Ocular melanoma treatment options differ depending on the location, site of origin in the eye, size of the tumor and other factors, such as age and general health. Radiation, surgeries and liver-directed therapies all may be recommended.

Ocular Melanoma Treatment

Once a diagnosis of ocular melanoma is made, choice of treatment depends on the location, site of origin within the eye, size of the tumor, as well as patient age, overall health, visual potential and status of the unaffected eye. Because OM is resistant to conventional systemic therapies, early diagnosis and treatment is essential. If the melanoma has metastasized, or spread, it can be more difficult to treat. Find an ocular melanoma specialist to help you with your treatment decision.

Treatment of Primary Ocular Melanoma

Definition

Primary ocular melanoma means that the tumor originated in the eye. View our Questions to Ask Your Doctor if you have primary disease.

Treatment of the Primary Tumor

The goals of treating the primary tumor are to stop tumor growth, spare the eye, preserve vision and improve patient survival. Treatment most often includes a combination of radiation and surgery but depends on the size and location of the tumor, among other factors.

Radiation

For most small and medium size tumors, radiation is the recommended treatment. There is currently no evidence that one form of radiation is better than the other. The different types of radiation therapy include:

• Plaque Brachytherapy (Radiotherapy) – A thin piece of metal, called a plaque, is sewn onto the outside wall of the eye. The radioactive seeds in the plaque give off radiation, which aims to kill the cancer. The treatment usually lasts a couple of days to little over a week and the plaque is removed at the end of treatment. This is the most common therapy in the United States for posterior (choroidal and ciliary body) ocular melanoma and is considered the standard of care for most OM patients with small or medium sized tumors. After this treatment, removal of the eye is not usually necessary, and most patients are able to retain some degree of visual function.
• Proton Beam Radiotherapy – A tube-shaped proton beam and clips are sewn onto they eye at the tumor base and an external beam of radiation is aimed at the tumor, most often through the front of the eye. Treatment is usually finished after 3-5 daily outpatient treatments.

Surgery

In some cases, the recommended treatment for ocular melanoma is surgical removal of the tumor. Surgery is often recommended for tumors of large size and for iris melanomas. Surgery may also be recommended after radiation. Types of surgery include:

• Enucleation – Removal of the eye is sometimes recommended in cases involving large tumors. Following enucleation, an artificial eye may be placed in the socket and, with the help of an ocularist, made to look like a natural eye.
• Iridectomy – Removal of part of the iris where the tumor is present.
• Iridocyclectomy – Removal of part of the iris (iridectomy) as well as the ciliary body (cyclectomy) where the tumor is present.
• Trans-Scleral Local Resection – Removal of the tumor through an opening in the wall, or the white part, of the eye. This is often used when the tumor is large. A radioactive plaque may be placed over the treated area to reduce the risk of tumor recurrence.

Other Treatments

• Transpupillary Thermotherapy – The temperature of the tumor is slowly raised, killing cancer cells and shrinking the tumor.  This treatment is most often used for small tumors in the retina and choroid.
• Cryotherapy – The temperature of the tumor is lowered since melanocytes are susceptible to freezing. This treatment option is not frequently used in OM.
• Gamma Knife – A focused, single dose of radiation is given to the tumor, sparing healthy tissue in and around the eye.
• Intraocular Injections – Intraocular injections are used to administer medications to treat a variety of ocular conditions. These medications may include steroids for inflammation and or anti-angiogenic factors, which shrink blood vessels. Intraocular injections might be used if changes have occurred to the retina and optic nerve due to radiation.

Adjuvant Treatment

In skin melanoma, adjuvant treatment is treatment used after the primary treatment (most often, surgery), to prevent the spread of disease. It can also refer to treatment used in addition to the primary form of treatment. Currently, in ocular melanoma, all adjuvant treatments are in the clinical trial stage and nothing yet has been proven to show great results.

 Treatment of Metastatic Ocular Melanoma

Once OM has spread beyond the eye, it is considered to be metastatic. Approximately half of OM patients will develop metastatic disease. When OM metastasizes, it spreads to the liver nearly 90% of the time. In general, prognosis is poor after the tumor has metastasized. Without treatment, the median survival time is between 2-8 months. Note that this is only a median overall survival and does not necessarily indicate your prognosis. Although there are currently no approved treatments for metastatic OM, there are several palliative treatments, as well as new clinical trials, offered in the US and Europe. Find an ocular melanoma specialist who can discuss all of the treatment options with you, including clinical trials. View our Questions to Ask Your Doctor if you have metastatic disease.

