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Rasouli FS, Masoudi SF. A simulation study on the effect of penetration of gold nanoparticles in the cytoplasm of healthy eye organs on dose enhancement of brachytherapy. Int J Radiat Biol 2024:1-9. [PMID: 39058379 DOI: 10.1080/09553002.2024.2381496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/07/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
PURPOSE Special properties and recent advances in the synthesis and biomolecular functionalization of gold nanoparticles (GNPs) have led to the evolution of their use in biomedical applications such as photon radiotherapy. Simulation-based studies on the effect of various parameters that govern the dose enhancement due to utilizing GNPs have facilitated the progress of knowledge in this field. Due to their flexibility and easier accessibility compared with experimental works, simulations have the potential to be considered for pre-clinical tests and, therefore, should be close to the realistic conditions as much as possible. MATERIALS AND METHODS To this aim, the present work investigates the effect of the presence of GNPs that are accumulated in the cytoplasm of the constituent cells in healthy tissues of a human eye phantom, inspired by the published experimental results which report that non-target tissues also receive the drugs containing GNPs. The GNPs' concentrations are assumed to decrease by moving from the tumor toward the depth of the phantom through a suggested pattern. The MCNPX Monte Carlo code is used for the simulations. RESULTS The results show that for four concentrations tested, the dose enhancement factor in the shallower layer reaches 6, and decreases to 1.2 in the last layer. The dose enhancements are also examined for critical structures of the iris, cornea, sclera, and lens, showing maximum deviations of about 3 to 200% compared with the absence of GNPs in the healthy tissue. Considering the reported doses to the lens by clinical institutions, the effect of penetration of GNPs to deep layers on treatment time is also investigated. CONCLUSIONS The results show that the penetration of GNPs from the tumor toward healthy tissues strongly controls the dose enhancement over the various eye structures and emphasizes the importance of modeling the GNPs' distribution in the medium on the overall dose enhancement. Considering the current challenges in the clinical use of GNPs, more effort needs to be made to reach an effective endpoint in treatment.
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Affiliation(s)
- Fatemeh S Rasouli
- Department of Physics, K.N. Toosi University of Technology, Tehran, Iran
| | - S Farhad Masoudi
- Department of Physics, K.N. Toosi University of Technology, Tehran, Iran
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2
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Yilmaz MT, Sari SY, Zorlu F, Yazici G. External Beam Radiotherapy in the Management of Uveal Melanoma. Curr Treat Options Oncol 2024; 25:932-951. [PMID: 38869695 PMCID: PMC11236855 DOI: 10.1007/s11864-024-01212-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/14/2024]
Abstract
OPINION STATEMENT Uveal melanoma is the most common primary ocular tumor in adults. With the evidence demonstrating that episcleral plaque brachytherapy (EPB) has similar survival rates as enucleation in the Collaborative Ocular Melanoma Study (COMS), eye-sparing treatments have come to the fore today. External radiotherapy techniques (proton beam radiotherapy and stereotactic radiosurgery/fractionated stereotactic radiosurgery) are an important treatment option for globe-sparing treatments. There are no prospective randomized trials comparing these techniques; however, retrospective series, meta-analyses, and reviews indicate that these EPB and external radiotherapy techniques are equal. With this review, we aimed to examine the external radiotherapy techniques used in the treatment of uveal melanoma in detail with reference to the current literature.
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Affiliation(s)
- Melek Tugce Yilmaz
- Hacettepe University Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey
| | - Sezin Yuce Sari
- Hacettepe University Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey
| | - Faruk Zorlu
- Hacettepe University Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey
| | - Gozde Yazici
- Hacettepe University Faculty of Medicine, Department of Radiation Oncology, Ankara, Turkey.
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Mishra S, Selvam TP, Sahoo S, Saxena SK, Kumar Y, Sapra BK. Monte Carlo-based dosimetry of proposed bi-radionuclide ( 125I and 106Ru/ 106Rh) eye plaque: A feasibility study. Med Phys 2024. [PMID: 38935327 DOI: 10.1002/mp.17257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 05/16/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Combining the sharp dose fall off feature of beta-emitting 106Ru/106Rh radionuclide with larger penetration depth feature of photon-emitting125I radionuclide in a bi-radionuclide plaque, prescribed dose to the tumor apex can be delivered while maintaining the tumor dose uniformity and sparing the organs at risk. The potential advantages of bi-radionuclide plaque could be of interest in context of ocular brachytherapy. PURPOSE The aim of the study is to evaluate the dosimetric advantages of a proposed bi-radionuclide plaque for two different designs, consisting of indigenous 125I seeds and 106Ru/106Rh plaque, using Monte Carlo technique. The study also explores the influence of other commercial 125I seed models and presence or absence of silastic/acrylic seed carrier on the calculated dose distributions. The study further included the calculation of depth dose distributions for the bi-radionuclide eye plaque for which experimental data are available. METHODS The proposed bi-radionuclide plaque consists of a 1.2-mm-thick silver (Ag) spherical shell with radius of curvature of 12.5 mm, 20 µm-thick-106Ru/106Rh encapsulated between 0.2 mm Ag disk, and a 0.1-mm-thick Ag window, and water-equivalent gel containing 12 symmetrically arranged 125I seeds. Two bi-radionuclide plaque models investigated in the present study are designated as Design I and Design II. In Design I, 125I seeds are placed on the top of the plaque, while in Design II 106Ru/106Rh source is positioned on the top of the plaque. In Monte Carlo calculations, the plaque is positioned in a spherical water phantom of 30 cm diameter. RESULTS The proposed bi-radionuclide eye plaque demonstrated superior dose distributions as compared to 125I or 106Ru plaque for tumor thicknesses ranges from 5 to 10 mm. Amongst the designs, dose at a given voxel for Design I is higher as compared to the corresponding voxel dose for Design II. This difference is attributed to the higher degree of attenuation of 125I photons in Ag as compared to beta particles. Influence of different 125I seed models on the normalized lateral dose profiles of Design I (in the absence of carrier) is negligible and within 5% on the central axis depth dose distribution as compared to the corresponding values of the plaque that has indigenous 125I seeds. In the presence of a silastic/acrylic seed carrier, the normalized central axis dose distributions of Design I are smaller by 3%-12% as compared to the corresponding values in the absence of a seed carrier. For the published bi-radionuclide plaque model, good agreement is observed between the Monte Carlo-calculated and published measured depth dose distributions for clinically relevant depths. CONCLUSION Regardless of the type of 125I seed model utilized and whether silastic/acrylic seed carrier is present or not, Design I bi-radionuclide plaque offers superior dose distributions in terms of tumor dose uniformity, rapid dose fall off and lesser dose to nearby critical organs at risk over the Design II plaque. This shows that Design I bi-radionuclide plaque could be a promising alternative to 125I plaque for treatment of tumor sizes in the range 5 to 10 mm.
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Affiliation(s)
- Subhalaxmi Mishra
- Radiological Physics and Advisory Division, Health, Safety & Environment Group, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - T Palani Selvam
- Radiological Physics and Advisory Division, Health, Safety & Environment Group, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushaktinagar, Mumbai, Maharashtra, India
| | - Sridhar Sahoo
- Radiological Physics and Advisory Division, Health, Safety & Environment Group, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - Sanjay Kumar Saxena
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - Yogendra Kumar
- Radiopharmaceuticals Division, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - Balvinder K Sapra
- Radiological Physics and Advisory Division, Health, Safety & Environment Group, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushaktinagar, Mumbai, Maharashtra, India
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Chen ZJ, Li XA, Brenner DJ, Hellebust TP, Hoskin P, Joiner MC, Kirisits C, Nath R, Rivard MJ, Thomadsen BR, Zaider M. AAPM Task Group Report 267: A joint AAPM GEC-ESTRO report on biophysical models and tools for the planning and evaluation of brachytherapy. Med Phys 2024; 51:3850-3923. [PMID: 38721942 DOI: 10.1002/mp.17062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/28/2024] [Accepted: 03/08/2024] [Indexed: 06/05/2024] Open
Abstract
Brachytherapy utilizes a multitude of radioactive sources and treatment techniques that often exhibit widely different spatial and temporal dose delivery patterns. Biophysical models, capable of modeling the key interacting effects of dose delivery patterns with the underlying cellular processes of the irradiated tissues, can be a potentially useful tool for elucidating the radiobiological effects of complex brachytherapy dose delivery patterns and for comparing their relative clinical effectiveness. While the biophysical models have been used largely in research settings by experts, it has also been used increasingly by clinical medical physicists over the last two decades. A good understanding of the potentials and limitations of the biophysical models and their intended use is critically important in the widespread use of these models. To facilitate meaningful and consistent use of biophysical models in brachytherapy, Task Group 267 (TG-267) was formed jointly with the American Association of Physics in Medicine (AAPM) and The Groupe Européen de Curiethérapie and the European Society for Radiotherapy & Oncology (GEC-ESTRO) to review the existing biophysical models, model parameters, and their use in selected brachytherapy modalities and to develop practice guidelines for clinical medical physicists regarding the selection, use, and interpretation of biophysical models. The report provides an overview of the clinical background and the rationale for the development of biophysical models in radiation oncology and, particularly, in brachytherapy; a summary of the results of literature review of the existing biophysical models that have been used in brachytherapy; a focused discussion of the applications of relevant biophysical models for five selected brachytherapy modalities; and the task group recommendations on the use, reporting, and implementation of biophysical models for brachytherapy treatment planning and evaluation. The report concludes with discussions on the challenges and opportunities in using biophysical models for brachytherapy and with an outlook for future developments.
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Affiliation(s)
- Zhe Jay Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David J Brenner
- Center for Radiological Research, Columbia University Medical Center, New York, New York, USA
| | - Taran P Hellebust
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Center, Mount Vernon Hospital, Northwood, UK
- University of Manchester, Manchester, UK
| | - Michael C Joiner
- Department of Radiation Oncology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Christian Kirisits
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Ravinder Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mark J Rivard
- Department of Radiation Oncology, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Bruce R Thomadsen
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin, USA
| | - Marco Zaider
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Bajpai V, Raval V, Reddy P VA, Kaliki S. Ruthenium-106 ( 106Ru) plaque brachytherapy for treatment of circumscribed choroidal hemangioma. Eur J Ophthalmol 2024:11206721241257974. [PMID: 38794917 DOI: 10.1177/11206721241257974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
PURPOSE To describe the clinical and imaging features of circumscribed choroidal hemangiomas (CCH) and their treatment outcomes with Ruthenium-106 (106Ru) plaque brachytherapy. METHODS Retrospective study of 24 patients (24 eyes) diagnosed with CCH and treated with 106Ru plaque between 2017 and 2022. Analysis included pre- and post-treatment clinical and imaging features such as tumor regression, reduction in height, subretinal fluid (SRF) resolution, and change in best-corrected visual acuity (BCVA). RESULTS The mean age at presentation was 36 years (range, 16-57). The most common tumor location was the temporal quadrant (n = 19) with macular involvement (n = 13). Associated features were macular SRF (n = 22) and inferior exudative retinal detachment (n = 10). Nineteen of the 24 patients underwent primary treatment, whereas 5 patients underwent plaque as a salvage treatment. The mean tumor apex dose was 40 Gy. At a median follow-up of 7.5 months (range 3-65 months), 18 eyes showed complete regression, whereas 6 eyes showed partial regression. The mean height decreased from 4.8 (SD 1.28) mm at presentation to 2.5 (SD 1.63) mm. Median BCVA improved from logMAR 1.2 (IQR 0.4-2) at baseline to logMAR 1.05 (IQR 0.1-1.95) (p = 0.4). Complete resolution of the macula and tumor SRF was observed in 15 (68%) and 13 (57%) eyes, respectively. The radiation-related complications observed were radiation maculopathy (4 eyes), retinopathy (1 eye), and vitreous hemorrhage (1 eye). CONCLUSION Ruthenium-106 plaque brachytherapy is effective for CCH (> 3 mm height) as a primary and salvage treatment for tumors unresponsive to other modalities.
