Treatment of Primary Tumors

Introduction

The treatment of the primary tumor in ocular melanoma has evolved quite dramatically over the past many years and has also been directed by numerous clinical studies including "The Collaborative Ocular Melanoma Study (COMS).” The treatment of metastatic disease continues to require more research to determine what the most effective, and life saving, treatments may be.

The course of treatment for the primary disease depends upon a number of factors, chief among them the size of the tumor. If your tumor is small enough, it may not require immediate treatment and you and your ophthalmologist (ideally one with significant experience with eye tumors) may decide to watch the melanoma closely to see if it grows. If it does, or if it begins to cause complications, you may decide to undergo treatment at some point in the future.

If you do decide to go ahead with treatment, generally it falls into one of two categories: radiation and surgery.

Radiation Treatments

Brachytherapy ("Plaque Therapy")

Also known as sealed source radiotherapy or endocurietherapy, brachytherapy is the most common form of radiation treatment  

With plaque therapy, a small disc-shaped shield known as a plaque encasing radioactive seeds (most often Iodine-125, though Ruthenium-106 and Palladium-103 can also be used) is attached to the outside surface of the eye, overlying the tumor. The plaque is left in place for a few days (6 days is not atypical) and then removed. Brachytherapy is commonly used to treat OM as well as localized prostate cancer, cervical cancer, and other cancers of the head and neck.

Dr. Finger has a good overview of plaque therapy on his Eye Cancer Foundation site.

Teletherapy (external beam radiotherapy)Transpupillary thermotherapy (TTT) 

A technique in which heat is delivered to the choroid and retinal pigment epithelium through the pupil using a modified diode laser. This laser technique contrasts with the nonthermal laser used in standard photocoagulation therapy which is designed to activate verteporfin, a photosensitizing agent. TTT uses a lower power laser for more prolonged periods of time and is designed to gently heat the choroidal lesion, thus limiting damage to the overlying retinal pigment epithelium. TTT is used less frequently in OM treatment due to issues with final control and recurrence.

Surgical Treatments

Resection (partial or full tumor removal)
  • Transscleral partial choroidectomy (cyclochoroidectomy) – A viable therapeutic option for the subset of patients with choroidal or ciliochoroidal tumors who are poor candidates for radiotherapy but are highly motivated to avoid enucleation (http://archopht.ama-assn.org/cgi/content/full/120/12/1659)
  • Transretinal endoresection

Enucleation

Enucleation refers to full removal of the affected eye. After enucleation surgery, the patient is admitted to the hospital and the eye is removed under either local or general anesthesia. The enucleated eye cannot be treated or repaired and replaced in the eye socket. Instead, it is replaced with a ball implant that may be made of plastic, a porous material called hydroxylapatite, or other materials. The implant is sewn into position and the eye is allowed to heal. The patient usually leaves the hospital one or two days after surgery. In some cases, patients are permitted to go home the same day. Three to six weeks later, a specialist who makes artificial eyes (called an ocularist) fits the patient with a prosthesis. The prosthesis is a plastic shell painted to resemble the other eye and inserted between the eyelids. When the other eye moves, the ball implant moves also, causing the prosthesis to move with the normal eye. Movement is usually less than that of the normal eye; however, the doctor and close relatives are most often the only people to notice that the patient does not have two normal eyes. If you have questions about different types of implants, be sure to ask your doctor. The purpose of the implant is to replace the volume in the socket that had been taken up by the eye. (http://www.jhu.edu/wctb/coms/booklet/book2.htm)

> Dr. Finger's overview of Enucleation
> Find an ocularist near you

Based on the COMS study, there is no statistical difference in risk of metastasis between enucleation and plaque radiotherapy, or of undergoing brachytherapy or not before undergoing enucleation for large tumors. After plaque surgery, your doctor may wait three months or thereabouts and then check for shrinkage in the eye tumor.

Post-Treatment

After treatment of your primary tumor, patients will likely experience fatigue for a few weeks. Normal diet may be resumed after discharge from the hospital, unless directed otherwise by your doctor.

Skin Care Around the Eye 
  • Wash the eye lids with mild soap and lukewarm water and gently pat dry. 
  • Avoid extreme temperatures (e.g. hot showers, hot water bottles, heating pads, or ice bags) on the affected area. 
  • Avoid any friction or eyelid rubbing or scratching. 
  • Radiation blepharitis (eyelid inflammation) can be treated with silvadine ointment, black tea soaks, or A&D ointment.
If not already working with one, patients are strongly encouraged to consult with an oncologist to construct a proper surveillance schedule for ongoing observation and care.