The treatment of the primary tumor in ocular melanoma has evolved quite dramatically over the past many years and has also been directed by numerous clinical studies including "The Collaborative Ocular Melanoma Study (COMS).” The treatment of metastatic disease continues to require more research to determine what the most effective, and life saving, treatments may be.

The course of treatment for the primary disease depends upon a number of factors, chief among them the size of the tumor. The most common radiation treatment is plaque brachytherapy, in which a small disc-shaped shield (plaque) encasing radioactive seeds (most often Iodine-125, though Ruthenium-106 and Palladium-103 can also be used) is attached to the outside surface of the eye, overlying the tumor. The plaque is left in place for a few days (6 days is not atypical) and then removed. Based on the COMS study, there is no statistical difference in risk of metastasis between enucleation and plaque radiotherapy, or of undergoing brachytherapy or not before undergoing enucleation for large tumors. After plaque surgery, your doctor may wait three months or thereabouts and then check for shrinkage in the eye tumor.

Other treatments for primary disease include transpupillary thermotherapy (TTT), external beam proton therapy, resection of the tumor, Gamma Knife stereotactic radiosurgery or a combination of different modalities. These various procedures are discussed herein.

Most importantly, after treatment of your primary tumor, you need to consult with an oncologist. They will be able to give you frequent scans (most recommend a chest and abdomen CT or MRI scan every 6 months, as the disease can progress quickly to the liver) and offer you proper medical advice. Note that this site is for information purposes only and is not a substitute for professional medical opinion. Everyone’s case is unique.

Radiotherapy (RT) (therapies involving radiation)

Brachytherapy
Also known as sealed source radiotherapy or endocurietherapy, brachytherapy is a form of radiotherapy where a radioactive source is placed inside or next to the area requiring treatment. Brachytherapy is commonly used to treat OM as well as localized prostate cancer, cervical cancer, and other cancers of the head and neck.

Teletherapy (external beam radiotherapy)
 Gamma Knife RT
 Charged particle RT
 Stereotactic Linac RT
 External beam proton therapy

Other therapies

Transpupillary thermotherapy (TTT) - technique in which heat is delivered to the choroid and retinal pigment epithelium through the pupil using a modified diode laser. This laser technique contrasts with the nonthermal laser used in standard photocoagulation therapy which is designed to activate verteporfin, a photosensitizing agent. TTT uses a lower power laser for more prolonged periods of time and is designed to gently heat the choroidal lesion, thus limiting damage to the overlying retinal pigment epithelium. TTT is used less frequently in OM treatment due to issues with final control and recurrence.

Surgical treatment

Resection (partial or full tumor removal)
 Transscleral partial choroidectomy (cyclochoroidectomy) – A viable therapeutic option for the subset of patients with choroidal or ciliochoroidal tumors who are poor candidates for radiotherapy but are highly motivated to avoid enucleation (http://archopht.ama-assn.org/cgi/content/full/120/12/1659)
 Transretinal endoresection

Enucleation
Enucleation refers to full removal of the affected eye. After enucleation surgery, the patient is admitted to the hospital and the eye is removed under either local or general anesthesia. The enucleated eye cannot be treated or repaired and replaced in the eye socket. Instead, it is replaced with a ball implant that may be made of plastic, a porous material called hydroxylapatite, or other materials. The implant is sewn into position and the eye is allowed to heal. The patient usually leaves the hospital one or two days after surgery. In some cases, patients are permitted to go home the same day. Three to six weeks later, a specialist who makes artificial eyes (called an ocularist) fits the patient with a prosthesis. The prosthesis is a plastic shell painted to resemble the other eye and inserted between the eyelids. When the other eye moves, the ball implant moves also, causing the prosthesis to move with the normal eye. Movement is usually less than that of the normal eye; however, the doctor and close relatives are most often the only people to notice that the patient does not have two normal eyes. If you have questions about different types of implants, be sure to ask your doctor. The purpose of the implant is to replace the volume in the socket that had been taken up by the eye. (http://www.jhu.edu/wctb/coms/booklet/book2.htm)

Liver-directed therapies (80% of OM metastases appear in the liver first)

Resection (surgical removal)
Only a small percentage of patients have this option and many doctors advise against it if there are multiple tumors and because the tumor has a high likelihood of recurrence. However, new research is showing better outcomes if tumors are caught early and are able to be resected. Therefore, if resection is deemed to be an option, it is something to consider seriously. It may also be a good idea for the surgeon to be prepared to do radio-frequency ablation (RFA or other ablative technique similar to this) on any small tumors they might find that the scan missed and that might make surgical resection impossible once the surgery is in process. Some surgeons will recommend a laparoscopic "look-see" prior to the major surgery to ensure it can go forward without surprises, as one doesn't want to have to recover from an aborted attempt before doing an alternate treatment.

Immuno-embolization / Chemo-embolization
The liver is isolated and infused with either immunotherapy drugs or chemotherapy drugs. The side effects are less than with systemic treatments. Interventional radiology doctors typically perform these procedures. Although doctors all around the country perform chemoembolization, often different chemotherapy drugs are used depending on the team performing the procedure. At this point, no particular chemotherapy has been shown, in research trials, to be more beneficial than another.

Radio-embolization (SIR-Spheres or "SS")
The liver is isolated and infused with radioactive Yttrium beads in solution. See http://sirtex.com for more info on the process and to find practitioners in your area. Although this treatment is still "off-label" for OM, the response seems to be good and the side effects relatively minimal (depending on how advanced the disease is). Although it is different for different patients, a person can have up to approx. three treatments, due to the lungs' capacity to tolerate the radiation as they receive some "spill-over" from the liver. As with other types of embolization, this procedure is typically performed by an interventional radiologist and is performed at many centers.

Percutaneous Hepatic Perfusion (PHP)
PHP involves isolating the liver and "bathing" the liver in a particular chemotherapeutic agent. A clinical trial is being done by NIH's NCI (National Cancer Institute) and you can receive this treatment at several locations around the country. The liver is isolated and infused with the chemo drug Melphalan. Here are a few links about this treatment: http://www.livercancertrials.com/ and http://www.clinicaltrials.gov/ct2/show/NCT00324727?term=PHP+and+liv...

For any of the above options, you would need to send a CD of your scans and reports to the treating physician. You may want to send scans to several at once to get opinions about which treatment to go with first (i.e. trying to make sure not to eliminate a treatment option down the road by the decisions you make now).