Clinical science
Transpalpebral proton beam radiotherapy of choroidal melanoma Lazaros Konstantinidis,1 Dawn Roberts,2 R Douglas Errington,3 Andrzej Kacperek,3 Heinrich Heimann,1 Bertil Damato4 1
Vitreoretinal and Ocular Oncology Service, Royal Liverpool University Hospital, Liverpool, UK 2 Liverpool Ocular Oncology Research Group, Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK 3 Douglas Cyclotron, Clatterbridge Cancer Centre, Wirral, UK 4 Ocular Oncology Service, Departments of Ophthalmology and Radiation Oncology, University of California, San Francisco, USA Correspondence to Dr Bertil Damato, Ocular Oncology Service, University of California, San Francisco, 10 Koret Way, K304, San Francisco, CA 94143-0730, USA; [email protected] Received 28 March 2014 Revised 4 July 2014 Accepted 26 July 2014 Published Online First 19 August 2014
ABSTRACT Background Collateral damage to upper eyelid margin during proton beam radiotherapy (PBR) for choroidal melanoma may cause squamous metaplasia of the tarsal conjunctiva with keratinisation, corneal irritation, discomfort and, rarely, corneal perforation. We evaluated transpalpebral PBR as a means of avoiding collateral damage to the upper eyelid margin without increasing the risk of failure of local tumour control. Methods Retrospective study of consecutive patients who underwent PBR for choroidal melanoma between 1992 and 2007 at the Royal Liverpool University Hospital and the Douglas Cyclotron at Clatterbridge Cancer Centre, UK. Results Sixty-three patients were included in this study. Mean basal tumour diameter and tumour thickness were 11.8 mm and 3.6 mm, respectively. PBR mean beam range and modulation were 26.5 mm and 16.9 mm respectively. The eyelid margin was included in the radiation field in 15 (24%) eyes. The median follow-up was 2.5 years. Local tumour recurrence developed in 2 (3.2%) patients. In these two cases that developed tumour recurrence the transpalpebral treatment did not involve the eyelid margin. Six (9.5%) patients died of metastatic disease. No eyelid or ocular surface problems developed in any of the 48 patients who were treated without eyelid rim involvement, while 7 of the 15 patients with unavoidable irradiation of the eyelid rim developed some degree of madarosis. These seven patients all received more than 26.55 proton Gy to the eyelid margin. Symptoms, such as grittiness occurred in 12% of 48 patients without eyelid margin irradiation as compared with 53% of 15 patients whose lid margin was irradiated. Conclusions Transpalpebral PBR of choroidal melanoma avoids eyelid and ocular surface complications without increasing failure of local tumour control.
INTRODUCTION
To cite: Konstantinidis L, Roberts D, Errington RD, et al. Br J Ophthalmol 2015;99:232–235. 232
Proton beam radiotherapy (PBR) is an effective treatment for uveal melanoma.1–5 The advantage of PBR is that the depth of destructive ionisation can be adjusted to cover the maximum depth of the tumour. The Bragg peaks offer some superficial tissue sparing; however, this varies according to the amount of multiple Bragg peaks (or ‘modulation’) required to cover tumours with a flat ‘plateau’ of proton radiation dose.6 If it is not possible to retract the upper eyelid margin out of the radiation field, damage to the muco-cutaneous junction may occur that can cause squamous metaplasia of the superior tarsal conjunctiva with the formation of keratin, which abrades
the cornea every time the patient blinks. This may cause keratopathy which can become so severe as to cause corneal perforation requiring enucleation.7 To circumvent these problems, we have, since 1991, been treating uveal melanomas through the eyelids, thereby avoiding or minimising collateral damage to the upper eyelid margin. The aim of this study was to evaluate such ‘transpalpebral’ PBR of uveal melanoma, in terms of ocular morbidity and local tumour control.
