External beam radiotherapy of choroidal metastases – final results of a prospective study of the German Cancer Society (ARO 95-08)
Introduction
Intraocular metastasis is the most common malignant tumor of the eye [1]. Autopsy studies estimate an incidence of microscopic asymptomatic choroidal metastases of 4–12% in patients with solid tumors of all types. Bloch and Gartner examined the eyes and orbit of 230 cancer patients post-mortem and found 28 eyes with metastases, with an overall incidence of 12% [3]. Nelson found an incidence of 9% of intraocular metastases in 716 eyes [14]. In a clinical screening program we found an incidence of 5% asymptomatic choroidal metastasis for patients with disseminated breast cancer [24]. However, the incidence of symptomatic intraocular metastases is lower (1–2%) and Albert estimated it to be 2.3% [1]. The primary tumors in up to 80% of the cases are breast cancer and lung cancer, and all other entities are rare. Almost 90% of metastases were found in the posterior uveal tract, which includes the choroid and the ciliary body [20], [22].
Choroidal metastasis commonly appears as a yellow plateau shaped subretinal tumor, often with a secondary retinal detachment. Typical symptoms are loss of visual acuity or visual field, photophobia and floaters [20]. The median survival time of these patients is about 6–12 months, but 10% of the patients with breast cancer survive more than 5 years [19], [20], and therefore a long-term palliative treatment is important for the patients' quality of life. Percutaneous irradiation is the treatment of choice resulting in high remission rates and significant improvement of visual acuity [17], [19]. However, a variety of different approaches are used for this treatment.
Therefore, the purpose of our prospective study was to evaluate the efficacy and safety for a standardized treatment with 40 Gy, since there is a lack of prospective data in the literature for uniformly treated patients. A prospective, nonrandomized monocentric study was initiated together with the ‘Arbeitsgemeinschaft Radiologische Onkologie’ (ARO) of the German Cancer Society. This paper reports on the final results of 50 patients with 65 involved eyes.
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Patient characteristics
Between 7/94 and 10/98, 56 patients with 71 eyes affected by metastatic disease were enrolled into the study. Of the 56 patients six were excluded from analysis. One patient refused radiotherapy (RT) after 4 Gy, four patients died due to metastatic disease before finishing RT and in one patient the diagnosis was changed to malignant uveal melanoma. Thus, 50 patients with 65 involved eyes could be evaluated.
Of the 50 patients, 38 were female and 12 were male. The patients' ages ranged from 33 to
Response to treatment
The median visual acuity of affected eyes before the start of treatment was 20/40. After a median follow-up of 5.8 months (range 1–52 months) 41 of 50 patients were deceased. Of the 50 symptomatic eyes visual acuity increased in 36% (18/50), was stabilized in 50% (25/50), and decreased in 14% (7/50) (Fig. 1). Of the 15 subjective asymptomatic eyes visual acuity was objectively improved in three (20%) and durably stabilized in 12 eyes (80%). Following RT, the median visual acuity was 20/32. In
Discussion
The aim of our prospective study was to characterize the therapeutic outcome and the side effects of standardized 40 Gy RT for choroidal metastases. A standardized treatment allows comparison with other studies using different total doses and fractionation schemes. To the best of our knowledge there are no prospective data of major series with uniformly treated patients in the literature.
The most important parameter of the patient's quality of life is an increase or stabilization of visual
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