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Uveal Melanoma National Guidelines Uveal Melanoma Guidelines January 2015 Uveal Melanoma National Guidelines January 2015 Authors: Nathan P, Cohen V, Coupland S, Curtis K, Damato B, Evans J, Fenwick S, Kirkpatrick L, Li O, Marshall E, McGuirk K, Ottensmeier C, Pearce N, Salvi S, Stedman B, Szlosarek P, Turnbull N This project is the independent work of the Uveal Melanoma Guideline Development Group and is funded by Melanoma Focus (http://melanomafocus.com/) Page 1 of 112 Uveal Melanoma Guidelines January 2015 Uveal Melanoma 1. Executive Summary ......................................................................................................................... 6 1.1 Care Pathway .......................................................................................................................... 6 1.2 Recommendations ................................................................................................................ 10 1.2.1 Patient Choice and Shared decision-making ................................................................ 10 1.2.2 Service Configuration .................................................................................................... 10 1.2.3 General Guidance.......................................................................................................... 10 1.2.4 Primary management ................................................................................................... 11 1.2.5 Prognostication ............................................................................................................. 14 1.2.6 Surveillance ................................................................................................................... 15 1.2.7 Metastatic disease ........................................................................................................ 16 2. Background ................................................................................................................................... 18 2.1 Introduction .......................................................................................................................... 18 2.2 Strengths and limitations of the evidence ............................................................................ 19 2.3 Risks versus benefits ............................................................................................................. 19 2.4 Scope and purpose ................................................................................................................ 19 2.4.1 Aim of the guideline ...................................................................................................... 19 2.4.2 Clinical areas covered by the guideline ......................................................................... 20 2.4.3 Target population and target audience ........................................................................ 20 2.5 Acknowledgements ............................................................................................................... 20 3. Methodology ................................................................................................................................. 20 3.1 Levels of Evidence ................................................................................................................. 21 3.2 Grade of recommendations .................................................................................................. 22 4. Management of the primary tumour ........................................................................................... 22 4.1 Introduction .......................................................................................................................... 22 4.2 Methods ................................................................................................................................ 23 4.2.1 Questions addressed ..................................................................................................... 23 4.2.2 Inclusion and Exclusion criteria for selecting evidence ................................................ 24 4.2.3 Appraisal and Extraction ............................................................................................... 24 4.3 Evidence Summary ................................................................................................................ 24 Page 2 of 112 Uveal Melanoma Guidelines January 2015 4.3.1 Question 1. What are appropriate pre-operative investigations for the primary tumour? 24 4.3.2 Question 2. Should patients be staged before primary treatment? ............................ 26 4.3.3 Question 3. What is the optimal primary treatment? .................................................. 28 4.4 Evidence Statements............................................................................................................. 40 4.4.1 Pre-operative investigations ......................................................................................... 40 4.4.2 Staging before primary treatment ................................................................................ 41 4.4.3 Primary Treatment ........................................................................................................ 41 4.5 Recommendations ................................................................................................................ 42 4.6 Linking evidence to recommendations ................................................................................. 42 5. Prognostication ............................................................................................................................. 44 5.1 Introduction .......................................................................................................................... 44 5.2 Methods ................................................................................................................................ 44 5.2.1 Questions addressed ..................................................................................................... 44 5.2.2 Inclusion and exclusion criteria for selecting evidence ................................................ 45 5.2.3 Appraisal and extraction ............................................................................................... 45 5.3 Review of Evidence ............................................................................................................... 45 5.3.1 Is there a preferred prognostic tool? ............................................................................ 45 5.3.2 What is the role of prognostic biopsy? ......................................................................... 48 5.4 Evidence Statements............................................................................................................. 49 5.4.1 Prognostic factors/tool ................................................................................................. 49 5.4.2 Prognostic biopsy .......................................................................................................... 49 5.5 Recommendations ................................................................................................................ 49 5.6 Linking Evidence to Recommendations ................................................................................ 49 6. Surveillance of patients at risk of recurrence ............................................................................... 50 6.1 Introduction .......................................................................................................................... 50 6.2 Methods ................................................................................................................................ 51 6.2.1 Questions addressed ..................................................................................................... 51 6.2.2 Inclusion and exclusion criteria for selecting evidence ............................................... 52 6.2.3 Appraisal and extractions ............................................................................................. 52 6.3 Evidence summary ................................................................................................................ 52 6.3.1 Question 1: Should all patients be offered surveillance? ............................................. 52 6.3.2 Question 2: Should there be a risk-adapted strategy for surveillance? If so, what is a high-risk and or low-risk uveal melanoma? .................................................................................. 53 Page 3 of 112 Uveal Melanoma Guidelines January 2015 6.3.3 Question 3: What is the optimal imaging modality for surveillance, overall and of the liver? 54 6.3.4 Question 4: What is the optimal surveillance interval? ................................................ 55 6.3.5 Question 5: What is the duration of surveillance? ....................................................... 55 6.4 Evidence Statements............................................................................................................. 56 6.5 Recommendations ................................................................................................................ 56 6.6 Linking evidence to recommendations ................................................................................. 56 7. Metastatic Disease ........................................................................................................................ 57 7.1.1 Introduction .................................................................................................................
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