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Affiliation(s)
- Vidhi Bajpai
- Anand Bajaj Retina Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Vishal Raval
- Anand Bajaj Retina Institute, L.V. Prasad Eye Institute, Hyderabad, India
- The Operation Eyesight Universal Institute for Eye Cancer, L.V. Prasad Eye Institute, Hyderabad, India
| | - Vijay Anand Reddy P
- The Operation Eyesight Universal Institute for Eye Cancer, L.V. Prasad Eye Institute, Hyderabad, India
| | - Swathi Kaliki
- The Operation Eyesight Universal Institute for Eye Cancer, L.V. Prasad Eye Institute, Hyderabad, India
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De Brabandere M, Placidi E, Siebert FA, Carlsson Tedgren Å, Slocker Escarpa A, Tagliaferri L, Andrássy M, Schulz C, Fog LS. GEC-ESTRO survey of 106Ru eye applicator practice for ocular melanoma - Physicist survey. Radiother Oncol 2024; 193:110114. [PMID: 38309583 DOI: 10.1016/j.radonc.2024.110114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/16/2024] [Accepted: 01/27/2024] [Indexed: 02/05/2024]
Abstract
AIM 106Ru eye plaque brachytherapy (BT, interventional radiotherapy) is an eye-preserving treatment for uveal melanoma performed in about 100 clinics worldwide. Despite this relatively low number, there is a considerable variation in clinical practice. In 2022, the BRAPHYQS and Head & Neck and Skin GEC-ESTRO working groups conducted a survey to map the current clinical practice. The survey consisted of a physicist and a physician part. This paper describes the physicist results. However, three physician questions with overlapping interest are included here as well. MATERIALS AND METHODS The survey questions pertained to commissioning and quality control (QC) of the plaques, treatment planning, radiobiological correction, as well as more general questions on practice improvement. The questions overlapping with the physician survey were related to dose prescription and margins. RESULTS Sixty-five physicist responses were included. A majority of the centres do not perform an independent measurement of the absorbed dose at reference depth, percentage depth dose (PDD) and off-axis data. A lack of calibration services and suitable equipment are the main reasons. About one third of the centres indicated that they do image based treatment planning. The use of margins and dose prescription showed a large variability, despite the availability of guidelines [1]. Many respondents expressed a strong wish for improvement in a wide range of aspects of clinical practice. CONCLUSION The physics survey showed a wide variability regarding quality control of the 106Ru sources and treatment planning practice.
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Affiliation(s)
| | - Elisa Placidi
- UOC Physics for Life Sciences, Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Frank-André Siebert
- Clinic of Radiotherapy (Radiooncology), University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Åsa Carlsson Tedgren
- Radiation Physics, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden; Department of Oncology Pathology, Karolinska Institute, Stockholm, Sweden
| | | | - Luca Tagliaferri
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Gemelli ART (Advanced Radiation Therapy), Interventional Oncology Center (IOC), Rome, Italy
| | - Michael Andrássy
- Eckert & Ziegler BEBIG GmbH, Robert-Rössle-Straße 10, 13125 Berlin, Germany
| | - Carmen Schulz
- Eckert & Ziegler BEBIG GmbH, Robert-Rössle-Straße 10, 13125 Berlin, Germany
| | - Lotte S Fog
- Ocular oncology unit, Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Alfred Health Radiation Oncology, Melbourne, VIC, Australia
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Khan SA, Almalki WH, Arora S, Kesharwani P. Recent approaches for the treatment of uveal melanoma: Opportunities and challenges. Crit Rev Oncol Hematol 2024; 193:104218. [PMID: 38040071 DOI: 10.1016/j.critrevonc.2023.104218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/03/2023] Open
Abstract
Uveal melanoma (UM) is the most prevalent primary intraocular cancer in adult population. Primary methods for treatment of UM involves surgery Proton Beam Therapy (PBT), Plaque Brachytherapy, phototherapy, and Charged Particle Radiation Therapy (CPT). It has been found that approximately 50 % of patients diagnosed with UM ultimately experience development of metastatic disease. Furthermore, it has been identified that majority of the patient experience metastasis in liver with a prevalence of 95 %. Management of metastatic UM (MUM) involves various therapeutic modalities, including systemic chemotherapy, molecular targeted therapy, immunotherapy and liver directed interventions. We outline gene mutation in UM and addresses various treatment modalities, including molecular targeted therapy, miRNA-based therapy, and immunotherapy. Additionally, inclusion of ongoing clinical trials aimed at developing novel therapeutic options for management of UM are also mentioned.
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Affiliation(s)
- Sauban Ahmed Khan
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Waleed H Almalki
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Swaranjeet Arora
- Department of Finance and Management, Lal Bahadur Shastri Institute of Management, 11/07 Dwarka Sector 11, Near Metro Station, New Delhi, Delhi 110075, India
| | - Prashant Kesharwani
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India.
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Pacheco-Callirgos GE, García-Alvarez C, Garcia-Onrubia L, Miguel-Pérez D, Alonso-Martinez P, Diezhandino P, de Frutos Barajas JM, Saornil-Alvarez MA. Brachytherapy in the prevention of recurrence of conjunctival melanoma : Results of a case report in a University Hospital in Valladolid, Spain. Strahlenther Onkol 2023; 199:1025-1030. [PMID: 37280383 DOI: 10.1007/s00066-023-02094-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 04/26/2023] [Indexed: 06/08/2023]
Abstract
AIM Describe the results of brachytherapy in the prevention of recurrences in conjunctival melanoma (CM) and describe a dosimetric protocol. METHODS Retrospective and descriptive case report. Eleven consecutive patients with a confirmed histopathological diagnosis of CM treated with brachytherapy between 1992 and 2023 were reviewed. Demographic, clinical, and dosimetric characteristics as well as recurrences were recorded. Quantitative variables were represented by the mean, median, and standard deviation, and qualitative variables by frequency of distribution. RESULTS Of a total of 27 patients diagnosed with CM, 11 who were treated with brachytherapy were included in the study (7 female; mean age at time of treatment: 59.4 years). Mean follow-up was 58.82 months (range 11-141 months). Of a total of 11 patients, 8 were treated with ruthenium-106 and 3 with iodine-125. Brachytherapy was performed in 6 patients as adjuvant therapy after biopsy-proven CM on histopathology and in the other 5 patients after recurrence. The mean dose was 85 Gy in all cases. Recurrences outside of the previously irradiated area were observed in 3 patients, metastases were diagnosed in 2 patients, and one case of an ocular adverse event was reported. CONCLUSION Brachytherapy is an adjuvant treatment option in invasive conjunctival melanoma. In our case report, only one patient had an adverse effect. However, this topic requires further research. Furthermore, each case is unique and should be evaluated by experts in a multidisciplinary approach involving ophthalmologists, radiation oncologists, and physicists.
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Affiliation(s)
- Gabriela Estefanía Pacheco-Callirgos
- Ocular Oncology Unit, Ophthalmology Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal 3, 47003, Valladolid, Spain.
| | - Ciro García-Alvarez
- Ocular Oncology Unit, Ophthalmology Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Luis Garcia-Onrubia
- Ocular Oncology Unit, Ophthalmology Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal 3, 47003, Valladolid, Spain
| | - David Miguel-Pérez
- Oncology Radiotherapy Department, Hospital Clínico Universitario de Valladolid, 47003, Valladolid, Spain
| | - Pilar Alonso-Martinez
- Oncology Radiotherapy Department, Hospital Clínico Universitario de Valladolid, 47003, Valladolid, Spain
| | - Patricia Diezhandino
- Oncology Radiotherapy Department, Hospital Clínico Universitario de Valladolid, 47003, Valladolid, Spain
| | | | - Maria Antonia Saornil-Alvarez
- Ocular Oncology Unit, Ophthalmology Department, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal 3, 47003, Valladolid, Spain
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Thariat J, Mathis T, Pace-Loscos T, Peyrichon ML, Maschi C, Rosier L, Nguyen M, Bonnin N, Aloi D, Gastaud L, Gaucher D, Caujolle JP, Château Y, Herault J. Single-Masked Randomized Phase 2 Study Assessing 2 Forms of Hypofractionated Proton Therapy in Patients With Large Choroidal Melanomas. Int J Radiat Oncol Biol Phys 2023; 117:357-369. [PMID: 37257661 DOI: 10.1016/j.ijrobp.2023.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Patients with large uveal melanomas are at major risk of liver metastases. Some patients are reluctant to undergo the standard treatment (ie, immediate enucleation). Proton therapy yields 5-year local control rates and eyeball retention of >85% and ≈20% in large uveal melanomas. Patients with T3/T4 uveal melanomas refusing enucleation were randomized between standard 4 to 13 Gy-fraction or moderately hypofractionated 8 to 6.5 Gy-fraction proton therapy. The main endpoint was the 2-year local recurrence-free survival without enucleation. METHODS AND MATERIALS A single-masked 1:2 randomized phase 2 trial was conducted between 2015 and 2017 with planned endoresection and distance to the posterior pole as strata. Local events were defined as local relapse, or enucleation due to complications or relapse. RESULTS The 32 patients, with a mean age of 64 years, had T3/4 (N = 17/15), M1 (N = 2) uveal melanomas, of mean tumor diameter and thickness of 16.5 mm and 9.1 mm, and of posterior location in 56.5%. Median follow-up was 56.7 months. The 2-year local recurrence-free survival rate without enucleation was 79% (95% confidence interval, 65%-96%), similar in both arms. There were 9 enucleations, 3 at relapse and 6 for toxicities. Twelve patients had distant metastases. The 2-year-overall survival was 72% (95% confidence interval, 58%-89%). At baseline, visual acuity by average logarithm value of the minimum angle of resolution was 0.68 and 0.70 in the standard and experimental arms, and at last follow-up 2 and 1.7, with mean differences of 1.44 and 1.01, respectively (P = .39). CONCLUSION An 8-times 6.5 Gy scheme is feasible without deteriorating local control and with similar toxicity rates in patients with large uveal melanomas. Larger studies incorporating adjuvant treatments are warranted.
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Affiliation(s)
- Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Caen, France; Laboratoire de Physique Corpusculaire, Caen, France; Unicaen-Normandie Université, Caen, France.
| | - Thibaud Mathis
- Service d'Ophtalmologie, Centre Hospitalier Universitaire de la Croix-Rousse, Hospices Civils de Lyon; Université Claude Bernard Lyon 1, Lyon, France; UMR5510 MATEIS, CNRS, INSA Lyon, Université Lyon 1, Lyon, France
| | - Tanguy Pace-Loscos
- Department of Radiation Oncology, Proton Therapy Center, Centre Antoine Lacassagne, Nice, France
| | - Marie Laure Peyrichon
- Department of Radiation Oncology, Proton Therapy Center, Centre Antoine Lacassagne, Nice, France
| | - Celia Maschi
- Department of Ophthalmology, Pasteur Hospital, Nice Teaching Hospital, Nice, France
| | - Laurence Rosier
- Eye Clinic, Centre d'Exploration et de Traitement de la Retine et de la Macula, Bordeaux, France
| | - Minh Nguyen
- Service d'Ophtalmologie, Centre Hospitalier Universitaire de la Croix-Rousse, Hospices Civils de Lyon; Université Claude Bernard Lyon 1, Lyon, France; UMR5510 MATEIS, CNRS, INSA Lyon, Université Lyon 1, Lyon, France
| | - Nicolas Bonnin
- Department of Ophthalmology, Eye University Clinic Gabriel Montpied, Clermont Ferrand, France
| | - Deborah Aloi
- Department of Radiation Oncology, Proton Therapy Center, Centre Antoine Lacassagne, Nice, France
| | - Lauris Gastaud
- Department of Radiation Oncology, Proton Therapy Center, Centre Antoine Lacassagne, Nice, France
| | - David Gaucher
- Department of Ophthalmology, New Civil Hospital, Strasbourg University Hospital, FMTS, Strasbourg, France
| | - Jean-Pierre Caujolle
- Department of Ophthalmology, Pasteur Hospital, Nice Teaching Hospital, Nice, France
| | - Yann Château
- Department of Radiation Oncology, Proton Therapy Center, Centre Antoine Lacassagne, Nice, France
| | - Joel Herault
- Department of Radiation Oncology, Proton Therapy Center, Centre Antoine Lacassagne, Nice, France
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Hashemi S, Aghamiri SMR, Siavashpour Z, Kahani M, Zaidi H, Jaberi R. Hydrogen nanobubbles: A novel approach toward radio-sensitization agents. Med Phys 2023; 50:6589-6599. [PMID: 37278345 DOI: 10.1002/mp.16521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 04/23/2023] [Accepted: 04/28/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Ocular melanoma is a rare kind of eye malignancy that threatens the patient's eyesight. Radiotherapy and surgical removal are the most commonly used therapeutic modalities, and nanomedicine has lately entered this field. Brachytherapy using Ruthenium-106 (106 Ru) ophthalmic plaques has been used for decades to treat ocular melanoma, with the applicator placed on the patient's eyes until the prescribed dose reaches the tumor apex. PURPOSE To investigate the efficiency of hydrogen nanobubbles (H2 -NBs) employment during intraocular melanoma brachytherapy using a 106 Ru electron emitter plaque. METHODS The Monte Carlo (MC) simulation and experimental investigation using a 3D-designed phantom and thermoluminescence dosimetry (TLD) were employed. Various concentrations of H2 -NBs with a diameter of 100 nm were simulated inside tumor tissue. The results were presented as deposited energy and dose enhancement factor (DEF). An equivalent Resin phantom of the human eyeball was made using AutoCAD and 3D-Printer technologies. The glass-bead TLDs dosimeter were employed and placed inside the phantom. RESULTS Using a 1% concentration of H2 -NBs, a DEF of 93% and 98% were achieved at the tumor apex of 10 mm from the experimental setup and MC simulation, respectively. For simulated concentrations of 0.1%, 0.3%, 0.5%, 1%, and 4% H2 -NBs, a maximum dose enhancement of 154%, 174%, 188%, 200%, and 300% were achieved, respectively, and a dose reduction was seen at about 3 mm from the plaque surface. CONCLUSION H2 -NBs can be used as an absorbed dose enhancer in 106 Ru eye brachytherapy because of their unique physical characteristics. Reducing plaque implantation time on the patient's eye, reducing sclera absorbed dose, and decreasing the risk of patients' healthy organs irradiation are reported as some of the potential benefits of using H2-NBs.
