Transitioning from a COMS-based plaque brachytherapy program to using eye physics plaques and plaque simulator treatment planning system: A single institutional experience.

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.

Optical Coherence Tomography Angiography Microvascular Variations in Pre- and Posttreatment of Retinoblastoma Tumors.

INTRODUCTION: The purpose of this study is to describe variations in microvasculature before and after treatment of treatment-naive lesions and during consolidation therapy of retinoblastoma lesions using an investigational portable optical coherence tomography angiography (OCTA) system. METHODS: This study is a single-center, prospective, observational case series. Recruited subjects were either undergoing surveillance for retinoblastoma or had newly detected retinoblastoma. Nine tumors from 7 eyes in 6 patients were included. During exams under anesthesia, the tumors were imaged with an investigational portable OCTA system. OCTA images were analyzed to assess vascular changes before and after treatment. RESULTS: In all 6 presented cases, OCTA imaging revealed distinctive vascular patterns, such as dilated feeder arteries and draining veins, disorganized and complex branching patterns, irregular vessel calibers, and dilation and tortuosity of vessels. After treatment, OCTA imaging revealed decreased intrinsic tumor vascularity and reduced dilation of draining and feeder vessels. Tumor relapse demonstrated prominent vascularity (n = 1) that resolved on repeat OCTA after transpupillary thermotherapy treatment. Type 2 (n = 1), 3 (n = 6), and 4 (n = 1) tumor regression patterns were seen in our patients after treatment, and OCTA findings were consistent with a previously published report. Interestingly, in one of the presented cases, OCTA demonstrated clear feeder, draining, and intrinsic tumor vessels that were not as evident on fluorescein angiography. CONCLUSIONS: OCTA may offer a noninvasive and sensitive technique to evaluate the vasculature of both the tumor and the surrounding retina in retinoblastoma. With additional research and development into its use in patients with retinoblastoma, OCTA may one day be useful in assessing treatment response and residual tumor activity.

Microvascular Features of Treated Retinoblastoma Tumors in Children Assessed Using OCTA.

BACKGROUND AND OBJECTIVE: To describe the microvascular features of treated, clinically regressed, or reactivated retinoblastoma lesions using an investigational portable optical coherence tomography angiography (OCTA) system. PATIENTS AND METHODS: Single-center, prospective, cross-sectional, consecutive case-series of children with previously treated retinoblastoma who underwent portable OCTA of posterior retinoblastoma lesions. RESULTS: Eight tumors from seven eyes of five children with retinoblastoma were included. Tumors with types 1 (calcified remnant, n = 3), 2 (non-calcified remnant, n = 1), and 3 (both calcified and noncalcified remnants, n = 1) regression revealed persistent intrinsic superficial vasculature on OCTA (five of five lesions; 100%). Lesions with type 4 regression (atrophic scar, n = 2) had complete vascular flow voids in the involved retina and underlying choriocapillaris. A reactivated tumor (n = 1) showed a distinct area of vascularity with prominent feeder/draining vessels. CONCLUSIONS: OCTA revealed that significant vascularity exists in inactive retinoblastoma lesions. Dilated feeder vessels may suggest continued disease activity. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:43-49.].

Small choroidal melanoma with monosomy 3.

PURPOSE: To report a patient with small juxtapapillary choroidal melanoma with chromosome 3 monosomy treated with I(125) plaque and transpupillary thermotherapy (TTT). A 64-year-old Caucasian male presented with painless blurred vision of the left eye. Ocular examination disclosed a small juxtapapillary choroidal melanocytic tumor with overlying subretinal fluid and orange pigment. Ultrasound showed an elevated choroidal mass of 2 mm thickness with low reflectivity on A-scan and hollowness on B scan, consistent with a small choroidal melanoma. The patient was treated with plaque I(125) radiotherapy combined with one session of TTT. Genetic testing of the tumor cells obtained by fine needle aspiration biopsy showed chromosome 3 monosomy. At 1 year after treatment, the tumor was regressed with resolution of subretinal fluid and 20/40 visual acuity. A small choroidal melanoma can manifest monosomy of chromosome 3, a known predictive factor for the development of systemic metastasis.

Regression of uveal melanoma after plaque radiotherapy and thermotherapy based on chromosome 3 status.

