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Table 1 Eye-preserving therapies of uveal melanoma

From: Diagnostic methods and therapeutic options of uveal melanoma with emphasis on MR imaging—Part II: treatment indications and complications

Technique

Method

Effects

Indication

Main complications

Limitations

Laser therapy (LT)

Laser photocoagulation

Xenon or argon laser

Rise temperature inducting denaturization of proteins and cellular apoptosis

Small-sized tumours (< 3 mm)

Retinal vein occlusion, vitreous hemorrhage, optic atrophy, thrombotic glaucoma, macular involvement, cystoid macular oedema

No more used (superseded by TTT) because poor tissue penetration and multiple treatment sessions

Transpupillary thermotherapy (TTT)

Infrared diode laser (810 nm)

Rise temperature (45°–60°) inducting cytotoxic effects, vascular occlusion and tumour necrosis

Tumours thickness < 4 mm

Distance from the fovea > 3 mm

Not touching the optic disc

Adjuvant treatment combined with other eye-sparing therapy

Retinal oedema

Fine intraretinal hemorrhage

Amelanotic or poor melanotic choroidal melanoma

Long-term possibility of recurrence and/or high metastatic risks

Limited tissue penetration of 4 mm

Radiotherapy (RT)

Brachytherapy (BRT)

Saucer-shaped plaque, sutured to the sclera, containing radioactive sources (62–70 Gy to the tumour apex):

X-ray isotopes;

γ-ray isotopes: Cobalt-60, Palladium-103, Iridium-192, Iodine-125;

β-ray isotope: Ruthenium-106

Radiation-induced irreversible DNA damage that leads to cell death, cell cycle redistribution and microenvironment changes

AJCC-UICC T1, T2, T3 and T4a-d

Basal diameter tumor < 16 mm

Tumor thickness < 11 mm

Supero-temporal quadrant

Radiation-induced retinopathy, cataract and maculopathy, secondary glaucoma, vitreous hemorrhage and retinal detachment, scleral necrosis, diplopia, strabismus, involvement of extra-ocular muscles

Large tumors (diameters > 15 mm; height > 10 mm)

Distance from optic disc < 2 mm

Limited tissue penetration of 4–5 mm

Not eligible in case of:

Blind painful eyes

Extraocular extension (T4e)

Limited light perception

Damage to surrounding normal choroid

Charged-particles beam radiotherapy

Tumor irradiation with charged particles, protons and helium ions (53–70 Gy), over 4 consecutive days

Bragg Peak: particles release ionizing radiation when they stop traveling

High dose of radiation leading to DNA damage and subsequent cell death

Basal diameter tumor < 28 mm

Tumor thickness < 14 mm

Neoadjuvant therapy before surgical resection

Retinopathy, rubeosis iridis, cataract, uveitis, optic neuropathy, maculopathy, dry eye, loss of eyelashes, retinal detachment, keratopathy

Low rates of visual prognosis and eye conservation for large melanomas

Involvement of lacrimal glands (supero-temporal quadrant lesion)

Stereotactic radiotherapy (SRT)

Gamma-Knife and Cyber-Knife

Stereotactic and robot-assisted radiosurgery with fractionated ionizing radiation (total dose of 30–50 Gy) delivered to a relatively small target, decreasing progressively at the margins (25–35 Gy)

Extremely focused dose of radiation leading to DNA damage and subsequent cell death

Tumor confined to the eye, sparing extra-ocular tissue (T4e)

Juxtapapillary uveal melanoma

Patients not eligible for BRT or surgery

Cataract, dry eye disease, vitreous hemorrhage, radiation retinopathy, radiation maculopathy, optic neuropathy, neovascular glaucoma

Lower availability

Ocular fixation

High rates of radiation-induced retinopathy and neovascular glaucoma

Linear accelerator (LINAC)

Stereotactic fractionated and hypofractionated photon radiotherapy (50–70 Gy in 5–7 Gy single-dose fractions)

Extremely focused dose of photon leading to DNA damage and subsequent cell death

Tumor confined to the eye, sparing extra-ocular tissue (T4e)

Juxtapapillary uveal melanoma

Patients not eligible for BRT or surgery

Conjunctivitis, skin reaction, maculopathy, cataract, ischemic retinopathy, glaucoma, retinal detachment, corneal ulcer, vitreous hemorrhage, optic nerve damage

Lower availability

High rates of radiation-induced retinopathy and neovascular glaucoma