Interventional Radiotherapy (Brachytherapy) in Eyelid and Ocular Surface Tumors: A Review for Treatment of Naïve and Recurrent Malignancies.

The goal of radiotherapy in the treatment of eyelid and ocular surface tumors is to eradicate tumor burden in a manner that maintains visual function and preserve surrounding sensitive ocular tissue. Interventional radiotherapy (IRT-brachytherapy) is a radiotherapy technique associated with a highly focal dose distribution, with the advantage of boosting limited size target volumes to very high dose while sparing normal tissue. The reduction in the ocular and adnexal complications that result from this form of therapy, has led in recent years, to an increase in the use of IRT for the treatment of eyelid and ocular surface tumors. For eyelid malignancies, IRT is used as an independent treatment in small eyelids tumors, in postoperative treatment of high-risk patients and as well as salvage therapy in local recurrences. In the treatment of conjunctival malignancies, due to the high risk of local recurrence, the use of adjuvant therapies as IRT has shown to improve outcomes. In this review, we focus on eyelid and ocular surface IRT techniques and provide an overview of indication, outcomes and toxicity of IRT for the treatment of naïve and recurrent eyelid and conjunctival tumors.

Modified argon laser therapy for benign tumor of the eyelid.

BACKGROUND: To report about the therapy of benign eyelid tumors with a modified argon laser technique as an alternative to surgery. METHODS: Nineteen benign tumors of the eyelid were included in this study. After staining the surface of the tumor with a violet marker, low-energy argon laser photoablation was performed. A mean number of 312 spots (spot size ranging from 150 to 500 µm) with a power of 200 to 400 mW, and a duration between 0.1 and 0.2 s were applied. RESULTS: The eyelid tumors were located mainly in the lower eyelid (58%). Dermal nevi and papilloma were the most frequently treated lesions. Over a mean follow-up period of 10.5 months (range 6-18 months), all eyelid tumors were successfully treated by a single session of laser therapy. All patients were satisfied with the laser therapy and the cosmetic result. No postoperative complications were observed. No relapses occurred during follow-up. CONCLUSIONS: Our modified method of argon laser therapy utilizes the staining of the surface of the eyelid tumor to increase the amount of thermal laser energy absorbed by the target. This novel technique is simple and effective for treating benign eyelid tumors.

Adjuvant radiation therapy for malignant tumours of the eyelid: Experience from a tertiary cancer centre in India.

Background: . Tumours of the eyelid are a rare subgroup of neoplasms with varied histology and inherent differences in clinical behaviour. Surgery is the standard of care, and adjuvant radiation therapy (RT) is given in the presence of features suggesting a high risk of local recurrence. The treatment of lymph nodes in the neck is debatable. We reviewed the utility of RT for lymph nodes in the neck in patients with malignant tumours of the eyelid. Methods: . We reviewed medical records of all patients with tumours of the eyelid treated at our centre from July 2006 to December 2014 for their demographic, clinical profile, treatment details and outcome. Results: . The records of 37 patients were included for analysis, of these 34 underwent surgery and 21 received adjuvant RT. Their median age was 60 (range 30-85) years. Sebaceous cell carcinoma was the most common (50.4%). The median disease-free survival (DFS) was 35 months (95% CI 17.9-52.0). The 1- and 3-year DFS were 82.7% and 45%, respectively. Univariate analysis showed a superior outcome with early stage (T1) tumours (p=0.01), RT dose of ≥60 Gy and those underwent lymph node dissection (p=0.03). The presence of high-risk factors including close or positive margin had an inferior outcome with a trend towards statistical significance (p=0.06). Conclusion: . We found a favourable outcome with early T stage, RT dose of ≥60 Gy and lymph node dissection. High-risk histopathological features including close margins and positive lymph nodes merit adjuvant RT including regional lymph nodes.

Radiotherapy in lymphoepithelioma-like carcinoma of the skin: review of the literature and report of a recurrent and metastatic case.

Primary lymphoepithelioma-like carcinoma of the skin (LELCS) is a very rare cutaneous neoplasm. Only about 70 cases have been documented in the literature. There are no prospective data regarding treatment methods. Surgical excision is sufficient therapy in the majority of cases. Radiation therapy is sometimes used in case of recurrence or positive margins after surgery. The metastatic potential of LELCS is extremely low and only five previously documented cases of lymph node spread have been reported. We present the case of an 80-year-old male with a tumor primarily located on the lower eyelid, with two regional recurrences and cervical lymph node spread after surgery, treated with concurrent chemoradiation. According to the available data, this is the first case of lymph node spread from an eyelid location and the first nodal recurrence after surgery.