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Affiliation(s)
- Samaneh Hashemi
- Medical Radiation Department, Shahid Beheshti University, Tehran, Iran
| | | | - Zahra Siavashpour
- Radiotherapy Oncology Department, Shohada Tajrish Educational Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mahdi Kahani
- Medical Radiation Department, Shahid Beheshti University, Tehran, Iran
| | - Habib Zaidi
- Geneva University Neurocenter, Geneva University, Geneva, Switzerland
| | - Ramin Jaberi
- Cancer Institute, Tehran University of Medical Science, Tehran, Iran
- Medical Physics Department, Surrey University, Guildford, UK
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11
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Meltsner SG, Rodrigues A, Materin MA, Kirsch DG, Craciunescu O. Transitioning from a COMS-based plaque brachytherapy program to using eye physics plaques and plaque simulator treatment planning system: A single institutional experience. J Appl Clin Med Phys 2023; 24:e13902. [PMID: 36637797 PMCID: PMC10161060 DOI: 10.1002/acm2.13902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/08/2022] [Accepted: 12/15/2022] [Indexed: 01/14/2023] Open
Abstract
The aim of this work is to describe the implementation and commissioning of a plaque brachytherapy program using Eye Physics eye plaques and Plaque Simulator treatment planning system based on the experience of one institution with an established COMS-based plaque program. Although commissioning recommendations are available in official task groups publications such as TG-129 and TG-221, we found that there was a lack of published experiences with the specific details of such a transition and the practical application of the commissioning guidelines. The specific issues addressed in this paper include discussing the lack of FDA approval of the Eye Physics plaques and Plaque Simulator treatment planning system, the commissioning of the plaques and treatment planning system including considerations of the heterogeneity corrected calculations, and the implementation of a second check using an FDA-approved treatment planning system. We have also discussed the use of rental plaques, the analysis of plans using dose histograms, and the development of a quality management program. By sharing our experiences with the commissioning of this program this document will assist other institutions with the same task and act as a supplement to the recommendations in the recently published TG-221.
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Affiliation(s)
- Sheridan G Meltsner
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Anna Rodrigues
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Miguel A Materin
- Departments of Ophthalmology, Duke University, Durham, North Carolina, USA
| | - David G Kirsch
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Oana Craciunescu
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
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12
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Oare C, Sun S, Dusenbery K, Reynolds M, Koozekanani D, Gerbi B, Ferreira C. Analysis of dose to the macula, optic disc, and lens in relation to vision toxicities - A retrospective study using COMS eye plaques. Phys Med 2022; 101:71-78. [PMID: 35981450 DOI: 10.1016/j.ejmp.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/08/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The aim of this study was to relate common toxicity endpoints with dose to the macula, optic disc, and lens for uveal melanoma patients treated with Iodine-125 Collaborative Ocular Melanoma Study (COMS) eye plaque brachytherapy. METHODS A cohort of 52 patients treated at a single institution between 2005 and 2019 were retrospectively reviewed. Demographics, dosimetry, and clinical outcomes were recorded. Univariate, relative risk, and Kaplan-Meier analyses were performed to relate dose to toxicity endpoints including retinopathy, vision decline, and cataracts. RESULTS By the end of follow up (Median = 3.6 years, Range = 0.4 - 13.5 years), 65 % of eyes sustained radiation retinopathy, 40 % demonstrated moderate vision decline (>5 Snellen lines lost), and 56 % developed cataracts. Significant (p < 0.05) risk estimates exist for retinopathy and VA decline for doses >52 Gy to the macula and >42 Gy to the optic disc. Moreover, dose to the lens > 16 Gy showed a significant risk for cataract formation. Kaplan-Meier analysis demonstrated significantly different incidence of radiation retinopathy for > 52 Gy to the macula and > 42 Gy to the optic disc. In addition, the Kaplan-Meier analysis showed significantly different incidence of cataract formation for patients with lens dose > 16 Gy. CONCLUSIONS Dose-effect relationships exist for the macula and optic disc with respect to the loss of visual acuity and the development of retinopathy. To better preserve vision after treatment, further research is needed to reduce macula, optic disc, and lens doses while maintaining tumor control.
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Affiliation(s)
- Courtney Oare
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States.
| | - Susan Sun
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Kathryn Dusenbery
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Margaret Reynolds
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Dara Koozekanani
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Bruce Gerbi
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
| | - Clara Ferreira
- University of Minnesota Medical School, 420 Delaware St SE, MMC 494, Minneapolis, MN 55455, United States
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13
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Taherparvar P, Fardi Z. Comparison between dose distribution from 103Pd, 131Cs, and 125I plaques in a real human eye model with different tumor size. Appl Radiat Isot 2022; 182:110146. [DOI: 10.1016/j.apradiso.2022.110146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/05/2022] [Accepted: 02/07/2022] [Indexed: 11/17/2022]
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Shah C, Vicini F, Beriwal S, Thaker N, Frank SJ, Rossi P, Orio P, Chang AJ, Joshi N, Campbell SR, Naghavi A, Chao S, Kamrava M, Deufel CL, Mourtada F, Suh JH. American brachytherapy society radiation oncology alternative payment model task force: Quality measures and metrics for brachytherapy. Brachytherapy 2021; 21:63-74. [PMID: 34732290 DOI: 10.1016/j.brachy.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/26/2021] [Accepted: 10/05/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Brachytherapy is an essential technique to deliver radiation therapy and is involved in the treatment of multiple disease sites as monotherapy or as an adjunct to external beam radiation therapy. With a growing focus on the cost and value of cancer treatments as well new payment models, it is essential that standardized quality measures and metrics exist to allow for straightforward assessment of brachytherapy quality and for the development of clinically significant and relevant clinical data elements. We present the American Brachytherapy Society consensus statement on quality measures and metrics for brachytherapy as well as suggested clinical data elements. METHODS AND MATERIALS Members of the American Brachytherapy Society with expertise in disease site specific brachytherapy created a consensus statement based on a literature review and clinical experience. RESULTS Key quality measures (ex. workup, clinical indications), dosimetric metrics, and clinical data elements for brachytherapy were evaluated for each modality including breast cancer, cervical cancer, endometrial cancer, prostate cancer, keratinocyte carcinoma, soft tissue sarcoma, and uveal melanoma. CONCLUSIONS This consensus statement provides standardized quality measures and dosimetric quality metrics as well as clinical data elements for each disease site to allow for standardized assessments of brachytherapy quality. Moving forward, a similar paradigm can be considered for external beam radiation therapy as well, providing comprehensive radiation therapy quality measures, metrics, and clinical data elements that can be incorporated into new payment models.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | | | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman cancer Center, Pittsburgh, PA
| | - Nikhil Thaker
- Division of Radiation Oncology, Arizona Oncology, Tucson, AZ
| | - Steven J Frank
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | | | - Peter Orio
- Department of Radiation Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Albert J Chang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Nikhil Joshi
- Department of Radiation Oncology, Rush University, Chicago, IL
| | - Shauna R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Arash Naghavi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
| | - Samuel Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Firas Mourtada
- Department of Radiation Oncology, Helen F. Graham Cancer Center, ChristianaCare, Newark, DE
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Wei S, Li C, Li M, Xiong Y, Jiang Y, Sun H, Qiu B, Lin CJ, Wang J. Radioactive Iodine-125 in Tumor Therapy: Advances and Future Directions. Front Oncol 2021; 11:717180. [PMID: 34660280 PMCID: PMC8514864 DOI: 10.3389/fonc.2021.717180] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022] Open
Abstract
Radioactive iodine-125 (I-125) is the most widely used radioactive sealed source for interstitial permanent brachytherapy (BT). BT has the exceptional ability to deliver extremely high doses that external beam radiotherapy (EBRT) could never achieve within treated lesions, with the added benefit that doses drop off rapidly outside the target lesion by minimizing the exposure of uninvolved surrounding normal tissue. Spurred by multiple biological and technological advances, BT application has experienced substantial alteration over the past few decades. The procedure of I-125 radioactive seed implantation evolved from ultrasound guidance to computed tomography guidance. Compellingly, the creative introduction of 3D-printed individual templates, BT treatment planning systems, and artificial intelligence navigator systems remarkably increased the accuracy of I-125 BT and individualized I-125 ablative radiotherapy. Of note, utilizing I-125 to treat carcinoma in hollow cavity organs was enabled by the utility of self-expandable metal stents (SEMSs). Initially, I-125 BT was only used in the treatment of rare tumors. However, an increasing number of clinical trials upheld the efficacy and safety of I-125 BT in almost all tumors. Therefore, this study aims to summarize the recent advances of I-125 BT in cancer therapy, which cover experimental research to clinical investigations, including the development of novel techniques. This review also raises unanswered questions that may prompt future clinical trials and experimental work.
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Affiliation(s)
- Shuhua Wei
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, China
| | - Chunxiao Li
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, China
| | - Mengyuan Li
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, China
| | - Yan Xiong
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, China
| | - Yuliang Jiang
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, China
| | - Haitao Sun
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, China
| | - Bin Qiu
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, China
| | | | - Junjie Wang
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, China
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Quiles B, Mataix J, Guinot JL, Wang I, De Los Dolores V, Peña M, La Rosa A, Tortajada M, Santos M, Arribas L. Choroidal Melanoma with Ultrasound-Guided Episcleral Brachytherapy: Long-Term Results and Risk of Metastasis. Ocul Oncol Pathol 2021; 7:280-286. [PMID: 34604201 DOI: 10.1159/000514649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/21/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction The aim of this study was to elucidate the long-term outcomes in patients with choroidal melanoma who received episcleral brachytherapy with 125-I seeds; analyse cause-specific survival (CSS), metastasis-free survival (MFS), and local control; and establish the relationship between tumour size and metastases. Methods From May 2007 to February 2013, 88 patients classified according to the American Joint Committee on Cancer guidelines underwent ultrasound-guided episcleral brachytherapy with a total prescribed dose of 72.40 Gy to the apex. Results Among the included cases, 47.7 and 44.3% had a clinical tumour stage of T2 and T3, respectively. With a median follow-up of 84 (range 7-153) months, local control at 5 and 10 years was 100 and 95%, respectively. Among the 88 patients, 9 (10.2%) were enucleated after brachytherapy. Those with T1-T2 and T3-T4 disease had a 10-year CSS of 100 and 87.3%, respectively (p = 0.017). MFS at 5 and 10 years was 100% in those with T1-T2 disease and 92.1 and 83.1% in those with T3-T4, respectively (p = 0.016). Five patients had liver metastases, all of whom had T3-T4 disease. Conclusion Ultrasound-guided episcleral brachytherapy with 125-I seeds yielded excellent local control for choroidal melanoma, with low complication rates and 90% eye preservation. Given the association between tumour stage and liver metastases, which remain the main cause of death, stricter control should be employed for T3-T4 tumours for the early detection and treatment of relapses.
