Treatment and Follow-up

Patients were fully informed of all relevant aspects of the procedures, including the controversy surrounding endoresection. The preoperative examination included a best-corrected Snellen visual acuity test, a complete ophthalmoscopic examination, and A- and B-scans to measure the maximum tumor thickness and diameter. Tumor size was classified according to the criteria established by the Collaborative Ocular Melanoma Study (COMS) and according to the tumor size categories (T) published in the 7th edition of the American Joint Committee of Cancer (AJCC) staging system. All patients underwent screening for metastatic disease, which included serum biochemistry with liver function determinations, ultrasound evaluation of the liver, chest radiography, and evaluation by an oncologist.

Brachytherapy was administered using iodine-125 COMS-type plaques. Trans-scleral illumination was used to assess tumor margins with the patient under local anesthesia. In all cases, a minimum safety margin of 2 mm was employed and the same surgeon (J.M.C.) performed all procedures in the Brachytherapy Department. A total dose of 85 Gy was delivered to the apex of the tumor using a dose rate of 50-120 cGy/hour. Initial follow-up was performed approximately 15 days after the intervention and at 3 months; thereafter, follow-up assessment, including screening for metastasis, was performed every 6 months during the first 5 years and annually thereafter.

In the case of endoresection, the surgical technique varied according to the degree of tumor invasion. In cases where the tumor had not invaded the retina, endoresection consisted of 20- to 23-gauge vitrectomy using a panoramic viewing system, followed by posterior hyaloid dissection, large retinotomy anterior to the tumor, and laser endophotocoagulation with 600-800 mW directed 2 mm beyond the tumor margins using the continuous mode of a 532-nm laser. The melanoma lesion was removed with the vitrectomy probe using a bimanual technique to separate and protect the retina. Intraoperative choroidal bleeding was controlled by temporarily raising the intraocular pressure (IOP) to 60-70 mm. In all cases, patient blood pressure remained within normal limits during the procedure. Tumor excision was performed from the tumor apex to the scleral bed. Cellular remnants at the scleral bed were photocoagulated with high doses (800-1000 mW) of continuous-mode laser endophotocoagulation at 532 nm. The retina was reattached with perfluorocarbon liquid. Laser retinopexy endophotocoagulation was performed at the margins of the retinotomy, and this procedure was followed by fluid-air exchange and silicone oil-air exchange (1300-5000 centistokes). In cases where the tumor had invaded the retina, continuous-mode laser endophotocoagulation at 532 nm was employed through the retina and around the tumor margins, and then both the tumor and the retina were removed without peripheral retinotomy. In all cases, the lens of the eye was removed before vitrectomy by phacoemulsification, and a 3-piece foldable acrylic intraocular lens was inserted. Patients were instructed to maintain a face-down position for 1 week after surgery. Postoperative follow-up was performed at 1 day, 1 week, 1 month, 3 months, and 6 months. Thereafter, follow-up, including screening for metastasis, was performed at 6-month intervals ( Figure 1 ).

Illustration of 3 patients with uveal melanomas who underwent endoresection. (Top row, left) Patient with a superior temporal choroidal melanoma in the left eye (height, 8.4 mm; maximum basal diameter, 9 mm) with a visual acuity of 20/40 at the time of diagnosis. (Top row, right) The same patient after surgery, with no evidence of regrowth during follow-up (84 months) and a visual acuity of 20/200. (Middle row, left) Patient with an inferior macular choroidal melanoma with foveal detachment in the left eye (height, 5.2 mm; maximum basal diameter, 10 mm) with a visual acuity inferior of 20/200 at the time of diagnosis. (Middle row, right) The same patient after surgery, with no evidence of regrowth during follow-up (97 months) and a visual acuity worse than 20/200. (Bottom row, left) Patient with a superior temporal choroidal melanoma in the left eye with macular detachment (height, 7.5 mm; maximum basal diameter, 9 mm) with a visual acuity worse than 20/200 at the time of diagnosis. (Bottom row, right) The same patient after surgery, with no evidence of regrowth during follow-up (36 months) and a visual acuity of 20/200.

Statistics

Descriptive analysis was performed, and measures of the central value (mean and median) and dispersion (standard deviation, interquartile range) were determined depending on whether there was a normal distribution (Kolmogorov-Smirnov test). For quantitative variables, the Student t test or the Mann-Whitney U test was used, as appropriate, to compare baseline characteristics resulting from tumor endoresection or iodine-125 brachytherapy. To evaluate differences in proportions, the χ ² test or Fisher exact test was employed as needed.

A Kaplan-Meier analysis was performed to determine predictive variables of overall survival. Those variables that showed a statistically significant association with survival by the log-rank test ( P < .05) were subsequently analyzed using a Cox regression model. Effect estimates were expressed as hazard ratios (HR) with 95% confidence intervals (95% CI). All statistical tests were 2-tailed, and P values of ≤.05 were deemed significant. All analyses were performed using SPSS 12.0 software (SPSS, Inc, Chicago, Illinois, USA).