Management of conjunctival melanoma with local excision and adjuvant brachytherapy

Abstract

Background/objectives

To evaluate the management of conjunctival melanoma with local excision and adjuvant brachytherapy.

Subjects/methods

Data of all patients who received local excision and adjuvant brachytherapy for conjunctival melanoma between 1999 and 2016 in a Dutch national referral centre were reviewed. A protocol with Sr-90 was used until 2012, a protocol with Ru-106 was used hereafter. Local recurrence, metastasis, survival, visual acuity and treatment complications were assessed.

Results

A total of 58 patients was identified: 32 patients were treated with Sr-90 and 26 with Ru-106. Mean follow-up time was 97.3 months (143.1 months after Sr-90, and 40.2 months after Ru-106). All lesions were epibulbar, the median tumour thickness was 0.9 mm. Local recurrence occurred in 13/58 cases (22%), with a 5-year recurrence rate of 21%. Local recurrence occurred equally often in both protocols, with 5-year recurrence rates of 19% (Sr-90) versus 23% (Ru-106) (p = 0.68). Metastasis developed in 3/58 cases (5%), with 2 cases after Sr-90, and 1 after Ru-106 (p = 1.00). The most reported complications were pain (29%), dry eyes (21%), symblepharon (9%), ptosis (12%) and cataract (9%). No severe corneal or scleral complications were observed. Median visual acuity was 1.00 pre-surgery, at the end of follow-up this was 1.00 (Sr-90) and 0.95 (Ru-106).

Conclusion

Local excision with adjuvant brachytherapy provides good tumour control with excellent visual outcome and mild side effects in patients with limited conjunctival melanoma. Results after Sr-90 or Ru-106 were comparable; a choice for either treatment may be based on experience of the clinician and availability of materials.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

Fig. 1: Brachytherapy devices.
Fig. 2: Recurrence-free survival per treatment protocol.

References

  1. 1.

    Tuomaala S, Eskelin S, Tarkkanen A, Kivela T. Population-based assessment of clinical characteristics predicting outcome of conjunctival melanoma in whites. Invest Ophthalmol Vis Sci. 2002;43:3399–408.

    PubMed  Google Scholar 

  2. 2.

    Yu GP, Hu DN, McCormick S, Finger PT. Conjunctival melanoma: is it increasing in the United States? Am J Ophthalmol. 2003;135:800–6.

    Article  Google Scholar 

  3. 3.

    Triay E, Bergman L, Nilsson B, All-Ericsson C, Seregard S. Time trends in the incidence of conjunctival melanoma in Sweden. Br J Ophthalmol. 2009;93:1524–8.

    CAS  Article  Google Scholar 

  4. 4.

    Wong JR, Nanji AA, Galor A, Karp CL. Management of conjunctival malignant melanoma: a review and update. Expert Rev Ophthalmol. 2014;9:185–204.

    CAS  Article  Google Scholar 

  5. 5.

    De Potter P, Shields CL, Shields JA, Menduke H. Clinical predictive factors for development of recurrence and metastasis in conjunctival melanoma: a review of 68 cases. Br J Ophthalmol. 1993;77:624–30.

    Article  Google Scholar 

  6. 6.

    Missotten GS, Keijser S, De Keizer RJ, De Wolff-Rouendaal D. Conjunctival melanoma in the Netherlands: a nationwide study. Invest Ophthalmol Vis Sci. 2005;46:75–82.

    Article  Google Scholar 

  7. 7.

    Jovanovic P, Mihajlovic M, Djordjevic-Jocic J, Vlajkovic S, Cekic S, Stefanovic V. Ocular melanoma: an overview of the current status. Int J Clin Exp Pathol. 2013;6:1230–44.

    PubMed  PubMed Central  Google Scholar 

  8. 8.

    Lommatzsch PK, Lommatzsch RE, Kirsch I, Fuhrmann P. Therapeutic outcome of patients suffering from malignant melanomas of the conjunctiva. Br J Ophthalmol. 1990;74:615–9.

    CAS  Article  Google Scholar 

  9. 9.

