-CT for staging. Two had been treated for conjunctival melanoma and two had been referred for atypical choroidal tumors. PET-CT images were studied for presence of tumor or tissue with increased standardized uptake values, indicating increased metabolic activity. RESULTS: In all cases, PET-CT revealed focal systemic lesions with increased uptake (SUV range 1.7-5.9 kg/mL). Cases 1 and 2 had a previous diagnosis of sarcoidosis (without ocular involvement), while cases 3 and 4 were diagnosed during their work-up. PET-CT revealed the presence and distribution of systemic sarcoid granulomas. CONCLUSIONS: In this series, PET-CT staged patients with eye cancer and systemic sarcoidosis and aided in differentiating between a metastatic choroidal tumor and uveal sarcoid granuloma. PET-CT offers a method to assess the presence and distribution of systemic sarcoidosis.

Chin K, Finger PT. · The New York Eye Cancer Center, 115 East 61st Street, New York, NY 10065, USA. · Optometry. · Pubmed #19264288 No free full text.

Abstract: PURPOSE: The aim of this study was to describe autofluorescence characteristics of 30 suspicious choroidal nevi. METHODS: Fundus autofluorescence (FAF) images were reviewed retrospectively on 30 consecutive cases of suspicious choroidal nevi. Autofluorescence imaging was achieved using a fundus camera-based system with a barrier filter of 695 nm and excitation of 580 nm. All nevi exhibited one or more of the following characteristics: tumor thickness, basal dimension greater than 5 mm, subretinal fluid, posterior location, ophthalmic symptoms, or lipofuscin (orange pigment). RESULTS: Suspicious choroidal nevi were found to have specific FAF features. Orange pigment was noted in 67% of the nevi and appeared as very bright hyperfluorescent areas. Overlying retinal pigment epithelium hypertrophy and atrophy were noted in 50% and appeared darkly hypofluorescent. Subretinal fluid (17%) and drusen (17%) both appeared mildly hyperfluorescent. CONCLUSIONS: Orange pigment was the most hyperfluorescent FAF finding. Because the presence of orange pigment is a known risk factor for malignant transformation, the use of camera-based FAF imaging may improve our ability to identify those choroidal nevi that will transform into malignant melanoma. More long-term follow-up studies will be required to determine the exact prognostic value of our findings.

Finger PT. · The New York Eye Cancer Center, The New York Eye and Ear Infirmary, and the New York University School of Medicine, New York 10065, USA. · Arch Ophthalmol. · Pubmed #18413524 links to  free full text

Abstract: OBJECTIVE: To use amniotic membranes as a buffer between the cornea and radioactive eye plaques. METHODS: Six melanomas were treated with ophthalmic plaque radiation therapy. Plaque-tumor localization required that a portion of the gold plaque touch the cornea during treatment. To enhance patient comfort and protect the cornea, an (0.1-mm-thick) amniotic membrane was interposed between the metal plaque edge and the cornea. RESULTS: Minimal ocular discomfort was noted during plaque radiation therapy. On a scale of 1 (none) to 10 (severe), all 6 patients reported pain levels of 1. As a tissue equivalent and because the mean thickness was only 0.1 mm, amniotic membranes had no significant effect on radiation dose calculations. No adverse effects, infections, or abrasions were noted. CONCLUSION: The amniotic membrane buffer technique improves patient comfort and protects the cornea during ophthalmic plaque radiation therapy.

Kurli M, Chin K, Finger PT. · The New York Eye Cancer Center, 115 East 61st Street, New York, NY 10065, USA. · Br J Ophthalmol. · Pubmed #18369064 No free full text.