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Affiliation(s)
- Beatriz Quiles
- Department of Radiation Oncology, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Jorge Mataix
- Department of Ophthalmology, FISABIO Oftalmología, Valencia, Spain
| | - José Luis Guinot
- Department of Radiation Oncology, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Isabel Wang
- Department of Radiation Oncology, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Victor De Los Dolores
- Department of Radiation Physics, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Marina Peña
- Department of Radiation Oncology, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Alonso La Rosa
- Department of Radiation Oncology, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Maribel Tortajada
- Department of Radiation Oncology, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Miguel Santos
- Department of Radiation Oncology, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Leoncio Arribas
- Department of Radiation Oncology, Fundacion Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
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Xu TT, Pulido JS, Parney IF, Ida CM, Dalvin LA, Olsen TW. Carbon Fiducial Markers for Tumor Localization in Stereotactic Irradiation of Uveal Melanoma. Ocul Oncol Pathol 2021; 7:368-375. [PMID: 34722494 PMCID: PMC8531828 DOI: 10.1159/000518742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/27/2021] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The aim of this study was to demonstrate the role of carbon fiducial markers (fiducials) for guiding radiotherapy in the management of uveal melanoma (UM). METHODS This is a retrospective interventional case series at a single-center ocular oncology practice. The medical records were reviewed retrospectively for all patients with UM treated with stereotactic radiosurgery using episcleral fiducials. We report our short-term experience with surgical placement of fiducials, UM localization, treatment outcomes, and optimization approaches. RESULTS We evaluated 11 cases of UM (mean age: 65 years; 64% female). The placed fiducials were numbered from 2 to 4, each secured to the sclera with a surgical microscope or surgical loupes and either 5-0 or 8-0 nylon sutures at 50% scleral depth and 3 mm beyond the tumor margin. Over a median follow-up of 11 months (range: 4.2-43.2 months), no recurrences of intraocular UM were observed. One case of enucleation after stereotactic radiosurgery developed because of radiation-related surface irritation, ocular dryness, and secondary keratopathy. Two patients (18%) with 5-0 nylon sutures required fiducial removal because of suture exposure, successfully accomplished in an outpatient setting. CONCLUSIONS Fiducials represent a viable alternative to tantalum rings for guiding stereotactic radiotherapy to manage UM and provide additional definition of the tumor border with linear orientation that helps optimize targeted radiation delivery. Fiducial placement with a 3-mm margin from the visible tumor border should not result in clinically important radiation dose attenuation at the tumor margins. Anteriorly placed fiducials may cause discomfort, yet they are easily removed in the outpatient setting.
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Affiliation(s)
- Timothy T. Xu
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jose S. Pulido
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian F. Parney
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cristiane M. Ida
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lauren A. Dalvin
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy W. Olsen
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
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Dupere JM, Munro JJ, Medich DC. Intensity modulated high dose rate ocular brachytherapy using Se-75. Brachytherapy 2021; 20:1312-1322. [PMID: 34561174 DOI: 10.1016/j.brachy.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/16/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE We propose an alternative to LDR brachytherapy for the treatment of ocular melanomas by coupling intensity modulation, through the use of a gold shielded ring applicator, with a middle energy HDR brachytherapy source, Se-75. In this study, we computationally test this proposed design using MCNP6. METHODS AND MATERIALS An array of discrete Se-75 sources is formed into a ring configuration within a gold shielded applicator, which collimates the beam to a conical shape. Varying this angle of collimation allows for the prescription dose to be delivered to the apex of various sized targets. Simulations in MCNP6 were performed to calculate the dosimetric output of the Se-75 ring source for various sized applicators, collimators, and target sizes. RESULTS The prescription dose was delivered to a range of target apex depths 3.5-8 mm in the eye covering targets 10-15 mm in diameter by using various sized applicators and collimators. For a 16 mm applicator with a collimator opening that delivers the prescription dose to a depth of 5 mm in the eye, the maximum percent dose rate to critical structures was 30.5% to the cornea, 35.7% to the posterior lens, 33.3% to the iris, 20.1% to the optic nerve, 278.0% to the sclera, and 267.3% to the tumor. CONCLUSIONS When using Se-75 in combination with the proposed gold shielded ring applicator, dose distributions are appropriate for ocular brachytherapy. The use of a collimator allows for the dose to more easily conform to the tumor volume. This method also reduces treatment time and cost, and it eliminates hand dose to the surgeon through the use of a remote afterloader device.
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Oare CC, Deufel CL, McCauley Cutsinger J, De La Fuente Herman T, Ferreira C. On the importance of quality assurance (QA) for COMS eye plaque Silastic inserts: A guide to measurement methods, typical variations, and an example of how QA intercepted a manufacturing aberration. J Appl Clin Med Phys 2021; 22:72-82. [PMID: 34231949 PMCID: PMC8364280 DOI: 10.1002/acm2.13325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/22/2021] [Accepted: 05/26/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Eye plaques are widely used for ocular melanoma and provide an effective alternative to enucleation with adequate tumor control. A COMS plaque utilizes a Silastic insert for precise positioning of the radioactive seeds with respect to the scleral surface of the eye; however, due to manufacturing variability, the insert may unintentionally increase or decrease the distance between the sources and tumor. The purpose of this work is to provide guidance in measuring and identifying outliers in Silastic inserts. The importance of regular quality assurance (QA) is illustrated in an experience where a systematic problem was detected and the manufacturer's 22-mm mold was corrected. METHODS A detailed description of the molds and manufacturing process used to produce Silastic inserts is provided, including photographs of the process steps. The variability in Silastic insert production was evaluated by measuring the thickness of 124 Silastic inserts. An estimate of how the observed Silastic thickness discrepancies impact the dose to the tumor and critical eye structures was performed using homogeneous dose calculations. A standard QA protocol was developed to guide the clinical user. RESULTS Thickness of the measured Silastic inserts ranged from 1.22 to 2.67 mm, demonstrating variation from the 2.25 mm standard. Six of the 22-mm inserts were outliers (Δthickness >3 standard deviations) and were excluded from the statistics. The outliers were investigated with the help of the manufacturer, who discovered that a systematic error was accidentally introduced into the 22-mm mold. CONCLUSIONS Due to manufacturing errors or variability, the Silastic inserts used in COMS eye plaques may be thicker or thinner than the design standard. Such variations may impact tumor control or increase the risk of normal tissue side effects. A standardized QA program is recommended to detect variations and communicate unusual findings to the manufacturer.
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Affiliation(s)
- Courtney C Oare
- Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
| | | | | | - Tania De La Fuente Herman
- Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Clara Ferreira
- Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, MN, 55455, USA
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Wang M, Levy G, Qin X, Adeniran AJ, Cai G. Fine-Needle Aspiration Biopsy of Intraocular Mass-Like Lesions. Am J Clin Pathol 2021; 156:268-277. [PMID: 33609033 DOI: 10.1093/ajcp/aqaa235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the diagnostic performance of fine-needle aspiration (FNA) biopsy for intraocular mass-like lesions and its contributing factors. METHODS Intraocular FNA cases were retrieved and reviewed along with histopathologic follow-ups, if available. The effects of rapid on-site evaluation (ROSE), repeated biopsy, and adjunct immunocytochemical studies on cytologic diagnoses were analyzed. RESULTS Of 72 FNA biopsies from 63 patients, nondiagnostic biopsy was seen in 17 cases (24%), whereas a definitive diagnosis was rendered in 39 cases (54%). The cytologic diagnoses correlated well with histopathologic follow-ups with a concordance rate of 61%. Almost all nondiagnostic biopsies (16/17, 94%) were seen in cases in which ROSE was not performed. Of the 7 patients in whom biopsy was repeated, a definitive diagnosis was rendered in 4 cases (57%). Immunocytochemistry was performed in the majority of cases with a malignant diagnosis, especially in metastatic tumors (75%). CONCLUSIONS Our data demonstrates that FNA is an effective tool for the diagnosis of intraocular tumors. ROSE, repeated biopsy, and adjunct immunocytochemistry can help reduce the nondiagnostic rate and/or enhance diagnosis of malignancy, further improving FNA diagnostic performance.
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Affiliation(s)
- Minhua Wang
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Gillian Levy
- Department of Pathology, Norwalk Hospital, Norwalk, CT, USA
| | - Xiaoyi Qin
- Wenzhou Medical University Eye Hospital, Wenzhou, China
| | | | - Guoping Cai
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
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21
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Dupere JM, Munro JJ, Medich DC. Shielded high dose rate ocular brachytherapy using Yb-169. Phys Med Biol 2021; 66. [PMID: 34010825 DOI: 10.1088/1361-6560/ac02d6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/19/2021] [Indexed: 11/12/2022]
Abstract
Purpose.We propose an approach for treating ocular melanoma using a new type of brachytherapy treatment device. This device couples Yb-169, a middle-energy high dose rate (HDR) brachytherapy source, with a gold shielded ring applicator to better conform radiation exposures to the tumor. In this study, we computationally test the dosimetric output of our proposed shielded ring applicator design using MCNP6 and validate it against an I-125 COMS plaque.Methods.The proposed Yb-169 ring applicator consists of an assembly of discrete sources delivered into an applicator with a conical collimated opening; this opening is tangent to the outside of the source tube. Using MCNP6, we simulated the dosimetric output of a ring of Yb-169 pellets placed within the collimator at various conical diameters and angles to demonstrate the dosimetric distribution for various prescription dose depths and target sizes using static intensity modulation.Results.Using various angles of collimation, the prescription dose was delivered to target apex depths of 3.5-8.0 mm into the eye covering target sizes ranging from 10 to 15 mm in diameter. This proposed device reduced the maximum absorbed dose to critical structures relative to I-125 by 5.2% to the posterior lens, 9.3% to the iris, 13.8% to the optic nerve, and 1.3% to the sclera.Conclusions.This proposed eye plaque design provides a more conformal dose distribution to the ocular tumor while minimizes dose to healthy ocular structures. In addition, the use of a middle-energy HDR brachytherapy source allows the use of a remote afterloader to expose the tumor after the plaque is sutured in place. This system is inherently safer and eliminates dose to the surgeon's hands.
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Affiliation(s)
- Justine M Dupere
- Worcester Polytechnic Institute, Worcester, MA 01609, United States of America
| | - John J Munro
- Montrose Technology Inc., North Andover, MA, 01845, United States of America
| | - David C Medich
- Worcester Polytechnic Institute, Worcester, MA 01609, United States of America
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22
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Abstract
Retinoblastoma in children and uveal melanoma in adults can pose a serious threat to both vision and life. For many decades, enucleation was often the only option to treat these intraocular malignancies. For retinoblastoma, intra-arterial chemotherapy is often utilized as the primary treatment at advanced academic centers and has dramatically improved local tumor control and eye salvage rates. For uveal melanoma, both plaque brachytherapy and proton beam irradiation have served as widely utilized therapies with a local failure rate of approximately 1–10%, depending on the series. Major recent advancements have allowed for a better understanding of the genomics of uveal melanoma and the impact of certain mutations on metastatic susceptibility. Gene expression profile stratifies uveal melanomas into two classes: low-risk (class 1) and high-risk (class 2). A loss-of-function mutation of BAP1 is associated with a class 2 gene expression profile and therefore confers worse prognosis due to elevated risk of metastasis. On the other hand, gain-of-function mutations of EIF1AX and SF3B1 correspond to a gene expression profile of class 1A and class 1B and confer a better prognosis. Preferentially expressed antigen in melanoma (PRAME) is an antigen that increases metastatic susceptibility when expressed in uveal melanoma cells. In addition to plaque brachytherapy and proton beam irradiation, both of which have demonstrated superb clinical outcomes, scientists are actively investigating newer therapeutic modalities as either primary therapy or adjuvant treatment, including a novel nanoparticle therapy and immunotherapy.
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Affiliation(s)
- Amy C Schefler
- Retina Consultants of Texas, Houston, Texas, USA
- Blanton Eye Institute, Houston, Texas, USA
| | - Ryan S Kim
- Retina Consultants of Texas, Houston, Texas, USA
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
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23
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Miguel D, Saornil MA, de Frutos JM, García-Álvarez C, Alonso P, Diezhandino P. Regression of posterior uveal melanoma following iodine-125 plaque radiotherapy based on pre-treatment tumor apical height. J Contemp Brachytherapy 2021; 13:117-125. [PMID: 33897784 PMCID: PMC8060957 DOI: 10.5114/jcb.2021.105278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/18/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The aim of this study was to analyze regression rates and local control of uveal melanoma patients treated with iodine-125 ( 125I) brachytherapy based on initial tumor apical height. MATERIAL AND METHODS Patients treated in a single institution from January 1st, 1996 to 2019 with 125I plaques (ROPES and COMS) for uveal melanoma were included in this study. Patients treated with brachytherapy for iris and those treated with transpupillary thermotherapy prior to brachytherapy were excluded. The sample was classified into 4 categories depending on initial apical tumor height (h0), i.e., h0 ≤ 2.5 (small), 2.5 < h0 ≤ 6.25 (small-medium), 6.25 < h0 ≤ 10 (medium-large), and h0 > 10 mm (large). Percentage of original tumor apical height (Δh) was collected during follow-ups. Patterns of regression were evaluated using linear least squares adjustments. Multivariable Cox regression were performed. RESULTS In total, 305 patients met the inclusion criteria, and 27, 166, 100, and 13 were considered for small, small-medium, medium-large, and large categories, respectively. Median follow-up was 82.4, 56.8, 76.1, 89.1, and 100.1 months for the entire cohort and each sub-group, respectively. Pattern of decrease when h0 ≤ 2.5 mm was not detectable. For the rest sub-groups, changes in height could be fitted using functional form: Δh (T) = ae-bT + c, R 2 ≥ 0.97. Multivariate Cox analysis factors predictive of local control failure revealed a hazard ratio (HR) of 6.1 (95% CI: 0.7-58.2%, p = 0.05) for patients who remained similar sized after treatment for small-medium tumors. For the rest sub-groups, Cox analysis did not indicate statistical significance in any single variable. CONCLUSIONS Height changes can be modeled by a negative exponential function for the first 7 years after treatment depending on the initial height, except for those less than 2.5 mm. Non-responding small-medium tumors multiply by 6 the probability of failure in local control.