    Krause L, Mladenova A, Bechrakis NE, Kreusel KM, Plath T, Moser L, et al. Treatment modalities for conjunctival melanoma. Klin Monbl Augenheilkd. 2009;226:1012–6.

    CAS  Article  Google Scholar 

  10. 10.

    Reichstein D, Karan K. Plaque brachytherapy for posterior uveal melanoma in 2018: improved techniques and expanded indications. Curr Opin Ophthalmol. 2018;29:191–8.

    Article  Google Scholar 

  11. 11.

    Westekemper H, Schallenberg M, Tomaszewski A, Nuckel H, Sauerwein W, Meller D, et al. Malignant epibulbar tumours: new strategies in diagnostics and therapy. Klin Monbl Augenheilkd. 2011;228:780–92.

    CAS  Article  Google Scholar 

  12. 12.

    Shields JA, Shields CL, Freire JE, Brady LW, Komarnicky L. Plaque radiotherapy for selected orbital malignancies: preliminary observations: the 2002 Montgomery Lecture, part 2. Ophthal Plast Reconstr Surg. 2003;19:91–5.

    Article  Google Scholar 

  13. 13.

    Brouwer NJ, Marinkovic M, van Duinen SG, Bleeker JC, Jager MJ, Luyten GPM. Treatment of conjunctival melanoma in a Dutch referral centre. Br J Ophthalmol. 2018;102:1277–82.

    Article  Google Scholar 

  14. 14.

    Marinkovic M, Horeweg N, Fiocco M, Peters FP, Sommers LW, Laman MS, et al. Ruthenium-106 brachytherapy for choroidal melanoma without transpupillary thermotherapy: Similar efficacy with improved visual outcome. Eur J Cancer. 2016;68:106–13.

    CAS  Article  Google Scholar 

  15. 15.

    Ellis F, Sorensen A. A method of estimating biological effect of combined intracavitary low dose rate radiation with external radiation in carcinoma of the cervix uteri. Radiology. 1974;110:681–6.

    CAS  Article  Google Scholar 

  16. 16.

    Coupland SE, Barnhill RL, Conway M, Damato B, Esmaeli B, Albert DM. Conjunctival melanoma. In: Amin MB ES, Green F, editors. AJCC canger staging manual, 8th ed. New York: Springer; 2017. p. 795–803.

  17. 17.

    Schemper M, Smith TL. A note on quantifying follow-up in studies of failure time. Control Clin Trials. 1996;17:343–6.

    CAS  Article  Google Scholar 

  18. 18.

    Supe SJ, Cunningham JR. A physical study of a strontium 90 beta-ray applicator. Am J Roentgenol Radium Ther Nucl Med. 1963;89:570–4.

    CAS  PubMed  Google Scholar 

  19. 19.

    Cohen VM, Papastefanou VP, Liu S, Stoker I, Hungerford JL. The use of strontium-90 Beta radiotherapy as adjuvant treatment for conjunctival melanoma. J Oncol. 2013;2013:349162.

    Article  Google Scholar 

  20. 20.

    Krause L, Ritter C, Wachtlin J, Kreusel KM, Hocht S, Foerster MH. et al. Recurrence rate following adjuvant strontium-90 brachytherapy after excision of conjunctival melanoma. Klin Monbl Augenheilkd. 2008;225:649–52.

    CAS  Article  Google Scholar 

  21. 21.

    Missotten GS, De Keizer RJ, Spileers W, Blank L. Strontium brachytherapy in conjunctival melanoma (abstract). Acta Ophthalmol. 2011;89:s248. https://doi.org/10.1111/j.1755-3768.2011.4262.x.

  22. 22.

    Damato B, Coupland SE. An audit of conjunctival melanoma treatment in Liverpool. Eye. 2009;23:801–9.

    CAS  Article  Google Scholar 

  23. 23.

    Stannard CE, Sealy GR, Hering ER, Pereira SB, Knowles R, Hill JC. Malignant melanoma of the eyelid and palpebral conjunctiva treated with iodine-125 brachytherapy. Ophthalmology. 2000;107:951–8.