Radiotherapy in Periocular Cutaneous Malignancies: A Retrospective Study.

BACKGROUND: Due to the importance of function and cosmetics, periocular skin malignancies represent a therapeutic challenge. OBJECTIVE: To evaluate the safety and efficacy of radiotherapy (RT) treating periocular skin tumors. METHODS: Data of patients with periocular tumors treated with grenz or soft X-rays at the University Hospital Zurich, Switzerland, between 2009 and 2014 were reviewed. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) with associated in situ lesions, cutaneous melanoma, lentigo maligna (LM), cutaneous lymphoma and Kaposi's sarcoma were included in the analysis. RESULTS: We found 159 periocular lesions in 145 patients. Overall recurrence was highest for actinic keratosis and Bowen's disease (27%), melanoma (17%) and LM (15%), whereas SCC and BCC showed recurrence in 11 and 10%, respectively. 45% of all recurrences occurred within 12 months after treatment, with a median time to recurrence of 13 months (range 3-73). CONCLUSION: RT, which provides a good therapeutic response with minimal adverse events, is a therapy option for periocular cutaneous malignancies.

A Crossover Reconstruction Between the Forehead Expansion and Upper Eyelid Skin.

BACKGROUND: In cosmetic surgery, the authors have successfully used forehead expansion for reconstruction of the upper eyelid, and have found it to be indispensable for reconstruction of the upper eyelid. In such an operation, preserving the eyebrow is often a problem, and they suggest an approach in 2 stages, which allows us to both save the eyebrow and use the expander flap at the same time. In the last 6 years, they have performed 5 forehead expansions for total upper eyelid skin reconstruction, achieving very good aesthetic outcomes. METHODS: Firstly, the authors measure the defect and choose an appropriate expander implant for the forehead. Secondly, they cut out the pathologically changed-turned red or scarred-skin to protect the eyebrow. Next they get out the tissue expander and use the tissue flap to repair the upper eyelid defect, while the eyebrow is under the expander flap, covered by skin, which they originally cut from the upper eyelid. Three weeks later they can cut down the pedicel and the flap becomes the new upper eyelid skin. RESULTS: The authors find that the new upper eyelid skin may be vascularized by dermatological vessels from the expander flap. The forehead expander flap is reliable and particularly well suited for an upper eyelid, with numerous advantages. In this way, they make maximal use of the expander flap and no additional incision is needed. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Interstitial brachytherapy for eyelid carcinoma. Outcome analysis in 60 patients.

BACKGROUND: Eyelid cancer is a therapeutic challenge due to the cosmetic and functional implications of this anatomical region and the objectives of therapy are tumor control, functional and cosmetic outcome. AIM: The present study was performed to analyze local control, toxicity, functional and cosmetic results in patients with eyelid carcinoma treated by interstitial brachytherapy. MATERIAL AND METHODS: In this study 60 patients with eyelid carcinoma were treated by interstitial brachytherapy using iridium ((192)Ir) wires with a linear activity of 1.2-1.7 mCi/cm. The prescription dose was 51-70 Gy (mean 65 Gy, median 66 Gy). RESULTS: Of the 60 patients 51 (85.0 %) had received no prior treatment, 4 (6.7 %) had received previous surgery with positive or close margins and 5 (8.3 %) had suffered local recurrence after surgery. Of the tumors 52 (86.7 %) were basal cell carcinoma, 7 (11.7 %) squamous cell carcinoma and 1 (1.7 %) Merkel cell carcinoma. Clinical stage of the 51 previously untreated tumors was 38 T1N0, 12 T2N0 and 1 T3N0. Mean follow-up was 92 months (range 6-253 months). Local control was maintained in 96.7 % of patients. Late effects higher than grade 2 were observed in 3.0 % of cases. Functional and cosmetic outcomes were optimal in 68.4 % of patients. CONCLUSION: Interstitial brachytherapy for carcinoma of the eyelid can achieve local control, cosmetic and functional results comparable to those of surgery.

Conjunctival metastasis as the presenting sign for stage IV lung cancer.