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Affiliation(s)
- David Miguel
- Intraocular Tumors Unit, Valladolid University Hospital, Valladolid, Spain
| | | | | | | | - Pilar Alonso
- Intraocular Tumors Unit, Valladolid University Hospital, Valladolid, Spain
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Development of GATE Monte Carlo Code for Simulation and Dosimetry of New I-125 Seeds in Eye Plaque Brachytherapy. Nucl Med Mol Imaging 2021; 55:86-95. [PMID: 33968275 DOI: 10.1007/s13139-020-00680-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/28/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022] Open
Abstract
Purpose Dose distributions are calculated by Monte Carlo (MC) simulations for two low-energy models 125I brachytherapy source-IrSeed-125 and IsoAid Advantage (model IAI-125A)-loaded in the 14-mm standardized plaque of the COMS during treatment of choroid melanoma. Methods In this study, at first, the radial dose function in water around 125I brachytherapy sources was calculated based on the recommendations of the Task Group No. 43 American Association of Physicists in Medicine (TG-43U1 APPM) using by GATE code. Then, brachytherapy dose distribution of a new model of the human eye was investigated for a 14-mm COMS eye plaque loaded with these sources with GATE Monte Carlo simulation. Results Results show that there are good agreements between simulation results of these sources and reporting measurements and simulations. Dosimetry results in the designed eye phantom for two types of iodine seeds show that the ratios of average dose of tumor to sclera, vitreous, and retina for IrSeed (IsoAid) source are 3.7 (3.7), 6.2 (6.1), and 6.3 (6.3), respectively, which represents the dose saving to healthy tissues. The maximum percentage differences between DVH curve of IsoAid and IrSeed seeds was about 8%. Conclusions Our simulation results show that although new model of the 125I brachytherapy source having a slightly larger dimension than IAI-125A, it can be used for eye melanoma treatment because the COMS eye plaque loaded with IrSeed-125 could produce similar results to the IsoAid seeds, which is applicable for clinical plaque brachytherapy for uveal melanoma.
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Immunostimulatory Effects of Radiotherapy for Local and Systemic Control of Melanoma: A Review. Int J Mol Sci 2020; 21:ijms21239324. [PMID: 33297519 PMCID: PMC7730562 DOI: 10.3390/ijms21239324] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 12/12/2022] Open
Abstract
Recently, modern therapies involving immune checkpoint inhibitors, cytokines, and oncolytic virus have been developed. Because of the limited treatment effect of modern therapy alone, the immunostimulatory effect of radiotherapy attracted increasing attention. The combined use of radiotherapy and modern therapy has been examined clinically and non-clinically, and its effectiveness has been confirmed recently. Because melanomas have high immunogenicity, better therapeutic outcomes are desired when using immunotherapy. However, sufficient therapeutic effects have not yet been achieved. Thus far, radiotherapy has been used only for local control of tumors. Although extremely rare, radiotherapy has also been reported for systemic control, i.e., abscopal effect. This is thought to be due to an antitumor immune response. Therefore, we herein summarize past information on not only the mechanism of immune effects on radiotherapy but also biomarkers reported in case reports on abscopal effects. We also reviewed the animal model suitable for evaluating abscopal effects. These results pave the way for further basic research or clinical studies on new treatment methods for melanoma. Currently, palliative radiation is administered to patients with metastatic melanoma for local control. If it is feasible to provide both systemic and local control, the treatment benefit for the patients is very large.
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Ramasubramanian A, Ahmed SF, Borchman D. Changes in meibum composition following plaque bachytherapy for choroidal melanoma. BMJ Open Ophthalmol 2020; 5:e000614. [PMID: 33294624 PMCID: PMC7689590 DOI: 10.1136/bmjophth-2020-000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/27/2020] [Accepted: 11/12/2020] [Indexed: 11/03/2022] Open
Abstract
Objectives Dry eye is common when external beam radiation is used for the treatment of choroidal melanoma (CM). As meibum structure and composition have been related to dry eye, we determined if plaque bachytherapy for CM alters meibum composition. Design 1H-NMR spectroscopy was used to measure the lipid composition of meibum. Setting The University of Louisville, Kentucky, USA. Participants All 13 participants had CM and one participant had iris melanoma. Main outcome measures Cholesteryl ester (CE) to wax ester (WE) ratio, amount of meibum esters (ME) and meibum lipid saturation were measured. Results ME decreased by 80%±18% (±99% CI) in 11 eyes that were treated compared with the contralateral untreated eye. ME increased by 181% in two eyes that were treated compared with the contralateral untreated eye. The mole % CE/WE for meibum was significantly (p<0.0001) 67% lower in eyes that were irradiated compared with control eyes from donors without CM and were not treated. Plaque brachytherapy induced the de-esterification of CE. The intensity of the meibum cis double bond resonances did not change significantly (p>0.05). Conclusion Eyes that had plaque brachytherapy had a lower amount of expressible meibum and a lower CE/WE ratio compared with meibum from the contralateral eye that received no treatment and eyes that did not have uveal melanoma. Both the quality and quantity of meibum should be considered in designing a therapy for dry eye after plaque brachytherapy.
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Affiliation(s)
| | - Simra Fatima Ahmed
- Department of Ophthtalmology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Douglas Borchman
- Department of Ophthtalmology, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Systematic Review and Meta-Analysis on the Use of Photon-based Stereotactic Radiosurgery Versus Fractionated Stereotactic Radiotherapy for the Treatment of Uveal Melanoma. Am J Clin Oncol 2020; 44:32-42. [DOI: 10.1097/coc.0000000000000775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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28
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Zaragoza FJ, Eichmann M, Flühs D, Timmermann B, Brualla L. Monte Carlo Computation of Dose-Volume Histograms in Structures at Risk of an Eye Irradiated with Heterogeneous Ruthenium-106 Plaques. Ocul Oncol Pathol 2020; 6:353-359. [PMID: 33123529 DOI: 10.1159/000508113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/18/2020] [Indexed: 11/19/2022] Open
Abstract
Background/Aims The aim of this work is to compare Monte Carlo simulated absorbed dose distributions obtained from <sup>106</sup>Ru eye plaques, whose heterogeneous emitter distribution is known, with the common homogeneous approximation. The effect of these heterogeneities on segmented structures at risk is analyzed using an anthropomorphic phantom. Methods The generic CCA and CCB, with a homogeneous emitter map, and the specific CCA1364 and CCB1256 <sup>106</sup>Ru eye plaques are modeled with the Monte Carlo code PENELOPE. To compare the effect of the heterogeneities in the segmented volumes, cumulative dose-volume histograms are calculated for different rotations of the aforementioned plaques. Results For the cornea, the CCA with the equatorial placement yields the lowest absorbed dose rate while for the CCA1364 in the same placement the absorbed dose rate is 33% higher. The CCB1256 with the hot spot oriented towards the cornea yields the maximum dose rate per unit of activity while it is 44% lower for the CCB. Conclusions Dose calculations based on a homogeneous distribution of the emitter substance yield the lowest absorbed dose in the analyzed structures for all plaque placements. Treatment planning based on such calculations may result in an overdose of the structures at risk.
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Affiliation(s)
| | - Marion Eichmann
- Fakultät Physik, Technische Universität Dortmund, Dortmund, Germany
| | - Dirk Flühs
- NCTeam, Strahlenklinik, Universitätsklinikum Essen, Essen, Germany
| | - Beate Timmermann
- West German Proton Therapy Center Essen (WPE), Essen, Germany.,West German Cancer Center (WTZ), Essen, Germany.,University Hospital Essen, Essen, Germany.,German Cancer Consortium (DKTK), Essen, Germany.,Department of Particle Therapy, University Hospital Essen, Essen, Germany
| | - Lorenzo Brualla
- West German Proton Therapy Center Essen (WPE), Essen, Germany.,West German Cancer Center (WTZ), Essen, Germany.,University Hospital Essen, Essen, Germany
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29
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Lee KE, Yeo JH, Kim YJ, Kim JG, Yoon YH, Kwon DH, Cho YH, Lee JY. Short-term Effect of Gamma Knife Radiosurgery for a Choroidal Tumor. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2020. [DOI: 10.3341/jkos.2020.61.10.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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30
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Masoudi SF, Daryabari FS, Rasouli FS. Distribution modeling of nanoparticles for brachytherapy of human eye tumor. EJNMMI Phys 2020; 7:53. [PMID: 32816237 PMCID: PMC7441132 DOI: 10.1186/s40658-020-00321-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to their unique properties, gold nanoparticles (GNPs) have been proposed to be used for a wide range of applications, especially for photon radiation therapy. In addition to experimental works, there are worthwhile simulation-based studies focused on the investigation of the effect of parameters governing the dose enhancement due to the presence of GNPs in tissue. In a recently published study, we found that the distribution of GNPs in a single cell plays an important role in nucleus dose enhancement. METHODS The present work investigates the sensitivity of dose enhancement of a macroscopic phantom to the modeling of GNPs at the cellular level by using the MCNPX Monte Carlo code. A human eye phantom containing the realistic structures and materials was simulated, with a typical tumor located in its corner filled with three different patterns of distribution of GNPs around the nuclei of the cells. The primary photons emit from a COMS eye plaque brachytherapy containing thirteen 131Cs seeds in the vicinity of the tumor. RESULTS The study was extended to estimate dose enhancement for various concentration, size, and density of the GNPs accumulated around the nuclei of the tumor. Moreover, the dose delivered to the healthy eye structures for different models has been investigated and discussed. The results show obvious differences between the dose enhancements in the tumor depending on the modeling of GNPs. CONCLUSION The results emphasized that an appropriate small-scale model for the distribution of GNPs in the cell would be of high importance to estimate the degree of dose enhancement in a macroscopic phantom to provide a trustworthy prediction to move towards clinical application.
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Affiliation(s)
- S Farhad Masoudi
- Department of Physics, K.N. Toosi University of Technology, P.O. Box 15875-4416, Tehran, Iran.
| | - Fahimeh S Daryabari
- Department of Physics, K.N. Toosi University of Technology, P.O. Box 15875-4416, Tehran, Iran
| | - Fatemeh S Rasouli
- Department of Physics, K.N. Toosi University of Technology, P.O. Box 15875-4416, Tehran, Iran
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31
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Itta F, Liuzzi R, Farella A, Porri G, Pacelli R, Conson M, Oliviero C, Buonanno F, Breve M, Cennamo G, Clemente S, Cella L. Personalized treatment planning in eye brachytherapy for ocular melanoma: Dosimetric analysis on ophthalmic structure at risk. Phys Med 2020; 76:285-293. [DOI: 10.1016/j.ejmp.2020.07.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 12/21/2022] Open
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Lee YC, Lin SC, Kim Y. Optic disc dose reduction in ocular brachytherapy using 125 I notched COMS plaques: A simulation study based on current clinical practice. J Appl Clin Med Phys 2020; 21:57-70. [PMID: 32656945 PMCID: PMC7497926 DOI: 10.1002/acm2.12966] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/20/2020] [Accepted: 06/08/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Although notched Collaborative Ocular Melanoma Study (COMS) plaques have been widely used, optic disc dose reduction by notched COMS plaques has not been discussed in the literature. Therefore, this study investigated optic disc dose reduction in ocular brachytherapy using 125 I notched COMS plaques in comparison with optic disc dose for 125 I standard COMS plaques. METHODS For this simulation study, an in-house brachytherapy dose calculation program was developed using MATLAB software by incorporating the American Association of Physicists in Medicine Task Group-43 Update (AAPM TG-43U1) dosimetry formalism with a line source approximation in a homogeneous water medium and COMS seed coordinates in the AAPM TG 129. Using this program, optic disc doses for standard COMS plaques (from 12 to 22 mm in diameter in 2 mm increments) and notched COMS plaques with one seed removed (Case #1, from 12 to 22 mm) and with two seeds removed (Case #2, from 14 to 22 mm) were calculated as a function of tumor margin-to-optic disc distance (DT) for various tumor basal dimensions (BDs) for prescription depths from 1 to 10 mm in 1 mm intervals. A dose of 85 Gy for an irradiation time of 168 h was prescribed to each prescription depth. Then absolute and relative optic disc dose reduction by notched COMS plaques (Cases #1 and #2) was calculated for all prescription depths. RESULTS Optic disc dose reduction by notched COMS plaques (Cases #1 and #2) had five unique trends related to maximum optic disc dose reduction and corresponding optimal DT for each BD in each plaque. It increased with increasing prescription depth. CONCLUSIONS The results presented in this study would enable the clinician to choose an adequate plaque type among standard and notched 125 I COMS plaques and a prescription depth to minimize optic disc dose.
