Locoregional Therapies for the Treatment of Uveal Melanoma Hepatic Metastases

Abstract

Uveal melanoma is the most common primary intraocular malignant tumor in adults. Approximately 50% of patients develop metastatic disease of which greater than 90% of patients develop hepatic metastases. Following the development of liver tumors, overall survival is dismal with hepatic failure being the cause of death in nearly all cases. To prolong survival for patients with metastatic uveal melanoma, controlling the growth of hepatic tumors is essential. This article will discuss imaging surveillance following the diagnosis of primary uveal melanoma; locoregional therapies used to control the growth of hepatic metastases including chemoembolization, immunoembolization, radioembolization, percutaneous hepatic perfusion, and thermal ablation; as well as currently available systemic treatment options for metastatic uveal melanoma.

Keywords: chemoembolization; immunoembolization; percutaneous hepatic perfusion; radioembolization; uveal melanoma.

Fig. 1

( a ) Left hepatic arteriography demonstrates a large hypervascular tumor in the left lobe of the liver. ( b ) Dense uptake of ethiodized oil following BCNU chemoembolization. ( c ) CT of the abdomen 3 weeks following BCNU chemoembolization demonstrates dense uptake of ethiodized oil within a treated left lobe tumor (arrow). ( d ) Repeat arteriography demonstrates significant decrease in tumor vascularity following chemoembolization. BCNU, 1,3-bis (2-chloroethyl)-1-nitrosourea.

Fig. 2

( a ) Contrast-enhanced coronal abdominal MRI of a patient with bulky hepatic tumors (arrows) presenting with fatigue, abdominal distention, pain, and weight loss. ( b ) Contrast-enhanced abdominal MRI following DEBDOX and BCNU chemoembolization demonstrates a decrease in size of both tumors (arrows) following treatment. Patient survived 48 months following initiation of liver-directed therapy and died due to progression of extrahepatic disease.

Fig. 3

( a ) Patient underwent multiple immunoembolization treatments with all tumors undergoing a complete response except for a “rogue” tumor in the medial segment of the left lobe of the liver seen on contrast-enhanced MRI (arrow). ( b ) “Rogue” tumor was treated with microwave ablation. Repeat MRI shows necrotic tumor in the ablation cavity (arrow). The patient is currently on a treatment break 7½ years after initiating liver-directed therapy.

Fig. 4

( a ) Contrast-enhanced CT of the abdomen (portal venous phase) demonstrates no definite liver tumors. ( b ) Contrast-enhanced (Eovist) MRI performed the same day as the CT demonstrates several tumors on the hepatobiliary phase and ( c ) diffusion-weighted imaging including a large tumor in the medial segment of the left lobe of the liver (arrows).

Fig. 5

( a ) Contrast-enhanced MRI of the abdomen demonstrates a small tumor in the medial segment of the left lobe (arrows). A repeat MRI was ordered by the patient's local oncologist. ( b ) Four months later, repeat MRI demonstrates significant tumor growth (arrows). Patient referred to our institution for treatment. ( c ) Repeat MRI performed ∼4 weeks later demonstrates rapid tumor progression highlighting the need for contemporaneous imaging prior to liver-directed treatment (arrows).