PURPOSE: Lung cancer is the leading cause of cancer-related death in North America. It is often diagnosed at an advanced stage, lending to a poor prognosis. Symptoms of lung cancer often do not present until more advanced stages. Common sites of lung cancer metastasis are the bones, liver, and brain. The etiology of eye masses ranges from the relatively benign to those with tremendous risk of morbidity, and the differentiation is often difficult clinically. This case highlights the importance of more detailed workup, including biopsy, to determine the exact nature of the lesion. CASE REPORT: A 50-year-old white man was referred for evaluation of a "bump" on his right upper eyelid. He had noticed it for 1 month and noted enlargement during the past 2 weeks. He also reported that he had been smoking about one pack per day since 1969. External examination was remarkable for a 1.5-cm nodule pushing up from under the right upper lid. When the lid was everted, there was a 0.9-cm red and black vascularized sessile lesion on the palpebral conjunctiva. The patient was referred to an oculoplastics specialist to rule out a malignant or metastatic conjunctival neoplasm. The oculoplastics service performed an excisional biopsy, and the pathologic examination showed a poorly differentiated and highly aggressive non-small-cell lung cancer (NSCLC). After systemic evaluation, he was diagnosed as having stage IV NSCLC, with metastases to the right eyelid, brain, liver, and right lung. He underwent multiple radiotherapy sessions. He died 5 months after our initial examination. CONCLUSIONS: Stage IV NSCLC is incurable, and its treatment is often palliative. Conjunctival metastasis of stage IV NSCLC is rare, and it is clinically difficult to differentiate eyelid tumors as benign or concerning by examination alone. This case highlights the importance of a thorough history, referral, proper imaging, and biopsy to diagnose a metastatic neoplasm in a patient at high risk for cancer.

Post-operative interventional radiotherapy (brachytherapy) in advanced ocular surface and eyelid tumors as an alternative to surgical retreatment.

PURPOSE: The main purpose of treatment of advanced ocular surface and periocular malignant tumors is to eradicate the tumor while trying to preserve visual function and aesthetics. Our purpose is to describe the outcome of a retrospective case series of 10 patients with advanced ocular surface and periocular tumors treated surgically in first instance and then with postoperative interventional radiotherapy (IRT/Brachiterapy). MATERIALS AND METHODS: We describe the clinicopathological features, treatments and outcome, in a retrospective case series of 10 patients with advanced tumors involving ocular surface (staging ≥ T2) and eyelids (staging ≥ T3), with involvement of periocular and/or orbit tissues. Patients were first surgically treated, most of them with incomplete excision, and then underwent a post-operative interventional radiotherapy (IRT/Brachytherapy) as an alternative to more invasive and disfiguring surgical retreatment. Tumor location, risk factors, staging, histological features, and follow-up timing were analyzed. RESULTS: Three patients had advanced eyelid basal cell carcinomas, 2 patients were diagnosed with eyelid and conjunctival squamous cell carcinomas, 3 as sebaceous carcinomas, and 2 as primary conjunctival melanomas. The mean follow-up time from IRT to last clinical follow-up was 58.6 weeks, range 28.4-168 (median 43.65, IQR 28.9-72.9). Two patients - one with ocular surface SCC, the other with conjunctival melanoma - had a local recurrence 23.4 and 40,9 weeks after IRT, respectively. An overview of the current knowledge on adjuvant or post-operative IRT is also provided. CONCLUSIONS: IRT can be considered an effective therapeutic option to avoid more invasive surgical retreatment in advanced tumors involving eyelids and ocular surface.

Two new cases of metastatic basal cell carcinoma from the eyelids.

BACKGROUND: Basal cell carcinoma (BCC) is an extremely common malignancy. Unlike other skin cancers, it very rarely metastasises. METHODS: We present two cases of advanced BCC on the eyelids that metastasized to the parotid region after local excision. DISCUSSION: We include a review of patients with metastatic BCC originating from the eyelids. CONCLUSION: Metastatic BCC from the eyelids is rare, but appears to occur in an older age group with a shorter time before metastasis when compared to metastatic BCC as a whole.

Uncorrectable ptosis: primary cutaneous signet-ring cell carcinoma.

