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Although the prognosis for posterior uveal melanoma remains poor, a look at recent developments and ongoing research provides hope for better outcomes in the future, said Jerry A. Shields, MD, in his delivery of the 2014 Charles L. Schepens, MD, Lecture.
Chicago-Although the prognosis for posterior uveal melanoma remains poor, a look at recent developments and ongoing research provides hope for better outcomes in the future, said Jerry A. Shields, MD, in his delivery of the 2014 Charles L. Schepens, MD, Lecture.
“We have come a long way in our management of posterior uveal melanoma from the time when ophthalmologists removed the eye and hoped for a cure,” said Dr. Shields, professor of ophthalmology, Thomas Jefferson University, and director, oncology service, Wills Eye Hospital, Philadelphia. “Today, with earlier recognition, use of new systemic therapies, and by collaborating with others, a cure for posterior uveal melanoma may not be far away.”
Reviewing the past, present, and future of posterior uveal melanoma management, Dr. Shields said that prior to the early 1970s, enucleation was performed for almost any pigmented choroidal lesion suspected to be a melanoma. Then, diagnostic accuracy began to improve, due in part to rising numbers of trained retinal specialists and also to the use of better diagnostic tools.
At the same time, new surgical methods were introduced aiming to decrease tumor dissemination during enucleation or to avoid enucleation completely, based on the hypothesis that enucleation itself induced metastasis.
Looking at management of posterior uveal melanoma today, Dr. Shields said that a variety of techniques are used. Radiotherapy represents the most common method for treating these tumors, and while it may be controversial, he believes that transpupillary thermotherapy is still an appropriate option that can eradicate tumor in properly selected cases.
At present, there is also a trend toward earlier treatment (versus observation) using understanding of risk factors for identifying small ocular melanomas (thickness >2 mm, subretinal fluid, symptoms, orange pigment, and margin <3 mm to the optic disc). In addition, findings from genetic testing of fresh lesional tissue are being incorporated in identifying patients at high risk for metastasis and a poor outcome.
Looking ahead, Dr. Shields said that ophthalmologists will not be managing posterior uveal melanoma in isolation, but rather they will be working together with oncologists and researchers.
“The ophthalmologist will be responsible for the earliest detection possible, using ophthalmoscopy and risk factor assessment, but also multimodal imaging that may detect the tumor before it is visible clinically,” he said.
“Researchers will be clarifying molecular pathways that lead to melanoma growth and metastasis and use the information in studies of animal models to explore novel therapies that may prevent metastasis or cure disease, and the oncologist will identify patient-specific genetic mutations associated with risk for metastasis and detect molecular pathway defects that will guide use of these forthcoming targeted therapies,” Dr. Shields said.