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【medical-news】对可疑脉络膜小黑素瘤的最好方法就是观察

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Observation is the best medicine for choroidal lesions

Dec 1, 2007
By:Nancy Groves
Ophthalmology Times （眼科时讯）

Boston—Observation is the best approach for patients with small, suspicious choroidal melanoma because it eliminates unnecessary treatment and does not compromise the survival of the patient, suggest results of a long-term study.

The study's melanoma-specific mortality rate of 0.7% over 10 years indicates that observation is safe when patients are watched closely for signs of change in their tumors, said Timothy G. Murray, MD, FACS, here at the annual meeting of the Retina Society.

Dr. Murray presented findings from a long-term study of patients with small choroidal melanoma, noting that the best approach to small, suspicious pigmented lesions has been a controversial subject for years. He is professor of ophthalmology with a secondary appointment in radiation oncology at the Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami.

Four decades ago, the customary treatment for every patient with a suspicious lesion was enucleation surgery. Around that time, however, three surgeons from the Bascom Palmer Eye Institute (Victor T. Curtin, MD; J. Donald M. Gass, MD; and Edward W. D. Norton, MD) began to advocate observational management as an option for patients with small choroidal and ciliary body malignant melanoma. They followed this strategy in a series of 46 patients evaluated and managed over 14 years.

"The majority of the patients had tumors that did not change, [and] . . . the patients didn't die from their tumors," Dr. Murray said. "This was the pivot point that changed how everybody thought about these smaller, presumed-malignant melanomas."

The Collaborative Ocular Melanoma Study (COMS) then was launched with an observational component for small tumors (1 to 3 mm in apical height and 5 to 16 mm in largest basal dimension). The study of 204 patients noted a 5-year tumor growth rate of 31% and a melanoma-specific mortality rate of 1%.

"Because those data were available to us, they suggested to me, as director of the ocular oncology service at Bascom Palmer, that a reasonable thing to do for patients with small tumors is bring them in and, if appropriate, watch them initially and not to treat them as having cancer until there is a change that suggests that the lesion is cancerous," Dr. Murray said.

Cohort followed

He and colleagues at Bascom Palmer then organized a study to follow a prospective cohort of patients undergoing plaque radiotherapy with iodine-125 after initial observation for documentation of growth in small choroidal melanomas. Patients were eligible if their tumors were 1.5 to 2.5 mm thick with a base of 5 to 16 mm and had a risk factor such as orange pigmentation or subretinal fluid.

Patients were seen every 4 months, and their tumors were documented with special high-resolution ultrasound and photography. The study enrolled 154 patients; 45 had tumor growth over the follow-up period, which was a minimum of 5 years for all patients.

Among the 109 whose tumors did not grow over the observation period, which for some patients was up to 15 years, no melanoma-related deaths occurred.

"If you watch someone with one of these high-risk tumors and the tumor doesn't change, they have essentially no risk of dying from the tumor," Dr. Murray said.

He also reported the outcomes of the 45 patients whose tumors had changed during the observation period. Only one patient died over a 10-year period from a tumor that had spread, resulting in a 2% melanoma-specific mortality rate. Another patient's tumor had metastasized, but the patient still was alive at the end of the 10-year period.

"What that suggested was that, if you looked at the entire 154 patients, the 10-year melanoma-specific mortality was approximately 1%, and in the group of patients whose tumors grew, the melanoma-specific mortality was 2%," Dr. Murray explained.

He added that in the COMS, the melanoma-specific mortality at 5 years for small tumors was 1%, the rate for medium tumors was 10%, and the mortality for large tumors was 30%.

"These data suggest that if you're lucky enough to see a patient with one of these small lesions and you can watch the patient very closely—every 4 months with special photographs and special ultrasound tests—then that patient has a very, very good chance of not ever dying from a melanoma," Dr. Murray continued. "And if the patient is in the group whose tumors never change, then [he or she has] no chance of dying."

Opposing views

Other investigators have opposing views about observation versus treatment in patients with small lesions, he noted. Some favor treating every patient who has a suspicious lesion, analogous to the practice in dermatology of removing every suspicious cutaneous lesion.

"Of course, we don't have the luxury of being able to remove a tumor unless we remove the eye," Dr. Murray said. "The important thing for our patients was that if you had good visual acuity when you entered the trial—and the average visual acuity of the patients who entered this trial was 20/25—then 10 years later, if your tumor did not change, your vision was 20/30. If your tumor did change and you got radiation treatment and your tumor was more than 3 mm from the optic nerve or the fovea, your vision was 20/30. But if your tumor was within 3 mm of the optic nerve or the fovea, the mean visual acuity was 20/100," he added.