Primary cutaneous signet-ring cell carcinoma (PCSRCC) is a rare but aggressive tumor. Our case highlights a 60-year-old man who presented with eyelid ptosis, for which he underwent multiple surgical procedures over a 3-year period prior to referral to our clinic. These procedures were complicated by scarring, delayed healing, and poor cosmetic outcome. In addition, the patient was noted to develop progressive enophthalmos. These concerning signs led to a CT scan and subsequent eyelid biopsy, which revealed a diagnosis of PCSRCC. Further management has involved an MRI and orbitotomy with biopsy revealing widespread extension of the carcinoma. Exenteration was performed to reduce the likelihood of metastasis. There are few documented case reports of PCSRCC of the eyelid in the literature. Of the 33 published cases of PCSRCC, 27 cases involve the eyelids and the other 6 cases involve the axilla. The unique clinical features of this case will be discussed, in particular the presentation as ptosis, an otherwise commonplace complaint in the oculoplastics clinic. The surgical course and histopathologic findings will be presented. The literature regarding PCSRCC will be reviewed including demographics, management, and prognosis. Although rare, PCSRCC follows an aggressive course with characteristically delayed diagnosis. Early identification and treatment likely offer a better prognosis. Thus, description of the clinical presentation of this rare tumor may aid in recognition and earlier treatment.

Relevance of dermatologic radiotherapy in the therapeutic strategy of skin epithelial neoplasms: excellent results in the treatment of lesions localized on eyelids and skin overlying the cartilage of the nose.

AIM: Epithelial cancer of the skin is the most common human neoplasm. In spite of the multiple modalities of treatment available, about 10 % of these tumours results resistant to them. Therefore, improving the therapeutic strategies is mandatory. METHODS: A retrospective study has been carried out on 905 patients affected by 986 basal and squamous cell carcinoma, histologically ascertained, localized on eyelids and on skin overlying the cartilages of the nose treated with conventional radiotherapy. All the lesions were classified according to TNM classification. RESULTS: Follow-up ranged from 1 to 425 months. The five-year cure-rate was 96.38% for eyelids neoplasms and 92.43% for those localized on skin covering nose cartilages, respectively. The percentage of relapse was 5.47%.The graphic representation shows how the risk of relapse remains high for the first five years. On the whole cosmetic and functional outcomes were good. CONCLUSION: Our results confirm dermatologic radiotherapy as a treatment proper to afford very high cure-rates, and support the importance of a correct follow-up. The knowledge of these data and the possibility to compare them with others obtained by different therapies and endowed with histopathologic investigation, TNM classification, adequate follow-up and significant clinical series would result in improvement of the management of skin epithelial neoplasms.

Radiation therapy for primary carcinoma of the eyelid: tumor control and visual function.

BACKGROUND AND PURPOSE: Surgical excision remains the standard and most reliable curative treatment for eyelid carcinoma, but frequently causes functional and cosmetic impairment of the eyelid. We therefore investigated the efficacy and safety of radiation therapy in eyelid carcinoma. PATIENTS AND METHODS: Twenty-three patients with primary carcinoma of the eyelid underwent radiation therapy. Sebaceous carcinoma was histologically confirmed in 16 patients, squamous cell carcinoma in 6, and basal cell carcinoma in 1. A total dose of 50-66.6 Gy (median, 60 Gy) was delivered to tumor sites in 18-37 fractions (median, 30 fractions). RESULTS: All but 3 of the 23 patients had survived at a median follow-up period of 49 months. The overall survival and local progression-free rates were 87% and 93% at 2 years, and 80% and 93% at 5 years, respectively. Although radiation-induced cataracts developed in 3 patients, visual acuity in the other patients was relatively well preserved. There were no other therapy-related toxicities of grade 3 or greater. CONCLUSION: Radiation therapy is safe and effective for patients with primary carcinoma of the eyelid. It appears to contribute to prolonged survival as a result of good tumor control, and it also facilitates functional and cosmetic preservation of the eyelid.

Locally advanced sebaceous cell carcinoma (T3) of eyelid: incidence and pattern of nodal metastases and combined modality management approach.

