Personalized treatment of uveal melanoma

Abstract

Personalized treatment of uveal melanoma involves the tailoring of all aspects of care to the condition, needs, wishes, and fears of the patient, taking account of the individual's circumstances. When selecting between radiotherapy, surgical resection, and phototherapy, or when deciding how best to combine these different therapeutic modalities, it is necessary to understand the patients utilities, with respect to tumour control, visual conservation, and preservation of the eye, so as to prioritize outcomes accordingly. For example, such considerations would influence the width of the safety margins when administering radiotherapy, according to whether the patient considers it more important to conserve vision or to guarantee tumour control. With 'suspicious naevi', the choice between observation, immediate treatment, and biopsy is complicated by the lack of adequate survival data on which to base rational decisions, making it necessary for both patient and doctor to accept uncertainty. Personalized care should involve close relatives, as appropriate. It must also adapt to changes in the patient's needs over time. Such personalized care demands the ability to respond to such needs and the sensitivity to identify these requirements in the first place. Personalized treatment enhances not only the patient's satisfaction but also the 'job satisfaction' of all members of the multidisciplinary team, improving quality of care.

Figure 1

(a) A melanocytic tumour of indeterminate malignancy in the right eye of a 48-year-old woman. The choice of management included: observation, with an unknown risk of metastasis; proton beam radiotherapy, which would inevitably have caused visual loss; and diagnostic biopsy, with risks of retinal detachment, haemorrhage, infection, and failure. As the fellow eye was amblyopic, with visual acuity of 6/18, the patient was observed. Thirteen years later, her condition was unchanged, with visual acuity of 6/6. (b) Left eye of a 38-year-old woman with a melanocytic tumour of indeterminate malignancy measuring 5.9 mm basally with a thickness of 1.4 mm. The patient was offered the choice between observation, immediate proton beam radiotherapy, and biopsy. She was unhappy about leaving a potentially malignant tumour untreated and did not wish to sacrifice vision unnecessarily if the tumour was benign. She therefore had a biopsy, which showed the lesion to be a spindle-cell melanoma. Proton beam radiotherapy was administered and 6 months later the visual acuity was 6/9. (c) Left eye of a 58-year-old woman with a juxtapapillary choroidal melanoma measuring 12.8 mm basally, with a thickness of 4.8 mm. The choice of treatment included enucleation, proton beam radiotherapy, plaque radiotherapy, and endoresection. (d) The patient opted for proton beam radiotherapy, receiving this together with transpupillary thermotherapy, which induced resolution of the exudative retinal detachment. Five years later the patient was well, with visual acuity of 6/6. (e) Left eye of a 45-year-old man with an inferonasal choroidal melanoma measuring 16.4 mm basally with a thickness of 5.9 mm, associated with an extensive exudative retinal detachment. The choice of treatment included ruthenium plaque radiotherapy, proton beam radiotherapy, trans-scleral local resection, and enucleation. (f) The patient underwent trans-scleral local resection because he needed good visual acuity to continue to work as a fireman. Four weeks post-operatively, the visual acuity had regained the pre-treatment level of 6/19 and was improving.

Figure 2

(a) Right eye of a 57-year-old man with a superior choroidal melanoma, which measured 15.2 mm basally with a thickness of 5.2 mm (ie, TNM stage IIB). The patient was treated with a 20 mm ruthenium-106 plaque. (b) The clinical features, considered alone, would have indicated a 30% risk of metastatic death at 10 years. (c) The patient underwent a prognostic trans-retinal biopsy, which showed the tumour to be of mixed cell type, with no chromosome 3 loss. Multivariate analysis using our online predictor indicated the 10-year risk of metastasis to be only 5%. (d) If this biopsy had shown chromosome 3 loss, this risk would have been 58%. Almost 5 years later, the patient was alive with good local tumour control, no metastatic disease, and visual acuity 6/9.