PATIENTS AND METHODS Patient selection This study is a retrospective, non-randomised study and includes consecutive patients who underwent PBR for a choroidal malignant melanoma between 1992 and 2007 at the Royal Liverpool University Hospital and the Douglas Cyclotron at Clatterbridge Cancer Centre, UK. The patients were identified by reviewing the computerised database of the Douglas Cyclotron at Clatterbridge Cancer Centre, UK. Inclusion criteria were: basal tumour diameter exceeding 7 mm and superior location of the tumour. These criteria were based on the fact that this subgroup of the patients was more likely to have undergone transpalpebral PBR. Additional inclusion criteria were: absence of extraocular tumour spread and absence of detectable metastases at presentation. Patients with a minimum of 2 years follow-up were included in this study. Patients were excluded if they had received any treatment for uveal melanoma prior to the PBR. The patients were reviewed at our centre until the risk of local tumour recurrence was considered to be
Transpalpebral proton beam radiotherapy of choroidal melanoma Lazaros Konstantinidis,1 Dawn Roberts,2 R Douglas Errington,3 Andrzej Kacperek,3 Heinrich Heimann,1 Bertil Damato4 1
Vitreoretinal and Ocular Oncology Service, Royal Liverpool University Hospital, Liverpool, UK 2 Liverpool Ocular Oncology Research Group, Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK 3 Douglas Cyclotron, Clatterbridge Cancer Centre, Wirral, UK 4 Ocular Oncology Service, Departments of Ophthalmology and Radiation Oncology, University of California, San Francisco, USA Correspondence to Dr Bertil Damato, Ocular Oncology Service, University of California, San Francisco, 10 Koret Way, K304, San Francisco, CA 94143-0730, USA; [email protected] Received 28 March 2014 Revised 4 July 2014 Accepted 26 July 2014 Published Online First 19 August 2014
ABSTRACT Background Collateral damage to upper eyelid margin during proton beam radiotherapy (PBR) for choroidal melanoma may cause squamous metaplasia of the tarsal conjunctiva with keratinisation, corneal irritation, discomfort and, rarely, corneal perforation. We evaluated transpalpebral PBR as a means of avoiding collateral damage to the upper eyelid margin without increasing the risk of failure of local tumour control. Methods Retrospective study of consecutive patients who underwent PBR for choroidal melanoma between 1992 and 2007 at the Royal Liverpool University Hospital and the Douglas Cyclotron at Clatterbridge Cancer Centre, UK. Results Sixty-three patients were included in this study. Mean basal tumour diameter and tumour thickness were 11.8 mm and 3.6 mm, respectively. PBR mean beam range and modulation were 26.5 mm and 16.9 mm respectively. The eyelid margin was included in the radiation field in 15 (24%) eyes. The median follow-up was 2.5 years. Local tumour recurrence developed in 2 (3.2%) patients. In these two cases that developed tumour recurrence the transpalpebral treatment did not involve the eyelid margin. Six (9.5%) patients died of metastatic disease. No eyelid or ocular surface problems developed in any of the 48 patients who were treated without eyelid rim involvement, while 7 of the 15 patients with unavoidable irradiation of the eyelid rim developed some degree of madarosis. These seven patients all received more than 26.55 proton Gy to the eyelid margin. Symptoms, such as grittiness occurred in 12% of 48 patients without eyelid margin irradiation as compared with 53% of 15 patients whose lid margin was irradiated. Conclusions Transpalpebral PBR of choroidal melanoma avoids eyelid and ocular surface complications without increasing failure of local tumour control.
INTRODUCTION
To cite: Konstantinidis L, Roberts D, Errington RD, et al. Br J Ophthalmol 2015;99:232–235. 232
Proton beam radiotherapy (PBR) is an effective treatment for uveal melanoma.1–5 The advantage of PBR is that the depth of destructive ionisation can be adjusted to cover the maximum depth of the tumour. The Bragg peaks offer some superficial tissue sparing; however, this varies according to the amount of multiple Bragg peaks (or ‘modulation’) required to cover tumours with a flat ‘plateau’ of proton radiation dose.6 If it is not possible to retract the upper eyelid margin out of the radiation field, damage to the muco-cutaneous junction may occur that can cause squamous metaplasia of the superior tarsal conjunctiva with the formation of keratin, which abrades
the cornea every time the patient blinks. This may cause keratopathy which can become so severe as to cause corneal perforation requiring enucleation.7 To circumvent these problems, we have, since 1991, been treating uveal melanomas through the eyelids, thereby avoiding or minimising collateral damage to the upper eyelid margin. The aim of this study was to evaluate such ‘transpalpebral’ PBR of uveal melanoma, in terms of ocular morbidity and local tumour control.
PATIENTS AND METHODS Patient selection This study is a retrospective, non-randomised study and includes consecutive patients who underwent PBR for a choroidal malignant melanoma between 1992 and 2007 at the Royal Liverpool University Hospital and the Douglas Cyclotron at Clatterbridge Cancer Centre, UK. The patients were identified by reviewing the computerised database of the Douglas Cyclotron at Clatterbridge Cancer Centre, UK. Inclusion criteria were: basal tumour diameter exceeding 7 mm and superior location of the tumour. These criteria were based on the fact that this subgroup of the patients was more likely to have undergone transpalpebral PBR. Additional inclusion criteria were: absence of extraocular tumour spread and absence of detectable metastases at presentation. Patients with a minimum of 2 years follow-up were included in this study. Patients were excluded if they had received any treatment for uveal melanoma prior to the PBR. The patients were reviewed at our centre until the risk of local tumour recurrence was considered to be
