Vitreoretinal surgical management In ocular surgical management In ocular oncology 1. Surgical resection

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Pournaras Jean-Antoine C

Vitreoretinal Surgery Unit

Vitreoretinal surgical management

In ocular oncology

1. Surgical resection after proton

beam therapy

2. Ocular Biopsy

3. RD in advanced

Retinablastoma

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Surgical tumor resection after proton beam therapy

Conservative treatment of uveal melanomas

COMS study 1986-2001

Enucleation : 660 cases

125I brachytherapy : 657 cases

Absence of similar study on surgical management

Three lines treatment

1. Tumor Control

2. Eye retention probability

3. Functional result

1. Sterilization of tumor site

Proton Beam Radiotherapy

Egger et al. Int J Radiat Oncol Biol Phys 2001

Local tumor control

91% before 1993

96% 1989-1993

98.8% after 1998

n = 2435 MM

Proton beam irradiation 10 years

Local tumor control 98.8 %

Eye retention probability 95.6 %

84- 87

88- 93 88- 93

94- 05 94- 05

Complications

Radiation induced retinopathy and maculopathy

Secondary Neovascular Glaucoma

Toxic Tumor Syndrome

caused by the presence of a large volume of irradiated

tumor

either because it becomes ischemic or

because it causes extensive retinal detachment or

both

Inflammatory cytokines release

Exudation from irradiated / incompetent vessels

VEGF from ischemic tissue

2. Management of complications

Panphotocoagulation

Anti-VEGF, Corticosteroids

Secondary enucleation

VR surgery exoresection / endoresection of toxic tumor

Exoresection

Indications: large tumor size, anterior location, exudative

retinal detachment Two matched group studies have reported that with large tumors, better

results after exoresection than after iodine plaque radiotherapy

Kivel et al. Ophthalmology 2003;Bechrakis et al. Ophthalmology 2002

Complex surgery; rarely use

Adjunctive brachytherapy or proton beam therapy

Excision of tumor with internal scleral lamellae

Risk of recurrence 50% in external scleral lamellae

Damato et al. 2012

Endoresection

Primary Endoresection Damato et al. BJO 1998; Garcia-Arumi et al. Retina 2001; Garcia-Arumi et al. BJO 2008; Konstantinidis et al. BJO 2014

small case series

short follow-up period

recent study concern

Endoresection: Surgical technique

1 23 G pars plana vitrectomy

2 retinotomy over the tumor

3 piecemeal tumor removal (increased intraocular

pressure)

4 endodiathermy to the margins

5 fluidair exchange to flatten the retina

6 endolaser retinopexy to attach retina around tumor site

7 airsilicone exchange to maintain retinal flattening and

to prevent postoperative hemorrhage

Peyman et al. 1988; Damato et al. BJO 1998

Case 1. Toxic tumor syndrome

Complex surgery

Common

retinectomy and

tumorectomy

1 or more surgeries

Phtisis

Case 2: Massive

ischemia, extensive

exudative RD

Man, 44 yo

Thickness 8.2

60Gy in 4 fractions (2.2012)

Indication: progression exsudative RD

Intravitreal hemorrhage 2.2013

Surgery 2.2013

9.2013

Case 3: Knapp-

Ronne type

Man, 48 yo

60Gy in 4 fractions

Indication: Risk progression exsudative RD

Risk Intravitreal hemorrhage

Tumorectomy +Silicon oil 5.2013

Silicon oil removal 8.2013

Case 4: Recurrent vitreous hemorrhage

Woman, 42 yo

Thickness 6.1mm

Vx silicon oil 25-28.1.2012

60Gy in 4 fractions (27.2-2.3.2012)

