Secondary glaucoma in small versus large uveal melanoma patients treated with stereotactic radiosurgery on linear accelerator.

AIM: Secondary radiation-related side effects like secondary glaucoma (SG) of different modalities of treatment in uveal melanoma patients can appear in certain interval after therapy. This study describes the incidence of SG in patients after stereotactic radiosurgery (SRS). METHOD: The data of 230 patients treated by SRS were reviewed for SG. Group of 83 patients who were observed 5 years after treatment in one center with follow-up regularly at least 4 times per year were analyzed. RESULTS: In group of 83 patients with the median age 59 years, the median tumor volume at baseline was 0.41 cm3. The survival without SG after single dose SRS was 94 % in 1.5 year, 77 % in 2 years, 57 % in 3 years, 43 % in 3.5 years, and 18 % in 4.5 year after irradiation. In 6 patients (7.2 %) secondary enucleation was necessary due to SG. Both predictors (tumor volume and age of patient) at the time of SRS were not statistically significant by Cox proportional-hazards regression. CONCLUSIONS: Complications like SG in 5 year interval after irradiation can lead to secondary enucleation of the eye globe (Fig. 3, Ref. 44).

[Sub-internal limiting membrane haemorrhage treated by pars plana vitrectomy]. / Krvácania pod vnútornú hranicnú membránu sietnice liecené pars plana vitrektómiou.

PURPOSE: A retrospective study of anatomical and functional results of haemorrhages sub-internal limiting membrane treated by pars plana vitrectomy with internal limiting membrane peeling. MATERIALS AND METHODS: The studied group consists of 6 patients - 6 eyes with acute bleeding under internal limiting membrane at the age of 18-59 years (mean age 37,3 years). The group was ethiopathogenetically various: 1x sarcoidosis, 1x cocaine abuse, 1x alcoholic and drug-induced hepatopathy, 1x morbus von Willebrand, 1x branch retinal vein occlusion combined with macroaneuryzm, 1x unknown cause - idiopathic. Best corrected visual acuity (BCVA) was hand motion in 3 of the eyes, counting fingers at 30 cm, 20/200 or 20/63 in the other 3 eyes. After a complete ophthalmologic examination including fluorescein angiography and optical coherence tomography a 23-gauge sutureless pars plana vitrectomy with internal limiting membrane peeling was performed in all patients. The follow-up period was 3-36 months (mean follow-up 18.3 months). RESULTS: In all 6 patients (6 eyes) an important improvement of visual functions was observed within 2-3 days after the surgery with a corresponding improvement of anatomical ophthalmoscopic findings and findings on optical coherence tomography. The BCVA at the last examination was 20/20 in 3 eyes, 20/32 in 2 eyes and 20/25 in 1 eye. We did not experience any complications like retinal tear, retinal detachment, endophthalmitis or relapse of bleeding neither during the surgery nor during the follow-up period. CONCLUSION: Sub-internal limiting membrane haemorrhage affect younger patients in working-age population. These patients need rapid visual recovery. Surgical treatment of sub-internal limiting membrane haemorrhages by pars plana vitrectomy with internal limiting membrane peeling is a safe and effective method, which facilitates a quick return to patients` previous working activities and social standard.

[Choroidal melanoma stage T1 - comparison of the planning protocol for stereotactic radiosurgery and proton beam irradiation]. / Choroidálny melanóm v stádiu T1 - porovnanie plánu oziarenia pri stereotaktickej rádiochirurgii a pri protónovej terapii.

OBJECTIVE: Comparison of two methods of irradiation of patients with malignant choroidal melanoma - stereotactic radiosurgery and proton beam irradiation. External (non-contact) applied irradiation is used as a source of accelerated protons, respectively helium ions. This method allows applications of ionizing irradiation also despite the low radiosensitivity of cells of malignant melanoma of the uvea (MMU). External source of ionizing radiation is modulated current energy electrons, protons or neutrons, accelerated in linear accelerators. From the external medium voltages resources (4-16 MeV) are irradiated tissues with target dose of 5.0-24.0 Gy. Volume protons permeate straight the structures of the eye to a certain distance. The use of proton radiation density of ionized protons increases in the vicinity of the impact due to energy losses for electrons interacting with the environment. At the end of the track there is a huge increase in the ionization dose ("Bragg spike"). Therefore, the structures surrounding the eye at the point of entry and little affected and increasing the dose at the end of the proton beam is ideal for the desired therapeutic effect. Fractionated application is also possible. CASE REPORT: In December 2011 we performed stereotactic radiosurgery to treat female patient (born 1939) with malignant melanoma of the choroid stage T1 N0 M0. Plan has been drawn up for stereotactic irradiation - model for linear accelerator Clinac, Corvus planning system ver. 6.2, verification and OmniPro IMRT planning system Liebinger ver. 4.3. Patient characteristics were compared with the virtual plan for proton radiation therapy, and we used the scheme in Physical parameters FIAN-technical center in the Russian Federation. We compared both planning protocols and assess in particular the extent of radiation surrounding non-tumor tissue. RESULTS: When comparing the two planning schemes irradiation levels of surrounding tissues and risk structures (lens, optic nerve, chiasm) in both methods were corresponding to the required standard. CONCLUSION: Treatment of uveal melanoma through proton beam irradiation in Slovakia is not available yet, although it has several advantages, such as fractionation and the possibility of achieving a higher dose of irradiation to deposit (more than 50.0 Gy). The fundamental difference between the two methods for an eye is particularly the possibility of proton beam irradiation exposure of tumor of iris and ciliary body, which can not be solved through stereotactic radiosurgery. The dose to the tumor during irradiation can be optimized. The model device allowed us to make OPTMI - Therapy (Proton Treatment with Optimized Modulated Intensity).

