Zusammenfassung
Hintergrund: Prüfung von Effizienz und Sicherheit der transpupillaren Thermotherapie (TTT) in Kombination mit einer dosisreduzierten Rutheniumbrachytherapie zur Behandlung maligner Aderhautmelanome. Patienten und Methoden: In einer prospektiven nicht randomisierten Analyse wurden 15 Patienten mit primär malignem Aderhautmelanom (posterior des Äquators, Basis ≤ 12 und Prominenz ≤ 4,5 mm) kombiniert mit TTT (Diodenlaser bei 810 nm, Spotgröße 2 - 3 mm, Leistung 0,3 - 0,9 Watt, Expositionszeit 21 - 45 Minuten) und einer abgeschwächten Ruthenium-106-Brachytherapie (Tumorspitzendosis 100 Gy) behandelt. Nachbeobachtungszeit war mindestens 12 Monate. Ergebnisse: Die mittlere Tumorprominenz vor Therapie betrug 3,2 mm (1,2 - 4,5 mm), die mittlere Tumorrückbildung drei Monate nach TTT 2,1 mm (0,5 - 4,5 mm). 12 Monate postoperativ zeigten alle Tumoren klinisch eine vollständige Regression zu einer flachen chorioretinalen Narbe. Fünf Augen zeigten einen Visusanstieg. Hauptgrund für Visusabfall in sieben Augen war in vier Augen subfoveale Tumorlage, in zwei Augen ein Makulaödem und einmal eine epiretinale Gliose. Bisher wurden weder retinale Gefäßverschlüsse, noch Strahlenretinopathie/Optikusneuropathie beobachtet. Trotz klinisch und fluoreszenzangiographisch vollständiger Tumorregression wurden ICG-angiographisch in allen 15 Tumoraugen vorwiegend am zentralen Rand des Behandlungsareals Choriokapillarisreste festgestellt. Rezidivierendes Tumorwachstum oder Fernmetastasen traten bisher nicht auf. Schlussfolgerungen: Die 1-Jahres-Ergebnisse einer auf 100 Gy in der Tumorspitze reduzierten „Sandwich-Therapy” für posteriore Aderhautmelanome ≤ 4,5 mm Prominenz entsprechen hinsichtlich Regression, Nebenwirkungsarmut und Visusverlauf den Befunden nach alleiniger TTT. Die ICG-Angiographie scheint als Monitoringinstrument hinsichtlich Entwicklung von Lokalrezidiven besonders geeignet. Zur Beurteilung radiogen induzierter Schäden sind jedoch Verlaufsbeobachtungen über mindestens 2 - 5 Jahre notwendig.
Abstract
Background: To evaluate the effectiveness of transpupillary thermotherapy (TTT) as an adjunct to ruthenium brachytherapy for treatment of choroidal melanoma with reduced radioactive dose. Patients and methods: In a prospective nonrandomised analysis 15 eyes with primary malignant melanoma of the choroid (posterior to the equator, thickness ≤ 4.5 and base ≤ 12 mm) were treated with TTT (diode laser at 810 nm, spot size 2 - 3 mm, energy 0.3 - 0.9 watt, exposure time 21 - 45 minutes) in conjunction with an attenuated ruthenium plaque (radioactive dose to the tumour apex 100 Gy). Follow-up was at least 12 months. Results: The mean tumour thickness before therapy was 3.2 mm (1.2 - 4.5 mm), the mean tumour regression 3 months postoperatively 2.1 mm (0.5 - 4.5 mm). 12 months postoperatively all tumours were regressed through a completely flattened chorioretinal scar. In 5 eyes visual acuity improved. The main reason for visual decrease in 7 eyes was subfoveal tumour location in 4 eyes, development of macular oedema in 2 eyes and epiretinal gliosis in one eye. Neither occlusion of retinal vessels nor radiation retinopathy/optic neuropathy were observed. Despite complete tumour regression clinically and fluoresceinangiographically, ICG-angiography revealed persistence of choriocapillary vessels especially at the posterior margin of the treatment zone in all eyes. No tumour regrowth or metastatic disease were recorded. Conclusions: Our 12-month results of TTT complementary to ruthenium brachytherapy with an attenuated tumour apex dose of 100 Gy for posterior choroidal melanoma with thickness ≤ 4.5 mm are comparable to findings after TTT alone, especially in regard to regression course, low rate of sideeffects and visual results. ICG angiography might be a useful tool to monitor an eventual tumour regrowth in the choriocapillary layer. For evaluation of sideeffects of brachytherapy a postradiation follow-up of at least 2 - 5 years is mandatory.
Schlüsselwörter
Ruthenium - Melanom - Aderhaut - Uvea - transpupillare Thermotherapie - Brachytherapie
Key words
Melanoma - choroidea - uvea - transpupillary thermotherapy - ruthenium - brachytherapy
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Dr. Bernhard M. Stoffelns
Augenklinik der Johannes Gutenberg-Universität
Langenbeckstraße 1
55131 Mainz
eMail: stoffelns@augen.klinik.uni-mainz.de