Single-Institutional Early Outcomes Of Uveal Melanoma Treated With Eye Physics Iodine-125 Episcleral Plaque Therapy Using Modern Biopsy Techniques And Intra-Operative Ultrasound Guidance

To report early outcomes of patients with uveal melanoma treated with Eye Physics Iodine-125 episcleral plaque therapy using modern biopsy techniques and intra-operative ultrasound guidance. A retrospective chart review was conducted for 48 consecutive uveal melanoma patients who were treated with Eye Physics episcleral plaque brachytherapy performed by one ocular oncologist at our institution from 01/2013 to 12/2015. All patients underwent intra-operative ultrasound for image guidance of plaque placement. A dose of 85 Gy was prescribed to the apical height of the tumor or 5 mm, whichever was greater. Forty-five patients underwent transscleral or transvitreal biopsy. Visual acuity, complication data, and recurrence rates were recorded. Median age at presentation was 63.0y (range 19-86y). Median follow-up was 12.7 months (range 1-32 months) at the time of this submission. Forty-five patients underwent biopsy prior to plaque placement, and 41/45 (91%) samples were adequate for genomic expression profiling (25 class IA, 7 class IB, and 9 class II). The patients were staged according to AJCC 7th edition: 20 patients were stage I, 15 stage IIA, 7 stage IIB, and 6 stage IIIA. Only one AJCC stage I patient was classified GEP class 2. Median tumor apical height was 3.3 mm (range 1.8-11.5 mm). The median radiation dose at the apex was 123.1 Gy (range 85.0-182.6 Gy). Median dose at apex for tumor height >5 mm was 85.0 Gy and 142.5 Gy for tumor height ≤ 5 mm. Mean percent decrease in tumor height from baseline at 3, 6, 12, 24, and 30 months were 19.5%, 30.1%, 41.5%, 52.4%, and 60.1%, respectively. At 12 and 24 months, 19/23 (83%) and 6/9 (67%) patients maintained vision within 2 lines of visual acuity. No complications were associated with biopsy. Four patients to date have radiation retinopathy; two of whom were treated with anti-VEGF therapy in the context of a clinical trial. No patients to date have local failure. Two patients have confirmed distant failure in the liver only. We reported no local failures and good reduction in tumor height in 48 patients who were treated with Eye Physics Iodine-125 episcleral plaque therapy using intra-operative ultrasound guidance. This is a stark contrast from historical rates of local recurrence in large studies such as the COMS trial, which reported failure rates of 5-20%, emphasizing the importance of image guided brachytherapy (IGB) with intra-operative ultrasound at the time of plaque placement. In addition, we showed that biopsy prior to plaque placement did not result in poor visual acuity or extraocular seeding of tumor cells.