Palladium-103 plaque therapy for multifocal iris melanoma: Radiation of the entire anterior segment of the eye

PURPOSE

To investigate the safety and tolerability of total anterior segment palladium-103 (¹⁰³Pd) eye plaque brachytherapy for multifocal iris melanoma.

METHODS

Interventional case series of 11 patients with multifocal iris melanomas. Anterior segment ultrasound revealed tumor size, location, and intraocular margins. Epicorneal amniotic membrane grafts protected the cornea and decreased pain during total anterior segment 103-Pd ophthalmic plaque brachytherapy.

RESULTS

Eleven diffuse iris melanomas were American Joint Committee on Cancer 8th edition-classified as T1 (n = 5, 45.5%) and T2 (n = 6, 54.5%). Plaque radiation was completed to a minimum mean tumor dose of 85 Gy (mean dose rate, 58.1 cGy/h). Ultrasonographic tumor thickness regression was 41% (follow up mean 58.7, median 50, range: 8-139 months). Despite 100% local control and 100% eye retention, one patient (9.1%) developed metastatic disease. Four eyes required cataract surgery. There was no corneal stem-cell deficiency, corneal opacity, radiation maculopathy, or optic neuropathy. While visual acuity prior to treatment was 20/40 or better in 10 (91%), 9 were 20/40 or better (81.9%) at last follow-up. Four (36%) had glaucoma prior to treatment and three eyes developed glaucoma after treatment for a total of 63%.

CONCLUSION

Total anterior segment (¹⁰³Pd) plaque brachytherapy resulted in local control, good visual acuity, eye and life preservation in the treatment of multifocal iris melanoma.

Super-Thick Amniotic Membrane Graft for Ocular Surface Reconstruction

PURPOSE

The purpose of this study was to evaluate super-thick amniotic membrane grafts (ST-AMGs) for ocular surface reconstruction.

DESIGN

Retrospective, interventional case series.

METHODS

This was a single-center study of clinical practice that included select patients with typically large ocular surface abnormalities that required reconstruction. The intervention studied was surgical insertion of a ST-AMG for reconstruction or repair of the ocular surface. Main outcome measures included intraoperative handling, graft position at 1 week post implantation, graft dissolution at 3 weeks, epithelialization of the ocular surface and symblepharon.

RESULTS

Eleven ST-AMGs were implanted after resection with cryotherapy: 5 conjunctival melanoma, 4 squamous cell carcinoma, 1 sebaceous carcinoma, and 1 atypical pterygium. In addition, 1 was implanted for scleral necrosis. ST-AMGs were up to nine times thicker than standard amniotic grafts and were therefore amenable to both running and interrupted 7-0 Vicryl sutures without cheese-wiring. All cases had a well-positioned ST-AMG at 1 week and 75% (n = 9) had partial graft dissolution at 3 weeks. Complete epithelialization without wound dehiscence was noted in all cases. However, secondary (after additional tumor treatment) symblepharon formed in 16.7% (n = 2). In all cases, the mean visual acuity and intraocular pressures remained unchanged during conjunctival reconstruction and subsequent secondary treatments. Post epithelialization adjuvant topical chemotherapy was given to extend treatment margins and treat presumed occult disease in 50% (n = 6). At mean follow-up of 25.5 months (median 10, range 3-90), 10 cases (83.3%) showed complete local tumor control, 1 showed revascularization of the scleral melt, and 1 required orbital exenteration.

CONCLUSION

ST-AMGs were easy to suture and relatively persistent. Epithelialization of the ocular surface without primary symblepharon formation was noted. ST-AMGs should be considered an alternative for ocular surface reconstruction.

Squamous Cell Carcinoma Invading a Transplanted Cornea: Eye- and Vision-Sparing Palladium-103 Plaque Radiation Therapy for a Functionally Monocular Patient

PURPOSE

To present a unique approach to eye and vision sparing for a patient with squamous cell carcinoma invading through a penetrating keratoplasty (PK) wound.

