Scleral necrosis in patients with posterior uveal melanomas evaluated by transcleral fine needle aspiration biopsy and treated by 125I plaque

ABSTRACT Purpose: To evaluate the incidence, potential correlation with transcleral fine needle aspiration biopsy, and treatment of scleral necrosis in patients with posterior uveal melanomas treated by 125I plaque radiotherapy and assessed by transcleral fine needle aspiration biopsy. Methods: We performed a retrospective review of posterior uveal melanoma treated by 125I plaque radiotherapy at a single academic institution between July 2006 and July 2013. Consecutive patients diagnosed with a posterior uveal melanoma during the study period that had an anterior margin at or anterior to the equator who were evaluated by transcleral fine needle aspiration biopsy prior to 125I plaque radiotherapy were included. The main outcome measure was development of scleral necrosis, and the secondary outcome was treatment of this complication. Statistical analysis included computation of conventional descriptive statistics, cross-tabulation and chi-square tests of potential factors related to the development of scleral necrosis, and summarizing of treatment approaches and results. The incidence of treatment of scleral necrosis was calculated using the Kaplan-Meier method. Results: During the 7-year study period, 87 posterior uveal melanomas were evaluated by transcleral fine needle aspiration biopsy and treated by 125I plaque radiotherapy. The median largest basal diameter of the tumor was 13.3 mm, and the median thickness was 6.8 mm. Eight patients (9.2%) developed scleral necrosis during follow-up. Thicker tumors (> 6.5 mm) were more likely to develop scleral necrosis (n=7) than thinner tumors (p=0.05). The median interval between 125I plaque radiotherapy and detection of scleral necrosis was 19.1 months. The overall cumulative probability of scleral necrosis was 6.2% at 6 months and 14.3% at 24 months, subsequently remaining stable. For thicker tumors, the probability of scleral necrosis was 23.5% at 45.4 months. Five patients were treated by scleral patch graft (62.5%) and three by observation (37.5%). One patient underwent enucleation after two failed scleral patch attempts and recurrent scleral necrosis. The mean follow-up period for patients with scleral necrosis was 34.5 months. Conclusions: Thicker posterior uveal melanomas are more likely to develop scleral necrosis after 125I plaque radiotherapy and transcleral fine needle aspiration biopsy. While observation is sufficient for managing limited scleral necrosis, scleral patch graft is a viable alternative for eye preservation in extensive scleral necrosis.

摘要

研究目的：评估接受碘-125巩膜敷贴放疗（125I plaque radiotherapy）、且经巩膜细针穿刺活检（transcleral fine needle aspiration biopsy）术前评估的后部葡萄膜黑色素瘤（posterior uveal melanoma）患者的巩膜坏死（scleral necrosis）发生率、该并发症与经巩膜细针穿刺活检的潜在关联，以及其治疗方案。

研究方法：本研究为单中心回顾性分析，纳入2006年7月至2013年7月期间于某学术医疗机构接受碘-125巩膜敷贴放疗的后部葡萄膜黑色素瘤患者。筛选标准为研究期内确诊、肿瘤前缘位于赤道部或赤道前，且于碘-125巩膜敷贴放疗前接受经巩膜细针穿刺活检评估的连续性病例。主要结局指标为巩膜坏死的发生情况，次要结局指标为该并发症的治疗方案。统计学分析包括常规描述性统计计算、与巩膜坏死发生相关的潜在因素的交叉制表及卡方检验，以及治疗方案与疗效总结。巩膜坏死的治疗发生率采用卡普兰-迈耶法（Kaplan-Meier）计算。

研究结果：本7年研究周期内，共纳入87例经巩膜细针穿刺活检评估并接受碘-125巩膜敷贴放疗的后部葡萄膜黑色素瘤病例。肿瘤的中位最大基底直径为13.3 mm，中位厚度为6.8 mm。随访期间共有8例患者（占比9.2%）发生巩膜坏死。肿瘤厚度＞6.5 mm的患者较薄肿瘤患者更易发生巩膜坏死（n=7，p=0.05）。从碘-125巩膜敷贴放疗至巩膜坏死检出的中位间隔时间为19.1个月。总体巩膜坏死累积发生率在6个月时为6.2%，24个月时为14.3%，后续趋于稳定。对于厚肿瘤患者，随访至45.4个月时巩膜坏死发生率为23.5%。5例患者接受了巩膜补片移植术（scleral patch graft）治疗（占比62.5%），3例采取观察随访（占比37.5%）。1例患者在两次巩膜补片移植失败且巩膜坏死复发后接受了眼球摘除术（enucleation）。发生巩膜坏死患者的平均随访时长为34.5个月。

研究结论：体积较厚的后部葡萄膜黑色素瘤患者，在接受碘-125巩膜敷贴放疗联合经巩膜细针穿刺活检后更易发生巩膜坏死。对于局限性巩膜坏死，观察随访即可满足管理需求；而对于广泛性巩膜坏死，巩膜补片移植术是保全眼球的可行方案。