    CAS  Article  Google Scholar 

  24. 24.

    Karim R, Conway RM. Conservative resection and adjuvant plaque brachytherapy for early-stage conjunctival melanoma. Clin Exp Ophthalmol. 2011;39:293–8.

    Article  Google Scholar 

  25. 25.

    Zehetmayer M, Menapace R, Kulnig W. Combined local excision and brachytherapy with ruthenium-106 in the treatment of epibulbar malignancies. Ophthalmologica. 1993;207:133–9.

    CAS  Article  Google Scholar 

  26. 26.

    Langmann G, Faschinger C, Kleinert R, Poier E, Langmann A. Zur bulbuserhaltenden therapie von Bindehautmelanomen. Spektrum Augenheilkd. 1991;5:266–9.

    Article  Google Scholar 

  27. 27.

    Mossbock G, Rauscher T, Winkler P, Kapp KS, Langmann G. Impact of dose rate on clinical course in uveal melanoma after brachytherapy with ruthenium-106. Strahlenther Onkol. 2007;183:571–5.

    Article  Google Scholar 

  28. 28.

    van Ginderdeuren R, van Limbergen E, Spileers W. 18 years’ experience with high dose rate strontium-90 brachytherapy of small to medium sized posterior uveal melanoma. Br J Ophthalmol. 2005;89:1306–10.

    Article  Google Scholar 

  29. 29.

    Fili M, Lundell G, Lundell M, Seregard S. High dose rate and low dose rate ruthenium brachytherapy for uveal melanoma. No association with ocular outcome. Br J Ophthalmol. 2014;98:1349–54.

    CAS  Article  Google Scholar 

  30. 30.

    Damato B, Patel I, Campbell IR, Mayles HM, Errington RD. Local tumor control after 106Ru brachytherapy of choroidal melanoma. Int J Radiat Oncol Biol Phys. 2005;63:385–91.

    Article  Google Scholar 

  31. 31.

    Ditta LC, Shildkrot Y, Wilson MW. Outcomes in 15 patients with conjunctival melanoma treated with adjuvant topical mitomycin C: complications and recurrences. Ophthalmology. 2011;118:1754–9.

    Article  Google Scholar 

  32. 32.

    Kurli M, Finger PT. Topical mitomycin chemotherapy for conjunctival malignant melanoma and primary acquired melanosis with atypia: 12 years’ experience. Graefes Arch Clin Exp Ophthalmol. 2005;243:1108–14.

    CAS  Article  Google Scholar 

  33. 33.

    Russell HC, Chadha V, Lockington D, Kemp EG. Topical mitomycin C chemotherapy in the management of ocular surface neoplasia: a 10-year review of treatment outcomes and complications. Br J Ophthalmol. 2010;94:1316–21.

    CAS  Article  Google Scholar 

  34. 34.

    Brouwer NJ, Marinkovic M, Luyten GPM, Shields CL, Jager MJ. Lack of tumour pigmentation in conjunctival melanoma is associated with light iris colour and worse prognosis. Br J Ophthalmol. 2019;103:332–7.

    Article  Google Scholar 

  35. 35.

    Stannard C, Sauerwein W, Maree G, Lecuona K. Radiotherapy for ocular tumours. Eye. 2013;27:119–27.

    CAS  Article  Google Scholar 

Download references

Acknowledgements

The authors like to thank Leo Blank, MD (Academic Medical Center/University of Amsterdam, The Netherlands) for his contributions to the Strontium-90 treatment of the study population and critical revision of the manuscript.

Funding

NJB is the recipient of a MD/PhD-programme grant of the Leiden University Medical Center. The sponsor or funding organisation had no role in the design or conduct of this research.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Marina Marinkovic.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Brouwer, N.J., Marinkovic, M., Peters, F.P. et al. Management of conjunctival melanoma with local excision and adjuvant brachytherapy. Eye (2020). https://doi.org/10.1038/s41433-020-0879-z

Download citation

Further reading

Search

Quick links