*4.3.6 Metastasis*

The risk factors for metastasis include (**Table 7**):

1.Thickness > 2 mm

2. Symptoms


The presence of four risk factors has a metastatic rate of 20% but the absence of risk factors has only <1% risk of systemic metastasis. Also, each millimeter increase in thickness adds 5% risk for metastasis at 10 years and a hazard ratio of 1.08 [27]. Doubling time of untreated metastases ranged from 34 to 220 days (median, 63 days). The metastasis from tumors as small as 3 3 1.5 mm has been noted in a study [28]. Based on the estimated growth rates, a rational follow-up interval to detect metastatic uveal melanoma would be 4–6 months. Primary uveal melanomas that develop clinically detectable metastasis after conservative therapy may have micrometastasized several years before treatment.

Damato's classification of metastasis [26]:

1.Metastasizing melanomas, which have already metastasized by the time of ocular treatment even though the metastases may not be detectable.


This is the largest study ever to be performed in Ocular oncology with 43 participating centers and more than 2000 patients [29, 30]. Objectives of the study:


Inclusion and exclusion criteria:


The epitheloid cell and the mixed cell melanoma have the poorest prognosis among all the subtypes (**Table 5**). Immunohistochemical markers characteristic of

**Clinical features Histopathologic features Cytogenetic features Transcriptomic**

(monosomy 3)

or 8p loss

BAP1 loss

Chromosome 8q gain

Chromosome 1p loss

Chromosome 9q loss

Older age at presentation Epithelioid cytology Chromosome 3 loss

High values of mean diameter of 10 largest nucleoli

Thicker tumor High microvascular density Chromosome 6q loss

Tumor-infiltrating lymphocytes, macrophages

immunostaining for BAP1

High expression of insulinlike growth factor 1 receptor

High expression of HLA class

Loss of nuclear

Male gender High mitotic activity/PC-10/ Ki-67

Ciliary body tumor location Microvascular loops and

patterns

I and II

**feature**

Gene expression profile class 2

The presence of four risk factors has a metastatic rate of 20% but the absence of risk factors has only <1% risk of systemic metastasis. Also, each millimeter increase in thickness adds 5% risk for metastasis at 10 years and a hazard ratio of 1.08 [27]. Doubling time of untreated metastases ranged from 34 to 220 days (median,

63 days). The metastasis from tumors as small as 3 3 1.5 mm has been noted in a study [28]. Based on the estimated growth rates, a rational follow-up interval to detect metastatic uveal melanoma would be 4–6 months. Primary uveal melanomas that develop clinically detectable metastasis after conservative therapy may have

1.Metastasizing melanomas, which have already metastasized by the time of ocular treatment even though the metastases may not be detectable.

choroidal melanoma are S-100, HMB-45.

The risk factors for metastasis include (**Table 7**):

micrometastasized several years before treatment. Damato's classification of metastasis [26]:

*4.3.6 Metastasis*

Larger tumor basal diameter

*Melanoma*

Diffuse tumor configuration

Association with ocular/ oculodermal melanocytosis

Advanced AJCC category

*The poor prognostic factors include [26].*

Extraocular tumor extension

and staging

**Table 5.**

1.Thickness > 2 mm

3.Margin <3 mm to disk

4.Documented growth

2. Symptoms

**44**


Outcome measures:

1.Primary outcome: Time to death from all-cause mortality

2. Secondary outcome: Metastasis-free survival, cancer-free survival, and years of useful vision

Trial design and treatment groups:


Results:

1.Pre-enucleation EBRT for large melanoma has no advantage over enucleation group. Five-year Kaplan–Meier estimates for survival were 57% for the enucleation group and 62% for the pre enucleation radiation group.

*4.3.9 Follow-up*

*Ocular Melanoma*

**Table 7.**

**5. Conclusion**

chest X-Ray are reasonably good.

*DOI: http://dx.doi.org/10.5772/intechopen.93760*

ocular melanoma in a better way.

**Acknowledgements**

**Conflict of interest**

**Author details**

**47**

A periodic follow-up with systemic investigations is mandatory in view of high metastatic rates of choroidal melanoma. An annual PET-CT scan is ideal, however, the monitoring of the liver function tests, ultrasonography of the abdomen and the

**Tumor size Monosomy 3 If M3, metastasis by 3 years**

Small 0–3 mm 23% 0% Med 3–8 mm 35% 24% Large >8 mm >50% 58%

*Metastasis depends on several factors: Size, markers-BAPI, and genetics [34].*

Ocular melanoma is being effectively managed currently. A protocol-based management of the patient can lead to good local tumor control and careful systemic monitoring can decrease the morbidity and mortality to a great extent. The ongoing research in genetics will probably help us understand and prognosticate

The authors acknowledge this chapter to their patients.

Centre for Sight Superspeciality Eye Hospital, Hyderabad, India

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: harikaregani@gmail.com

The authors declare no conflict of interest.

Harika Regani\* and Santosh G. Honavar

provided the original work is properly cited.