METHODS

A 56-year-old functionally monocular man was found to have squamous cell carcinoma with intraocular invasion through a PK wound. Eye- and vision-salvaging palladium-103 plaque radiation was performed. An amniotic membrane graft was used to buffer and thus protect the cornea during the 7-day treatment. Leaded eye glasses were worn during the day to block emitted radiation and allow functional vision during irradiation.

RESULTS

At 3.5 years status posttreatment, the tumor has regressed, PK has become progressively hazy (within the irradiated zone), and his vision is stable at 20/320. The epicorneal tumor has disappeared, and the intraocular tumor nodules are more highly reflective, but persistent. There has been no intraocular tumor progression, worsening of his glaucoma, or evidence of intraocular radiation vasculopathy.

CONCLUSIONS

Transcorneal intraocular tumor invasion was controlled using palladium-103 ophthalmic plaque radiation therapy applied through the natural and donor cornea. Definitive treatment resulted in local tumor control and preservation of vision.

Phase I/II study on kilovoltage surface brachytherapy in conjunctival cancer: preliminary results

INTRODUCTION

In ocular conjunctival carcinoma after surgery, adjuvant treatment has a role and kilovoltage surface brachytherapy opens a new door for the range of therapeutic options.

MATERIALS AND METHODS

Between October 2014 and June 2017, at the National Institute of Neoplastic Diseases (INEN) from Peru, 39 patients with squamous cell carcinoma of ocular conjunctiva, T1-T3, resected, were selected to receive adjuvant treatment. The portable accelerator of 50-kV INTRABEAM (Carl Zeiss Meditec) was used, after local anaesthesia and blocking of ocular muscles movement. The doses used were 18 Gy for patients with free margins and 22 Gy for positive edges, according to calculation of equivalent dose of 2Gy per fraction of 46 and 66 Gy, respectively, assuming a tumoural α/β ratio of 8 Gy. The prescription was done to 2 mm depth.

RESULTS

The median age was 69 years, distributed evenly between both genders, with a median follow-up of 12 months. The surgical margins were 59% free and 41% committed, with no difference between the institutions where the surgery was performed (P = 0.069). The median tumour size was 7 mm with 2 mm of invasion, 61.5% was T2 and 35.9% T1. The mean time between surgery and irradiation was 1.5 months, 23.1% of patients developed grade I toxicity of spontaneous resolution, without evidence of greater degree in any case. The dose had no statistical relationship with toxicity (P = 0.533). One-year disease-free survival was 96.7%.

CONCLUSIONS

Kilovoltage surface brachytherapy is an applicable and reproducible tool in the treatment of squamous cell carcinoma of ocular conjunctiva. The administered doses are well tolerated by patients with low levels of acute toxicity. Longer follow-up is needed to establish disease control rates and late toxicities.

Palladium-103 plaque radiation therapy for ciliary body melanoma through a functioning glaucoma filtering bleb

PURPOSE

To provide a clinical description of the long-term outcome of a ¹⁰³Pd plaque-irradiated ciliary body melanoma with extrascleral extension while attempting to preserve a subadjacent glaucoma filtering bleb.

METHODS

A 75-year-old woman with pseudoexfoliative glaucoma for 17 years, 16 years status post argon laser trabeculoplasty, and 15 years status post trabeculectomy in the left eye, was diagnosed with an ipsilateral ciliary body melanoma with visible extrascleral extension. Treatment involved insertion of a ¹⁰³Pd radioactive plaque over the functioning trabeculectomy, with removal 7 days later. At plaque insertion, amniotic membrane grafts were used to cover the plaque and protect the filtering site.

