Jorge E. Freire

Plaque radiotherapy for selected orbital malignancies: preliminary observations: the 2002 Montgomery Lecture, part 2.

Purpose To describe the principles and preliminary results of plaque brachytherapy for selected orbital malignancies. Methods A custom-designed Iodine-125 plaque, designed to deliver a target dose of 50 Gray, was placed surgically in the region from which an orbital malignancy was partially resected. The mean dose to the target area was 50 Gray. The initial and follow-up patient data were reviewed. Results Of the 8 patients, the diagnosis was adenoid cystic carcinoma of the lacrimal gland (4 cases), orbital invasion by basal cell carcinoma (2), orbital extension of conjunctival melanoma (1), and metastatic carcinoma (1). Of the 4 with adenoid cystic carcinoma, there was microscopic residual tumor after excision and orbital exenteration was considered. Three have tumor control with follow-up of 1, 3, and 6 years. One patient required exenteration for recurrence separate from the field of brachytherapy and is free of tumor after 10 years. All 4 patients are alive and well with tumor control. Of the 2 patients with orbital extension of basal cell carcinoma, tumor control without recurrence has been achieved in both after 2 years. The patient with orbital metastasis responded to plaque radiotherapy, with no orbital recurrence, but died of systemic metastasis. The patient with orbital melanoma had local orbital recurrence separate from the area of irradiation and is currently being treated for systemic metastasis. Conclusions Based on preliminary observations, plaque radiotherapy appears to be a reasonable alternative to exenteration and external irradiation for selected orbital malignancies.

Plaque radiotherapy for juxtapapillary choroidal melanoma overhanging the optic disc in 141 consecutive patients.

OBJECTIVE To evaluate tumor control with plaque radiotherapy for juxtapapillary choroidal melanoma that overhangs the optic disc. METHODS Retrospective medical record review of 141 consecutive patients with data on complications of treatment, final visual acuity, visual loss, enucleation, tumor recurrence, metastasis, and death. RESULTS The median patient age was 61 years. Presenting symptoms included reduced visual acuity in 72 eyes (51%), photopsia in 14 (10%), and visual field defect in 18 (13%); 35 patients (25%) were asymptomatic. The median tumor basal diameter was 11 mm and the median thickness was 5.2 mm. The tumor overhung 50% or less of the disc in 88 eyes (62%) and more than 50% of the disc in 53 eyes (38%). In 19 cases (13%), the tumor overhung the entire disc. All patients were treated with plaque radiotherapy, using a notched design in 126 eyes (89%) and a round design in 14 eyes (10%), with iodine 125 in 132 eyes (94%) and cobalt 60 in 9 eyes (6%). The median radiation dose to the tumor apex was 8500 cGy. Adjuvant transpupillary thermotherapy was used in 54 eyes (39%). During a mean follow-up of 56 months, complications included nonproliferative retinopathy in 61 eyes (51%), proliferative retinopathy in 26 (22%), maculopathy in 44 (37%), papillopathy in 57 (48%), neovascular glaucoma in 23 (19%), and vitreous hemorrhage in 48 (40%). A final visual acuity of 20/200 or worse was measured in 72 eyes (77%), and visual loss of more than 5 Snellen lines occurred in 59 eyes (63%). Enucleation was necessary in 27 eyes (23%). Tumor recurrence was found in 12 eyes (10%). Metastasis developed in 15 patients (13%) and death in 4 cases (3%). CONCLUSIONS Using plaque radiotherapy for choroidal melanoma overhanging the optic disc, local tumor control was achieved in 90% of cases. Tumor and radiation effects led to poor visual acuity in 77% of eyes. The metastatic rate was 13% and the mortality rate was 3%.

