Brachytherapy for Posterior Uveal Melanomas

Since the reports from the Collaborative Ocular Melanoma Study (COMS) trials indicated that there was no difference in melanoma-specific mortality rates between patients treated with plaque brachytherapy and enucleation for medium-sized tumors, brachytherapy has become the mainstay therapeutic modality for treatment-eligible patients. Currently, iodine-125, ruthenium-106, and palladium-103 are the most commonly used radioactive isotopes for brachytherapy. Many investigators are studying whether a lower radiation dose than the COMS recommendation can achieve similar local tumor control rate, with some promising results. Intraoperative fine needle aspiration biopsy is commonly performed in many centers for further histopathologic, cytogenetic, and genomic analyses that provide critical patient prognostic information. Modern pre-insertion plaque planning and intraoperative ultrasound confirmation of plaque position have led to better local tumor control, which exceeds 95% in many experienced centers. Precise dosimetry is essential because local recurrence of the tumor has been identified as a major risk factor for metastatic disease. Radiation retinopathy is now often managed with anti-vascular endothelial growth factor injections before or at the time of clinically significant development of radiation-induced macular edema.