Liver Directed Treatments:

• Resection – Surgical removal of metastatic tumor. Only about 9% of patients are eligible for resection because of the presence of multiple tumors in the liver at the time of diagnosis
• Ablation – Can be done percutaneously (through the skin) or surgically. Ablation involves inserting small probes into tumors and heating (i.e. radio frequency ablation, microwave ablation) or freezing (cryoablation) the tumors to kill them.
• Radiation – Targeted radiation can be used to treat liver disease. This includes treatments such as stereotactic radiosurgery (Gamma Knife and Cyber Knife), that can be used to target specific tumors while sparing normal tissue.

Transarterial Catheter-Directed Liver Therapies

A particular substance is infused into the liver through a catheter that is inserted into an artery. Unlike ablation, these therapies treat an entire side of the liver or can treat both sides at once.

• Hepatic Arterial Chemoinfusion (HAI): Infusion of chemotherapy into the liver through a specialized infusion system in which a catheter is placed into the hepatic artery to directly and continuously deliver the chemotherapy to the liver. This direct infusion minimizes the side-effects of the chemotherapy and allows high doses to be administered.
• Transarterial Chemoembolization (TACE): Infusion of chemotherapy into the liver through the hepatic artery. Unlike HAI, this procedure results in episodic doses of chemotherapy. Also, unlike HAI, TACE exerts its actions in two ways: 1) delivering chemotherapy to the tumors, and 2) the procedure results in intermittent decrease of blood to tumor tissue. The goal is tumor death.
• Immunoembolization: Similar to TACE, but infusion of immunotherapy agent into the liver (e.g. GMCSF) rather than a chemotherapeutic agent.
• Radioembolization: Similar to TACE, but infusion of radioactive beads into the liver. The radioactive beads lodge in the small blood vessels around the tumor and radiate the tumor. The goal is tumor death. Two examples of this treatment include Sirspheres and Theraspheres.
• Isolated Hepatic Perfusion (IHP): A different type of procedure to deliver high doses of chemotherapy to the liver. In IHP, a catheter is placed into the artery that provides blood to the liver; another catheter is placed into the vein that takes blood away from the liver. This temporarily separates the liver’s blood supply from blood circulating through the rest of the body and allows high doses of chemotherapy to be directed to the liver only. When it is done percutaneously, or in a less invasive method, it is referred to as Percutaneous Hepatic Perfusion (PHP).

Other Local Interventions that May be Recommended:

• Radiation: Described above, radiation can be used to treat other areas of the body including lung, bone, and brain. Depending on the location of the tumors, regular external beam radiation therapy may be better suited than stereotactic radiosurgery. Radiation therapy can be used to treat isolated metastases or to relieve symptoms caused by a specific lesion.
• Ablation: Described above, ablation can be used in other areas of the body beyond the liver, such as lung, kidney, and soft tissue.

Systemic Treatments

Although, currently, there are no approved systemic treatments for metastatic ocular melanoma, some providers recommend treatment with systemic agents, such as ipilimumab (Yervoy), that have been approved for cutaneous melanoma. Alternatively, there are ongoing clinical trials in which patients have access to systemic agents before they are approved. To learn about clinical trials, please visit the MRF’s Clinical Trial Finder.

• Immunotherapy: A type of systemic therapy given in an attempt to activate a person’s own immune system so that it will destroy any melanoma cells within the body.
• Targeted therapy: A form of treatment in which drugs are developed with the goal of destroying cancer cells while leaving normal cells intact. A targeted approach allows the classification of melanoma into different “subtypes” based on the genetic profile of the tumor.
• Chemotherapy: Overall, chemotherapy has not been shown to be effective for melanoma. However, it may still be recommended in some cases.

The MRF’s CURE OM initiative hosted a Scientific Meeting at the 2016 Society for Melanoma Research Congress to present the lastest news in OM immunotherapy. Summaries of the research discussed at this meeting can be found below:

• Immunotherapy and Clinical Trials for Uveal Melanoma by Udai S. Kammula, M.D., F.A.C.S., National Cancer Institute. Dr. Kammula also discussed OM immunotherapy at the 6th Annual Eyes on a Cure: Patient & Caregiver Symposium.
• The Small GTPase ARF6 is an Actionable Node in Uveal Melanoma by Dean Y. Li, M.D., PhD, University of Utah. The MRF is proud to support the work of Dr. Li’s lab through our Career Development Award.