"What that tells you is that radiation therapy is very effective for curing the cancer, but it is associated with vision loss from radiation-related complications. You don't want to get treated with radiation therapy unnecessarily, because . . . you have a significant chance of having a significant loss of vision related to radiation retinopathy or radiation optic neuropathy."

If all 154 patients in the Bascom Palmer study had been treated rather than observed, more than half of them, or approximately 80, would have been expected to be legally blind 10 years later despite entering the trial with very good visual acuity, he added. Instead, none of the patients who were observed became legally blind, and only 15 of the 45 treated patients had visual acuity of 20/400 or less.

"We kept them alive, and we preserved their vision by not having to treat them," Dr. Murray said.

Although the trial has formally ended, all the patients continue to be observed because the potential for tumor growth remains indefinitely. "One of the things to make clear is that, if you've got patients with these suspicious lesions, they need to be followed forever," Dr. Murray emphasized.

He added that if for some reason a patient could not be followed, it might be appropriate to treat the tumor while it is small, because the risk of dying from melanoma would be much higher if the tumor grew larger.

http://www.ophthalmologytimes.com/ophthalmologytimes/Retina/Observation-is-the-best-medicine-for-choroidal-les/ArticleStandard/Article/detail/480608?contextCategoryId=522

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2008-01-04 18:52 浏览 : 515 回复 : 3

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• 综合医院全科门诊中乏力患者特征及就诊原因分析

jamesroro

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本人已认领该文编译，48小时后若未提交译文，请其他战友自由认领。

2008-01-04 19:39

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• 给饶毅教授的回复

jamesroro

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section1粗译:

Observation is the best medicine for choroidal lesions
观望乃脉络膜病灶之最佳良药
Dec 1, 2007
By:Nancy Groves
Ophthalmology Times （眼科时讯）

Boston—Observation is the best approach for patients with small, suspicious choroidal melanoma because it eliminates unnecessary treatment and does not compromise the survival of the patient, suggest results of a long-term study.
波斯顿消息:一项长期研究显示,对出现小的可疑脉络丛黑色素瘤的患者采取观望的态度是最佳策略.因为该法在不影响患者生存率的情况下,避免了一些不必要的治疗.

The study's melanoma-specific mortality rate of 0.7% over 10 years indicates that observation is safe when patients are watched closely for signs of change in their tumors, said Timothy G. Murray, MD, FACS, here at the annual meeting of the Retina Society.
作为美国外科医师协会会员(FACS=fellow of the american college of surgeons)之一的医学博士Timothy G. Murray在"视网膜协会"年会上说,研究显示,10多年间黑色素瘤死亡率为0.7%,这提示采取仔细观察患者肿瘤变化征象的(随访)观望态度是安全的.

Dr. Murray presented findings from a long-term study of patients with small choroidal melanoma, noting that the best approach to small, suspicious pigmented lesions has been a controversial subject for years. He is professor of ophthalmology with a secondary appointment in radiation oncology at the Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami.
Murray博士,在对小脉络丛黑色素瘤患者的长期研究中发现,对小的可疑色素沉着采取随访观望态度是最佳处理方法.对此观点人们早已争论多年.他是迈阿密大学.米勒医学院.Bascom Palmer眼科(分)院的眼科学兼放射肿瘤学的教授.

Four decades ago, the customary treatment for every patient with a suspicious lesion was enucleation surgery. Around that time, however, three surgeons from the Bascom Palmer Eye Institute (Victor T. Curtin, MD; J. Donald M. Gass, MD; and Edward W. D. Norton, MD) began to advocate observational management as an option for patients with small choroidal and ciliary body malignant melanoma. They followed this strategy in a series of 46 patients evaluated and managed over 14 years.
40余年前,对每位怀疑该病的患者的传统治疗方法都是(病灶)剜除术.然而在那段时期,有三位来自Bascom Palmer眼科学院的外科医生(Victor T. Curtin, MD; J. Donald M. Gass, MD; and Edward W. D. Norton, MD)却主张,对小的脉络丛及睫状体恶性黑色素瘤可以选择随访观望态度.他们用这种策略评估并处理了46位患者达14年余.

"The majority of the patients had tumors that did not change, [and] . . . the patients didn't die from their tumors," Dr. Murray said. "This was the pivot point that changed how everybody thought about these smaller, presumed-malignant melanomas."
Murray博士说,"肿瘤患者的死亡率并没有变化,而且,（……此处被删除N多字？）患者并没有死于肿瘤.正是这种观点改变了(多年来)人们对于小的可疑恶性黑色素瘤的认识.