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Affiliation(s)
- Yongsook C Lee
- Department of Radiation Oncology, The University of Arizona, Tucson, AZ, USA
| | - Shih-Chi Lin
- Department of Radiation Oncology, The University of Arizona, Tucson, AZ, USA
| | - Yongbok Kim
- Department of Radiation Oncology, The University of Arizona, Tucson, AZ, USA
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Abstract
The purpose of this study was to review the limitations of dose calculation formalisms for photon-emitting brachytherapy sources based on the American Association of Physicists in Medicine (AAPM) Task Group No. 43 (TG-43) report and to provide recommendations to transition to model-based dose calculation algorithms. Additionally, an overview of these algorithms and approaches is presented. The influence of tissue and seed/applicator heterogeneities on brachytherapy dose distributions for breast, gynecologic, head and neck, rectum, and prostate cancers as well as eye plaques and electronic brachytherapy treatments were investigated by comparing dose calculations based on the TG-43 formalism and model-based dose calculation algorithms.
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34
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Filì M, Trocme E, Herrspiegel C, Seregard S, Stålhammar G. Effect of plaque brachytherapy dose and dose rate on risk for disease-related mortality in 1238 patients with choroidal melanoma. Br J Ophthalmol 2020; 105:57-62. [PMID: 32430342 DOI: 10.1136/bjophthalmol-2019-315722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/17/2020] [Accepted: 03/11/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Episcleral brachytherapy is the most common treatment for medium-sized choroidal melanomas. Although controversial, inadequate brachytherapy dose and dose rates have at least a hypothetical implication on patient survival. METHODS All patients who received ruthenium-106 or iodine-125 brachytherapy for choroidal melanoma at St. Erik Eye Hospital 1996 to 2016 were included (n=1238). Cox regression hazard ratios for melanoma-related mortality across deciles, quartiles and individual integers of apex radiation doses (Gy) and dose rates (Gy/hour) were calculated, adjusted for tumour size and location. RESULTS The average radiation dose at the tumour apex ranged from 73.0 Gy in the first decile to 108.6 Gy in the tenth. Decreasing apex dose by 1 Gy increments or by decile or quartile group was not associated with melanoma-related mortality (p>0.2) The average radiation dose rate at the tumour apex ranged from 0.5 Gy/hour in the first decile to 2.8 Gy/hour in the tenth. Similarly, decreasing apex dose rate by 1 Gy/hour increments or by decile or quartile groups was not associated with melanoma-related mortality (p>0.5). CONCLUSION There are no increased hazards for choroidal melanoma-related mortality after brachytherapy with decreasing doses between 108.6 and 73.0 Gy, or with decreasing dose rates between 2.8 and 0.5 Gy/hour.
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Affiliation(s)
- Maria Filì
- St. Erik Eye Hospital, Stockholm, Sweden .,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eric Trocme
- St. Erik Eye Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Christina Herrspiegel
- St. Erik Eye Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Seregard
- St. Erik Eye Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gustav Stålhammar
- St. Erik Eye Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Thomson RM, Furutani KM, Kaulich TW, Mourtada F, Rivard MJ, Soares CG, Vanneste FM, Melhus CS. AAPM recommendations on medical physics practices for ocular plaque brachytherapy: Report of task group 221. Med Phys 2020; 47:e92-e124. [PMID: 31883269 DOI: 10.1002/mp.13996] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/12/2019] [Accepted: 12/23/2019] [Indexed: 12/14/2022] Open
Abstract
The American Association of Physicists in Medicine (AAPM) formed Task Group 221 (TG-221) to discuss a generalized commissioning process, quality management considerations, and clinical physics practice standards for ocular plaque brachytherapy. The purpose of this report is also, in part, to aid the clinician to implement recommendations of the AAPM TG-129 report, which placed emphasis on dosimetric considerations for ocular brachytherapy applicators used in the Collaborative Ocular Melanoma Study (COMS). This report is intended to assist medical physicists in establishing a new ocular brachytherapy program and, for existing programs, in reviewing and updating clinical practices. The report scope includes photon- and beta-emitting sources and source:applicator combinations. Dosimetric studies for photon and beta sources are reviewed to summarize the salient issues and provide references for additional study. The components of an ocular plaque brachytherapy quality management program are discussed, including radiation safety considerations, source calibration methodology, applicator commissioning, imaging quality assurance tests for treatment planning, treatment planning strategies, and treatment planning system commissioning. Finally, specific guidelines for commissioning an ocular plaque brachytherapy program, clinical physics practice standards in ocular plaque brachytherapy, and other areas reflecting the need for specialized treatment planning systems, measurement phantoms, and detectors (among other topics) to support the clinical practice of ocular brachytherapy are presented. Expected future advances and developments for ocular brachytherapy are discussed.
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Affiliation(s)
- Rowan M Thomson
- Carleton Laboratory for Radiotherapy Physics, Physics Department, Carleton University, Ottawa, ON, K1S 5B6, Canada
| | - Keith M Furutani
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Theodor W Kaulich
- Department of Medical Physics, University of Tübingen, 72074, Tübingen, Germany
| | - Firas Mourtada
- Department of Radiation Oncology, Christiana Care Hospital, Newark, DE, 19713, USA
| | - Mark J Rivard
- Department of Radiation Oncology, Warren Alpert Medical School of Brown University, Providence, RI, 02903, USA
| | | | | | - Christopher S Melhus
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, MA, 02111, USA
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Guidelines for uveal melanoma: a critical appraisal of systematically identified guidelines using the AGREE II and AGREE-REX instrument. J Cancer Res Clin Oncol 2020; 146:1079-1088. [PMID: 32036455 PMCID: PMC7085474 DOI: 10.1007/s00432-020-03141-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/30/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Clinical practice guidelines provide recommendations for the management of diseases. In orphan conditions such as uveal melanoma (UM), guideline developers are challenged to provide practical and useful guidance even in the absence of high-quality evidence. Here, we assessed the methodological quality and identified deficiencies of international guidelines on UM as a base for future guideline development. METHODS A systematic search was carried out in guideline databases, Medline and Embase until 27th May 2019 for guidelines on UM published between 2004 and 2019. Five independent reviewers assessed the methodological quality of the identified guidelines using the instruments "Appraisal of Guidelines for Research and Evaluation II" (AGREE II) and AGREE-REX (Recommendation EXcellence). Descriptive analysis was performed and subgroup differences were explored with the Kruskal-Wallis (H) test. The relationship between the individual domains and items of the instruments were examined using Spearman's correlation. RESULTS Five guidelines published from 2014 to 2018 by consortia of the United States of America, Canada and the United Kingdom (UK) were included. The highest scores were obtained by the UK guideline fulfilling 48-86% of criteria in AGREE II and 30-60% for AGREE-REX. All guidelines showed deficiencies in the domains "editorial independence", "applicability", and "recommendation". Subgroup differences were identified only for the domain "editorial independence". CONCLUSION The UK guideline achieved the highest scores with both instruments and may serve as a basis for future guideline development in UM. The domains "editorial independence", "recommendation", and "applicability" were identified as methodological weaknesses and require particular attention and improvement in future guidelines.
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Ghassemi F, Sheibani S, Arjmand M, Poorbaygi H, Kouhestani E, Sabour S, Samiei F, Beiki-Ardakani A, Jabarvand M, Sadeghi Tari A. Comparison of Iodide-125 and Ruthenium-106 Brachytherapy in the Treatment of Choroidal Melanomas. Clin Ophthalmol 2020; 14:339-346. [PMID: 32099319 PMCID: PMC7007774 DOI: 10.2147/opth.s235265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/31/2019] [Indexed: 01/28/2023] Open
Abstract
Background To compare iodine-125 (125I) with ruthenium-106 (106Ru) episcleral plaque radiation therapy in terms of the effectiveness and non-inferiority for choroidal melanoma treatment. Objective To report the non-inferiority of new made iodine-125 (125I) compared with ruthenium-106 (106Ru) episcleral plaque radiation. Patients and Methods A retrospective, non-randomized comparative case series. In this series the patients treated with 125I and 106Ru episcleral plaques for choroidal melanoma between September 2013 and August 2017 at Farabi Hospital are compared. Local control of choroidal melanomas after 125I and 106Ru plaques implantation and vision changes are the main outcome measures. Results A total of 35 patients were identified (125I = 15, 106Ru = 20). No significant difference between two groups in visual acuity, diameter and thickness changes were observed after treatment. Multivariate linear regression (MLR) analysis showed that final diameter was only, independently and significantly, correlated with the pre-treatment diameter of the tumor (β = 0.59, 95% confidence interval [CI]: 0.29, 1.34, P = 0.003). The same MLR analysis for the final thickness and visual acuity, after adjusting for age and sex showed no significant difference between two groups. A single patient treated with 106Ru had local tumor recurrence with no one in the 125I group. No statistical difference in the rate of ocular complications was observed. Conclusion The treatment with our 125I plaques is as effective as 106Ru plaques in controlling choroidal melanoma tumor and preserving the vision during the two and half year of follow-up. The complication rates are alike. It means that the effectiveness of 125I is not only comparable to 106Ru but also superior when the outcome of the interest is the thickness of the tumors.
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Affiliation(s)
- Fariba Ghassemi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran.,Retina & Vitreous Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran.,Ocular Oncology Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran
| | - Shahab Sheibani
- Radiation Application Research School, Nuclear Science and Technology Research Institute, Tehran, Iran
| | - Mojtaba Arjmand
- Ocular Oncology Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran
| | - Hosein Poorbaygi
- Radiation Application Research School, Nuclear Science and Technology Research Institute, Tehran, Iran
| | - Emad Kouhestani
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran
| | - Siamak Sabour
- Safety Promotion and Injury Prevention Research Centre, Department of Clinical Epidemiology, School of Health,Shahid Beheshti University of Medical Sciences, Tehran, IR, Iran
| | - Farhad Samiei
- Radiation Oncology Department, Cancer Institute, Imam Hospital and Medical Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mahmood Jabarvand
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran
| | - Ali Sadeghi Tari
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, IR, Iran
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Delivered dose changes in COMS plaque-based ocular brachytherapy arising from vitrectomy with silicone oil replacement. Brachytherapy 2019; 18:668-674. [PMID: 31272841 DOI: 10.1016/j.brachy.2019.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/24/2019] [Accepted: 05/31/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE The purpose of the study was to determine dosimetric effects of performing concurrent I-125 Collaborative Ocular Melanoma Study plaque brachytherapy and vitrectomy with replacement using silicone oil, previously shown to be a means of shielding uninvolved parts of the eye. METHODS AND MATERIALS Monte Carlo simulations using MCNP6 were performed to compare the dosimetry with all eye materials assigned as water, and for the vitreous (excluding the tumor), composed of polydimethylsiloxane oil for three generic, one large tumor, and two patient geometry scenarios. Dose was scored at the tumor apex, along the sclera, and within a 3D grid encompassing the eye. The assessed patient cases included vitrectomies to treat intraocular pathologies; not to enhance attenuation/shielding. RESULTS The doses along the sclera and for the entire eye were decreased when the silicone oil replaced the vitreal fluid, with a maximum decrease at the opposite sclera of 63%. Yet, absolute changes in dose to critical structures were often small and likely not clinically significant. The dose at the tumor apex was decreased by 3.1-9.4%. Dose was also decreased at the edges of the tumor because of decreased backscatter at the tumor-oil interface. CONCLUSIONS Concurrent silicone vitrectomy was found to reduce total radiation dose to the eye. Based on current radiation retinopathy predictive models, the evaluation of the absolute doses revealed only a subset of patients in which a clinically significant difference in outcomes is expected. Furthermore, the presence of the silicone oil decreased dose to the tumor edges, indicating that the tumor could be underdosed if the oil is unaccounted for.