RESULTS

The tumor was successfully treated without clinical evidence of harm to the filtering bleb, with resultant stable intraocular pressure. However, the patient developed blebitis 1.5 years later. Though it resolved with topical antibiotic therapy, the bleb became less succulent. Two years postoperatively, she developed a spontaneous hyphema that resolved after one injection of transscleral bevacizumab 1.25 mg. Her tumor continually regressed in thickness. Without additional glaucoma surgery, her intraocular pressure remained well-controlled on topical medications for 6 years.

CONCLUSIONS

Ciliary body melanoma with minimal extrascleral extension beneath a functioning filtering bleb can be treated using radioactive plaque therapy. In this case, we were able to achieve both tumor regression and glaucoma control by covering the plaque with an amniotic membrane graft.

[Plaque radiotherapy for anterior uveal melanomas]

AIM

To determine the effectiveness of plaque radiation therapy for anterior uveal melanomas and to evaluate the risk and frequency of complications at different time intervals after the treatment.

MATERIAL AND METHODS

During 2010-2013 a total of 30 patients (10 male, 20 female) aged 11-73 (50 years on the average) with iris or iridociliary melanomas were treated with Ru-106 and Sr-90 ophthalmic plaques. In 8 patients the brachytherapy was preceded by local tumor excision. Morphological diagnosis was verified in 10 patients (8 iridectomies, 2 enucleations), of them 8 cases turned out to be spindle cell melanomas and the other 2--mixed cell melanomas. Follow-up period ranged from 1 to 54 months with the median of 13,5 months.

RESULTS

Tumor regression was achieved in all cases. Enucleation had to be performed in 2 patients due to cornea and sclera necrosis. In the early post-brachytherapy period (up to 1 month) the most frequent radiation-related complications were keratopathy and uveitis (8 and 6 patients correspondingly). In patients observed for up to 3 months (28 patients) these were keratopathy and cataract (8 and 5 patients correspondingly). In the long-term (over 6 months) cataract predominated (17 patients). At the end of the study all patients were alive. Metastatic disease was diagnosed in one patient 30 months after the treatment.

CONCLUSIONS

The results of the present clinical study confirm the effectiveness of brachytherapy for iris and iridociliary melanomas, which implies that tumor is well locally controlled and radiation-related complications are moderate and curable. This method of local tumor destruction can be another alternative to enucleation in cases when local tumor excision cannot be performed.

The American Brachytherapy Society consensus guidelines for plaque brachytherapy of uveal melanoma and retinoblastoma

PURPOSE

To present the American Brachytherapy Society (ABS) guidelines for plaque brachytherapy of choroidal melanoma and retinoblastoma.

METHODS AND MATERIALS

An international multicenter Ophthalmic Oncology Task Force (OOTF) was assembled to include 47 radiation oncologists, medical physicists, and ophthalmic oncologists from 10 countries. The ABS-OOTF produced collaborative guidelines, based on their eye cancer-specific clinical experience and knowledge of the literature. This work was reviewed and approved by the ABS Board of Directors as well as within the journal's peer-reivew process.

RESULTS

The ABS-OOTF reached consensus that ophthalmic plaque radiation therapy is best performed in subspecialty brachytherapy centers. Quality assurance, methods of plaque construction, and dosimetry should be consistent with the 2012 joint guidelines of the American Association of Physicists in Medicine and ABS. Implantation of plaque sources should be performed by subspecialty-trained surgeons. Although there exist select restrictions related to tumor size and location, the ABS-OOTF agreed that most melanomas of the iris, ciliary body, and choroid could be treated with plaque brachytherapy. The ABS-OOTF reached consensus that tumors with gross orbital extension and blind painful eyes and those with no light perception vision are unsuitable for brachytherapy. In contrast, only select retinoblastomas are eligible for plaque brachytherapy. Prescription doses, dose rates, treatment durations, and clinical methods are described.

CONCLUSIONS

Plaque brachytherapy is an effective eye and vision-sparing method to treat patients with intraocular tumors. Practitioners are encouraged to use ABS-OOTF guidelines to enhance their practice.