Tumorectomy 12.6.12

Phaco + silicon oil removal 23.10.12

VA 0.8 cc 2014

Endoresection: Indications

Risk of hemorrhage, pigment dispersion, retinal infiltration

early tumorectomy

Risk of hemorrhage, pigment dispersion, retinal infiltration

Without previous episode

wait for tumor regression 3 to 6 months

No changes at 3 or 6 months:

tumorectomy

Any tumor with diffuse exudative RD, lipid deposits,

necrosis, excessive inflammation

early tumorectomy

Primary vitrectomy

Diagnosis and Prognosis

Transillumination gives information about basal infiltration

in order to define tumor borders, impeded by vitreous

hemorrhage

1. US of tumor with AL calculation.

2. Vx + silicon oil (particles speed modified in silicon oil)

3. Proton beam therapy

4. Silicon removal + Vx + tumorectomy + silicon oil

5. Removal of silicon oil

Conclusions

1. Local tumor control

Primary vitrectomy may be discussed in vitreous hemorrhage cases

without tumorectomy

2. Secondary Endoresection

Development of VR instrumentation

Surgery may become essential in tumor management

Oncologists decision with high variability among centers

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Ocular biopsy

Role of biopsy

Diagnostic tool when all investigations failed and if management may be influenced

Biospy reveals 50% Choroidal melanoma

50% uveal metastasis

Molecular and genomic analysis

Characterisation of the tumor (cell type, mutational status)

Prognostic information

monosomy 3 + 8q gain in choroidal melanoma are clinically relevant and strongly associated with metastatic disease and death

Prescher et al. Lancet 1996; White et al. Cancer 1998; Scholes et al. IOVS 2003; Cassoux et al. 2013

Targeted therapy

Biopsies

Transcleral choroidal biopsy

Transvitreal choroidal biopsy

Fine Needle Aspiration Biopsy

Transcleral biopsy

Indications:

If access to the tumor (avoid VR complications)

Benign tumor or adjuvant radiotherapy should be performed

Do D, Nguyen QD. In Ryan, Retina, 5th.

Transcleral biopsy

Dissection of 66 mm scleral flap, nearly full-thickness and hinged

(usually posteriorly)

Near Full-thickness scleral flap is retracted

biopsy specimen is grasped at one edge

Incision of choroidal tissue with a sharp blade. Scissors may be used to

complete the dissection

Careful separation of the retina from the choroid

Suture of the scleral flap

Pericard patch

Vitrectomy reduces bulging of the retina during procedure Peyman et al. 1978

Do D, Nguyen QD. In Ryan, Retina, 5th.

Transvitreal biopsy

Indications:

no access by transcleral route

posterior plan tumor

malign tumor lead directly to enucleation / RX / Chimioth

without dispersion by transcleral approach

Transvitreal biopsy

Pars plana vitrectomy

Endolaser around the margins of the intended biopsy site

Increased intraocular pressure

Retinotomy

Biopsy of the tumor

Fluid/gas exchange, 20% SF6

A newly developed instrument, the Essen biopsy forceps was reported to

be effective in the diagnosis of choroidal tumors in 20 patients Bechrakis et al. 2002; Akgul et al. BJO 2011

photo

Photo avant aprs

Film 1

Intraocular metastasis of

pulmonary adenocarcinoma

(cords and ductal structures;

TTF1 +; naspin A +)

Film 2

Marginal zone B cell lymphoma

Fine-needle biopsy

Extensively used in the diagnostic evaluation including

tumors of the orbit and eye

Major concern about risk of dissemination

No tumor dissemination along the needle track, no such

occurrence has been documented with a needle of 25G or finer McCannel et al. Ophthalmology 2012

As diagnostic tool, no histological information, only

cytology

Prognostic informations

Fine-needle biopsy: surgical technique

22G30G needles for intraocular aspiration Jakobiec et al. 1979; Augsburger JJ, Shields JA, et al. 1985

Needle length depends on tumor intraocular location of

the tumor and planned biopsy route

Biopsy needle is connected to a plastic disposable

aspirating syringe via a standard plastic tubing

Complications

Usual vitreoretinal surgery complications

increased intraocular pressure

Cataract progression

Peripheral retinal tears

Retinal detachment

Choroidal hemorrhage

Vitreous hemorrhage

Endophthalmitis

Exacerbation of the underlying inflammatory disease

Proliferative vitreoretinopathy

Young TA, et al. AJO 2008

Conclusions

No diagnosis by current modalities (clinical observation,

angiogram, ulttrasonography)

Biopsy is recommended if there is substantial likelihood

that the results will improve patient management

These procedures can be safely performed by retina

surgeons according to experienced oncologists