Long-term visual acuity results of treated and untreated radiation retinopathy (an AOS thesis)

PURPOSE

To report ocular findings in eyes with radiation retinopathy and visual acuity (VA) results of photocoagulation for macular edema and proliferative retinopathy.

METHODS

This retrospective case series compared VA after photocoagulation treatment and nontreatment of radiation macular edema. Visual outcomes were assessed with regression analyses.

RESULTS

Eighty-seven eyes (78 [89.7%] treated with external beam irradiation and 9 treated with local plaques) were studied. Fifty-nine (67.8%) and 28 (32.2%) eyes had nonproliferative and proliferative retinopathy, respectively; macular edema developed in 42 nonproliferative eyes (71.2%) and 24 proliferative eyes (85.7%). Initial VAs (median) were 20/40 and 20/65 for nonproliferative and proliferative eyes, respectively, and final VA was 20/80 and 20/400. Initial VA (median) in eyes with macular edema was 20/50 compared to 20/25 in eyes without edema; final VAs were 20/200 and 20/30. Comparing treated (19 [45.2%]) and untreated (23[54.8%]) macular edema in 42 eyes with nonproliferative retinopathy, initial median VA (20/40 and 20/50) and final VA (20/100 and 20/200) were better in treated eyes. Regression analysis showed significant treatment effect (P = .003) when initial VA (logMAR) and months of follow-up were kept constant; treated eyes had mean final VA (logMAR) 0.36 (95% CI, 0.12-0.60) better than untreated eyes.

CONCLUSIONS

The presence of macular edema and proliferation indicates more severe retinopathy and worse visual prognosis than for eyes without macular edema and proliferation. Although these VA results suggest macular photocoagulation is beneficial, eyes with macular edema continue to lose vision despite treatment. Better prevention and treatment methods are needed for radiation retinopathy.

Radiotherapy for orbital lymphoma : outcome and late effects

PURPOSE

To analyze the effectiveness of radiotherapy in the management of orbital non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

42 patients (median age 64.5 years) were reviewed retrospectively. The median follow-up period was 58 months. 26 patients had stage IE orbital lymphoma (22 indolent, four aggressive NHLs). 16 patients had advanced NHLs in stages II-IV with orbital involvement (eleven indolent, five aggressive NHLs). The median radiation dose was 40 Gy (20-46 Gy) for indolent lymphoma and 44 Gy (20-48 Gy) for aggressive lymphoma. Patients with stage IE were treated with at least 30 Gy.

RESULTS

The 5-year local control rate for patients with stage I was 100%, the 5-year overall survival 91%. Two distant relapses were found, but no lymphoma-related death was detected. The 5-year local control rate for patients in stages II, III, and IV was 80%. Two local failures were detected. The 5-year overall survival for the advanced stages was 47%, nine patients with stages III and IV died due to systemic progression of lymphoma. Acute, radiotherapy-related complications grade 3/4 were not observed. Late effects grade 1/2 were documented in 45%. Six patients, treated with doses of > 36 Gy, developed grade 3 complications (four cataract, two dryness).

CONCLUSION

Radiotherapy alone yields excellent local control and overall survival rates in orbital lymphoma stage IE. Local irradiation is also well tolerated and effective in advanced NHL stages with orbital infiltration. Doses of > 36 Gy resulted in an increase of late complications.

Carbon ion therapy for ocular melanoma: planning orthogonal two-port treatment

We recently started orthogonal two-port carbon ion therapy for choroidal melanoma with the intent to reduce the incidence of radiation complications that occur with mono-port therapy. Treatment planning techniques involving therapeutic beam characteristics are described here. The vertical (140 MeV/u) and horizontal (170 MeV/u) carbon ion beams from the synchrotron at the NIRS were shaped, using the passive beam delivery system, to irradiate the target volume. The range modulating ridge filters were designed to produce spread-out Bragg peaks (SOBPs) with a region of uniform HMV-I cell killing. The apertures and range compensators were designed for individual patients. A commercial treatment planning system, which was customized to our general carbon ion therapy, was tested for applicability to this treatment. Dose distributions were calculated with either a broad beam or a pencil beam algorithm using parameters determined by measurements and calculations. We evaluated the accuracy of the system software features, and replaced or added some other features to the software. The system was used for 12 patients during the past year. For nine patients two-port treatment was assessed to be more effective than mono-port therapy and these patients were treated with two fractions of vertical beams and three fractions of horizontal beams.

Secondary reconstruction of the eye socket in a free flap transferred after complete excision of the orbit

Reconstruction of the eye socket in a free flap transferred after complete excision for malignancy is difficult. Between 1980 and 2005 we secondarily reconstructed five eye sockets in free flaps after resection of cancer, cirsoid haemangioma, and the consequences of irradiation for retinoblastoma. Free flaps were used during the primary operations to cover the defects. The eye socket was then reconstructed during the secondary operations with a conventional skin graft in two cases, and with a skin graft using the modified Antia's method in three cases. All free flaps survived and all eye sockets accepted ocular prostheses. Three patients in particular, whose eye sockets were reconstructed using the modified Antia's method, had excellent results. Here we describe operations and problems related to secondary reconstruction of eye sockets in previously transferred free flaps after complete excision, and describe some typical cases.

