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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 10

CyberKnife robotic-assisted stereotactic radiosurgery for iridociliary melanoma


1 Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Science; Ocular Oncology Service, Institute of Oncology, Tecnologico de Monterrey, Monterrey, Jalisco, Mexico
2 Ophthalmological Clinic, Santa Lucía, Guadalajara, Jalisco, Mexico
3 Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Science; Ocular Oncology Service, Institute of Oncology, Tecnologico de Monterrey, Monterrey; Ophthalmological Clinic, Santa Lucía, Guadalajara, Jalisco, Mexico

Date of Submission17-Dec-2021
Date of Decision23-Dec-2021
Date of Acceptance27-Dec-2021
Date of Web Publication09-Feb-2022

Correspondence Address:
Dr. David Ancona-Lezama
Ocular Oncology Service, Institute of Oncology, Tecnologico de Monterrey, Monterrey, Mexico. School of Medicine and Health Sciences, Av. Ignacio Morones Prieto 3000, Colonia Los Doctores, CP 64710, Monterrey, Nuevo León
Mexico
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_131_21

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  Abstract 


Iridociliary melanoma represents a rare and aggressive variant of intraocular melanoma. We report the case of a 30-year-old male with iridociliary melanoma that started as a uveitis masquerade syndrome. Noninvasive, stereotactic radiosurgery with CyberKnife® at a dose of 27 Gy to the 90% isodose line was promptly performed. Six months after treatment, no postoperative complications were observed. The patient achieved local tumor control, maintained a 20/20 visual acuity, and no signs of systemic metastasis were observed. The versatility and outpatient nature of CyberKnife® make it an option to consider for the multidisciplinary management of these patients.

Keywords: Case report, CyberKnife, eye, iris melanoma, ocular oncology, stereotactic radiosurgery


How to cite this article:
Ortiz-Morales G, Parra-Bernal C, Dominguez-Varela I, Gonzalez-Godinez S, Aguilera-Partida J, Ancona-Lezama D. CyberKnife robotic-assisted stereotactic radiosurgery for iridociliary melanoma. Pan Am J Ophthalmol 2022;4:10

How to cite this URL:
Ortiz-Morales G, Parra-Bernal C, Dominguez-Varela I, Gonzalez-Godinez S, Aguilera-Partida J, Ancona-Lezama D. CyberKnife robotic-assisted stereotactic radiosurgery for iridociliary melanoma. Pan Am J Ophthalmol [serial online] 2022 [cited 2022 May 25];4:10. Available from: https://www.thepajo.org/text.asp?2022/4/1/10/337479




  Introduction Top


Uveal melanoma is the most frequent primary intraocular malignancy.[1] The most frequently affected tissue is the choroid (90%), followed by the ciliary body (6%) and iris (4%).[1] Iridociliary melanoma may present as a masquerading syndrome and is later characterized by a fleshy, nodular lesion that might raise intraocular pressure and might cause iris heterochromia.[2] Hereby, we report the case of a patient with iridociliary melanoma treated with CyberKnife® (CK) stereotactic radiosurgery (SRS).


  Case Report Top


A 30-year-old male was referred to the uveitis department (JAP), presenting with sudden decrease in visual acuity, red-eye, ocular pain, and anterior chamber inflammation. He had no relevant family history. A diagnosis of anterior uveitis was made, and topical steroids and cycloplegic agents were started. Two weeks later, a lightly pigmented, fleshy, vascularized mass was observed in the iridocorneal angle during a follow-up evaluation [Figure 1]. No increase in intraocular pressure and no iris heterochromia were observed. He was subsequently sent to ocular oncology where an urgent iris biopsy, ultrasound biomicroscopy, and systemic evaluation were performed. The latter was performed by a medical oncologist and included: complete blood count, liver function test, liver ultrasound, brain magnetic resonance imaging (MRI), and chest imaging. These evaluations revealed a stage T2a tapioca iris melanoma (8.59 mm diameter and 4.48 mm thickness) [Figure 2]. No metastatic disease was observed. After informed consent, the patient decided to undergo CK (Accuray Inc, USA) based on availability and as an alternative to avoid enucleation.
Figure 1: Anterior segment photography shows sentinel vessels (left) and a fleshy, nodular vascularized iris mass (right). No iris heterochromia was seen in this patient

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Figure 2: Ultrasound biomicroscopy shows a solid, hypoechoic, mildly heterogeneous, clustered lesion involving the ciliary body and iris

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SRS was performed under retrobulbar anesthesia. Computed tomography and MRI images were obtained and fused in collaboration with the medical physics department and fed into the Multiplan®System (Accuray Inc, USA) for target volume delimitation and radiation beam planning [Figure 3]. An individualized radiation thermoplastic mask (Orfit Industries, Belgium) was used and a mean dose of 27Gy was administered to the 90% isodose line in single-session SRS. Clinical and imaging follow-up was performed on days 1 and 7, and 1, 3, and 6 months after radiosurgery. No complications from the radiosurgery were reported. No secondary enucleation was required at the last follow-up. At the last ultrasound biomicroscopy, a reduced 4.66 mm × 3.05 mm lesion was observed. Eight months after treatment, the best-corrected distance visual acuity was 20/20, and the patient achieved local tumor control.
Figure 3: The integrated software enables the creation of precise radiation beam therapy, allowing efficient and noninvasive treatment alternatives

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  Discussion Top


Iris melanoma represents up to 26% of all iris tumors and only 4% of all uveal melanoma across all ages.[1] Iridociliary melanoma may start as uveitis masquerade syndrome, with anterior chamber cellularity as in this case and may delay diagnosis. Although the comparatively lower metastatic rate of iris melanoma (4% vs. 15% for choroidal melanoma at 5 years), tumor extension and thickness growth are common occurrences without proper treatment.[3] Thus, local tumor control and globe salvage are considered primary therapeutic objectives in these cases.