The Collaborative Ocular Melanoma Study (COMS) then was launched with an observational component for small tumors (1 to 3 mm in apical height and 5 to 16 mm in largest basal dimension). The study of 204 patients noted a 5-year tumor growth rate of 31% and a melanoma-specific mortality rate of 1%.
眼黑色素留联合研究(COMS:一种组织?一种长期前瞻性研究计划?)才开始对小肿瘤(顶高为1-3mm,基底最大经为5-16mm).对204名患者的研究提示,肿瘤5年增大率为31%,黑色素瘤相关死亡率为1%.

"Because those data were available to us, they suggested to me, as director of the ocular oncology service at Bascom Palmer, that a reasonable thing to do for patients with small tumors is bring them in and, if appropriate, watch them initially and not to treat them as having cancer until there is a change that suggests that the lesion is cancerous," Dr. Murray said.
Murray博士说,"因为有他们提供的数据在手,所以我觉得把这些长了小肿瘤的人群,作为Bascom Palmer眼部肿瘤方面的导引纳入我的研究是合理的.如果符合条件的话,对他们从一开是就只是观察而不当作肿瘤来治疗,直到病灶出现提示癌变的变化为止.——该句翻译感觉不是很舒服.

section2粗译:

Cohort followed
随访队列（跟踪队列）

He and colleagues at Bascom Palmer then organized a study to follow a prospective cohort of patients undergoing plaque radiotherapy with iodine-125 after initial observation for documentation of growth in small choroidal melanomas. Patients were eligible if their tumors were 1.5 to 2.5 mm thick with a base of 5 to 16 mm and had a risk factor such as orange pigmentation or subretinal fluid.
他与Bascom Palmer的同事们组织了一项前瞻性队列研究，随访那些初期观察后再接受血小板碘-125放射性（示踪）研究的患者，以取得小脉络膜黑色素瘤增长相关的进一步资料。

Patients were seen every 4 months, and their tumors were documented with special high-resolution ultrasound and photography. The study enrolled 154 patients; 45 had tumor growth over the follow-up period, which was a minimum of 5 years for all patients.
每4月随访观察患者一次，通过高分辨率的超声和影像记录肿瘤相关信息。该研究纳入154名患者，45名在随访期间出现肿瘤增大，随访时间至少为5年。

Among the 109 whose tumors did not grow over the observation period, which for some patients was up to 15 years, no melanoma-related deaths occurred.
观察期内，那些没有出现肿瘤生长的共109名患者里，有些人长达15年内都没有出现黑色素瘤导致的死亡。

"If you watch someone with one of these high-risk tumors and the tumor doesn't change, they have essentially no risk of dying from the tumor," Dr. Murray said.
Murray博士说，“如果这些高风险肿瘤的患者，观察期内没有肿瘤增长，那么实质上，我们就可以认为其死于该肿瘤的风险为0了。”

He also reported the outcomes of the 45 patients whose tumors had changed during the observation period. Only one patient died over a 10-year period from a tumor that had spread, resulting in a 2% melanoma-specific mortality rate. Another patient's tumor had metastasized, but the patient still was alive at the end of the 10-year period.
他还报道了随访期间，肿瘤增大的45名患者的预后情况。仅一人在10年后因肿瘤扩散而死亡，占黑色素瘤相关死亡率的2%。另一个患者的肿瘤虽有转移，但10年内却死里逃生了。

"What that suggested was that, if you looked at the entire 154 patients, the 10-year melanoma-specific mortality was approximately 1%, and in the group of patients whose tumors grew, the melanoma-specific mortality was 2%," Dr. Murray explained.
博士解释说，“这些情况提示我们：这154名患者整体看来，10年黑色素瘤相关死亡率近1%，肿瘤增大组中，为2%。”

He added that in the COMS, the melanoma-specific mortality at 5 years for small tumors was 1%, the rate for medium tumors was 10%, and the mortality for large tumors was 30%.
COMS上，他补充道，黑色素瘤相关5年死亡率为：小肿瘤1%，中等大小10%，大型30%。