[MALT-type lymphoma of lacrimal gland: case report]

A 72-year-old female presented with a lump in the left superior-lateral eyelid. The magnetic resonance imaging showed a well-delineated mass in the left lacrimal gland. The tumor was isointense on both the T1 and T2 weighted images, and it was homogenously enhanced with Gd-DTPA. Surgery via the trans-cranial approach revealed a pinkish and elastic-hard tumor. Total resection was successfully performed. The hematoxilyn-eosin staining of the surgical specimen showed a dense infiltrate of lymphocytes, which were composed predominantly of small lymphocytes, centrocyte-like cells, monocytoid cells, and occasionally transformed lymphocytes. The immunohistochemical findings for CD20, CD3, UCHL-1, CD23, CD5, cyclinD1, and bcl-2 were compatible with Mucosa Associated Lymphoid Tissue (MALT)-type lymphoma. The patient received local radiation therapy (30 Gy/15 fractions). She remained in complete clinical remission of the disease about one and a half years after treatment.

Combined keratectomy, strontium-90 irradiation and permanent bulbar conjunctival grafts for corneolimbal squamous cell carcinomas in horses (1990-2002): 38 horses

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of postoperative beta-irradiation with strontium-90 as an adjunctive treatment to superficial keratectomy and permanent bulbar conjunctival graft for removal of equine corneolimbal squamous cell carcinoma (SCC), in decreasing recurrence rate.

STUDY

The retrospective case study included 38 horses diagnosed and treated for SCC of the eye that involved the limbus and/or cornea. The patients were treated between 1990 and 2002, with strontium-90 irradiation immediately after corneal and conjunctival graft surgery. Recurrence was defined as the postoperative and postirradiation regrowth of SCC in the same site and globe that was previously treated.

RESULTS

The Appaloosa was the most commonly represented breed and horses that had more than one base coat color represented the majority of the cases (53%). The coat colors of white, chestnut/sorrel and gray were the most commonly represented colors of the horses treated. Eight horses (21%) could not be assessed for tumor recurrence due to lack of two or more post-treatment examinations, and another horse was enucleated 6 days postoperatively due to progressive corneal ulceration. Twenty-four horses (63% of the entire study population; 83% of the followed cases) had a mean +/- SD of 1754 +/- 1319 days without tumor recurrence, ranging from 14 days to 5110 days. Five horses (13% of the entire study population; 17% of the assessed horses) had tumor recurrence at a mean +/- SD of 449 +/- 339 days with a range of 29 days to 900 days. For the five recurrences, treatment included local excision (n = 1), enucleation (n = 2), and additional strontium-90 therapy (n = 3).

CONCLUSIONS

The combination of superficial keratectomy, beta-irradiation and permanent bulbar conjunctival grafts for limbal, corneal or corneolimbal SCC in horses is effective in at least 83% of the horses. Recurrence occurred in about 17% of the horses. Multiple biannual re-examinations are recommended to observe for tumor recurrence.

Trilateral retinoblastoma

BACKGROUND

Trilateral retinoblastoma (TRB) is a syndrome consisting of unilateral or bilateral hereditary retinoblastoma (Rb) associated with an intracranial neuroblastic tumor. Although its incidence is low, the prognosis is very poor. This article reports four cases of TRB and discusses the role of neuroimaging screening for early detection.

PROCEDURE

From January 1986 to December 2003, 470 children with Rb were admitted to the Pediatrics and Ophthalmology Departments, A C Camargo Hospital, São Paulo, Brazil.

RESULTS

There were four patients with pineoblastoma, two of whom had a positive familial history. The age at diagnosis of Rb was 4, 6, 10, and 24 months while the age of diagnosis of TRB was 10, 25, 57, and 72 months. One patient presented TRB at initial diagnosis of Rb. Three patients had bilateral disease and all of them had one eye enucleated, followed by chemotherapy and/or external beam radiation therapy (EBRT). One child with unilateral disease was only submitted to enucleation. In spite of intensive treatment, all patients died with progressive disease within 7, 8, 12, and 12 months after diagnosis of TRB.

CONCLUSIONS

Early diagnosis as well as new therapeutic approaches are needed to achieve better results.

Retinoblastoma in children older than 5 years of age

BACKGROUND

Retinoblastoma is a malignant tumor of the embryonic neural retina. About 80% of cases are diagnosed before age 4, with a median age at diagnosis of 2 years.

OBJECTIVE

To determine characteristics and prognosis of retinoblastoma in children older than 5 years.

PROCEDURES

From 1986 to 2002, medical records of 16 patients out of 453 cases referred to Hospital do Câncer AC Camargo, São Paulo, Brazil.

RESULTS

Median age at diagnosis was 73.7 months (range 65-144) and there was an equal gender distribution. Fifteen patients presented with unilateral disease. The mean time between first symptoms and diagnosis was 9.6 months (range 0-48). Most cases were diagnosed in advanced stages and 15 eyes were enucleated. Eleven patients presented with intraocular tumor (1 Reese II and 10 Reese V) and five presented with extraocular disease (one CCG II and four CCG III). Twelve patients are still alive with a median follow-up of 92 months (range 65-199).

