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  • Management of Low-Risk Small Choroidal Melanoma

    By Lynda Seminara
    Selected by Richard K. Parrish II, MD
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    Journal Highlights

    American Journal of Ophthalmology, September 2022

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    The approach to managing small choroidal melanoma (SCM) remains a highly debated topic. Diagnostic un­certainty is common, and many tumors labeled SCMs have turned out to be choroidal nevi that wouldn’t need vi­sion-threatening intervention. Despite the trend toward immediate treatment of tumors deemed to be SCMs, the risk of metastasis in patients with these tumors is reportedly very low (≤3%). Using a diagnostic predictive model, Singh et al. applied probabilistic selec­tion to discern SCMs that could be ob­served rather than treated immediately. They also quantified the potential loss of vision and the potential avoidance of metastasis for patients treated imme­diately who may have benefited from a surveillance period to monitor growth before proceeding to treatment.

    The authors identified 167 patients who appeared to have an SCM (5-16 mm in largest basal diameter and 1-2.5 mm in height). Forty-two were treated after documentation of tumor growth during surveillance, and 125 were treat­ed immediately. A model was applied to each patient in the immediate-treat­ment group to obtain the predicted risk of melanoma (high vs. low) and to compare gain (freedom from metasta­sis) and loss (vision loss) between the low-risk immediate treatment group and the group treated after surveillance. Kaplan-Meier methodology was used to estimate the rates of metastasis-free and overall survival.

    Using the optimal cutoff point (.60; 95% confidence interval, .37-.61) of predicted risk for SCM (sensitivity, .74; specificity, .95), 75% of cases were classified as high risk (score ≥.6) and 25% as low risk (score <.6). During the median follow-up period of 34.6 months, metastasis occurred in five patients in the immediate-treatment group (four high risk, one low risk) and one in the initial-surveillance group. By 36 months, the proportion of patients whose VA declined by less than 15 let­ters did not differ significantly between low-risk patients treated immediately or after surveillance (81% vs. 83%, respectively). Among patients with doc­umented tumor growth before treat­ment, none died, and one experienced metastasis. Among the low-risk group treated immediately (no surveillance), two died, and one had metastasis. The Kaplan-Meier estimate of three-year metastasis-free survival was 100% for those who initially were observed and 96% for low-risk patients treated immediately.

    “Low-risk choroidal melanoma identified by the prediction model can be labeled as an indeterminate melano­cytic tumor,” said the authors. For such cases, they recommend an observation period to monitor tumor growth before initiating treatment, which does not appear to increase the risk of metasta­sis-related death, they said.

    The original article can be found here.