Popovic et al.[4] reviewed 761 eyes with iris melanoma and analyzed the results and complications of each treatment regimen. Proton-beam radiotherapy was found to be the most used modality, followed by plaque radiotherapy. Local recurrence ranged from 0%–7% with proton-beam radiotherapy and 0%–8% with plaque radiotherapy as well as with surgical resection. Metastasis rate was consistently under 5% with both proton-beam radiotherapy and plaque radiotherapy.[4] A wider range was reported with surgical resection (0%–14%), seemingly owed to high-risk cases.[3],[4]

In a retrospective study of uveal melanoma treated with stereotactic radiosurgery, Yazici et al. reported a disease-free survival rate of 57%, local recurrence-free survival rate of 73%, metastasis-free survival rate of 69%, and enucleation-free survival of 73%.[5] When assessing the quality of life after CK radiosurgery in patients with uveal melanoma, authors have demonstrated a significant improvement in mental health and social functioning items, remarkably if BCVA has been preserved and if the eye has been spared from glaucoma.[6]

Current evidence supporting the use of CK for iris melanoma is limited. To our knowledge, only one case series is currently available. Schmelter et al.[7] recently shared their experience with eight patients with a median follow-up of 23 months. With a mean radiation dose of 21 Gy at a 70% isodose line, the mean reduction in thickness was 0.74 mm (P = 0.01) and the mean reduction in diameter was 0.58 mm (P = 0.16). Although all patients responded favorably with conservative treatment, the most frequent complications were radiation keratopathy (62.5%) and secondary glaucoma (50%). Finally, all of the patients achieved local tumor control, with no metastatic disease observed.[7] As of now, these radiotherapy techniques have shown a risk for cataract development, limbal stem cell deficiency, and secondary glaucoma as associated complications in patients with iris melanoma.[4],[7]

In this case, after biopsy and SRS, tumor diameter decreased -3.93mm, thickness -1.43mm, and tumor size has remained stable during current follow-up consultations. No complications associated with the radiation therapy were observed up to the last follow-up evaluation. The patient achieved globe salvage and local tumor control during the short follow-up time reported.


  Conclusion Top


Similar to other types of uveal melanoma,[8] CK might represent an alternative therapeutic option for the effective management of an infrequent variant of iris melanoma. The versatility and outpatient nature of CK radiosurgery make it an option to consider for the multidisciplinary management of these patients. Larger case series with longer follow-up periods is needed to confirm the efficacy of CK SRS in iris melanoma and its variants.

Consent

Written informed consent following the tenets of the Declaration of Helsinki was obtained from the patient for publication of anonymized patient's data.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shields CL, Kaliki S, Furuta M, Mashayekhi A, Shields JA. Clinical spectrum and prognosis of uveal melanoma based on age at presentation in 8,033 cases. Retina 2012;32:1363-72.  Back to cited text no. 1
    
2.
Karimi S, Pahlevani P. Tapioca melanoma of the iris: A case report. J Ophthalmic Vis Res 2019;14:376-81.  Back to cited text no. 2
    
3.
Shields CL, Shields JA, Materin M, Gershenbaum E, Singh AD, Smith A. Iris melanoma: risk factors for metastasis in 169 consecutive patients. Ophthalmology 2001;108:172-8.  Back to cited text no. 3
    
4.
Popovic M, Ahmed II, DiGiovanni J, Shields CL. Radiotherapeutic and surgical management of iris melanoma: A review. Surv Ophthalmol 2017;62:302-11.  Back to cited text no. 4
    
5.
Yazici G, Kiratli H, Ozyigit G, Sari SY, Cengiz M, Tarlan B, et al. Stereotactic radiosurgery and fractionated stereotactic radiation therapy for the treatment of uveal melanoma. Int J Radiat Oncol Biol Phys 2017;98:152-8.  Back to cited text no. 5
    
6.
Klingenstein A, Fürweger C, Nentwich MM, Schaller UC, Foerster PI, Wowra B, et al. Quality of life in the follow-up of uveal melanoma patients after CyberKnife treatment. Melanoma Res 2013;23:481-8.  Back to cited text no. 6
    
7.
Schmelter V, Heidorn S, Muacevic A, Priglinger SG, Foerster P, Liegl R. Robotic assisted CyberKnife radiosurgery for the treatment of iris melanoma. Sci Rep 2021;11:5685.  Back to cited text no. 7
    
8.
Ortiz-Morales G, Dominguez-Varela IA, Gomez-Elizondo D, Valdez-Balli JA, Perez-Ramos E, Ancona-Lezama D. CyberKnife robot-assisted radiosurgery for ciliochoroidal melanoma: Early results in Mexico. Invest Ophthalmol Vis Sci 2021;62:2858-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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