CONCLUSIONS

Because of its low incidence at this age, diagnosis of retinoblastoma is usually delayed due to low level of suspicion. Therefore, it is important that physicians are aware of this disease in order to perform an earlier diagnosis, and decrease treatment-related morbidity.

Intraocular lymphoma metastasis from larynx

PURPOSE

To present a rare case of primary larynx diffuse large B cell lymphoma non-Hodgkin's lymphoma (NHL), disseminated to the cerebellum and the intraocular tissue.

METHODS

A 69-year-old man noticed blurred vision in both eyes. The vitreous contained infiltrating cells bilaterally, and floating opacities were increased. We performed vitrectomy to recover the vision and diagnose for both eyes.

RESULTS

The authors discovered diffuse large B cell NHL with cytopathologic examination from vitreous specimen in this case, which was identical with diffuse large B cell NHL of the larynx and cerebellum, and therefore could diagnose the intraocular lesion as the metastasis of NHL. Although the vision improved, the patient had remarkable visual disturbance in both eyes at 6 months after surgery because of the chorioretinal lesion. The authors treated by the combined curative chemotherapy and radiotherapy to ocular tissue, since providing sufficient evidence that the chorioretinal lesion was to predict the metastasis of diffuse large B cell NHL After those treatments, chorioretinal lesions have disappeared in both eyes and the vision has recovered.

CONCLUSIONS

Increased attention to the possibility of dissemination of laryngeal NHL to the intraocular tissue is needed.

A high-resolution anthropomorphic voxel-based tomographic phantom for proton therapy of the eye

Proton therapy is increasingly used in medical treatments for cancer patients due to the sharp dose conformity offered by the characteristic Bragg peak. Proton beam interactions with the eye will be simulated using the MCNPX Monte Carlo code and available nuclear cross-section data to calculate the dose distribution in the eye gel and surrounding organs. A high-resolution eye model will be employed using a 3D geometrical voxel-based anthropomorphic head phantom obtained from the Visible Human Project (female data). Manual segmentation of the eye, carried out by the Medical Physics group at the University of Surrey resulted in 15 identified structures. This work emphasizes the use of a realistic phantom for accurately predicting dose deposition by protons.

[Gastric relapse of stage I ocular adnexal mucosa-associated lymphoid tissue lymphoma]

A 57-year-old male with right ocular adnexal mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) was successfully treated with local radiation therapy. The gastroendoscopic examination revealed a slight inflammatory change of the gastric mucosa, and the urease test was positive. Eradication therapy against Helicobacter pylori was successfully done, however, the patient developed gastric MALT lymphoma two years after the initial treatment. Southern blot analysis of the immunoglobulin heavy chain gene rearrangement revealed that the lymphoma cells from the ocular adnexal and gastric MALT lymphomas were identical, indicating that the gastric MALT lymphoma was not the primary but the metastatic region from the ocular adnexal MALT lymphoma. Further, immunohistochemical staining demonstrated the expression of integrin alpha4beta 7 on ocular adnexal MALT lymphoma cells, which is essential for the adhesion of lymphocytes to gastrointestinal mucosa. These results indicate that ocular adnexal MALT lymphoma cells can metastasize to the stomach, depending on the adhesional function of integrin alpha4 beta7.

Treatment of primary intraocular lymphoma with radiation therapy: a multi-institutional survey in Japan

This study evaluated the clinical features and treatment outcome of 15 patients with primary intraocular lymphoma. There were nine females, with a median age of 68 years. Thirteen patients presented with bilateral lesions and median time from the onset of symptoms to diagnosis was 12 months. All but one showed the B-cell phenotype. All patients received radiation therapy (RT) with a median of 41 Gy and 10 were administered chemotherapy as well. Three patients were treated with high-dose methotrexate and nine received prophylactic cranial irradiation (PCI) with a median of 30.6 Gy. Thirteen patients obtained a complete remission. The 2-year overall and disease free survival were 74% and 58%, respectively. Although only one patient experienced local recurrence, PCI did not prevent intracranial recurrence. One patient developed a grade 3 cognitive disturbance. It was concluded that ocular RT was effective to control primary lesions. However, some modifications are indispensable to improve outcomes.

Reconstruction of Large Orbital Exenteration Defects after Resection of Periorbital Tumors of Advanced Stage

Orbital exenteration is a devastating procedure because of the social impact and psychological stress put upon the patient. Besides cancer ablative surgery, reconstruction after removal of the tumor constitutes a major problem and the final aesthetic result is quite important. Both obliteration of the orbital cavity and continuation of the epithelial lining are required. Free rectus abdominis muscle and musculocutaneous flaps are versatile flaps which both enable filling the cavity and reconstituting the skin defect with a cutaneous portion or with a skin graft. Both free rectus abdominis muscle and musculocutaneous flaps were used for reconstruction of orbital exenteration defects in 19 patients. All suffered partial maxillectomy as well. The flaps provided satisfactory aesthetic results in all patients.

Radiotherapy and cataract formation

In the past five decades, the treatment options for intraocular tumors have expanded from one surgical option of enucleation to numerous regimens including radiotherapy. Radiotherapy has proven to be as efficacious in controlling the malignant lesion; however, normal ocular structures can also be affected. The lens is radio-sensitive and therefore the development of post radiation cataract commonly impairs vision and the ability to monitor tumor recurrence. Prevalence, severity, onset, and prognosis of radiation-induced cataract depend highly on the dose and rate of radiation. Recently, additional studies have given insight into this important relationship and the efficacy of treatment options.

