Surgical management of liver metastases from uveal melanoma: 16 years' experience at the Institut Curie

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Abstract

Background

Uveal melanoma is characterised by a high prevalence of liver metastases and a poor prognosis.

Aim

To review the evolving surgical management of this challenging condition at a single institution over a 16-year period.

Patients and Methods

Between January 1991 and June 2007, among 3873 patients with uveal melanoma, 798 patients had liver metastases. We undertook a detailed retrospective review of their clinical records and surgical procedures. The data was evaluated with both uni- and multivariate statistical analysis for predictive survival indicators.

Results

255 patients underwent surgical resection. The median interval between ocular tumour diagnosis and liver surgery was 68 months (range 19–81). Liver surgery was either microscopically complete (R0; n = 76), microscopically incomplete (R1; n = 22) or macroscopically incomplete (R2; n = 157). The median overall postoperative survival was 14 months, but increased to 27 months when R0 resection was possible.

With multivariate analysis, four variables were found to independently correlate with prolonged survival: an interval from primary tumour diagnosis to liver metastases >24 months, comprehensiveness of surgical resection (R0), number of metastases resected (≤4) and absence of miliary disease.

Conclusions

Surgical resection, when possible, is able to almost double the survival and appears at present the optimal way of improving the prognosis in metastatic uveal melanoma. Advances in medical treatments will be required to further improve survival.

Introduction

Uveal melanoma is the most common primary ocular malignancy in the adult caucasian population and once metastases occurs the liver is the sole organ involved in 60–80% of cases.1, 2, 3 When liver metastases develop, the prognosis is poor and life expectancy reduces to less than 6 months in the absence of treatment.4 No adjuvant therapy has proven efficacy for the prevention of metastases following ocular treatment and only minimal improvements in disease-free survival have been observed with intra-arterial chemotherapy.5

The best survival rates with established liver metastases have been obtained with maximal tumour reduction, where technically possible.6, 7 Disseminated, or ‘miliary’, metastases are a very poor prognostic factor, frequently diagnosed only at the time of operation as current imaging methods (abdominal ultrasonography, computed tomography) are insufficiently sensitive to reliably exclude their presence pre-operatively.

The aim of this study was a long-term (16 years) review of the surgical management of liver metastases from uveal melanoma in a single institution with regard to survival and the determination of predictive factors for the optimal surgical candidate.

Section snippets

Patient selection

After primary ocular treatment, surveillance combined clinical ophthalmologic examination and abdominal ultrasonography (US) every 6 months. If metastases were suspected, hepatic computed tomography (CT) and/or magnetic resonance imaging (MRI) scanning was performed to both confirm the diagnosis and evaluate the feasibility of resection. The presence of lung metastases was evaluated pre-operatively initially by chest X-ray and more recently by CT. Pre-operative liver biopsy was performed, where

Results

During the study period 255 patients underwent hepatic surgery with a mean age of 56 years (range 19–81) and 133 were male. The median time between primary tumour diagnosis and hepatic surgery was 68 months (1–96). Only 13 patients had synchronous liver metastases.

Discussion

At our institution we developed an aggressive surgical approach to hepatic metastases of uveal melanoma. Initially, we undertook surgical exploration in all patients, but laparoscopic evaluation was not available and, due to the dissemination of the disease in the majority of patients, survival was almost uniformly poor. With increasing experience and improvements in hepatic imaging, we felt that the selection of patients for liver resection could be optimised by the prognostic features

Conclusion

Our results strongly support the notion that hepatic resection for liver metastases from uveal melanoma offers a greatly improved long-term survival in carefully selected patients. Important survival indicators include the time to metastases, the number and comprehensiveness of resected metastases, and the presence or absence of miliary disease.

Conflict of interest

The authors state that they have no conflict of interest.

Acknowledgements

We are grateful to Professor J. Belghiti for his scientific advice.

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