Endoresection for choroidal melanoma: palliative or curative intent?

There seems to be perpetual controversy surrounding treatment of uveal melanoma since publication of a landmark article by Zimmerman, McLean, and Foster in this journal titled “Does enucleation of the eye containing a malignant melanoma prevent or accelerate the dissemination of tumour cells.”1 Over the last 30 years, we have come to realise the limitations of the “Zimmerman–McLean–Foster hypothesis”2 and observed that for comparable-sized tumours, survival is independent of the method of treatment such as plaque radiotherapy, enucleation and proton-beam radiotherapy.3 4 Survival is perhaps similar with trans-scleral resection (TSR), although there are no randomised trials comparing survival following TSR with other methods of treatment.5 These observations imply that distant metastasis of choroidal melanoma, although undetectable at the time of ocular diagnosis by present-day imaging techniques, has perhaps taken place prior to the treatment of primary tumour. This concept is further supported by estimates of growth rates of primary and metastatic tumours6 7 and the high frequency of circulating melanoma cells detected in patients with primary uveal melanoma.8 It must be emphasised that these observations do not imply that the ocular treatment of choroidal melanoma has no effect on the risk for metastasis. The fact of the matter is that we do not know the effect of the treatment of choroidal …