[Extrascleral overgrowth of malignant choroidal melanoma after endoresection]. / Extrasklerálne prerastanie malígneho melanómu choroidey po endoresekcii.

OBJECTIVE: Course of progression of the malignant choroidal melanoma diagnosed in T2 stage up to stage T4 with infiltration of the orbit. Case report 41 year old patient identified with intraocular malignant melanoma in the year 2005, documentation of disease progression and disease. Access to treatment of intraocular malignant melanoma in stage T1 - T2 in the last decade has changed from a radical approach (enucleation) towards conservative treatment (brachytherapy, radiosurgical methods) or combined procedures (pars plana vitrectomy and endoresection followed by irradiation or addition of laser treatment). Currently, more than 60% of uveal melanoma is treated by brachytherapy or radiosurgical techniques and combined procedures. CASE REPORT: A 41 years old female patient with malignant melanoma in the choroid stage T2 since 2005. The volume of the tumor was 0.9 cm³, maximal elevation was over 12 mm. The patient refused a radical treatment (primary enucleation). Due to the stage of the melanoma she was recommended to stereotactic radiosurgery and combined therapy. She underwent stereotactic radiosurgery (TDmax - total dose of 35.0 Gy) in 2005. In 2006 pars plana vitrectomy with incomplete endoresection of the tumor and silicon oil instillation was done. In 2006-2007 appeared bleeding into the anterior chamber and she underwent three times an anterior chamber lavage in another department with subsequent development of secondary glaucoma. In January 2010 patient came to our department with the local finding of malignant melanoma in stage T4 with epibulbar growth process and the infiltration of the orbit. In the period have been found two solid liver metastases. Indicated exenteration of the orbit, histopathologically confirmed mixed cell type malignant melanoma. CONCLUSION: Progression of malignant melanoma after incomplete endoresection despite previous radiosurgical treatment can be very rapid in the course of the disease documented by ultrasound, computed tomography and magnetic resonance. The patient subsequently passed to another workplace and underwent repeated lavage of the vitreous cavity. During endoresection is opened the package fibrous mesh gateway for the infiltration process in the cavity of the orbit and epibulbar space. In the case of residual melanoma after endoresection even though the tumor was irradiated before the procedure the melanoma might progress very fast into the surrounding tissues.

[Selected prognostic factors of malignant uveal melanoma]. / Vybrané prognostické faktory malígneho melanómu uvey.

Malignant uveal melanoma is the most common intraocular tumor in adults. Despite very good local treatment results, patients' survival has not improved in the last decades. The main cause of death is metastatic spread, which occurs with a variable time delay after tumor discovery in 50% of patients. After metastasis development the mean survival rate decreases to less than 6 months. Progression to metastatic disease is associated with different prognostic factors. The spectrum of conventional clinical and histopathologic prognostic factors like age, tumor size, location, extrascleral growth, histopathologic cell type, vascularisation, invasion of sclera, etc., has been enlarged by using new immunological, molecular, immunohistochemical and cytogenetical methods. Current research also focuses on development of an adjuvant systemic therapy which could delay or prevent metastasis development in high-risk patients. It is necessary to determine reliable prognostic factors in order to select potential candidates for such a systemic treatment. In this article we present a short overview of known prognostic factors of uveal melanoma.

[The current state of the evidence of malignant tumors of the eye and its adnexa (dg. C69) in the Slovak Republic and in the Czech Republic]. / Súcasný stav evidencie zhubných nádorov oka a ocných adnexov (dg. C69) v SR a CR.

The area of ophthalmooncology includes not only intraocular tumors but also adnexal and extraocular tumors, relatively rare malignancies. To get valid data and to study the incidence, diagnosis and treatment is extremely difficult. The most frequently occurring intraocular tumor in adults is malignant melanoma, in children it is retinoblastoma. We present the results of the nationwide group of patients based on the diagnosis report C69 - Tumors of the eye and adnexa according to data of the National Cancer Registry in Slovak Republic. We monitor the incidence, distribution by age group, survival and staging. In the second part of the thesis analyzed data are compared with the data from Cancer Registry in the Czech Republic. After analyzing the data, we found that the incidence of intraocular tumors have been reported to be comparable with neighbouring countries. The classification of the disease in different stages due to TNM classifying in the report is below 50 % in Slovakia. The incidence observed in each year ranges from 0.6 to 1.0 per 100 000 inhabitants. Survival of patients with dg. C69 is comparable with other countries. The proportion of clinically defined stages of the disease is in the database of Slovakia lower than in the Czech Republic. The delay of inserting data of patients in the National Cancer Registry in Slovakia and the availability of data for analysis is currently unsatisfactory. In Slovakia are available data only up to year 2003, in Czech Republic up to year 2009.