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Uveal melanoma

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Updated 2023 ASCO guidelines for the management of uveal melanoma.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of uveal melanoma are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2023), the Uveal Melanoma Consensus Group (UM-CG 2016), and the United Kingdom National Multidisciplinary Guidelines (UKNMG 2015). ...
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Diagnostic investigations

Initial assessment
As per UM-CG 2016 guidelines:
Evaluate all intraocular malignancies and indeterminate lesions by a provider trained in all aspects of care (medical, oncologic, surgical, radiotherapy, and laser therapy) to determine the appropriate treatment, as observation with the subsequent delay in therapy (even in small intraocular malignancies with ≤ 2 mm thickness) can increase the risk of metastasis.
E
Obtain a complete ophthalmologic assessment of risk factors for future growth in patients with indeterminate lesions. Discuss with the patient about treatment, including the future risk of growth and metastasis balanced with the risk of visual loss from treatment, in the presence of risk factors.
E
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  • Imaging for staging

  • Laboratory tests

Diagnostic procedures

Biopsy
As per UKNMG 2015 guidelines:
Consider performing a diagnostic biopsy if the clinical diagnosis is uncertain following noninvasive techniques.
C
Consider performing FNA biopsy either with a direct transscleral or transvitreal approach.
C

Medical management

Expectant management: as per UM-CG 2016 guidelines, do not offer observation in patients with uveal melanoma except in unique situations.
D

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  • Systemic therapy

Therapeutic procedures

Brachytherapy: as per UM-CG 2016 guidelines, offer brachytherapy in patients with high-risk indeterminate lesions and lesions < 10 mm in thickness and 18 mm in maximum diameter.
E
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  • Transpupillary thermotherapy

Surgical interventions

Indications for surgery
As per UM-CG 2016 guidelines:
Reserve enucleation for lesions > 10 mm in thickness or 18 mm in diameter (or both) because of complications secondary to radiation, including the risk of severe vision loss and loss of the eye.
E
Consider performing excision (iridocyclectomy and iridectomy) for selected ciliary body and iris lesions.
E

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  • Resection of metastases

Patient education

General counseling
As per UKNMG 2015 guidelines:
Discuss all available procedural and treatment options with the patient, including their risks, benefits, and impact on QoL.
B
Inform patients that there is no proven survival advantage between any of the offered modalities.
A

Follow-up and surveillance

Follow-up
As per UM-CG 2016 guidelines:
Obtain an annual liver ultrasound and perform a physical examination indefinitely in low-risk patients (gene-expression profiling class 1a or 1b, no monosomy 3 detected, or tumor < 9 mm thick and no genetic assessment). Consider transitioning follow-up to the family physician at 5 years.
E
Perform an annual physical examination indefinitely and obtain imaging every 6 months (consisting of liver ultrasound alternating with abdominal or liver MRI; consider obtaining other modalities if the body habitus limits ultrasound) for 10 years in high-risk patients (gene-expression profiling class 2, monosomy 3 detected, or tumor ≥ 9 mm thick and no genetic assessment). Consider transitioning follow-up to the family physician at 5-10 years.
E