"These data suggest that if you're lucky enough to see a patient with one of these small lesions and you can watch the patient very closely—every 4 months with special photographs and special ultrasound tests—then that patient has a very, very good chance of not ever dying from a melanoma," Dr. Murray continued. "And if the patient is in the group whose tumors never change, then [he or she has] no chance of dying."
“这些数据提示我们，如果偶然幸运的在某个病人身上发现了这些小病灶，你就可以开始对他进行每4月一次的随访观察了——通过专门的超声及影像设备——然后，病人就会因此而最大可能的在罹患该高死亡风险的肿瘤后而死里逃生了。”他继续说到，“如果观察组内的患者的肿瘤从来没增大过，那么，他的死亡风险接近0。”

section3粗译：

Opposing views
反方观点

Other investigators have opposing views about observation versus treatment in patients with small lesions, he noted. Some favor treating every patient who has a suspicious lesion, analogous to the practice in dermatology of removing every suspicious cutaneous lesion.
他指出，另一些研究人员就观望与治疗两种策略提出了反对观点。一些人提倡对有可疑病灶的每一个患者都采取治疗（干预），就像皮肤病实践中那样，对每一个可疑皮肤病灶都要祛除。

"Of course, we don't have the luxury of being able to remove a tumor unless we remove the eye," Dr. Murray said. "The important thing for our patients was that if you had good visual acuity when you entered the trial—and the average visual acuity of the patients who entered this trial was 20/25—then 10 years later, if your tumor did not change, your vision was 20/30. If your tumor did change and you got radiation treatment and your tumor was more than 3 mm from the optic nerve or the fovea, your vision was 20/30. But if your tumor was within 3 mm of the optic nerve or the fovea, the mean visual acuity was 20/100," he added.
Murray博士说，“当然，我们不可能奢望彻底根除肿瘤，除非挖出整个眼球。患者加入试验研究时关心的问题是视力能否得到改善。——
参与研究前，我们的患者平均视力为20/25——10年后，肿瘤如果不增大，视力平均为20/30。如果肿瘤有变化，且离视神经或中央凹3mm以外，同时接受放射治疗，那么平均视力为20/30。但是，如果肿瘤离视神经或中央凹3mm内，那么平均视力为20/100。”

"What that tells you is that radiation therapy is very effective for curing the cancer, but it is associated with vision loss from radiation-related complications. You don't want to get treated with radiation therapy unnecessarily, because . . . you have a significant chance of having a significant loss of vision related to radiation retinopathy or radiation optic neuropathy."
“这就告诉我们，放射治疗虽然对肿瘤治疗很有效，但放射治疗的并发症却可以导致视力减低，而这与疗效也有关系。你不希望接受不必要的放射治疗，因为……放射治疗所致的视网膜病与视神经病会引起严重的视力减低。”

If all 154 patients in the Bascom Palmer study had been treated rather than observed, more than half of them, or approximately 80, would have been expected to be legally blind 10 years later despite entering the trial with very good visual acuity, he added. Instead, none of the patients who were observed became legally blind, and only 15 of the 45 treated patients had visual acuity of 20/400 or less.
他补充说，如果Bascom Palmer研究中的154名患者是接受放射治疗而不是随访观察，那么他们中的半数，或者说是近80人，10年后也许都可判为“失明”了，尽管他们参加研究之初视力良好。而目前的情况是，接受观察而非治疗的患者们没有以人是失明的，仅在随访后确定治疗的45人中出现15人有视力减低于20/400。

"We kept them alive, and we preserved their vision by not having to treat them," Dr. Murray said.
Murray博士说，“保留生存率的同时，我们还通过非治疗手段保存了他们的视力。”

Although the trial has formally ended, all the patients continue to be observed because the potential for tumor growth remains indefinitely. "One of the things to make clear is that, if you've got patients with these suspicious lesions, they need to be followed forever," Dr. Murray emphasized.
尽管治疗形式上已结束，但所有的患者仍然在接受随访观察，因为肿瘤是否存在潜在生长可能仍需明确。“有件事情可以明确，就是，如果患者有可疑病灶，那么他就需要终身随访。” Murray博士说。

He added that if for some reason a patient could not be followed, it might be appropriate to treat the tumor while it is small, because the risk of dying from melanoma would be much higher if the tumor grew larger.
他补充道，如果因为某些原因，患者没有能成功随访，那么在肿瘤很小的时候就接受治疗可能是合适的，因为，黑色素瘤如果增大的话，其致死的风险是很大的。

http://www.ophthalmologytimes.com/ophthalmologytimes/Retina/Observation-is-the-best-medicine-for-choroidal-les/ArticleStandard/Article/detail/480608?contextCategoryId=522

2008-01-05 00:21

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jamesroro 编辑于 2008-01-06 16:24

• 可以瞒着医院偷偷考研吗？

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Dr. Murray is director of the ocular oncology service at Bascom Palmer.

2008-01-05 13:42

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