|Year : 2011 | Volume
| Issue : 3 | Page : 103-104
Recent trends in ocular oncology
Swathi Kaliki, Carol L Shields
Ocular Oncology Service, Wills Eye Institute, Thomas Jefferson University, Philadelphia, PA, USA
|Date of Web Publication||29-Dec-2011|
Carol L Shields
Ocular Oncology Service, Suite 1440, Wills Eye Institute, 840 Walnut Street, Philadelphia, PA 19107
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kaliki S, Shields CL. Recent trends in ocular oncology. Oman J Ophthalmol 2011;4:103-4
New and exciting treatment options have emerged in the field of ocular oncology. Despite these novel therapeutic options, it is important to consider if a new treatment modality is truly beneficial over a proven standard treatment. Various factors such as patient features, tumor features, and benefit-risk potential should be carefully assessed in every individual case to determine which patients or tumors will directly benefit from a specific treatment. Therapeutic options of ocular tumors have evolved from observation, cryotherapy, laser therapy, systemic/intralesional steroids, topical antimetabolites, wide surgical excision, systemic chemotherapy, enucleation, and exenteration to more recent options of systemic/topical beta-blockers, topical imiquimod (IMQ), topical/intralesional interferon alpha-2b (IFNα2b), systemic/intralesional rituximab, photodynamic therapy (PDT), superselective intraophthalmic artery chemotherapy (IAC), gamma knife radiosurgery, and cyber knife radiosurgery over the past few years. Herein, we discuss the recent trends in the management of eyelid, conjunctival, intraocular, and orbital tumors.
| Eyelid Tumors|| |
In 2008, Leaute-Labreze et al.  discovered the efficacy of oral propranolol in the treatment of infantile hemangiomas (IH) incidentally when oral propranolol was used to combat the adverse cardiac effects secondary to high-dose corticosteroids in two children with severe infantile hemangiomas. Since then, a paradigm shift has occurred in the management of IH, with oral propranolol emerging as a first-line treatment at various centers. There are ongoing efforts to determine the optimal dose and duration of treatment with oral propranolol in IH. The concern about the benefit-risk profile of systemic beta-blockers lead to the successful use of topical beta-blocker (timolol) in the treatment of capillary hemangioma of the eyelid by Guo and Ni. 
The use of topical IMQ 5% cream and PDT for various skin conditions has been extensively reported in the dermatology literature. Recently, IMQ has been used successfully in the treatment of periocular lentigo maligna  and superficial or nodular basal cell carcinoma (BCC) of the eyelid.  IMQ with or without cryotherapy is a useful alternative to surgery in patients with periocular lentigo maligna or BCC when other therapies have failed or contraindicated. However, large size lesions (>1 cm) and patients with compromised immune system may not respond adequately to IMQ.  Also, the tolerability and safety of use of IMQ in the periocular region is not adequately determined. PDT with topical methyl aminolevulinate is being successfully used for the treatment of periocular squamous papilloma, squamous cell carcinoma, and basal cell carcinoma, with a response rate of 75% and with minimal damage to surrounding tissues and excellent cosmetic outcome. 
| Conjunctival Tumors|| |
In more recent years, topical/perilesional injection of IFNa2b has been extensively used for the treatment of ocular surface squamous neoplasia (OSSN). In a recent survey of 81 OSSN tumors treated with IFNα2b by Shields et al.,  95% tumor control was achieved when IFNa2b was appropriately combined with surgical excision. IFNα2b has also been used with variable success in the treatment of primary acquired melanosis, conjunctival melanoma, mucosa-associated lymphoid tissue lymphoma, and Kaposi sarcoma. Personally, we have not found IFNα2b to be effective in control of melanosis or melanoma. On the other hand, IFNa2b has a powerful effect on OSSN. Topical IFNα2b displays a distinct advantage over surgical excision that it coats the entire ocular surface and treats not only the affected site but also the remote preclinical sites, thus potentially eliminating subclinical tumors. In cases of extensive OSSN, PDT can be a useful alternative, and in cases with localized corneoscleral or intraocular invasion, plaque brachytherapy is an effective and well-tolerated modality. From a different perspective, there are several new modalities for conjunctival lymphoma, particularly CD 20+ lymphoma, in that they could respond to systemic or intralesional rituximab.
| Intraocular Tumors|| |
For the past 5 years, there has been an increasing popularity of IAC in the treatment of retinoblastoma, with reliable success (tumor control and globe salvage) of group C and group D eyes, and limited success of group E eyes (based on the International Classification of Retinoblastoma).  However, the major concerns with IAC are lack of control of potential metastatic disease and possibility for toxicities such as vascular injury, end-organ ischemia, and fluoroscopic-related radiation exposure. In a recent study by Wilson et al.,  it was found that the higher the International Classification of Retinoblastoma classification the greater the risk for invasive, potentially metastastic retinoblastoma. In fact, 50% of group E eyes and 15% of group D eyes displayed high-risk histopathological features for metastatic events.  Based on our previously published series,  untreated high-risk retinoblastoma carries a 24% risk for metastatic disease, and adjuvant systemic intravenous (not intra-arterial) chemotherapy is strongly advised. In cases of group D and E eyes treated with IAC, adequate evidence is not available to comment on whether IAC alone can inactivate retinoblastoma invading choroid, optic nerve, and/or sclera, and thus prevent metastatic disease. Further studies on clinical and histopathological correlation of enucleated eyes post-IAC are recommended.
