Uveal melanoma management is challenging due to its metastatic propensity. DecisionDx-UM is a prospectively validated molecular test that interrogates primary tumor biology to provide objective information about metastatic potential that can be used in determining appropriate patient care. To evaluate the continued clinical validity and utility of DecisionDx-UM, beginning March 2010, 70 patients were enrolled in a prospective, multicenter, IRB-approved study to document patient management differences and clinical outcomes associated with low-risk Class 1 and high-risk Class 2 results indicated by DecisionDx-UM testing. Thirty-seven patients in the prospective study were Class 1 and 33 were Class 2. Class 1 patients had 100% 3-year metastasis-free survival compared to 63% for Class 2 (log rank test p = 0.003) with 27.3 median follow-up months in this interim analysis. Class 2 patients received significantly higher-intensity monitoring and more oncology/clinical trial referrals compared to Class 1 patients (Fisher's exact test p = 2.1 × 10−13 and p = 0.04, resp.). The results of this study provide additional, prospective evidence in an independent cohort of patients that Class 1 and Class 2 patients are managed according to the differential metastatic risk indicated by DecisionDx-UM. The trial is registered with Clinical Application of DecisionDx-UM Gene Expression Assay Results (NCT02376920).

The management of conjunctival surface melanomas is complicated by local recurrence and metastatic disease, particularly for lesions greater than 2 mm in thickness and arising from nonbulbar conjunctiva. Early complete excision with appropriate adjuvant cryotherapy and topical chemotherapy may be curative in some patients. Conjunctival anatomy and high recurrence rate with resultant metastatic spread undermines the utility of sentinel lymph node biopsy in this condition. Further research and innovation for detection of systemic micrometastases and treatment of metastatic disease are needed.

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Paraneoplastic retinopathies comprise a diverse group of immune-mediated conditions affecting the eye. Cancer-associated retinopathy (CAR) typically has a sudden onset of severe visual loss and an ominous association with an occult malignancy. CAR is one of the best studied and better understood conditions in the multifarious group of autoimmune retinopathies. Recent developments have correlated the disease presentation, course, and therapeutic response to the underlying immune mediators and the inciting antigens. Signaling involving cytotoxic T-lymphocytes antigen 4 (CTLA-4) and vascular endothelial growth factor (VEGF) receptor-1 appears to play a role in the pathogenesis and may offer novel avenues for therapeutic intervention in CAR. Future developments in rapid identification and longitudinal quantification of antibody levels would enable individualized management in these patients. The goal of this review is to analyze the clinical features of diagnosis and management of retinopathy in the context of recent advances in the elucidation of CAR pathogenesis.

PurposeThe purpose of this study is to report the use of intravitreal triamcinolone for treatment of cancer-associated retinopathy (CAR) refractory to systemic therapy.MethodsThis was a retrospective chart review study.ResultsA 67-year-old man presented with cancer-associated retinopathy with antibodies against a 46-kDa retinal protein, alpha enolase. There was disease progression despite therapy with mycophenolate and intravenous immunoglobulin. Serial intravitreal injections of triamcinolone resulted in restoration of photoreceptor anatomy on optical coherence tomography and visual improvement. The patient’s vision was preserved at 20/40 OD and 20/32 OS until his death from lung cancer 31 months after CAR diagnosis.ConclusionsIntravitreal triamcinolone may be beneficial for maintenance of vision in patients with CAR.

Introduction: The prognostic 15-gene expression profile (15-GEP) test for uveal melanoma (UM) predicts metastatic risk based on primary tumor biology. Here we report outcomes from a prospective registry of 15-GEP-tested patients, and a meta-analysis with published cohorts. Objectives: Management and 5-year clinical outcomes following 15-GEP testing were evaluated. Methods: Eighty-nine patients with 15-GEP results were prospectively enrolled at four centers. Physician-recommended management plans were collected, and clinical outcomes tracked every 6 months. Results: Eighty percent of Class 1 (low-risk) patients underwent lowintensity management; all Class 2 (high-risk) patients underwent high-intensity management (p < 0.0001). Median follow-up for event-free patients was 4.9 years. Five Class 1 (10%) and 23 Class 2 (58%) tumors metastasized (p < 0.0001). Five-year Class 1 and 2 metastasis-free survival rates were 90% (81-100%) and 41% (27-62%; p < 0.0001), and melanoma-specific survival rates were 94% (87-100%) and 63% (49-82%; p = 0.0007). Class 2 was the only independent predictor of metastasis and was associated with increased risk for metastasis and mortality by meta-analysis. Conclusions: UM patient management is guided by 15-GEP testing. Class 2 patients were managed more intensely, in accordance with an observed metastatic rate of > 50%; Class 1 patients were safely spared intensive surveillance, resulting in appropriate utilization of healthcare resources.

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Functional magnetic resonance imaging was used to compare cortical organization of the first (L1, Russian) and second (L2, English) languages. Six fluent Russian-English bilinguals who acquired their second language postpuberty were tested with words and nonwords presented either auditorily or visually. Results showed that both languages activated similar cortical networks, including the inferior frontal, middle frontal, superior temporal, middle temporal, angular, and supramarginal gyri. Within the inferior frontal gyrus (IFG), L2 activated a larger cortical volume than L1 during lexical and phonological processing. For both languages, the left IFG was more active than the right IFG during lexical processing. Within the left IFG, the distance between centers of activation associated with lexical processing of translation equivalents across languages was larger than the distance between centers of activation associated with lexical processing of different words in the same language. Results of phonological processing analyses revealed different centers of activation associated with the first versus the second language in the IFG, but not in the superior temporal gyrus (STG). These findings are discussed within the context of the current literature on cortical organization in bilinguals and suggest variation in bilingual cortical activation associated with lexical, phonological, and orthographic processing.