[Protons and ions in the treatment of cancer; a systematic review of the literature]

OBJECTIVE

To provide an overview of the present role of proton and ion therapy, also referred to as 'charged particle therapy', in the treatment of cancer.

DESIGN

Systematic literature study.

METHOD

Systematic electronic searches were carried out in 12 databases according to the Cochrane Collaboration criteria, without restriction as to year of publication or study design. Manual searches of bibliographies and journals were also performed. The inclusion criteria were: at least 20 patients and a follow-up of at least 2 years. In addition, experts on the subject were consulted by correspondence for their opinion.

RESULTS

The search identified 36 relevant articles on proton therapy and 15 on ion therapy. Based on prospective and retrospective studies, proton irradiation emerged as the treatment of choice for ocular tumours, chordomas and skull-base tumours. For prostate cancer, the results were comparable with the best results of photon therapy. Ion therapy was still in an experimental phase.

CONCLUSION

According to the current literature, proton therapy is looked upon as the preferred treatment modality for certain rare tumours, such as ocular tumours, chordoma, and skull-base tumours. However, charged particle therapy as a whole, and especially ion therapy, is not supported as the treatment of choice for cancer by published evidence. Nevertheless, the potential theoretical benefit of this treatment is great.

Amniotic membrane transplantation for corneal surface reconstruction after excision of corneolimbal squamous cell carcinomas in nine horses

OBJECTIVE

The purpose of this study was to evaluate the usefulness and effectiveness of permanent amniotic membrane transplantation as an adjunctive treatment to superficial keratectomy alone or combined with strontium-90 irradiation for treatment of equine corneolimbal squamous cell carcinoma (SCC) to decrease corneal scarring and recurrence rate.

STUDY

The retrospective case study included 11 horses (n = 12 eyes) diagnosed and treated for ocular SCC that involved the limbus and cornea. Nine of those horses (n = 9 eyes) were treated between 2002 and 2006, with superficial lamellar keratectomy alone or combined with strontium-90 irradiation and followed by placement of a permanent amniotic membrane graft in the surgical defect. The level of scarring (i.e. the clarity of the cornea) resulting with the use of amniotic membrane was subjectively compared to cases where a permanent bulbar conjunctival graft was performed following keratectomy combined with strontium-90 irradiation or cryotherapy (n = 3 eyes). Recurrence was defined as the postoperative and postirradiation regrowth of SCC in the same site and globe.

RESULTS

The nine horses that received an amniotic membrane graft after keratectomy alone or combined with irradiation showed a minimal level of scarring in a cornea that regained a greater transparency in comparison to the horses that were treated with a bulbar conjunctival graft. All of the horses that received an amniotic membrane graft had 226 +/- 218 days of follow-up without tumor recurrence (mean +/- SD), ranging from 21 days to 778 days.

CONCLUSIONS

The combination of superficial keratectomy alone or associated with beta-irradiation and permanent amniotic membrane transplantation is an effective treatment of corneal or corneolimbal SCC in horses. The placement of an amniotic membrane material represents an alternative surgical procedure to bulbar conjunctival grafts, especially if there is a lack of bulbar conjunctiva tissue available after tumor resection or if a particularly large corneal resection is necessary. The amniotic membrane is incorporated into the corneal defect and seems to create noticeably much less scarring than a corneal defect covered by bulbar conjunctiva.

Effects of therapy with [177Lu-DOTA0, Tyr3]octreotate in patients with paraganglioma, meningioma, small cell lung carcinoma, and melanoma

Therapy using the radiolabeled somatostatin analog [177Lu-DOTA0,Tyr3]octreotate (177Lu-octreotate) (DOTA is 1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic acid) has been used primarily in gastroenteropancreatic neuroendocrine tumors. Here we present the effects of this therapy in a small number of patients with metastasized or inoperable paragangliomas, meningiomas, small cell lung carcinomas (SCLCs), and melanomas.

METHODS

Twelve patients with paraganglioma, 5 with meningioma, 3 with SCLC, and 2 with eye melanoma were treated. Three meningiomas were very large and exophytic and all standard treatments had failed. Patients with melanoma had rapidly progressive disease (PD). The intended cumulative dose of 177Lu-octreotate was 22.2-29.6 GBq. Effects of the treatment on tumor size were evaluated using the Southwest Oncology Group criteria.

RESULTS

Two of 4 patients with progressive paraganglioma had tumor regression and 1 had stable disease (SD). Of 5 patients with stable paraganglioma, 2 had SD, 2 had PD, and in 1 patient treatment outcome could not be determined. Paraganglioma was stable in 3 patients in whom the disease status at the beginning of therapy was unknown. One of 4 patients with progressive meningioma had SD and 3 patients had PD. One patient with stable meningioma at the beginning of therapy had SD. All patients with SCLC or melanoma died within 5 mo after starting therapy because of tumor progression. Although not statistically significant, a positive trend was found between high uptake on pretherapy somatostatin receptor scintigraphy and treatment outcome.