BACKGROUND: Sebaceous carcinoma (SbCC) is a rare malignancy that often mimics benign conditions. Lymphatic involvement, large T3 tumors herald a dismal survival for patients. We present our series of 13 cases of locally advanced SbCC of the eyelid treated at a surgical oncology unit and describe the clinical profile, patterns of nodal spread and recurrence pattern in this subset of SbCC. METHODS: A retrospective analysis of case records was carried out for patients presenting with orbital tumors between January 1997 and April 2010 in the department of Surgical Oncology, AIIMS, New Delhi, India. All patients underwent orbital exenteration and superficial parotidectomy with neck dissection was added to patients with clinically significant lymphadenopathy. All patients who underwent OE after 2002 were advised radiotherapy as adjuvant therapy. The end point was development of recurrence or end of two year follow up period which ever occurred earlier. RESULTS: Thirteen patients underwent orbital exenteration. Eleven patients had clinically palpable lymphadenopathy. Ten patients (76.9%) had pathologically confirmed metastatic nodes. Parotid lymph node involvement was present in all patients (100%); two of these ten patients also had level II b cervical lymph node involvement. Recurrence was observed in seven patients (53.8%). All recurrences were loco-regional only and no systemic metastases was seen. There were only two recurrences in the group that received PORT. CONCLUSIONS: Eyelid SbCC is a loco-regionally aggressive malignancy and adequate disease control can be achieved with combined modality approach of radical surgery followed by post operative radiotherapy.

[Morphological changes in meibomian glands following radiotherapy].

PURPOSE: To examine the morphological changes in meibomian glands using noncontact infrared meibography in patients undergoing radiotherapy and to compare the results with those of a normal population. CASES AND METHOD: Thirteen eyes of 8 patients (2 men and 6 women; 65.1 +/- 17.6 years, mean +/- standard deviation) diagnosed as having ocular adnexal lymphoma and had undergone radiotherapy were included in this study. Meibomian gland morphological changes (meiboscore) were assessed by noncontact meibography. The results were compared with those of forty-one eyes of 21 healthy volunteers (9 men and 12 women ; 66.9 +/- 11.6 years). RESULTS: The meiboscore was 3.69 +/- 0.75 in the irradiation group and 2.41 +/- 1.34 in the control group, showing a significant difference between the groups (p = 0.0029). When compared with the irradiated and fellow eyes in the patients with unilateral radiotherapy, the mean meiboscore of irradiated eyes (4.00 +/- 1.00) was higher than that of the fellow eyes (2.66 +/- 0.57) even though there was no significant difference. CONCLUSION: Radiotherapy causes morphological changes in the meibomian glands such as atrophy and dropout.

Clinical significance of tumor-infiltrating FOXP3+ T cells in patients with ocular adnexal mucosa-associated lymphoid tissue lymphoma.

We evaluated the association between tumor-infiltrating FOXP3+ T cells and clinical outcomes in patients with ocular adnexal lymphoma of mucosa-associated lymphoid tissue type (OAML). Pretreatment formalin-fixed paraffin-embedded tissues from 42 patients with OAML were stained with 236A/E7 anti-FOXP3 murine monoclonal antibody as well as CD3, CD4 and CD8 antibodies. The amount of FOXP3+ T cells was numerically quantified using an image analysis program. Front-line treatments were as follows: combination chemotherapy (n = 25); radiotherapy (n = 9); doxycycline (n = 6); and wait and see (n = 2). Complete response (CR) was observed in 20 (50%) of 40 evaluable patients. Median progression-free survival (PFS) was 50 months. A high number of FOXP3+ T cells (n = 21, ≥ 180/0.58 mm(2)) showed a higher CR rate (33%vs 71%, P = 0.013) and tendency towards prolonged PFS (48 vs 67 months, P = 0.110). In the combination chemotherapy group, a high number of FOXP3+ T cells was significantly associated with a higher CR rate (29%vs 82%, P = 0.008) and prolonged PFS (17 vs 79 months, P = 0.003). A high number of tumor-infiltrating FOXP3+ T cells correlates with a favorable clinical outcome in OAML patients.

Case Series of Laser Therapy of Eyelid Peripunctal Benign Tumor.