Abstract: AIM: To evaluate 18-fluoro-2-deoxyglucose (FDG) whole-body positron emission tomography/computed radiographic tomography (PET/CT) for lymph node and metastatic staging of patients with conjunctival melanoma. METHODS: Fourteen patients with T3 (n = 13) and T4 (n = 1) conjunctival melanoma (as defined in Chapter 42 of the AJCC staging manual) were staged for metastatic disease with PET/CT imaging with fusion. The patients had lymph node and clinical staging evaluations before PET/CT imaging. PET/CT images were studied for the presence and distribution of metastatic conjunctival melanoma (determined by standardised uptake values) and later confirmed by biopsy. MRI imaging was performed if abnormalities were noted on PET/CT images. RESULTS: Fourteen patients with conjunctival melanoma underwent PET/CT imaging. Seven were newly diagnosed (presurgical screening), and seven had undergone prior treatment (follow-up group). Only one patient with conjunctival melanoma (7.1%) was found to have metastatic disease on PET/CT imaging. Abnormal foci were found in the liver, lung, peritoneal cavity, lumbar spine as well as a supraclavicular node (T4N1M4). All liver function tests were normal. The mean length of follow-up after PET/CT imaging was 13 months (range 4-30 months). CONCLUSIONS: PET/CT imaging did not reveal any regional or systemic metastasis among 14 patients with advanced, diffuse and multifocal disease.

Anonymous00191, Boldt HC, Byrne SF, Gilson MM, Finger PT, Green RL, Straatsma BR, Simpson ER, Hawkins BS. · No affiliation provided · Ophthalmology. · Pubmed #18267342 No free full text.

Abstract: PURPOSE: To report baseline echographic characteristics of tumors in patients enrolled in the Collaborative Ocular Melanoma Study (COMS) randomized trials, to determine how often these characteristics matched prespecified criteria for choroidal melanoma, to explore associations between echographic variables, and to compare specific echographic characteristics with pathologic characteristics of tumors in enucleated eyes. DESIGN: Retrospective analyses of baseline data from multicenter randomized clinical trials. PARTICIPANTS: Patients enrolled in the COMS large trial or medium tumor trials (N = 2320). METHODS: Standardized echography was used to document selected characteristics of tumors at baseline. Criteria were established to assess the consistency of echographic features with the diagnosis of melanoma. For eyes assigned to enucleation, the echographic diagnosis and evaluation for extraocular extension by the Echography Center were compared with gradings made by the Pathology Center and Pathology Review Committee. MAIN OUTCOME MEASURES: Presence of various echographic and pathologic characteristics. RESULTS: Two thousand forty-three tumors (88%) exhibited low to medium reflectivity (n = 1409), a mushroom shape (n = 101), or both (n = 533). Tumors with apical height > 10 mm were more likely (P<0.001) to have a mushroom shape and less likely to have a posterior location (P<0.001) than less elevated tumors. One thousand five hundred fifty-nine (99.7%) of 1563 tumors judged by echography to be consistent with the diagnosis of melanoma were confirmed by pathology to be choroidal melanoma. For measurable extrascleral tumors < 1.5 mm in height by pathology, the Echography Center graders judged extrascleral extension as possibly present in only 1 of 16 (6%) tumors, compared with 57% (4/7) of eyes with extrascleral extension measuring > or = 1.5 mm in height. CONCLUSIONS: Eighty-eight percent of the tumors in the COMS exhibited features characteristic for melanoma: low to medium reflectivity, the classic mushroom shape, or both. Using additional preset criteria, 96% of tumors exhibited baseline echographic characteristics consistent with the diagnosis of melanoma. Echography graders were able to detect extrascleral nodules > or = 1.5 mm in elevation but not minimally elevated extraocular tumor extension. Clinicians and echographers can use these data to improve their understanding of the echographic features of untreated uveal melanomas.

Hu DN, Yu G, McCormick SA, Finger PT. · Department of Pathology, New York Eye and Ear Infirmary, New York, New York 10003, USA. · Am J Ophthalmol. · Pubmed #18191091 No free full text.