CONCLUSION

177Lu-octreotate can be effective in patients with paraganglioma and meningioma. Response rates are lower than those in patients with gastroenteropancreatic neuroendocrine tumors. Most meningiomas were very large. Further studies are needed to confirm the treatment outcome because of the limited number of patients. 177Lu-octreotate did not have antitumor effects in patients with small lung carcinoma and melanoma.

Treatment of periocular and non-ocular sarcoids in 18 horses by interstitial brachytherapy with iridium-192

Treatment of the equine sarcoid has posed a significant challenge to clinicians for years and many different methods have been tried with varying success, including ionising radiation. The aim of this study was to review the efficacy of iridium-192 interstitial brachytherapy for the treatment of eight periocular sarcoids and 15 non-ocular sarcoids on 18 horses. All the periocular sarcoids and 13 of the 15 non-ocular sarcoids were treated successfully.

Dose distributions of a proton beam for eye tumor therapy: hybrid pencil-beam ray-tracing calculations

For the case of eye tumor therapy with protons, improvements are introduced compared to the standard dose calculation which implies straight-line optics and the constant-density assumption for the eye and its surrounding. The progress consists of (i) taking account of the lateral scattering of the protons in tissue by folding the entrance fluence distribution with the pencil beam distribution widening with growing depth in the tissue, (ii) rescaling the spread-out Bragg peak dose distribution in water with the radiological path length calculated voxel by voxel on ray traces through a realistic density matrix for the treatment geometry, yielding a trajectory dependence of the geometrical range. Distributions calculated for some specific situations are compared to measurements and/or standard calculations, and differences to the latter are discussed with respect to the requirements of therapy planning. The most pronounced changes appear for wedges placed in front of the eye, causing additional widening of the lateral falloff. The more accurate prediction of the dose dependence at the field borders is of interest with respect to side effects in the risk organs of the eye.

Lymphoplasmacytic Lymphoma Isolated to an Extraocular Muscle

A 44-year-old woman presented with a 1-month history of right-sided tearing, redness, and chronic headache. Clinical examination was notable for 4-mm proptosis and decreased visual acuity OD. Orbital CT demonstrated isolated enlargement of the right lateral rectus. Surgical biopsy was undertaken after an unsuccessful trial of oral steroids. Histopathology and immunophenotyping demonstrated a lymphoplasmacytic lymphoma. External beam radiation induced regression of the lymphoma with decreased proptosis and improved visual acuity.

Multiple limbal haemangiosarcomas in a border collie dog: management by lamellar keratectomy/sclerectomy and strontium-90 beta plesiotherapy

An eight-year-old, neutered, male border collie dog was presented with a six-week history of left ocular discomfort and a raised, red mass at the lateral limbus. The right eye had been enucleated approximately 12 months previously following suspected trauma when the eye had become red and painful. The mass was excised using superficial keratectomy/sclerectomy and the surgery site was treated with strontium-90 beta radiation. Histopathological findings were consistent with a diagnosis of haemangiosarcoma. Immunohistochemical staining showed uniform expression of CD31 in neoplastic cells, confirming their endothelial origin. Two further treatments with strontium-90 beta radiation were applied to the surgical site at weekly intervals. Twenty-six weeks after surgery, a second, raised, red limbal mass became apparent at the medial limbus of the left eye. Surgical excision and adjuvant strontium-90 beta plesiotherapy were performed as described for the initial tumour. Routine histopathological analysis confirmed haemangiosarcoma at this site. Eighty-six weeks following the initial presentation, no recurrence of ocular haemangiosarcoma was evident.

Extensive bone metastases from basal cell carcinoma of the eye

The incidence of metastases from basal cell carcinoma is rare. We report a 66-year-old woman who had basal cell carcinoma of the outer canthus of the left eye. Six months following radical radiotherapy, she developed local recurrence for which an orbital exenteration was done. Four months later, she developed rapidly-progressive multiple skeletal metastases and died soon after.

[Ten year experience with ocular lymphomas and ocular adnexae lymphomas]

BACKGROUND

Ocular lymphomas and ocular adnexae lymphomas (OL and OAL) constitute 7-8% of all extranodal lymphomas.

OBJECTIVE

Describe the clinical, morphologic and immunophenotypic characteristics of OAL seen in our hospital.

MATERIAL AND METHODS

Retrospective analysis of patient records with OL and OAL between July 1994 and July 2005. The following data was analyzed: Clinical presentation, therapy, treatment response, overall survival and disease free survival.

RESULTS

Ten patients with OL and OAL were identified. Of these, 8 were women and 2 men. Median age was 50. Eight of 10 patients achieved complete remission, 6 of the 6 presenting MALT Lymphoma. Two patients with stage IV had refractory disease.

CONCLUSIONS

In our series 0.02% of lymphomas were OL and OAL of a total 498 LNH. MALT lymphomas appear at a more advanced age, sixty percent of the cases were MALT lymphomas and were diagnosed during their early stages. Patients were followed during 21 months, global survival was 100%, free illness survival had a mean of 868 days and a survival median of 442 days.

Socioeconomic impact of modern multidisciplinary management of retinoblastoma

OBJECTIVE

Our objective for this study was to examine the impact of the modern management of intraocular retinoblastoma on the patient and the family.