Recent advances in the treatment of choroidal tumors include the efficacious use of oral propranolol in the treatment of circumscribed  and diffuse choroidal hemangioma.  However, this deserves further study. PDT has been successfully used for choroidal hemangioma and now it shows favorable results for choroidal metastasis.  But, due to limited depth penetration of 689 nm diode laser, PDT is not useful in tumors more than 4 mm in thickness and in tumors with extensive bullous retinal detachment.
Newer modalities in the treatment of orbital lymphoma include intralesional injection of rituximab  and cyber knife radiosurgery.  Gamma knife radiosurgery provides an effective management strategy in orbital tumors including optic nerve sheath meningioma, optic nerve glioma, schwannoma, orbital metastasis, orbital retinoblastoma, pseudotumors of the orbit, cavernous hemangioma, and lacrimal gland tumors. Oral propranolol has proven successful in the management of orbital IH with a significant tumor size reduction in 80% cases. 
| Orbital Tumors|| |
In summary, there have been numerous improvements in the detection and management of ocular tumors. Given the rarity of most ocular tumors, many publications are limited by relatively small number of patients and short follow-up. Multicenter trials with larger number of patients and longer follow-up could help to develop a more robust and meaningful index of efficacy.
| References|| |
|1.||Leaute-Labreze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taieb A. Propranolol for severe hemangiomas of infancy. N Engl J Med 2008;358:2649-51. |
|2.||Guo S, Ni N. Topical treatment for capillary hemangioma of the eyelid using beta-blocker solution. Arch Ophthalmol 2010;128:255-6. |
|3.||Demirci H, Shields CL, Bianciotto CG, Shields JA. Topical imiquimod for periocular lentigo maligna. Ophthalmology 2010;117:2424-9. |
|4.||Garcia-Martin E, Idoipe M, Gil LM, Pueyo V, Alfaro J, Pablo LE, et al. Efficacy and tolerability of imiquimod 5% cream to treat periocular basal cell carcinomas. J Ocul Pharmacol Ther 2010;26:373-9. |
|5.||Togsverd-Bo K, Haedersdal M, Wulf HC. Photodynamic therapy for tumors on the eyelid margins. Arch Dermatol 2009;145:944-7. |
|6.||Shields CL, Kaliki S, Kim HJ, Al-Dahmash SA, Shah SU, Lally SE, et al. Interferon Alpha-2b with Surgical Resection for Ocular Surface Squamous Neoplasia in 81 Cases: Outcomes Based on American Joint Committee on Cancer (AJCC) Classification [In Press]. |
|7.||Shields CL, Bianciotto CG, Jabbour P, Ramasubramanian A, Lally SE, Griffin GC, et al. Intra-arterial chemotherapy for retinoblastoma: Report no. 1, control of retinal tumors, subretinal seeds, and vitreous seeds. Arch Ophthalmol 2011;129:1399-406. |
|8.||Wilson MW, Qaddoumi I, Billups C, Haik BG, Rodriguez-Galindo C. A clinicopathological correlation of 67 eyes primarily enucleated for advanced intraocular retinoblastoma. Br J Ophthalmol 2011;95:553-8. |
|9.||Honavar SG, Singh AD, Shields CL, Meadows AT, Demirci H, Cater J, et al. Postenucleation adjuvant therapy in high-risk retinoblastoma. Arch Ophthalmol 2002;120:923-31. |
|10.||Sanz-Marco E, Gallego R, Diaz-Llopis M. Oral propranolol for circumscribed choroidal hemangioma. Case Report. Ophthalmology 2011;2:84-90. |
|11.||Arevalo JF, Arias JD, Serrano MA. Oral propranolol for exudative retinal detachment in diffuse choroidal hemangioma. Arch Ophthalmol 2011;129:1373-5. |
|12.||Kaliki S, Shields CL, Al-Dahmash SA, Mashayekhi A, Shields JA. Photodynamic therapy for choroidal metastasis in 8 cases. (Unpublished). |
|13.||Laurenti L, De Padua L, Battendieri R, Tarnani M, Sica S, Blasi MA, et al. Intralesional administration of rituximab for treatment of CD20 positive orbital lymphoma: Safety and efficacy evaluation. Leuk Res 2011;35:682-4. |
|14.||Bianciotto C, Shields CL, Lally SE, Freire J, Shields JA. Cyber Knife radiosurgery for the treatment of intraocular and periocular lymphoma. Arch Ophthalmol 2010;128:1561-7. |
|15.||Fridman G, Grieser E, Hill R, Khuddus N, Bersani T, Slonim C. Propranolol for the treatment of orbital infantile hemangiomas. Ophthal Plast Reconstr Surg 2011;27:190-4. |