PURPOSE: To evaluate regression rates after plaque radiotherapy and thermotherapy of uveal melanoma with chromosome 3 monosomy versus disomy. DESIGN: Noncomparative case series. PARTICIPANTS: Two hundred and seventy patients with uveal melanoma. METHODS: Fine needle aspiration biopsy was used at the time of plaque radiotherapy to sample tumor cells for genetic testing. MAIN OUTCOME MEASURES: Tumor thickness regression based on chromosome 3 status. RESULTS: At the time of plaque radiotherapy, the median tumor thickness was 4.0 mm for melanomas with chromosome 3 monosomy and 3.5 mm for those with disomy 3. The median tumor thickness (% original thickness) at 4, 8, 12, 15, and 18 months after radiotherapy for melanoma with monosomy 3 was 77%, 67%, 58%, 55%, and 50% and for those with disomy 3 was 82%, 70%, 69%, 67%, and 61%. The median monthly regression rate was 3.1% for tumors with monosomy 3 and 2.7% for those with disomy 3. The overall regression and monthly rate of regression was statistically greater at 12 months (P < 0.001) and 15 months (P = 0.003) for melanomas with monosomy 3 compared with disomy 3. CONCLUSIONS: Uveal melanomas with chromosome 3 monosomy showed faster and greater tumor thickness regression at 12 and 15 months after plaque radiotherapy and thermotherapy than melanomas with disomy 3.

Early macular morphological changes following plaque radiotherapy for uveal melanoma.

PURPOSE: To evaluate the time of onset and risk factors for the development of macular edema following plaque radiotherapy for uveal melanoma, using optical coherence tomography (OCT). METHODS: This observational case series included 135 consecutive patients with uveal melanoma treated with Iodine(125) plaque radiotherapy and adjunctive transpupillary thermotherapy (TTT) laser. Patients were evaluated at baseline and 6-month intervals following treatment using ophthalmoscopy, B-scan ultrasonography, fundus photography, and OCT. RESULTS: Median follow-up was 24 months. The mean time to onset of macular edema by OCT was 12 months. Median best-corrected logMAR visual acuity at the time of onset of OCT-evident macular edema was 0.3 (equivalent to 20/40 Snellen). The development of OCT-evident macular edema was significantly associated with maximum tumor thickness (P = 0.0016), largest tumor base (P < 0.0001), radiation dose, and dose-rate to the tumor base (P = 0.0315 and P = 0.0204, respectively). Neither radiation dose to the foveola nor treatment with adjunctive TTT laser was significantly associated with the development of macular edema. CONCLUSIONS: OCT is useful in the early detection of radiation-induced macular edema, before clinical signs of radiation maculopathy develop and before substantial visual loss occurs. The development of macular edema is significantly associated with larger initial tumor size.

Changing concepts in management of circumscribed choroidal hemangioma: the 2003 J. Howard Stokes Lecture, Part 1.

BACKGROUND AND OBJECTIVE: To review trends in the management of circumscribed choroidal hemangioma (CCH) and to propose treatment guidelines based on review of recent literature and the authors' personal experience with more than 250 METHOD: The English-language literature on the management of CCH was reviewed, with emphasis on changing concepts in recent years. RESULTS: Xenon arc and argon laser photocoagulation and thermotherapy have been used to treat CCH with localized retinal detachment, but there has recently been enthusiasm for photodynamic therapy (PDT) using fluorescein angiography and optical coherence tomography to monitor subretinal fluid and cystoid retinal edema before and after treatment. Tumors with extensive retinal detachment have been managed by surgical attempts at retinal reattachment followed by photocoagulation or cryotherapy, and more recently by radiotherapy. Management currently includes observation, argon laser photocoagulation, transpupillary thermotherapy, PDT, and radiotherapy. Enucleation may be necessary in rare cases. The goal of treatment should be to induce resolution of existing retinal detachment and to improve or stabilize visual loss. CONCLUSIONS: There is increasing use of PDT for CCH with localized retinal detachment and radiotherapy for CCH with more extensive detachment. Although follow-up is short, current methods may achieve better tumor control and better visual outcome. However, caution is advised because long-term follow-up is still not available.