Melphalan intra-arterial chemotherapy for choroidal melanoma chemoreduction

Abstract

Background: Intra-arterial chemotherapy (IAC) has been used to treat multiple cancers including liver metastasis from uveal and cutaneous melanoma but not as primary tumor treatment. We report the compassionate use of chemoreduction with intra-arterial melphalan before ruthenium brachytherapy to salvage an eye with choroidal melanoma.

Case presentation: A 61-year-old female patient complained of decreased vision and central-temporal scotoma in OS (left eye) for 1 month. Visual acuity was 20/20 in right eye (OD) and 20/125 OS. Anterior segment examination and intraocular pressure were unremarkable in both eyes, as was fundus examination of the OD. Fundus examination of OS revealed a brown, solid tumor partially obscuring the temporal optic disc margin and extending to the equatorial fundus midzone. Serous retinal detachment was present over the lesion and around it. Ultrasonography revealed a solid choroidal tumor with a largest basal diameter (LBD) of 13.0 mm and thickness of 10.4 mm. The tumor presented acoustic hollowness and a superimposing retinal detachment. After metastatic screening was negative, the patient underwent intra-arterial chemotherapy with melphalan. Three weeks later, her visual acuity was 20/200 and there was noticeable tumor regression to 11.9 mm (LBD) by 7.9 mm (thickness) allowing brachytherapy to be performed. Ten weeks after brachytherapy (13 weeks after IAC), visual acuity was HM due to biopsy-related vitreous hemorrhage (VH). Tumor dimensions were 9.9 (LBD) mm and 6.5 mm (thickness) and PPV was performed to remove VH. Six weeks after PPV (20 weeks after IAC), her visual acuity was 20/200 and further reduction of tumor dimensions was observed: largest basal diameter was 8.9 mm and thickness was 4.9 mm.

Conclusion: This case illustrates the feasibility of combining induction IAC prior to ruthenium brachytherapy for large choroidal melanoma. More studies are warranted to confirm these early preliminary findings.

Keywords: Chemotherapy, Intra-arterial; Melanoma, uveal; Melphalan; Ruthenium-106.

Fig. 1

Multimodal assessment of tumor response to intra-arterial chemoreduction. A–D Baseline, immediately before IAC). Color fundus picture of OS revealed a brownish-pigmented, elevated lesion covering the nasal margin of the optic nerve and extending to the equatorial region also nasally. There was serous retinal detachment over the lesion and around it. B Ultrasonography picture showing an elevated choroidal lesion with acoustic hollowness and a thickness of 10.4 mm (1:red line) and a LBD of 13 mm (2:yellow line); the lesion presented superimposing retinal detachment. C Near-infrared reflectance image illustrating the shadow of the temporal margin of the choroidal tumor obscuring part of the papillomacular bundle and the temporal margin of the optic disc. D Optical coherence tomography showed epiretinal membrane, retinoschisis, and discrete amount of subfoveal fluid. E–H: three weeks after IAC: E Color fundus photo shows partial tumor regression with overlying retinal detachment (mainly inferiorly); F On Ultrasonography, choroidal tumor thickness was 7.9 mm (3:red line) and LBD was 11.9 mm (4:yellow line); cystic changes suggestive of necrosis were also verified (asterisk); G On infrared reflectance image, there was evident reduction of papillomacular bundle shadowing by the choroidal lesion and optical coherence tomography H showed a discrete increase on subfoveal fluid, with maintenance of the remaining retinal architecture. I–L: 20 weeks after IAC): I Most of the optic nerve was now visible on color fundus picture. It also shows further tumor size reduction, which is corroborated by ultrasound measurements (J): thickness: 4.9 mm (5:red line), LBD: 8.9 mm (6:yellow line). K Infrared reflectance demonstrated complete tumor regression in the papillomacular bundle. L OCT illustrates persistent discrete subretinal fluid