Objective: This study is the first time to explore the feasibility of CO2 laser treating some eyelid lacrimal puncta benign tumor. Background: Eyelid lacrimal papillae is special anatomy region. Treatment of eyelid peripunctal tumor is relatively intractable and needs reconstruction of the lacrimal passage in most of the time. We use super pulse CO2 laser to treat peripunctal benign tumor and appears to be effective. Materials and methods: It contained 12 participants treated with super pulse CO2 laser photocoagulation without lacrimal duct silicone tube placement. The areas of lesions were as follows: eight cases were located in the upper eyelid lacrimal puncta, four cases in the lower lacrimal puncta. Super pulse CO2 laser was used to treat it. The follow-up period was 4 weeks, 24 weeks, and 3 years after treatment. Histological diagnoses were obtained in all patients. Results: All patients were satisfactory after treatment with their cosmetic outcomes, and the wounds are dry, with no infections. No patient has functional damage, secondary epiphora, and lacrimal drainage system obstruction. Complete epithelialization occurs 2-4 weeks after treatment and forms normal epithelium. It showed no obvious scars or notches after treatment, and only temporarily less hyperpigmentation is in the treated area than the circumambient normal skin. During the follow-up period, there were no complications and no relapses were observed. Conclusions: Super pulse CO2 laser therapy for eyelid peripunctal benign tumors without lacrimal duct silicone tube placement sometime appears to be available, effective, and well-tolerated alternative to traditional surgery in the clinic, especially for selected disease. The IRB proved number is 2016034.

Uveal Melanoma Metastasis to the Contralateral Eye Structures: A Retrospective Comparative Analysis of 13 Consecutive Patients.

PURPOSE: To report uveal melanoma (UM) metastasis to the contralateral ocular and periocular structures. DESIGN: Retrospective study. PARTICIPANTS: Thirteen patients with UM metastasis to the contralateral ocular and periocular structures were included. METHODS: Clinical records were reviewed retrospectively. MAIN OUTCOME MEASURES: The development and time to onset of contralateral ocular and periocular metastasis, systemic metastasis, and death. RESULTS: Of the 13 000 treated UM patients, 13 patients were diagnosed with UM metastasis to the contralateral ocular and periocular structures. Mean patient age at primary UM diagnosis was 60 years (median, 60 years; range, 37-87 years). The primary uveal melanoma was in the choroid (n = 11) or ciliary body (n = 2) and was treated with brachytherapy (n = 11), proton beam radiotherapy (n = 1), or enucleation (n = 1). Systemic metastasis developed in 11 patients (85%) at a mean of 66 months (median, 34 months; range, 12-216 months) after diagnosis of the primary UM. All 11 patients (100%) showed liver metastasis and 8 patients (62%) also showed extrahepatic metastasis. The sites of metastasis to the contralateral ocular or periocular structures included the choroid in 4 patients (31%), the orbit in 7 patients (54%), and the eyelid in 2 patients (15%). One patient with eyelid metastasis demonstrated concurrent conjunctival nodule. Mean time to diagnosis of contralateral ocular or periocular metastasis was 94 months (median, 48 months; range, 9-375 months). Contralateral choroidal metastasis was multifocal in 3 of 4 patients (75%). Of 7 patients with orbital metastasis, 5 showed extraocular muscle involvement with restricted ocular motility. Treatment for contralateral choroidal metastasis included brachytherapy (n = 2), transpupillary thermotherapy (n = 1), and observation (n = 1). Treatment for contralateral periocular (orbit or eyelid) metastasis was excision (n = 5), external beam radiotherapy (n = 2), and observation (n = 2). Of 13 patients, death was documented in 11 patients at a mean of 17 months (median, 9 months; range, 3-54 months) as a result of systemic UM metastasis (n = 10) or unrelated cause (n = 1). CONCLUSIONS: Metastasis resulting from UM to the contralateral ocular and periocular structures is rare and generally occurs in patients with disseminated metastasis. Orbital tissue is the most common site of involvement, and these patients have short life expectancy.

Technical considerations for noncoplanar proton-beam therapy of patients with tumors proximal to the optic nerve.

PURPOSE: To investigate technical feasibilities of noncoplanar proton-beam therapy (PBT) on dose reduction to critical organs. MATERIAL AND METHODS: The degree of mechanical precision, rotational limitations of the gantry and the treatment couch were evaluated, and dose-volume histograms were compared for noncoplanar and coplanar PBT. Following these studies, three patients with tumors proximal to the optic nerve underwent noncoplanar PBT. RESULTS: Noncoplanar PBT offered advantage in dose reduction to the optic nerve when compared to coplanar therapy. This advantage was more significant if the tumor reduced in size during treatment. None experienced radiation injury to the optic nerve during a short follow-up time of 7-12 months. CONCLUSION: Noncoplanar PBT appears to reduce doses to organs at risk.