PRIMARY AND METASTATIC UVEAL MELANOMA:

towards a therapeutic approach

Tekening omslag: Yolanda Eijgenstein

Druk & vormgeving: Vormgeving Rotterdam

ISBN 90 72206 09 6

PRIMARY AND METASTATIC UVEAL MELANOMA:

towards a therapeutic approach

(Primair en gemetastaseerd oogmelanoom:

naar een therapeutische benadering)

Proefschrift

Ter verkrijging van de graad doctor

aan de Erasmus Universiteit Rottenhun

op gezag van de rector Illagnifïcus

Prof. Dr. P. W.C. Akkermans M.A.

en volgens besluit van het college voor promoties.

De openbare verdediging zal plaatsvinden op

woensdag 15 mei 1996 011113.45 uur

!loOI'

Gregorius Petrus Maria Luyten geboren te Etten-Leur

Pro 111 0 ti eco Illllliss i e

Promotor:

Co-promoter:

Overige leden:

Prof'. Dr. P.T.V.M. de Jong

Dr. C.M. Mooy

Prof. Dr. D. Bootsm3

Prof. Dr. G. Stoter

Prof. Dr. W . .J. l'vIooi

To m)' dearcsl Yolanda

CONTENTS

CHAPTER 1 Introduction 8

1.1 Clinical aspects of uveallllelallollla 8

1.1.1 Introduction to the subject 8

1.1.2 Treatment of the primary tumor 10

1.1.3 Metastatic disease and sllI'vival 12

1.2 AilllS aJul scope of the thesis 15

1.3 Illtroductioll to the studies 17

1.3.1 Chapter 2: Thc origins of metastases 17

1.3.2 Chapter 3,4 and 5: Clinical and histopathological factors 18

1.3.3 Chapter 6 to 9: Experimcntal studies 20

1.3.3.1 Chapter 6: Uvealmclanoma cclllines 20

1.3.3.2 Chapter 7: Tumor genetics and inullunology 21

1.3.3.3 Chapter 8 and9: Animalmodels 29

Relerences 32

CHAPTER2

CHAPTER3

No delllonstnlted effect of pre-ellucleation irradiation of

uveallllelallollla patiellts

Metastatic uveallllelanollla:

44

A lllol'phologÏcal and illllllunohistochelllical allalysis 56

CHAPTER4

CHAPTER5

CHAPTER6

CHAPTER 7

CHAPTER8

CHAPTER9

CHAPTER 10

SUlunulry

Neuml eeIl a(I11esion molecule distribution in primary

and llletastatic llveallllelanOlna

The expression NM23 gene in uveal melanoma

Establishment mul eharaeterization of primary mul

metastatic uveal melanoma eelllines

Expression of MAGE, GP100 and tyrosillase in uveal

melanoma eelllines

Relationship between natural killer eeIl susceptibility and

metastasis of hmlUm uveal melanoma eeIls in

a lllurine lllodel

A chicken embryo model to study growth of

uveallnelauOlua

Discussion and future perspectives

Samenvatting in het Nederlands

List of abbreviations

Curriculum vitae

List of publications

Dankwoord

70

86

102

126

137

153

167

175

179

186

187

188

190

CHAPTER 1

INTRODUCTION

1.1 Clinical aspects of uveal melanoma

1.1.1 Inlroduclioll 10 Ihe subject

Uveal melanoma is a unCOll111lon discase with on estimation 80-100, yeurly incident

cases in The Netherlands (6 per million) (De Jong, 1987). Neverlhe1ess, uvea1

melanoma is the most coml11on primary malignant intraocular tumors in adults (Egan,

1988). Morcover, this type of cancel' orten proves fatal to the patient. Although 50 % of

the patients treated for their primary lIveal tumor recovers eompletely, the other

50 % eventually dies of metastatic diseuse (Gamel,1993; MeLean, 1993; Diener-West,

1992; Jensen, 1982). Tn other 1V0rds, half of the patients suffering from a primary uvea1

melanoma c1evelops metastatie discase at a distant site, whieh is then lethal in all cases.

Tn contrast ta cutaneous melanoma, uvealmclanoma disseminates primarily

hacmatogenously anel with a slrong preferenee for the Iiver; once metastases have been

diagnosed, the patient's life expeetancy is only 2 to 9 months (Kath, 1993; Alberl,

1992; Gragouclas, 1991; Rajpal, 1983; Bedikian, 1981; ehar, 1978). These metastases

offen becoll1c c1inically manifest years after initial trealment, that is, llveal melanomas

metastasize relatively late. The patient's median survival time aftel' discovery of the

primary tumor is 6.5 years (McLean, 1993), with a peak of elanomH-related deaths

between the secOIld ano fourth year following initial treatment (Zimmerman, 1978).

