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Title: The assessment of choroidal melanoma regression in patients treated with brachytherapy

Abstract:

The aim of my dissertation was to conduct the retrospective assessment of choroidal melanoma regression in patients treated with brachytherapy and the comparison of local, distant and functional results of the treatment with the application of Ru-106 and I-125 isotopes.376 patients aged 14 to 102, including 195 female and 181 male individuals, who suffered from choroidal and ciliary body melanoma were the subject of study. The patients were treated in the Clinical Unit of the Department of Ophthalmology and Ocular Oncology in the Jagiellonian University Hospital in Krakow between 1995 and 2005. Brachytherapy, a method allowing both conservative and organ-sparing treatment of the eyeball tumour, was instituted in all the patients. Ruthenium brachytherapy was performed in 171 individuals and iodine brachytherapy was administered in 205 subjects.The ophthalmological examinations included: assessing distant and near vision acuity, measuring intraocular pressure, examining the anterior part and the fundus of the eye, performing eyeball ultrasonography in A and B presentation and, in some cases, accessory tests.In clinical assessment of melanoma, the following parameters were taken into account: tumour size, shape, pigmentation, location, and in case of enucleation, the histopathological type. Medium-sized tumours were detected in 247 patients (65.7%), large tumours were found in 71 patients (18.9%) and small tumours were present in 58 patients (15.4%). In 280 patients (74.5%) melanoma tumours were found to be dome-shaped, in 80 subjects (21.3%) they were mushroom-shaped, and in 8 individuals (2.1%) the shape was flat. Medium-pigmented tumours were present in 237 patients (63%) while intensive and amelanotic melanomas were found in 52 (13.8%) and 72 (19.1%) patients, respectively.Tumour regression rate (in mm/year) was determined for each patient on the basis of the alterations in tumour height. Further, each patient was assigned to one of the following treatment response models: model I: tumour height reduction of > 2 mm/year, model II: height reduction of 2 - 0.5 mm/year, model III: height reduction of < 0.5 mm/year.Statistical analysis revealed that the type/model of treatment response depended on the type of the applied brachytherapy. II model (53.8%) prevailed in the group of patients treated with Ru-106 isotope. In the group of patients treated with I-125 brachytherapy most tumours (81%) showed quick response to the treatment (model I). The treatment response model was found to be dependent also on the tumour size, relapse and metastases occurrence, secondary enucleation and the histopathological type. Statistically, the type of the applied isotope was more significant than the tumour size as regards the treatment response rate.The assessment of the correlation between the degree of tumour height regression and the applied treatment revealed that the tumours treated with Ru-106 isotope showed lower regression range (47.5% lower after 3 years) and were stable at greater initial height (52.5%) than the tumours treated with I-125 isotope. In the latter group the height reduction was more considerable (67.3%) and ; stabilization occurred at lower initial height (32.7%).Positive local results, which were defined as tumour growth inhibition with or without tumour size reduction, were observed in 130 patients (76.0%) treated with Ru-106 brachytherapy and in 195 patients (95.1%) treated with I-125 brachytherapy. Cox regression analysis revealed that the tumour regression type (model II and III), the apical height radiation dose ( 100 Gy) and the patient’s age ( 40) were the factors which significantly determined a positive result of the treatment.Local treatment failure, understood as a relapse or tumour growth in spite of the treatment, occurred in 40 patients (23.4%) treated with Ru-106 isotope and in 9 patients (4.4%) treated with I-125 isotope. Cox regression analysis showed that the radiation dose below 100 Gy applied to the top of the tumour and the epithelioid histopathological type of melanoma were the factors which significantly increased the risk of tumour relapse. The study of factors affecting the primary lack of response to the treatment revealed adverse impact of the type of applicator (Ru-106), tumour location (the front edge – rearwardly from the equator of the eye, the rear edge - in close proximity to the optic nerve), the apical height radiation dose ( 100 Gy) and the base diameter of the tumour ( 10 mm).During the entire time of the study tumour metastases were found in 25 patients (14.6%) treated with Ru-106 therapy and in 31 patients (15.1%) treated with I-125 therapy. The most common site of metastases was the liver (89.3%). Less frequent sites included the lungs, brain, skin, pancreas, adrenal glands, spinal cord, spleen and ureter. Cox proportional hazards model revealed the correlation between the type of tumour regression (model I), retinal detachment, the location of the rear edge of the tumour rearwardly from the equator of the eyeball, and the occurrence of metastases.During the whole period of observation the enucleation procedure was performed in 47 patients (12.5%), including 24 (14%) treated with Ru-106 isotope and 23 (11.2%) treated with I-125 isotope. In 95.8% of the patients treated with Ru-106 brachytherapy the indication for removal of the eyeball was a relapse and the primary lack of treatment response, whereas in the group treated with I-125 isotope the main indication for surgery constituted postradiation complications (78.3%). Cox analysis demonstrated a significant correspondence between the type of tumour regression (model I), presence of relapse, mushroom tumour shape, and the risk of secondary loss of the eye. ; In 72 patients (47.7%) treated with Ru-106 isotope and in 152 patients (89.4%) treated with I-125 isotope the visual acuity after the treatment was less than 0.1. In patients with a good visual acuity before the treatment (0.5-1-0) the acuity deteriorated in 37 individuals (59.7%) treated with Ru-106 and in 43 individuals (95.6%) treated with I-125 isotope. In the same group of patients the visual acuity did not change after the treatment in 25 subjects (40.3%) who underwent Ru-106 brachytherapy and in 2 subjects (4.4%) who underwent I-125 brachytherapy. The analysis of the factors affecting the occurrence of the post-treatment visual acuity of less than 0.1 revealed a negative influence of the type of applicator (I-125), the height of the tumour ( 8 mm), the size of the tumour according to the Collaborative Ocular Melanoma Study classification (large tumours), the radiation doseapplied to the tumour top ( 100 Gy) and the presence of symptoms at the time of diagnosis.Ru-106 and I-125 brachytherapy is the method which allows effective local control of the disease (Ru-106 -76% vs I-125 - 95.1%) and does not worsen distant prognosis in reference to the occurrence of metastases (Ru-106 -14.6% vs I-125 - 15.1%). In comparison to other available methods of treatment, it is a recognized and a commonly used procedure in the treatment of uveal melanoma. Due to this method the eye can be preserved in a large number of patients (Ru-106 - 86% vs I-125 - 88.8%) and the functional visual acuity can be retained in a considerable number of patients (Ru-106 - 52.4% vs I-125 – 10.6%), which is significant in assessing the psychological and social aspects of the procedure. The results obtained in our centre, presented in my dissertation, remain consistent with the results offered by other authors in the field.

Place of publishing:

Kraków

Level of degree:

2 - studia doktoranckie

Degree discipline:

okulistyka ; onkologia

Degree grantor:

Uniwersytet Jagielloński. Collegium Medicum. Wydział Lekarski.

Promoter:

Bożena Romanowska-Dixon

Date issued:

2014

Format:

application/pdf

Identifier:

oai:dl.cm-uj.krakow.pl:3959

Call number:

ZB-122313

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Language:

pol

Access rights:

tylko w bibliotece

Location of original object:

Biblioteka Medyczna Uniwersytetu Jagiellońskiego- Collegium Medicum

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Last modified:

May 24, 2021

In our library since:

Mar 5, 2015

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ZB-122313 May 24, 2021
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