Abstract: PURPOSE: To investigate racial and ethnic differences in the incidence of conjunctival melanoma in a large population-based study. DESIGN: Observational cross-sectional study. METHODS: Using data from 1992 through 2003 provided by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program, we calculated age-adjusted incidence rates of conjunctival melanoma in various racial and ethnic groups (Black, American Indian, Asian and Pacific Islander, Hispanic, and non-Hispanic White). In addition, we calculated the standard incidence ratios (risk ratios) and 95% confidence intervals to describe the differences within these racial and ethnic groups. RESULTS: From 1992 through 2003, there were a total of 168 conjunctival melanomas diagnosed in 13 SEER registries with known racial and ethnic groups. The annual age-adjusted incidence rates (per million population) of conjunctival melanoma was 0.18 (Blacks), 0.17 (American Indians), 0.15 (Asians), 0.33 (Hispanics), and 0.49 (non-Hispanic Whites). The difference in the incidence of conjunctival melanoma between Whites and Blacks or Asians was statistically significant, but was not significant between Blacks and Asians. CONCLUSIONS: The overall White-to-Black incidence ratio in conjunctival melanoma was 2.6:1, which is much less than that of uveal melanoma (18:1) and cutaneous melanoma (13:1 to 26:1), but is similar to that of mucosal melanoma (2.2:1 to 2.3:1). The cause and significance of this difference of racial and ethnic incidence in various melanomas are discussed.

Finger PT, Sedeek RW, Chin KJ. · The New York Eye Cancer Center, New York, New York 10065, USA. · Am J Ophthalmol. · Pubmed #17981257 No free full text.

Abstract: PURPOSE: To report on topical interferon alfa-2b for conjunctival malignant melanoma (CMM) and primary acquired melanosis with atypia (PAM). DESIGN: Retrospective, interventional case series. METHODS: Five eyes of five consecutive patients with biopsy-proven malignant melanoma were treated with topical interferon alfa-2b as treatment for primary or recurrent disease. One drop of interferon alfa-2b (1 million units/ml) was placed into the superior fornix four times daily for three months. Punctal plugs limited systemic absorption. The main outcome measure was tumor regression by clinical examination and comparative slit-lamp photography. RESULTS: Five consecutive patients with conjunctival melanoma (American Joint Committee on Cancer-International Union Against Cancer stages T2 [n = 3] and T3 [n = 2]) were included. Two patients had recurrent corneal tumors, eight and 13 months after local excision, cryotherapy, and topical mitomycin C therapy. Two months after topical interferon alfa-2b treatment, the lesions regressed without side effects. Two additional patients (who could not tolerate topical mitomycin C) were switched to topical interferon alfa-2b. They experienced transient chemical conjunctivitis and have no signs of recurrence (mean, 15 months of follow-up). The fifth had recurrent tumor despite multiple surgeries. This melanoma did not respond to topical interferon alfa-2b nor did the patient tolerate treatment (keratoconjunctivitis). No systemic side effects were noted. CONCLUSIONS: We present evidence that conjunctival and corneal melanoma regresses after exposure to topical interferon alfa-2b. A larger-scale longer-term study must evaluate the long-term efficacy and safety of this therapy.

Finger PT, Reddy S, Chin K. · The New York Eye Cancer Center, Department of Ophthalmology, New York University School of Medicine, 115 E 61st St, New York, NY 10065, USA. · Arch Ophthalmol. · Pubmed #17698751 links to  free full text

Abstract: OBJECTIVE: To evaluate size, characteristics, and regression of iris and iridociliary melanomas on high-frequency ultrasound images before and after plaque brachytherapy. METHODS: Retrospective review of high-frequency ultrasound characteristics of 24 consecutive iris and iridociliary melanomas before and after radiation therapy. RESULTS: The median tumor thickness before radiation therapy was 2.3 mm (range, 1.4-4.3 mm). Nineteen iris melanomas (79%) involved the ciliary body, 18 (75%) involved the iris pigment epithelium, 11 (46%) were club shaped, and 4 (17%) caused disinsertion of the iris root. At a median follow-up of 30 months after plaque brachytherapy, the mean tumor thickness had diminished to 1.2 mm (median, 1.2 mm; range, 0.9-1.9 mm). While all tumors exhibited a reduction in thickness, no tumors showed additional regression after 30 months past treatment. Fourteen tumors (58%) were noted to have increases in internal reflectivity. There was 1 failure of local control (at 6 years), successfully treated by a second application of plaque brachytherapy. CONCLUSION: High-frequency ultrasonography revealed unique tumor characteristics, quantified tumor size, and demonstrated tumor response to radiation therapy.

