Transpupillary thermotherapy effective in treating many choroidal melanomas

Issue: February 10, 2014

PHILADELPHIA — Transpupillary thermotherapy is still a viable treatment option for many types of choroidal melanoma, a speaker told colleagues here.

Perspective from Carol L. Shields, MD

“Transpupillary thermotherapy has been a subject of some controversy recently, and I disagree with some of the things that have been said and written,” Jerry A. Shields, MD, said at Macula 2014.

He showed a case in which transpupillary thermotherapy (TTT) reduced a pigmented lesion within about 3 months.

“I can tell you that if we had used proton beam or plaque radiotherapy, we would not have had such a good result,” Shields said. “So, there’s still a role for it. … We found some long-term problems, but they can be managed.”

Plaque radiotherapy is a sound alternative for tumors involving the optic disc, Shields said.

“Plaque radiotherapy rather than enucleation is an acceptable method for most choroidal melanomas that touch, surround and obscure the disc. We’ve treated well over 1,000 cases,” he said.

Combined treatment has also been shown to be effective.

“Most of the time today, we combine plaque radiotherapy with TTT, so-called sandwich treatment, and you can see the result, before and after, with disappearance of the tumor and the retinal detachment,” Shields said.

Plaque radiotherapy may also be used for corneal melanoma, he said.

Small iris tumors of less than 3 clock hours may be removed with iridectomy or iridocyclectomy, Shields said.

"It’s much better if you can remove these tumors locally and leave everything else intact,” he said.

Disclosure: Shields has no relevant financial disclosures.

Perspective

Carol L. Shields, MD

Jerry A. Shields, MD, emphasized that transpupillary thermotherapy serves an important role for patients with melanoma, particularly those near the optic disc or foveola, or those with diabetes. This precise treatment can completely eradicate small melanoma, leaving a chorioretinal scar and the surrounding retina intact.
Regarding plaque radiotherapy, he emphasized that iris, ciliary body and choroidal melanoma can all be well treated with plaque brachytherapy. He further explained that even those in difficult locations such as the juxtapapillary region can be custom fit with iodine 125 plaque for complete tumor control.
Dr. Shields has had extensive experience with local resection of intraocular melanoma. He described that this technique is most useful for iris melanoma with documented growth or iridociliary melanoma. He showed an example of a patient 25 years after local resection with chorioretinal scar from the tumor site but 20/20 vision.
The last topic covered by Dr. Shields was the role of cytogenetics in the management of melanoma. Currently at the Ocular Oncology Service, all patients are offered genetic testing and nearly 75% of the patients agree to have the test performed at the time of their surgery. With this technique, a tiny specimen is obtained using fine needle aspiration biopsy, yielding only a few cells sufficient for DNA analysis. He stated that if the results show findings suggestive of high risk for metastatic disease, then the patient is entered on to systemic protocols. One preliminary protocol has shown slight favorable results for patients who are treated before metastatic disease is overtly evident. If the patient shows low risk for metastatic disease, then standard monitoring is advised.
The field of ocular melanoma is evolving and patients are detected at an earlier point when the tumor is smaller and now with better prognosis. Any patients with clinical features that could suggest an active small melanoma should be examined by a qualified ocular oncologist.

Carol L. Shields, MD

Oncology Service, Wills Eye Hospital, Philadelphia

Disclosures: Shields has no relevant financial disclosures.