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Treatment planning considerations for 125I eye plaque brachytherapy. J Contemp Brachytherapy 2019; 11:280-284. [PMID: 31435435 PMCID: PMC6701382 DOI: 10.5114/jcb.2019.86370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/10/2019] [Indexed: 12/21/2022] Open
Abstract
Effective cancer brachytherapy requires a treatment plan that delivers high-dose to tumor, while minimizing the dose to critical normal tissues. Therefore, an accurate knowledge of the sources and magnitude of the techniques is essential for producing robust and well optimized-plans. The purpose of this technical note is to establish general procedures and strategies for optimization and customization of the plaques loaded with radioactive seeds, particularly focusing on the definition of useful tactics to limit high doses to organs at risk and adapt the treatment time to the necessity of institution.
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Wani SQ, Dar IA, Khan T, Lone MM, Afroz F. Radiation Therapy and its Effects Beyond the Primary Target: An Abscopal Effect. Cureus 2019; 11:e4100. [PMID: 31057994 PMCID: PMC6476619 DOI: 10.7759/cureus.4100] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/19/2019] [Indexed: 12/16/2022] Open
Abstract
Radiation therapy (RT) has been used for the treatment of various malignancies since decades with curative or palliative intent. RT for primary disease is often used with curative intent while its use in metastatic settings has been essentially palliative. However, in certain malignancies with metastatic disease, RT to primary disease has led to the regression of not only the primary site but also of the metastatic sites, a phenomenon known as "abscopal effect." Keeping in view the positive effects of RT beyond the primary site, we review the clinical utility of RT regarding its abscopal effect.
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Affiliation(s)
- Shaqul Qamar Wani
- Radiation Oncology, Sher I Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Ishtiyaq A Dar
- Radiation Oncology, Sher I Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Talib Khan
- Anesthesiology, Sher I Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Mohammad M Lone
- Radiation Oncology, Sher I Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Fir Afroz
- Radiation Oncology, Sher I Kashmir Institute of Medical Sciences, Srinagar, IND
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Daniels AB, Veverka KK, Patel SN, Sculley L, Munn G, Pulido JS. Computing uveal melanoma basal diameters: a comparative analysis of several novel techniques with improved accuracy. Int J Retina Vitreous 2019; 5:2. [PMID: 30652028 PMCID: PMC6325820 DOI: 10.1186/s40942-018-0151-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/17/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We sought to compare the accuracy of standard and novel echographic methods for computing intraocular tumor largest basal diameter (LBD). DESIGN Multicenter, retrospective cohort study. SUBJECTS All patients presenting with new diagnosis of uveal melanoma (UM). METHODS Ultrasounds were obtained for all patients, and axial length (AL) was measured for a subset of patients. LBD was calculated as: (1) a single chord measured on B scan ultrasound (one-chord method [1CM]), or (2) by subdividing the basal diameter into two chords, which were summated (two-chord method [2CM]), or (3) by a mathematically-derived formula (MF) based on geometric relationships. The accuracy of each method was then compared, and sensitivity of each technique to factors such as tumor size and AL were analyzed. MAIN OUTCOME MEASURES Accuracy, robustness, correctness of predicted plaque size. RESULTS 116 UMs were analyzed; 1CM-calculated LBD underestimated 2CM-calculated LBD by 7.5% and underestimated LBD by MF by 7.8%; 2CM and MF were tightly correlated (average LBD difference = 0.038%). At larger LBDs, 1CM underestimated 2CM and MF by a much greater percentage (p < 0.001). By linear regression, 1CM underestimated LBD compared to 2CM by 0.8% and underestimated LBD compared to MF by 1.2% for every 1-mm LBD increase (p < 0.001 for each). Increasing the number of ultrasound chords beyond two did not significantly impact LBD calculations. For eyes with AL within two standard deviations of the mean, AL did not impact plaque selection using MF. 1CM would have led to selection of an undersized plaque in 41% of cases compared to 2CM and would have misclassified half of all eyes that actually required enucleation. For tumors with LBD < 12 mm, 1CM does not significantly underestimate LBD. CONCLUSIONS Tumor LBD by 1CM is an inaccurate means of determining actual LBD, especially for larger tumors. Using either 2CM or MF is much more accurate, especially for tumors > 12 mm, where a single chord on ultrasound is more likely to lead to incorrect, undersized plaque selection. Our MF can be applied with great accuracy even in cases where the AL of the eye is not measured, using the population average AL (23.7 mm), and the formula LBD = 23.7 sin - 1 ( chord length / 23.7 ) .
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Affiliation(s)
- Anthony B. Daniels
- Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, 2311 Pierce Avenue, Nashville, TN 37232 USA
- Program in Cancer Biology, Vanderbilt University, Nashville, TN USA
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN USA
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN USA
| | - Kevin K. Veverka
- Department of Ophthalmology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905 USA
| | - Shriji N. Patel
- Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, 2311 Pierce Avenue, Nashville, TN 37232 USA
| | - LuAnne Sculley
- Department of Ophthalmology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905 USA
| | - Garvin Munn
- Department of Ophthalmology and Visual Sciences, Vanderbilt Eye Institute, Vanderbilt University Medical Center, 2311 Pierce Avenue, Nashville, TN 37232 USA
| | - Jose S. Pulido
- Department of Ophthalmology, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905 USA
- Department of Molecular Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905 USA
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Lee YC, Lin SC, Kim Y. A practical approach to estimating optic disc dose and macula dose without treatment planning in ocular brachytherapy using 125I COMS plaques. Radiat Oncol 2018; 13:221. [PMID: 30424782 PMCID: PMC6234692 DOI: 10.1186/s13014-018-1166-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background It has been reported that proximity of the tumor to the optic disc and macula, and radiation dose to the critical structures are substantial risk factors for vision loss following plaque brachytherapy. However, there is little dosimetry data published on this. In this study, therefore, the relationship between distance from tumor margin and radiation dose to the optic disc and macula in ocular brachytherapy using 125I Collaborative Ocular Melanoma Study (COMS) plaques was comprehensively investigated. From the information, this study aimed to allow for estimation of optic disc dose and macula dose without treatment planning. Methods An in-house brachytherapy dose calculation program utilizing the American Association of Physicists in Medicine Task Group-43 U1 formalism with a line source approximation in a homogenous water phantom was developed and validated against three commercial treatment planning systems (TPS). Then optic disc dose and macula dose were calculated as a function of distance from tumor margin for various tumor basal dimensions for seven COMS plaques (from 10 mm to 22 mm in 2 mm increments) loaded with commercially available 125I seeds models (IAI-125A, 2301 and I25.S16). A prescribed dose of 85 Gy for an irradiation time of 168 h was normalized to a central-axis depth of 5 mm. Dose conversion factors for each seed model were obtained by taking ratios of total reference air kerma per seed at various prescription depths (from 1 mm to 10 mm in 1 mm intervals) to that at 5 mm. Results The in-house program demonstrated relatively similar accuracy to commercial TPS. Optic disc dose and macula dose decreased as distance from tumor margin and tumor basal dimension increased. Dose conversion factors increased with increasing prescription depth. There existed dose variations (<8%) among three 125I seed models. Optic disc dose and macula dose for each COMS plaque and for each seed model are presented in a figure format. Dose conversion factors for each seed model are presented in a tabular format. Conclusions The data provided in this study would enable clinicians in any clinic using 125I COMS plaques to estimate optic disc dose and macula dose without dose calculations. Electronic supplementary material The online version of this article (10.1186/s13014-018-1166-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yongsook C Lee
- Department of Radiation Oncology, The University of Arizona, 3838 N. Campbell Avenue, Building #2, Tucson, AZ, 85719, USA
| | - Shih-Chi Lin
- Department of Radiation Oncology, The University of Arizona, 3838 N. Campbell Avenue, Building #2, Tucson, AZ, 85719, USA
| | - Yongbok Kim
- Department of Radiation Oncology, The University of Arizona, 3838 N. Campbell Avenue, Building #2, Tucson, AZ, 85719, USA.
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Zaragoza FJ, Eichmann M, Flühs D, Wittig A, Sauerwein W, Brualla L. Monte Carlo Simulation of the Treatment of Uveal Melanoma Using Measured Heterogeneous 106Ru Plaques. Ocul Oncol Pathol 2018; 5:276-283. [PMID: 31367591 DOI: 10.1159/000492599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/31/2018] [Indexed: 11/19/2022] Open
Abstract
Background/Aims Ruthenium plaques are used for the treatment of ocular tumors. The aim of this work is the comparison between simulated absorbed dose distributions tallied in an anthropomorphic phantom, obtained from ideal homogeneous plaques, and real eye plaques in which the actual heterogeneous distribution of <sup>106</sup>Ru was measured. The placement of the plaques with respect to the tumor location was taken into consideration to optimize the effectiveness of the treatment. Methods The generic CCA and CCB, and the specific CCA1364 and CCB1256 <sup>106</sup>Ru eye plaques were modeled with the Monte Carlo code PENELOPE. To compare the suitability of each treatment for an anterior, equatorial and posterior tumor location, cumulative dose-volume histograms for the tumors and structures at risk were calculated. Results Eccentric placements of the plaques, taking into account the inhomogeneities of the emitter map, can substantially reduce the dose delivered to structures at risk while maintaining the prescribed dose at the tumor apex. Conclusions The emitter map distribution of the plaque and the computerized tomography of the patient used in a Monte Carlo simulation allow an accurate determination of the plaque position with respect to the tumor with the potential to reduce the dose to sensitive structures.
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Affiliation(s)
| | - Marion Eichmann
- Fakultät Physik, Technische Universität Dortmund, Dortmund, Germany
| | - Dirk Flühs
- NCTeam, Strahlenklinik, Universitätsklinikum Essen, Essen, Germany
| | - Andrea Wittig
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Jena, Jena, Germany
| | | | - Lorenzo Brualla
- West German Proton Therapy Centre Essen (WPE), Essen, Germany
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Le BHA, Kim JW, Deng H, Rayess N, Jennelle RL, Zhou SY, Astrahan MA, Berry JL. Outcomes of choroidal melanomas treated with eye physics plaques: A 25-year review. Brachytherapy 2018; 17:981-989. [PMID: 30082188 DOI: 10.1016/j.brachy.2018.07.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 07/03/2018] [Accepted: 07/06/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE To review long-term outcomes of the University of Southern California Plaque Simulator (PS) software and Eye Physics (EP) plaques. We hypothesize that the PS/EP system delivers lower doses to critical ocular structures, resulting in lower rates of radiation toxicity and favorable visual outcomes compared to Collaborative Ocular Melanoma Study plaques, while maintaining adequate local tumor control. METHODS AND MATERIALS Retrospective review of 133 patients treated for choroidal melanoma with 125I brachytherapy, using PS software and EP plaques, from 1990 through 2015. A dose of 85 Gy at a rate of 0.6 Gy/h was prescribed to the tumor apex (with a typical margin of 2 mm) over 7 days. Primary outcomes were local tumor recurrence, globe salvage, and metastasis. Secondary outcomes were changes in visual acuity and radiation complications. RESULTS With median followup of 42 months, 5-year Kaplan-Meier estimated rates for tumor control, globe salvage, and metastatic-free survival were 98.3%, 96.4%, and 88.2%, respectively. Median doses to the macula and optic nerve were 39.9 Gy and 30.0 Gy, respectively. Forty-three percent of patients developed radiation retinopathy, and 20% developed optic neuropathy; 39% lost ≥6 Snellen lines of vision. CONCLUSIONS The PS/EP system is designed to improve the accuracy and conformality of the radiation dose, creating a steep dose gradient outside the melanoma to decrease radiation to surrounding ocular structures. We report favorable rates of local tumor control, globe salvage, metastases, and radiation complications when compared to the Collaborative Ocular Melanoma Study and other studies. Overall, the PS/EP system results in excellent tumor control and appears to optimize long-term visual and radiation-related outcomes after brachytherapy.
