Pearls for managing care of high-risk uveal melanoma patients

This article was reviewed by Carol L. Shields, MD

When it comes to adjuvant treatment for high-risk uveal melanoma, physicians are turning to sunitinib malate (Sutent, Pfizer) as a viable option, according to Carol L. Shields, MD, chief, ocular oncology service, Wills Eye Hospital, Philadelphia. Sunitinib malate is an oral multi-targeted tyrosine kinase inhibitor with anti-tumor and immune modulating effects, Dr. Shields said.

It is used to treat gastrointestinal stromal tumors that fail on imatinib mesylate (Gleevec, Novartis), and it is used to prevent renal cell carcinoma metastasis in high-risk patients.

Related: Liquid biopsies: Not yet ready for prime time in uveal melanoma 

Dr. Shields and colleagues found improved survival rates with sunitinib in their high-risk uveal melanoma patients. Physicians can help identify high-risk uveal melanoma by using genetics alone, genetics and American Joint Committee on Cancer (AJCC) classification, or gene expression profiling.

In a study of more than 1,000 patients with uveal melanoma that looked at cytogenetic profiles, Dr. Shields and fellow researchers found chromosome 3 monosomy and eight abnormalities as the strongest predictors of prognosis. “

So, if you have chromosome 3 loss and 8q gain, you have an 11 to 123 times greater risk of metastatic disease,” she said. Other research has found that by using the AJCC classification, physicians can further refine prognosis, Dr. Shields added.

At Wills Eye, there is a 96% yield for cytogenetics via use of a fine-needle aspiration biopsy, Dr. Shields said. There are ways through gene expression profiling to neatly separate melanoma into two groups, Dr. Shields said.

To help treat these patients, sunitinib malate, valproic acid, and some of the newer immune therapy options are available, Dr. Shields said.

The now-available immune therapy options include vaccines, immune-modulated T-cells against cancer, and checkpoint inhibitors. Sunitinib malate is what Dr. Shield uses most frequently.

Related: Targeted therapy for ocular melanoma 

A pilot study conducted among researchers at Wills Eye and Thomas Jefferson University included 20 patients and focused on those with uveal melanoma metastasis who failed other treatment.

In 30% of cases, there was progression-free survival at six months, which Dr. Shields described as a modest effect.

However, when using low-dose sunitinib malate in high-risk uveal melanoma patients with no metastasis but high-risk cytogenetics, there was improved survival of 85% at 6 years compared with only 40% in those not using additional medications.

This benefit appeared in patients under age 60 years. Side effects of sunitinib malate include fatigue, diarrhea, nausea and vomiting, and heartburn, Dr. Shields concluded.

Carol Shields, MDE: carolshields@gmail.com
This article was adapted from Dr. Shield’s presentation at the Ocular Oncology and
Pathology Subspecialty Day at the annual meeting of the American Academy of Ophthalmology. Dr. Shields is a consultant for Aura Bioscience.