Chin K, Finger PT, Kurli M, Tena LB, Reddy S. · The New York Eye Cancer Center, New York, NY 10065, USA. · Optometry. · Pubmed #17662928 No free full text.

Abstract: BACKGROUND: Positron-emission tomography/computed tomography (PET/CT) is a unique imaging tool that aids in the detection of cancerous lesions. It is currently and widely used for cancer staging (both initial and follow-up). Here we report our findings of second primary cancers incidentally discovered during PET/CT staging of patients with choroidal melanomas. METHODS: We performed a retrospective case review of 139 patients with uveal melanoma who were subsequently evaluated by whole-body [18-fluorine-labeled] 2-deoxy-2-fluoro-D-glucose ((18)FDG) PET/CT imaging. In this series, 93 were scanned before treatment and 46 during the course of their follow-up systemic examinations. Their mean follow-up was 50.9 months. RESULTS: Six patients (4.3%) had second primary cancers revealed by PET/CT imaging. Three patients (50%) were synchronous (found at initial staging), and the remaining 3 patients (50%) were metachronous (found at follow-up staging). Second primary cancers were found in the lung, breast, uterus, colon, and thyroid. CONCLUSIONS: Although whole-body PET/CT scans were ordered as part of the staging process of patients with diagnosed choroidal melanoma, both synchronous and metachronous second primary cancers were found. PET/CT has become an indispensable tool for staging, diagnosis, and treatment planning for choroidal melanoma. The possibility of detecting second primary cancers should also be considered valuable.

Finger PT. · The New York Eye Cancer Centre, 115 East 61st Street, New York City, NY 10065, USA. · Br J Ophthalmol. · Pubmed #17327263 No free full text.

Abstract: AIM: To create "slotted eye plaques" for the treatment of juxtapapillary and circumpapillary intraocular tumours. METHODS: Eye plaques were altered such that 8 mm-wide slots (variable length) were created to accommodate the orbital portion of the optic nerve. Thus, as the nerve entered the slot, the plaque's posterior margin extended beyond the optic disc. Radioactive seeds were affixed around the slot, surrounding the juxtapapillary and posterior tumour margins. RESULTS: As proof of principle, three patients with choroidal melanomas that encircled or were in contact with the optic disc (considered untreatable with a notched eye plaque) were considered to be initial candidates for slotted-plaque radiotherapy. Preoperative three-dimensional C-scan imaging of their optic nerve sheath diameters insured that they would fit in the slotted plaque. Intraoperative ultrasound imaging was used to confirm proper plaque placement. Radiation dosimetry modelling showed that all tumour tissue received a minimum of 85 Gy (despite the gap created by the slot). With relatively short-term follow-up, there has been no evidence of ocular ischaemia, tumour growth or complications attributable to the use of slotted-plaque radiation therapy. CONCLUSION: Slotted plaques accommodate the retrobulbar optic nerve into the device and thereby shift the treatment zone to improve coverage of both juxtapapillary and circumpapillary intraocular tumours.

Finger PT. · New York Eye Cancer Center, New York, New York 10021, USA. · Am J Ophthalmol. · Pubmed #17258524 No free full text.