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Affiliation(s)
- Bao Han A Le
- USC Roski Eye Institute, Keck School of Medicine of University of Southern California, Los Angeles, CA; John A. Burns School of Medicine at the University of Hawaii, Honolulu, HI
| | - Jonathan W Kim
- USC Roski Eye Institute, Keck School of Medicine of University of Southern California, Los Angeles, CA; The Vision Center at Children's Hospital Los Angeles, Los Angeles, CA
| | - Hao Deng
- USC Roski Eye Institute, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Nadim Rayess
- USC Roski Eye Institute, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Richard L Jennelle
- Department of Radiation Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Sue Y Zhou
- Department of Radiation Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Melvin A Astrahan
- Department of Radiation Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA
| | - Jesse L Berry
- USC Roski Eye Institute, Keck School of Medicine of University of Southern California, Los Angeles, CA; The Vision Center at Children's Hospital Los Angeles, Los Angeles, CA.
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Ebrahimi-Khankook A, Vejdani-Noghreiyan A. Dosimetric comparison between realistic ocular model and other models for COMS plaque brachytherapy with 103Pd, 131Cs, and 125I radioisotopes. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2018; 57:265-275. [PMID: 29882078 DOI: 10.1007/s00411-018-0748-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/02/2018] [Indexed: 06/08/2023]
Abstract
Nowadays, Monte Carlo calculations are commonly used for the evaluation of dose distributions and dose volume histograms in eye brachytherapy. However, currently available eye models have simple geometries, and main substructures of the eye are either not defined in details or not distinguished at all. In this work absorbed doses of eye substructures have been estimated for eye plaque brachytherapy using the most realistic eye model available, and compared with absorbed doses obtained with other available eye models. For this, a medium-sized tumour on the left sides of the right eye was considered. Dosimetry calculations were performed for four different eye models developed based on a literature review, and using a 12 mm Collaborative Ocular Melanoma Study plaque containing 131Cs, 103Pd, and 125I sources. Obtained results illustrate that the estimated doses received by different eye substructures strongly depend on the model used to represent the eye. It is shown here that using a non-realistic eye model leads to a wrong estimation of doses for some eye substructures. For example, dose differences of up to 35% were observed between the models proposed by Nogueira and co-workers and Yoriyaz and co-workers, while doses obtained by use of the models proposed by Lesperance and co-workers, and Behrens and co-workers differed up to 100 and 63% as compared to the situation when a realistic model was used, respectively. Moreover, comparing different radionuclides showed that the most uniform dose distribution in the considered tumour region was that from 131Cs, with a coefficient of variation of 33%. In addition, considering the realistic eye model, it was found that the radiosensitive region of the lens received more than the threshold dose of cataract induction (0.5 Gy), for all investigated radionuclides.
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Miguel D, de Frutos-Baraja JM, López-Lara F, Saornil MA, García-Álvarez C, Alonso P, Diezhandino P. Radiobiological doses, tumor, and treatment features influence on local control, enucleation rates, and survival after epiescleral brachytherapy. A 20-year retrospective analysis from a single-institution: part I. J Contemp Brachytherapy 2018; 10:337-346. [PMID: 30237817 PMCID: PMC6142652 DOI: 10.5114/jcb.2018.77849] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/25/2018] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To assess influence of the radiobiological doses, tumor, and treatment features on local control, enucleation rates, overall and disease-specific survival rates after brachytherapy for posterior uveal melanoma. MATERIAL AND METHODS Local control, enucleation, overall and disease-specific survival rates were evaluated on the base of 243 patients from 1996 through 2016, using plaques loaded with iodine sources. Clinical and radiotherapy data were extracted from a dedicated prospective database. Biologically effective dose (BED) was included in survival analysis using Kaplan-Meier and Cox regressions. The 3-, 5-, 10-, and 15-year relative survival rates were estimated, and univariate/multivariate regression models were constructed for predictive factors of each item. Hazard ratio (HR) and confidence interval at 95% (CI) were determined. RESULTS The median follow-up was 73.9 months (range, 3-202 months). Cumulative probabilities of survival by Kaplan-Meier analysis at 3, 5, 10 and 15 years were respectively: 96%, 94%, 93%, and 87%, for local control; 93%, 88%, 81%, and 73% for globe preservation; 98%, 93%, 84%, and 73% for overall survival, and 98%, 96%, 92%, and 87% for disease-specific survival. By multivariate analysis, we concluded variables as significant: for local control failure - the longest basal diameter and the juxtapapillary location; for globe preservation failure - the longest basal dimension, the mushroom shape, the location in ciliary body, and the dose to the foveola; for disease-specific survival - the longest basal dimension. Some radiobiological doses were significant in univariate models but not in multivariate ones for the items studied. CONCLUSIONS The results show as predictive factors of local control, enucleation, and disease-specific survival rates those related with the features of the tumor, specifically the longest basal dimension. There is no clear relation between radiobiological doses or treatment parameters in patients after brachytherapy.
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Affiliation(s)
- David Miguel
- Intraocular Tumor Unit, Hospital Universitario de Valladolid, Valladolid
- University of Valladolid, Valladolid, Spain
| | - Jesús María de Frutos-Baraja
- Intraocular Tumor Unit, Hospital Universitario de Valladolid, Valladolid
- University of Valladolid, Valladolid, Spain
| | - Francisco López-Lara
- Intraocular Tumor Unit, Hospital Universitario de Valladolid, Valladolid
- University of Valladolid, Valladolid, Spain
| | - María Antonia Saornil
- Intraocular Tumor Unit, Hospital Universitario de Valladolid, Valladolid
- University of Valladolid, Valladolid, Spain
| | - Ciro García-Álvarez
- Intraocular Tumor Unit, Hospital Universitario de Valladolid, Valladolid
- University of Valladolid, Valladolid, Spain
| | - Pilar Alonso
- Intraocular Tumor Unit, Hospital Universitario de Valladolid, Valladolid
- University of Valladolid, Valladolid, Spain
| | - Patricia Diezhandino
- Intraocular Tumor Unit, Hospital Universitario de Valladolid, Valladolid
- University of Valladolid, Valladolid, Spain
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De Caluwé A, Termote K, Van Gestel D, Van Limbergen E. Dose-response in choroidal melanoma. Radiother Oncol 2018; 127:374-378. [PMID: 29680322 DOI: 10.1016/j.radonc.2018.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/13/2018] [Accepted: 03/15/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE In choroidal melanoma the radiation threshold dose for local control remains largely unknown. The present study examined a group of patients that received a wide range of minimum tumor dose in order to investigate a dose-response relationship. A literature review is performed to compare our results with available evidence in brachytherapy and charged particle external beam radiotherapy. MATERIALS AND METHODS A retrospective study was conducted on all choroidal melanomas treated with Strontium-90 (Sr-90) at the University Hospital of Leuven between 1983 and 2012. Local failure was defined as primary endpoint and was estimated according to the competing risk method. RESULTS In 135 patients, the minimum tumor dose (Dmin) ranged from 0 Gy to 287 Gy (median: 27.6 Gy). Multivariable analysis revealed Dmin ≥ 65 Gy (p = 0.04; HR = 0.09) and tumor distant from the optic disc (p < 0.001, HR = 0.09) to be independent variables favoring local control. The scleral dose, the tumor diameter and tumor height did not significantly affect local failure in multivariate analysis. CONCLUSION This is the first study to examine a group of patients treated with a Dmin ranging from 0 Gy to >250 Gy. Treatment with a Dmin of 65 Gy is necessary to achieve durable tumor response. The dose-response data provided by our study could be used for the design of future trials examining the ideal dose for the treatment of choroidal melanoma with brachytherapy or charged particle external beam radiotherapy.
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Affiliation(s)
- Alex De Caluwé
- Department of Radiation Oncology, Institut Jules Bordet - Université Libre de Bruxelles (ULB), Brussels, Belgium.
| | - Karolien Termote
- Department of Ophthalmology, University Hospital of Brussels (UZ Brussel), Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation Oncology, Institut Jules Bordet - Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Erik Van Limbergen
- Department of Radiation Oncology, University Hospital of Leuven (UZ Leuven), Leuven, Belgium
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Abstract
Melanomas affecting different components of the uvea occur with differing frequencies and clinical presentations. Uveal melanoma is diagnosed via funduscopic exam and ancillary tests. These lesions may present with visual findings or incidental findings on physical exam. Metastasis occurs in approximately half of all patients with primary uveal melanoma. The liver is the most common site of metastasis. Enucleation was at one time considered the definitive local treatment for primary uveal melanoma, but has been largely replaced by other therapeutic procedures that aim to prevent metastasis while preserving vision. Unfortunately, metastasis of uveal melanoma almost always proves to be fatal. The current treatment of metastatic uveal melanoma is limited by the intrinsic resistance of uveal melanoma to conventional systemic therapies. Advancements in molecular biology have resulted in the identification of a number of promising prognostic and therapeutic targets. Early detection and therapy are important factors in disease survival. It is imperative that the treating physician be familiar with the clinical features of uveal melanoma and distinguish it from mimickers in order to ensure effective and timely treatment.
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Affiliation(s)
| | - Priya Durairaj
- Department of Ocular Oncology, The Princess Margaret Hospital, Toronto, ON, Canada
| | - Jensen Yeung
- Department of Medicine (Dermatology), University of Toronto, Toronto, ON, Canada
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49
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Maheshwari A, Finger PT. Regression patterns of choroidal melanoma: After palladium-103 ( 103Pd) plaque brachytherapy. Eur J Ophthalmol 2018; 28:722-730. [PMID: 29788760 PMCID: PMC6210576 DOI: 10.1177/1120672118776146] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose: To describe the patterns of regression of choroidal melanoma after treatment with plaque brachytherapy. Methods: Retrospective interventional case series including 170 consecutive patients treated with 103Pd eye plaque radiation for choroidal melanoma. Outcome measures were changes in tumor thickness, surface characteristics, tumor vascularity, ultrasonography, fluorescein angiography, optical coherence tomography, and histopathology. Results: The mean initial tumor thickness was 3.9 mm (median 2.8 mm; range 2–11.3 mm) that decreased to 1.7 mm (median 1.2 mm; range 0–7.1 mm) after plaque brachytherapy. On imaging, tumors were pigmented in 51% (n = 86/170), amelanotic in 10% (n = 17/170), and variably pigmented in 39% (n = 67/170). Tumor pigmentation increased in 64% (n = 106/166), decreased in 18% (n = 30/166), and was unchanged in 18% (n = 30/166). Of the 120 that demonstrated intrinsic vascularity, 10% (n = 12/120) had decreased tumor-related vascularity and 90% (n = 108/120) showed complete resolution. Subretinal fluid was present in 34% (n = 58/170) of eyes at presentation. Of them, 15% (9; n = 9/58) had persistent SRF at last follow-up. On ultrasound imaging, 88% (n = 149/170) tumors presented with low to moderate internal reflectivity of which 61% (n = 91/149) showed increased reflectivity on regression. We noted a crescendo–decrescendo fluctuation in the presence of orange pigment lipofuscin along with complete resolution of drusenoid retinal pigment epithelial detachments. In the entire series of 170 patients, there was 0.5% (1) failure of local control, 2% (4) secondary enucleations, and 6% (10) patients developing metastasis. Conclusion: Findings related to choroidal melanoma regression after 103Pd plaque brachytherapy included decreased intrinsic tumor vascularity, decreased tumor-related subretinal fluid, increased pigmentation, specific changes in orange pigment lipofuscin and resolution of drusenoid retinal pigment epithelial detachments, as well as decreased tumor thickness with an increase in internal reflectivity on ultrasound.
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Brewington BY, Shao YF, Davidorf FH, Cebulla CM. Brachytherapy for patients with uveal melanoma: historical perspectives and future treatment directions. Clin Ophthalmol 2018; 12:925-934. [PMID: 29844657 PMCID: PMC5963830 DOI: 10.2147/opth.s129645] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Surgical management with enucleation was the primary treatment for uveal melanoma (UM) for over 100 years. The Collaborative Ocular Melanoma Study confirmed in 2001 that globe-preserving episcleral brachytherapy for UM was safe and effective, demonstrating no survival difference with enucleation. Today, brachytherapy is the most common form of radiotherapy for UM. We review the history of brachytherapy in the treatment of UM and the evolution of the procedure to incorporate fine-needle-aspiration biopsy techniques with DNA-and RNA-based genetic prognostic testing.
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Affiliation(s)
- Beatrice Y Brewington
- Havener Eye Institute, Department of Ophthalmology and Visual Science, Ohio State University
| | - Yusra F Shao
- Medical Student Research Program, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Fredrick H Davidorf
- Havener Eye Institute, Department of Ophthalmology and Visual Science, Ohio State University
| | - Colleen M Cebulla
- Havener Eye Institute, Department of Ophthalmology and Visual Science, Ohio State University
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