METHODS

This study comprises a retrospective, noncomparative case series of 25 consecutive patients with multifocal, intraocular retinoblastoma that was treated with primary systemic chemotherapy. Medical charts were reviewed, and the following data were extracted: patients' age and gender, laterality of disease, and Reese-Ellsworth classification of each eye as well as the number of central venous lines placed, cycles of chemotherapy received, outpatient appointments, examinations under anesthesia, focal therapies administered, computed tomography/MRI, radiation treatments, anesthetic procedures administered, and miles traveled.

RESULTS

Twenty patients with bilateral and 5 with unilateral intraocular retinoblastoma (median age: 9.3 months) had 895 outpatient appointments and underwent 698 examinations under anesthesia with 230 focal therapies, 347 days of radiotherapy, 226 computed tomography scans/MRIs, and 38 central venous line placements. A total of 1272 anesthetic procedures (median: 50) were performed with no major complication. In all, patients traveled 822312 miles (median: 22214 miles) to receive their care. The median follow-up was 82 months.

CONCLUSIONS

Successful retinoblastoma management requires close surveillance, aggressive consolidation, and numerous anesthetic procedures, all of which the patients and the families must endure. There is a significant impact on the patient, the family, and hospital resources.

Treatment outcomes for primary intraocular lymphoma: implications for external beam radiotherapy

PURPOSE

Intravitreal chemotherapy for primary intraocular lymphoma (PIOL) increasingly is promoted as an alternative to radiotherapy, owing to putative high failure and complication rates of the latter modality. Our aim was to confirm whether these concerns about radiotherapy were borne out in patients treated at our institution over the last decade.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

A total of 21 eyes of 12 patients with PIOL.

METHODS

Comprehensive chart review of ophthalmologic and systemic manifestations, treatments, and outcomes.

MAIN OUTCOME MEASURES

Radiation complications and local tumour control.

RESULTS

Cytology-confirmed lymphoma involved one eye in three patients and both eyes in nine patients. Initial treatment included external beam radiotherapy and chemotherapy (six patients), chemotherapy alone (four patients), radiotherapy alone (one patient), and no treatment (one patient). Ocular relapses occurred in no patients receiving radiotherapy and in two patients who did not receive radiotherapy. Complications of radiotherapy included dry eye (four patients), cataract (four patients), and mild radiation retinopathy (two patients).

CONCLUSIONS

Radiotherapy for PIOL is highly effective with acceptable complications. In the absence of a clear advantage to intravitreal chemotherapy, which involves repetitive injections and associated risks, radiotherapy may still be the most appropriate first-line treatment in most cases.

Survival in extra-orbital metastatic retinoblastoma:treatment results

INTRODUCTION

Retinoblastoma (RB) is the most frequent malignant eye tumor in childhood. In developing countries advanced stages are common. The purpose of this paper is to present our 21-year clinical experience with metastatic extra ocular RB patients treated with 5 different chemotherapy schemas at a single Mexican Pediatric referral center.

MATERIALS AND METHODS

A retrospective analysis was carried out reviewing the clinical characteristics of patients with metastatic RB. The information analyzed included the delay in diagnosis after first symptoms, age, sex, ocular staging, and anatomic site of metastases, treatment scheme, initial response and status at the last contact or date of death.

RESULTS

Eighty-one patients were included; age range was from 3 to 80 months. The most common site of metastasis was central nervous system (83.9%). From those patients treated with chemotherapy (n = 74), 89.2% presented a complete initial response (n = 66). Early mortality occurred in 7 cases before any treatment. Fifty-six received treatment and died with progressive disease. All patients without radiotherapy died with tumor activity (n = 15). The use of cisplatin was related with longer disease free intervals; no other variable was related with survival. Four patients were alive and disease free at 33 to 144.3 months of follow up from diagnosis. The prevalent cause of death was tumor progression.

CONCLUSIONS

In our experience, metastatic RB has a very high mortality rate in spite of the use of different chemotherapy regimens.

Unsual ocular metastasis from breast cancer

Herein a clinical case of an unusual metastasis from breast cancer to the retina and vitreous confirmed by diagnostic vitrectomy is described. Further investigation also demonstrated the central nervous system metastasis.

Canine limbal melanoma: 30 cases (1992-2004). Part 2. Treatment with lamellar resection and adjunctive strontium-90beta plesiotherapy - efficacy and morbidity

OBJECTIVES

To evaluate the efficacy of lamellar resection and adjunctive 90Sr-beta plesiotherapy in the management of canine limbal melanoma and the frequency and morbidity of early and late-onset side effects following treatment.

DESIGN

Retrospective study.

ANIMALS STUDIED

Thirty dogs treated for limbal melanoma at the Animal Health Trust (AHT), between 1992 and 2004.

METHODS

Medical records were reviewed and information collected on the radiation dose administered, duration of follow-up, and the frequency of early- and late-onset ocular side effects. Follow-up information was obtained by re-examination of patients or completion of a telephone interview with the referring veterinary surgeons or the owners.

