Article
BACH LECTURE: Changing concepts in the management of uveal melanoma over 40 years
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Authors
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Jerry A. Shields
- Shields & Shields Oncology, Philadelphia, USA
| Published: | June 9, 2015 |
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Outline
Text
Purpose: To review management of ciliary body and choroidal melanoma (posterior uveal melanoma; PUM) over the last 40 years with emphasis on changing concepts.
Methods: Review of personal experience over 40 years and pertinent literature on management of PUM.
Results: In the early 1900s, most patients presented with a large symptomatic melanoma, that necessitated enucleation, and the systemic prognosis was poor. In the 1970s, controversy erupted regarding the role of enucleation for PUM. Some authorities advocated prompt enucleation while others proposed that enucleation promoted metastasis, known as the Zimmerman hypothesis. Others recommended observation, withholding treatment until tumor growth was documented.
During the 1970s there became a trend toward eye-saving procedures, including laser photocoagulation, surgical removal of tumor, and techniques of radiotherapy. Despite local treatment success, systemic prognosis remained guarded with approximately 40% mortality overall. However, there was convincing evidence that smaller tumors offered a significantly better prognosis.
Currently, there is a movement toward earlier identification and treatment of small PUM using clinical factors predictive of malignant potential, in keeping with similar philosophy regarding other cancers. Further understanding of melanoma cytogenetics and molecular pathways have helped to recognize patients at risk for metastasis. At-risk patients are offered systemic therapeutic trials to prevent metastasis. It is anticipated that future management of PUM will focus on detection of clinical and imaging clues for earliest diagnosis, prompt local tumor treatment, and systemic targeted therapies for microscopic metastasis or prevention of metastasis. Personalized evaluation of patient-specific melanoma molecular pathway signature could potentially allow for therapeutic intervention at a site specific to the pathway abnormality that leads to the development of melanoma.
Conclusion: Management of PUM has made major strides over the past century from the days of enucleation for massive, tumor to early detection of smallest tumors with a more favorable prognosis. Current and future targeted pathway interruption using systemic agents could improve survival.