Abstract: PURPOSE: To evaluate intravitreal bevacizumab treatment for radiation optic neuropathy (RON). DESIGN: Interventional case report. METHODS: At The New York Eye Cancer Center, a patient symptomatic of decreased vision because of RON was treated with intravitreal bevacizumab (1.25 mg). Main outcome measures included visual acuity, appearance of the optic nerve, fundus photography, angiography, and optical coherence tomography/scanning laser ophthalmoscopy (OCT/SLO). RESULTS: Within one week, her vision improved from 20/32 to 20/20 with a reduction in optic disk hemorrhage. At six weeks, evidence of both decreased hemorrhage and optic disk edema was documented by photography, angiography, and OCT/SLO. At the three and five-month follow-up visits, the hemorrhages resolved, and her disk margins were sharp. There were no ocular or systemic side effects. CONCLUSIONS: Intravitreal bevacizumab was tolerated, improved vision, and reduced hemorrhage as well as optic disk edema (angiographic leakage). Anti-VEGF therapy (e.g. bevacizumab) should be investigated for both ocular and nonocular radiation neuropathy.

Reddy S, Finger PT, Kurli M, Bui A, Iacob CE. · New York Eye Cancer Center, New York, NY 10021, USA. · Cornea. · Pubmed #17133070 No free full text.

Abstract: PURPOSE: To describe a case of conjunctival malignant melanoma associated with pseudomelanomatous alteration of the apposing tarsal conjunctiva. METHODS: A 93-year-old woman presented with an elevated, pigmented mass on her superior bulbar conjunctiva. The tumor was associated with increased pigmentation of the apposing superior tarsal conjunctiva. An excisional biopsy of the epibulbar melanoma and pigmented tarsal conjunctiva was performed. RESULTS: Histopathologic evaluation of the epibulbar tumor revealed epithelioid melanocytes diagnostic of malignant melanoma. Histopathologic evaluation of the pigmented tarsal lesion showed large areas of ulceration and foci of granulation tissue composed of neovascular sprouts arising in the background of a loose connective tissue, with a moderate chronic inflammatory infiltrate. The infiltrate was composed of mature lymphocytes, plasma cells, and scattered histiocytes. Densely packed intracytoplasmic, brown pigment granules that stained positive with HMB 45 were found, attesting to adjacent melanocytes' releasing melanin-laden granules. There was no evidence of malignancy in the pigmented tarsal specimen. CONCLUSION: Noncontiguous pigmented conjunctival tumor can be found in apposition to an epibulbar melanoma. Although a limited biopsy could be considered, only a complete resection and histopathologic evaluation can determine whether the entire lesion is free of malignant melanoma.

Finger PT, Chin K, Iacob CE. · The New York Eye Cancer Centre, New York City, NY 10021, USA. · Br J Ophthalmol. · Pubmed #16837539 No free full text.

Abstract: AIMS: To correlate the clinical, ultrasound and pathological features of the eyes first evaluated by 18-fluorine-labelled 2-deoxy-2-fluoro-d-glucose (FDG) positron emission tomography (PET)/computed tomography and then enucleated for choroidal melanoma. METHODS: 14 consecutive patients enucleated for choroidal melanoma were examined. At presentation, clinical, ultrasound and PET/computed tomography imaging were carried out. Ultrasound was used to measure the tumour size and evaluate the tumour shape and intrinsic vascularity (blood flow). Histopathological and immunohistochemical evaluations included tumour cell type, necrosis, glycogen content, vascularity and extrascleral extension. RESULTS: 13 tumours were T3 and one T2 (American Joint Committee on Cancer - International Union against Cancer). The mean tumour height was 10.6 (range 3.5-17.7) mm with a largest basal dimension of 19.3 (range 14.5-30) mm. Patients having melanoma with the highest six standardised uptake values ((SUV) > or =4.0) were (on average) >10 years older, their melanomas had larger basal dimensions and were epithelioid-cell type; three melanomas were centred anterior to the equator; three contained enlarged blood vessels (>150 mum in diameter); and three formed extrascleral extension. Patients with the two highest SUV tumours died due to metastatic melanoma. CONCLUSION: PET/computed tomography imaging offers a physiological assessment of glucose metabolism in primary choroidal melanomas. Increased FDG PET/computed tomography SUV was positively correlated with known clinical, pathological and ultrasound features linked to metastatic potential of choroidal melanoma.