RESULTS

Recurrence of limbal melanoma occurred in 1 of 30 cases (3%; 95% CI: 0.2-14%). One or more side effects occurred in 16 of 30 cases (53%; 95% CI: 28.1-74.9). The occurrence of side effects was not associated with the number of sites treated or the total surface dose of radiation. Short-term side effects were reported in 16/30 cases (53%) and included corneal scarring (12/30), corneal neovascularization (6/30), conjunctivitis with or without granulation tissue formation (5/30), lipid keratopathy (1/30), and localized bullous keratopathy (2/30). Long-term side effects were reported in 6 of 30 cases (20%) cases and included deep scleral thinning (5/30), focal scleromalacia (3/30), globe perforation (2/30), lipid keratopathy (3/30), localized bullous keratopathy (1/30), and sectoral cortical cataract (1/30).

CONCLUSIONS

Lamellar resection and adjunctive 90Sr-beta plesiotherapy is relatively easy to perform, is minimally invasive, and extremely well tolerated by patients. The treatment is highly efficacious in the management of canine limbal melanoma. Modification of the radiation dosimetry, in particular reducing the total dose of radiation and the dose per radiation fraction, is necessary to reduce the incidence of late onset side effects.

Studies on the production and quality assurance of miniature 125I radioactive sources suitable for treatment of ocular and prostate cancers

(125)I sources were prepared by adsorption of (125)I on palladium-coated silver wires. The effect of reducing agent on percentage adsorption of (125)I was studied and the amount of adsorbed activity on source core was studied by repeated adsorption cycles. The activity per source in the sources produced from the same batch varied with coefficient of variation (i.e. the ratio of standard deviation to mean multiplied by 100) less than 10%. The unencapsulated source exhibited low leachability (< 0.01%). The laser parameters were optimized to obtain quality welds with negligible leak rate. The sources were laser-encapsulated in titanium capsules of 0.8 mm (OD) x 4.5mm (l). The release of radioactivity from encapsulated sources in an immersion test at 50 degrees C for 5 h was <5 nCi (185 Bq). The surface contamination on the sealed capsules was found to be<0.05 nCi or 1.85 Bq per source. The sources were used in the treatment of a child having retinoblastoma.

Epithelial lacrimal gland tumors: a clinicopathological study of 18 cases

OBJECTIVE

The aim of this study was to report the clinicopathological features of 18 epithelial tumors of the lacrimal gland treated in a single institution.

STUDY DESIGN AND SETTING

Clinical data and treatment were recorded and histological features reviewed.

RESULTS

Twelve tumors (66.7%) were adenoid cystic carcinoma (ACC), 5 (27.8%) pleomorphic adenoma (PA), and 1 (5.5%) carcinoma ex pleomorphic adenoma. All patients with ACC presented with advanced clinical stage, and most were treated by wide surgical resection followed by adjuvant radiotherapy. No recurrence was observed in 4 cases of ACC; however, 7 patients died from persistence of disease or by local and/or distant recurrence. All PA patients were successfully treated by surgical resection.

CONCLUSIONS

Epithelial lacrimal gland tumors are mainly PA and ACC, and malignancies are more common than benign tumors. Although ACC presented typically with advanced clinical stage, 33% of the patients survived without tumor recurrence or metastasis.

The clinical characteristics and treatment results of ocular adnexal lymphoma

PURPOSE

To assess the clinical pattern, the histopathological findings, the response to treatments, the recurrence pattern and the prognosis of malignant lymphoma in the ocular adnexa.

METHODS

This study was performed on 22 total eyes from 17 patients who were diagnosed with ocular adnexal malignant lymphoma. We retrospectively analyzed the medical records for patient information including the histological classification based on age, the gender of each patient, the symptoms and signs at the initial diagnosis, the presence of binocular invasion, the findings of the surgical biopsy, the clinical stage of each patient's tumor, and the treatment methods used and their effectiveness. The mean follow-up period was 24.8 months.

RESULTS

The mean age of patients studied was 46.8 years old. Six females and 11 males were included in the study. Fifteen cases consisting of 20 total eyes represented extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT). Five of seven patients (71.4%) whose lymphoma occurred within the conjunctiva relapsed after irradiation or chemotherapy, and four of the relapsed patients were salvaged with further therapy.

CONCLUSIONS

Extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT) constituted 88.2% of all lymphomas involving the ocular adnexa. Lymphoma in the ocular adnexa responded well to conventional treatment, but the recurrence rate of lymphoma in the conjunctiva was significantly high.

Intraocular malignant teratoid medulloepithelioma in an adult: clinicopathological case report and review of the literature

PURPOSE

To report a case of intraocular medulloepithelioma, an embryonal tumour with extremely rare presentation in adults.

METHOD

The case of a 44-year-old man with intraocular malignant teratoid medulloepithelioma, primarily diagnosed as intraocular teratoma, is described and the literature on this subject is reviewed.

RESULTS

The patient presented with progressive proptosis caused by a tumour in the left eyeball. He had a 28-year history of loss of vision in the left eye. Histopathological examination of the enucleated eye demonstrated an intraocular teratoma. No adjuvant treatment was given. Six months later the patient presented with massive progression in the left orbit and intracranial invasion. Cisplatin-based chemotherapy was administered, but discontinued after two cycles due to poor tolerance and lack of response. At subsequent pathology review, a final diagnosis of malignant teratoid medulloepithelioma was made. Salvage radiotherapy (60 Gy in 30 fractions) resulted in partial response of the intracranial lesion. However, the patient died 6 months later due to intracranial tumour progression.

