Uvea melanomlarında rutenyum 106 plak radyoterapisi
Özet
Ru-106 Plaque Radiotherapy in the Treatment of Uveal Melanoma Uveal melanoma is the most common primary malignant intraocular tumor in adults. In the past, the most common treatment method was enucleation but recently, globe sparing methods have become more popular. Globe sparing treatment methods are radiotherapy, transpupillary thermotherapy and local resection. The factors that affect treatment selection are rumor base size, tumor thickness, location, the risk factors for tumor activation, visual acuity of the affected eye, state of the fellow eye, age of the patient, general health state, patient's preference. Plaque radiotherapy is the most preferred method in the treatment of uveal melanoma. To evaluate the efficacy and safety of Ru-106 plaque radiotherapy in the treatment of uveal melanoma, 65 patients with uveal melanoma were treated with Ru-106 plaque radiotherapy. Plaque radiotherapy was used as a single treatment in 36 patients, in combination with TTT in 26 patients and after PLSU in 3 patients. In all patients age, sex, presence of systemic disease, initial visual acuity, initial largest tumor diameter, initial tumor thickness, presence of subretinal fluid, radiation dose and radiation dose rate at the tumor apex and base, change in tumor thickness during the follow up, treatment complications, last visual acuity, recurrence rate, enucleation rate and metastasis were evaluated. In the first group, Ru-106 plaque radiotherapy was applied as primary treatment in patients with ciliochoroidal and choroidal melanoma. In the second group, combined Ru-106 plaque radiotherapy and TTT was done to treat selected cases of choroidal melanoma and in the third group, plaque radiotherapy was done following PLSU to treat any possible remaining tumor cells in the surrounding uvea. In the first group, there were 36 patients with ciliochoroid and choroidal melanoma treated with plaque radiotherapy only. The mean largest basal diameter of the tumor was 9.9 (6-15) mm. The mean initial tumor thickness was 5.5 (3-8) mm. The mean follow-up period was 19.4 (1-53) months. After the plaque radiotherapy the mean tumor thickness was 4.0 mm at 3 month; 3.2 mm at 6 month; 2.8 mm at 12 57months; 2.8 mm at 18 months; 2.7 mm at 24 months and 2.6 mm at 30 months. The change in tumor thickness between baseline and 3 month was not significant but with regard to the initial, tumor thickness decreased significantly at the other months. Complications in the Ru-106 plaque radiotherapy group, included radiation retinopathy in 9 patients (25.0%), vitreous hemorrhage in 8 patients (22.2%), cataract in 8 patients (22.2%), increase in exudative retinal detachment in 3 patients (8.4%), radiation papillopathy in 2 patients (5.6%), ischemic maculopathy in 2 patients (5.6%), ptosis in 1 patient (2.8%), pigment dispersion into vitreous cavity in 1 patient (2.8%) and choroidal detachment in 1 patient (2.8%). Most of the patients with radiation retinopathy did not require any treatment. Cataract surgery was done to only one patient. Enucleation was done to 2 patients with nonresolving vitreous hemorrhage. For the patients with increase in exudative retinal detachment, 1 mg/kg/day systemic corticosteroid treatment was given and after the treatment subretinal fluid was absorbed. Enucleation was done in one patient (2.8%) due to tumor recurrence and in 2 patients (5.6%) due to nonresolving vitreous hemorrhage. The local recurrence rate was 2.8% and the local tumor control rate was 97.2%. None of the patients developed metastasis and tumor related death. In the second group, combined plaque radiotherapy and TTT were done. in 26 patients with choroidal melanoma. The largest basal tumor diameter was 9.4 (6.0- 12.0) mm. The mean initial tumor thickness was 5.6 (2.0-9.0) mm. The mean follow- up period was 25.5 (6.0-51.0) months. The mean tumor thickness was 4.5 mm at 3 month, 4.1 mm at 6 month, 4.1 mm at 12 months, 3.4 mm at 18 months, 3.0 mm at 24 months and 3.1 mm at 30 months. The change in tumor thickness with regard to baseline was not significant at 3, 6 and 12 months but decrease in tumor thickness was significant at the other months. The mean number of TTT session was 2.7 (1-6). Complications of combined Ru-106 plaque radiotherapy and TTT included retinopathy in 16 patients (61.5%), increase in exudative retinal detachment in 6 patients (23.1%), cataract in 5 patients (19.2%), vitreous hemorrhage in 4 patients (15.4%), papillopathy in 2 patients (7.6%), pigment dispersion into vitreous cavity in 2 patients (7.6%) and ptosis in 1 patient (3.8%). Most of the patients with retinopathy 58did not require any treatment. Cataract surgery was done to only 3 patients. Vitreous hemorrhage was resorbed spontaneously in patients with vitreous hemorrhage. Patients with increase in exudative retinal detachment were treated with 1 mg/kg/day systemic corticosteroid treatment and after the treatment subretinal fluid was absorbed. Enucleation was done to 3 patients (11.5%) due to tumor recurrence and exenteration was done to 1 patient (3.8%) due to orbital invasion. The local recurrence rate during the follow-up was 19.2 % and the local tumor control rate was 84.6%. None of the patients developed metastasis and death. In the third group, plaque radiotherapy was done in 3 patients following PLSU. The initial tumor thickness was 7.7 (7.0-9.0) mm. The mean follow-up period was 28 (10-50) months. No recurrence, metastasis and death were seen during the follow-up. Cataract surgery was done minimum one or two years after Ru-106 plaque radiotherapy without any complication. At the end of the study, according to the LogMar scale visual acuity was generally well preserved. In conclusion, Ru-106 plaque radiotherapy is an effective and safe method either alone, combined with TTT or after PLSU in the treatment of selected patients with uveal melanoma at short term. Key words: PLSU, Ru-106 plaque radiotherapy, TTT, tumor thickness, uveal melanoma.