External beam radiotherapy of choroidal metastases – final results of a prospective study of the German Cancer Society (ARO 95-08)

doi:10.1016/S0167-8140(02)00134-2

Radiotherapy and Oncology

Volume 64, Issue 1, July 2002, Pages 13-18

https://doi.org/10.1016/S0167-8140(02)00134-2 Get rights and content

Abstract

Purpose: In 1994 a prospective study of the ‘Arbeitsgemeinschaft Radiologische Onkologie’ of the German Cancer Society was initiated to examine the results of a standardized radiation therapy for choroidal metastases with 40 Gy. Recommendations in the literature vary from 21 to 50 Gy of total dose and from 2 to 5 Gy per single fraction. To date, no larger series treated with both a standardized technique and dose has been reported.

Patients and methods: Between 1994 and 1998, 56 patients were enrolled and 50 patients with 65 involved eyes were available for analysis. Thirty-five patients (70%) had unilateral and 15 patients (30%) had bilateral choroidal metastases. Fifty eyes (77%) were symptomatic and 15 eyes (23%) were asymptomatic. Thirty-one patients (62%) had breast cancer and 13 patients (26%) lung cancer as the primary tumor. Patients were treated with 40 Gy in 20 fractions with bilateral asymmetric fields for bilateral or a unilateral field for unilateral choroidal metastasis. Seventeen patients had additional chemotherapy after radiotherapy for general tumor progression.

Results: With a median follow-up of 5.8 months (1–44 months) 41 out of 50 patients were dead. The median survival of all patients was 7 months and for patients with breast cancer 10 months. Of the 50 symptomatic eyes visual acuity increased for two or more lines in 36% (18/50), was stabilized in 50% (25/50 eyes), and decreased in 14% (7/50). No patient with asymptomatic metastasis (n=15 eyes) developed ocular symptoms during follow-up. No patient with unilateral tumor and unilateral irradiation developed contralateral metastasis. Severe side effects, possibly related to tumor progression, occurred in three eyes (5%).

Conclusion: Radiation therapy with 40 Gy is an effective and safe palliative treatment for symptomatic and asymptomatic choroidal metastases to preserve vision in the majority of the patients. A unilateral field for unilateral metastasis seems to be sufficient to prevent contralateral disease. Side effects of radiotherapy are acceptable: 50% of patients developed a mild skin erythema and conjunctivitis (RTOG I). Late side effects were seen in three eyes (5%).

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.

Section snippets

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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External beam radiotherapy of choroidal metastases – final results of a prospective study of the German Cancer Society (ARO 95-08)

Abstract

Introduction

Section snippets

Patient characteristics

Response to treatment

Discussion

Am J Ophthalmol

Ophthalmology

Radiother Oncol

Int J Radiat Oncol Biol Phys

Ophthalmology

Radiother Oncol

Tumor metastasis to the eye. Part I. Incidence in 213 adult patients with generalized malignancy

Am J Ophthalmol

The incidence of ocular metastatic carcinoma

Arch Ophthalmol

Regression models and life tables

J R Stat Soc B

Breast cancer to the eye

Onkologie

Medizinische Statistik