CONCLUSION

Medulloepithelioma should be considered in the differential diagnosis of intraocular tumours in adults, especially in the case of coexisting, long-standing ocular symptoms. In some cases this disease is very aggressive.

Pitfalls and modelling inconsistencies in computational radiation dosimetry: lessons learnt from the QUADOS intercomparison. Part II: Photons, electrons and protons

'QUADOS', a concerted action of the European Commission, has promoted an intercomparison aimed at evaluating the use of computational codes for dosimetry in radiation protection and medical physics. This intercomparison was open to all users of radiation transport codes. Eight problems were selected for their relevance to the radiation dosimetry community, five of which involved photon and proton transport. This paper focuses on a discussion of lessons learned from the participation in solving the photon and charged particle problems. The lessons learned from the participation in solving the neutron problems are presented in a companion paper (in this issue).

A case of primary adenocarcinoma of the lacrimal sac

PURPOSE

To present a rare case of adenocarcinoma arising from the lacrimal sac.

DESIGN

Interventional case report.

METHODS

Report of a new case of primary lacrimal sac adenocarcinoma.

RESULTS

The clinical presentation, workup, surgical treatment and pathology of a case of adenocarcinoma of the lacrimal sac are described.

CONCLUSION

Although very rare, these tumors should be in the differential diagnosis of any lacrimal sac mass, especially those presenting above the medial canthal tendon. Other common features include expressible blood from the punctum, lack of pain, and a history of chronic epiphora or intermittent dacryocystitis. Local destruction and metastatic spread can be prevented by a high index of suspicion and early intervention.

Primary Ductal Adenocarcinoma of the Lacrimal Gland

OBJECTIVE

To report the case of a 59-year-old man with a right lacrimal gland mass, subsequently diagnosed as primary ductal adenocarcinoma of the lacrimal gland.

DESIGN

Interventional case report.

METHODS

We report the clinical presentation, histopathologic and immunohistochemical features, and treatment of a patient with primary ductal adenocarcinoma of the lacrimal gland. The current literature regarding this uncommon neoplasm also is reviewed.

RESULTS

Excisional biopsy revealed primary ductal adenocarcinoma of the lacrimal gland. The patient subsequently underwent extensive local resection of the tumor and is awaiting radiotherapy to the orbit and neck. A literature search revealed only 3 prior reports of primary ductal adenocarcinoma of the lacrimal gland.

CONCLUSIONS

Although uncommon, primary ductal adenocarcinoma of the lacrimal gland displays characteristic histologic and immunohistochemical findings that allow its distinction from the other primary lacrimal gland adenocarcinomas. Awareness and recognition of this rare malignancy may aid in further delineation of its biologic behavior, management, and prognosis.

Radiotherapy-Induced Ocular Surface Disease

Today radiation is routinely used as a therapeutic modality for select tumors of the orbit, adnexa, paranasal sinus, and nasopharynx. Despite significant improvements in mechanisms of delivery and protective shielding, acute and chronic complications of radiation can affect different segments of the eye. In this report, we provide an overview of ocular damage secondary to radiotherapy. We identify the characteristic clinical changes and underlying pathophysiologic mechanisms involving the ocular surface and provide a rational approach to their prevention and treatment.

Monte Carlo simulations of a nozzle for the treatment of ocular tumours with high-energy proton beams

By the end of 2002, 33 398 patients worldwide had been treated with proton radiotherapy, 10 829 for eye diseases. The dose prediction algorithms used today for ocular proton therapy treatment planning rely on parameterizations of measured proton dose distributions, i.e., broad-beam and pencil-beam techniques, whose predictive capabilities are inherently limited by severe approximations and simplifications in modelling the radiation transport physics. In contrast, the Monte Carlo radiation transport technique can, in principle, provide accurate predictions of the proton treatment beams by taking into account all the physical processes involved, including coulombic energy loss, energy straggling, multiple Coulomb scattering, elastic and nonelastic nuclear interactions, and the transport of secondary particles. It has not been shown, however, whether it is possible to commission a proton treatment planning system by using data exclusively from Monte Carlo simulations of the treatment apparatus and a phantom. In this work, we made benchmark comparisons between Monte Carlo predictions and measurements of an ocular proton treatment beamline. The maximum differences between absorbed dose profiles from simulations and measurements were 6% and 0.6 mm, while typical differences were less than 2% and 0.2 mm. The computation time for the entire virtual commissioning process is less than one day. The study revealed that, after a significant development effort, a Monte Carlo model of a proton therapy apparatus is sufficiently accurate and fast for commissioning a treatment planning system.

Proton therapy analysis using the Monte Carlo method

The range and straggling data obtained from the transport of ions in matter (TRIM) computer program were used to determine the trajectories of monoenergetic 60 MeV protons in muscle tissue by using the Monte Carlo technique. The appropriate profile for the shape of a proton pencil beam in proton therapy as well as the dose deposited in the tissue were computed. The good agreements between our results as compared with the corresponding experimental values are presented here to show the reliability of our Monte Carlo method.