CyberKnife Radiosurgery for the Treatment of Intraocular and Periocular Lymphoma

OBJECTIVES To evaluate efficacy, patient tolerance, and adverse effects of CyberKnife radiosurgery for the treatment of intraocular and periocular lymphoma. METHODS Retrospective case series of 13 patients who underwent CyberKnife radiosurgery was conducted. RESULTS Fourteen eyes of 13 patients were included. The tissue location of the lymphoma was orbit (7 eyes), conjunctiva (3 eyes), choroid (2 eyes), and retina (2 eyes). The lymphoma type was classified as extranodal marginal zone B-cell lymphoma in 7 eyes (50%), diffuse large B-cell lymphoma in 3 eyes (21%), follicular lymphoma in 2 eyes (14%), and benign reactive lymphoid hyperplasia in 2 eyes (14%). The mean treatment dose was 1718 centigrays (cGy) (range, 1350-2250 cGy) given over a mean of 5 days (range, 3-5 days) with a mean dose rate of 320 cGy per fraction. Complete tumor resolution without local recurrence over a mean follow-up of 23 months was documented in all cases. Radiation-associated adverse effects included mild dry eye in 2 patients and cataract in 1 patient with conjunctival lymphoma. There was no radiation retinopathy or papillopathy, and visual acuity was preserved or improved in 13 eyes and decreased in 1 eye due to the presence of cataract. CONCLUSIONS CyberKnife radiosurgery is a well-tolerated technique for the treatment of intraocular and periocular lymphoma, allowing for local resolution of the lesions. An important benefit is that treatment was completed over 5 days.

Intracavitary brachytherapy for carcinoma of the esophagus

Local control of unresectable esophageal carcinomas remains a significant problem in spite of aggressive treatments. External beam radiation therapy, chemotherapy, and combined modality treatment have all been employed with limited success. Here we review the existing literature and our own experience with external beam radiation followed by low-dose-rate or high-dose-rate intracavitary radiation for carcinoma of esophagus. The addition of intracavitary brachytherapy to external beam irradiation is well tolerated, causes no significant toxicity, and improves local control. Low-dose-rate intracavitary boost compared to high-dose-rate intracavitary boost has the advantage of a greater margin of safety, requires a single application, does not require highly sophisticated computerized technology, and is accompanied with fewer high-grade toxicities. Combined modality therapy consisting of concomitant infusional chemotherapy, external beam irradiation, and low-dose-rate intracavitary boost needs to be investigated.

Brachytherapy for Macular Degeneration Associated with Subretinal Neovascularization

Macular degeneration is the leading cause of severe irreversible blindness in the Western world (Bressler et al. 1988; Hyman et al. 1983). Most patients develop the “dry” form characterized by slowly progressive atrophy of the macular choroid and retina with mild to moderate loss of central vision. In contrast, a minority of patients develop the “wet” form of macular degeneration, which is characterized by the development of subretinal neovascularization, leakage, and scarring. Wet macular degeneration can be a rapid process destroying central vision in a matter of days, weeks, or months. Such subretinal neovascular events have been associated with age-related macular degeneration (ARMD), diabetes, high myopia, histoplasmosis, and laser photocoagulation. Clearly, the ability to control or stop neovascularization would be helpful in the management of these diseases.

Radiation Therapy for Age-Related Macular Degeneration - a Wet Type Summary

Age-related macular degeneration (ARMD) is the leading cause of legal blindness in persons over the age of 65, with most patients demonstrating the non-exudative or dry form (National Advisory Eye Council 1998; Klein et al. 1992). However, approximately 90% of severe visual loss occurs secondarily to the exudative or wet type. It has been estimated that 5%–10% of all patients with age-related macular degeneration have the wet type.

External radiotherapy in macular degeneration: technique and preliminary subjective response

Results: At 2-3 weeks after treatment 29 patients (70%) retained their visual acuity without ehaaqe, 10 (24.5%) stated they had hnproved vision, and 2 (4.8%) stated their vision conthmed to decrease. At 2-3 mon&hs a&er treatment, 27 patients (658%) had no change in their vision, 3 (7.2%) had a decrease in visual acuity. Six patients of 41 in Couclt&orX Our observations in this group of 41 patients su imuroved or stable vision after treatment with low-dose irradiation for age-related wet-type macular degeneration. Copyright 0 1996 Elsevier Science Inc. Macular degeneration, Radiation therapy.