Possible That Early Treatment of Choroidal Melanoma Might Prevent Metastatic Death

By Will Boggs MD

March 19, 2014

NEW YORK (Reuters Health) - Early treatment might be better than watchful waiting for some patients with choroidal melanoma, a prospective study suggests.

"Patients suspected of having choroidal melanoma tend to be observed for months or years until growth is documented," Dr. Bertil E. Damato from University of California, San Francisco, told Reuters Health by email. "Compared to watchful waiting, biopsy may be the safer option, with immediate therapy if lethal genetic abnormalities are detected."

Despite successful eradication of the primary tumor, almost 50% of patients with choroidal melanoma die of metastatic disease. Survival time after treatment has been reported to be shorter for large tumors than for small tumors, but this could reflect lead-time bias (larger tumors having had more time to grow and metastasize).

Dr. Damato and colleagues from Royal Liverpool University Hospital and University of Liverpool in the UK sought to determine whether treatment of choroidal melanoma influences survival by correlating age at death, cause of death, age at treatment, and survival predictors in a prospective study of 3072 patients.

Tumors ranged in size from 2.4 to 23.8 mm in basal diameter (median, 12.1 mm) and from 0.6 to 18.3 mm in thickness (median, 4.1 mm).

The largest basal diameter correlated with all survival predictors except chromosome 6p gain, according to the March 13 JAMA Ophthalmology online report.

Median age at treatment was 60.7 years in patients with basal tumor diameters less than 10 mm and 65.6 years in patients with basal tumor diameters larger than 18 mm.

Older age at treatment correlated with ciliary body involvement, extraocular spread, largest basal tumor diameter, tumor thickness, TNM stage, chromosome 3 loss, and chromosome 8q gain.

Among the 1005 patients who had died by the end of the study, the cause of death was metastatic disease from uveal melanoma in 561. The median age of death was younger (68.6 years) for those who died from metastatic melanoma than for those who died from any cause (74.0 years).

For the patients who died of metastasis, none of the survival predictors correlated with age at death except for mitotic count, and it showed only a weak correlation.

"The management of patients with possible or definite choroidal melanoma is complicated by the fact that we do not really know whether ocular treatment ever influences survival and, if so, in whom," Dr. Damato said. "In the absence of randomized trials, investigating cause of death may provide some clues. Our study tentatively suggests that the death is more likely to be caused by metastasis if treatment is delayed; however . . . further studies are needed on similarly-sized cohorts in which all patients have died."

"We hope that physicians will take special care to ensure that patients with a melanocytic tumor of uncertain malignancy understand the risks and benefits of observation, biopsy, and treatment," Dr. Damato said. "If watchful waiting is selected, the patient's consent for deferred treatment should be adequately informed and documented."

"Although biopsy of small choroidal tumors is demanding, ongoing advances in surgical and laboratory techniques are increasing the scope of this procedure," Dr. Damato said. "Attitude to risk varies greatly between patients and this must be taken into account when planning care. This is a difficult and controversial area."

SOURCE: http://bit.ly/1g6vNJW

JAMA Ophthalmol 2014.

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