Tn brief, the studies presented in this thesis basically aim at prevention of (death by)

metastatic uvea1melanoma. Before we continue, it should be noted that wherever the

term uvea1melanoma is used in this baak, it relers only to melanoma of the choroid

and the ci1iary body. Melanomas 10cated in the iris, the third part of the uvea, are

re1atively benign with a low incidence of developing metastases at distant sites and are

therefore left out of the study here. The reader interested in iris melanoma is referred to

other reports (Grossniklaus, 1995; Jensen, 1993; Brown, 1990).

8

INTRODtJCTION ____ _

Tu date, studies on uveal melanoma mainly focused on the rcfinement of

clinical eliagnosis anel treatmcnt of the primary tumor. This has resulteel in a dccrease

in the c1inicalmisdiagnosis ratc from 3.5 up to 20 % (COMS, 1990; Jensen, 1963) to

less than 1 % at present (Davidorf, 1983; COMS, 1990; pers on al data). The fact th at

tocltty, in specialized centers, the correct diagnosis of primary uvcal melanoma can be

made in 1110re than 99 % of the cases is mainly owed to the application of indirect

ophthalmoscopy in experienced hands together with the use of ultrasonography.

Fluorescenee angiography has made the diagnosis also more reliablc. These devices

are hclpful in diseriminating uvealmelanoma from other types of ocular tumors and

disorelers, sueh as choruidal nevi, haemangiomas and metastases, granulomas and

macular c1egeneration, For instanee, a tumor or biconvex or lllUshroom-like shape lhat shows choroidal excavation on the B-mode and a low to moderate high intern al

rellectivity on the A-mode in an examination by ultrasonography will, when combined

with indirect ophthalmoscopy, certainly be recognized as a choroidalmelanoma.

However, metastatic choroidallesions, that usually show a high internal rellectivity on

the A-mode, can be highly variabie in their ultrasound pa((ern. In sueh cases

examination of fine-needle aspiration biopsies (FNAB) can be useful (Shields, 1993),

but then again, in the cytological evaluation ofFNAB, differentiating melanomas and

other intraocular tumors ean be hard too. Next, in cases in which it is difficult to

discriminate a small dormant melanoma from a choroidal nevus, tumor growth can be

followed by B-mode ultrasonography to evaluate the tumor height, and by serial

Iluorescence angiography to cvaluate thc tumor diameter. Finally, in diagnosing

primary uvea( melanomas, magnetic resonance imaging with contrast (gadolinium)

may be used. The problem with applying this techniqlle, however, is that the

characteristical image of thc paramagnctic melanin is not present in all cases (Fen'is,

1995; De Potter, 1994; Bioom, 1992).

When a primary uvealmelanoma has been diagnosed, the patient is usually

screcned for the presence of extraocwar malignancies anel distant metastases of the

uvealmelanoma by a complete physical examination, an X-ray of the chest, liver

funetion tests, and liver lIltrasonography. In about 8% of the cases another seeOlld

primary tumor can be found (l

CHAPTEI~ .~I ___ _

light in approximately 2 % of the cases (Paeh, 1986; pers(lJlal data). Furthennore,

before the decision of treatment can be made, aU factors that may be of importanee to

the therapeutic choke have to be evaluated for each patient individually, sueh as visu,,1

aeuity, intraoclliar pressure and other concomitant disorders or the affected anel the

non-affeeteel eye; size, location anel episcleral extension of the tumor, and age anel

general health of the patient (Shields, 1993; id. 1991).

1.1.2 Treatmellt of the primary tumor

Ollee thc diagnusis of primary llvealmelanoma has been made) the choicc of

treatment is controversial (Shields, 1993; id. 1991).ln the past, thc only available

treatment was enueleation of the tumor-eontaining eye. Tt is generaUy agreed up on that

this therapy is still preferabie in cases of large melanomas (largest tumor diameter (LTO)

> 15 mm and/or tumor height > 5 mm) (De Jong, 19X7; Manschot 1980). However,

mainly with regm'd to small (LTD

_---'I"N-'T R 0 D U CT JON --- -_._- --_.

llltrasonography and fluorescence ungiography, - some tlLllhors advocate mere

observation untillumor enlargemenl has been demonstrateu (Butler, 1994;

Augsburger, 1993). However, a recenl clinical study reports thai 3 % of lhe palients wilh

lumors less lhan 3 mm in height and up to 19% of them in case ol' proven tumor groWlh

will develop distant metastases af ter all (Shields, 1