Clinical investigation: eye
The American Brachytherapy Society recommendations for brachytherapy of uveal melanomas

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Abstract

Purpose

This article presents the American Brachytherapy Society (ABS) guidelines for the use of brachytherapy for patients with choroidal melanomas.

Methods

Members of the ABS with expertise in choroidal melanoma formulated brachytherapy guidelines based upon their clinical experience and a review of the literature. The Board of Directors of the ABS approved the final report.

Results

Episcleral plaque brachytherapy is a complex procedure and should only be undertaken in specialized medical centers with expertise in this sophisticated treatment program. Recommendations were made for patient selection, techniques, dose rates, and dosages. Most patients with very small uveal melanomas (<2.5 mm height and <10 mm in largest basal dimension) should be observed for tumor growth before treatment. Patients with a clinical diagnosis of medium-sized choroidal melanoma (between 2.5 and 10 mm in height and <16 mm basal diameter) are candidates for episcleral plaques if the patient is otherwise healthy and without metastatic disease. A histopathologic verification is not required. Small melanomas may be candidates if there is documented growth; some patients with large melanomas (>10 mm height or >16 mm basal diameter) may also be candidates. Patients with large tumors or with tumors at peripapillary and macular locations have a poorer visual outcome and lower local control that must be taken into account in the patient decision-making process. Patients with gross extrascleral extension, ring melanoma, and tumor involvement of more than half of the ciliary body are not suitable for plaque therapy. For plaque fabrication, the ophthalmologist must provide the tumor size (including basal diameters and tumor height) and a detailed fundus diagram. The ABS recommends a minimum tumor 125I dose of 85 Gy at a dose rate of 0.60–1.05 Gy/h using AAPM TG-43 formalism for the calculation of dose. NRC or state licensing guidelines regarding procedures for handling of radioisotopes must be followed.

Conclusion

Brachytherapy represents an effective means of treating patients with choroidal melanomas. Guidelines are established for the use of brachytherapy in the treatment of choroidal melanomas. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose reporting policies. These guidelines will be modified as further clinical results become available.

Introduction

Enucleation had been considered the standard treatment for patients with posterior uveal melanoma. In an effort to preserve vision and the globe, episcleral plaque radiotherapy has become a commonly used alternative. Moore first used radon seed brachytherapy to preserve vision for a monocular patient with uveal melanoma (1). Stallard also tried implanting seeds directly into the tumor, but went on to develop cobalt-60 (60Co) plaque radiotherapy (2). Since that time, a number of other radioisotopes (radionuclides), including gold-198, iodine-125, Ru-106/Rh-106, iridium-192, and palladium-103, have been used for episcleral radiotherapy with varying results from retrospective studies 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24. In an effort to resolve some of the controversies, the Collaborative Ocular Melanoma Study (COMS) Group performed a nationwide, multi-institutional, prospective randomized clinical trial to compare efficacy of enucleation vs. I-125 eye plaque radiotherapy for medium-sized choroidal melanomas and recently reported the preliminary results 25, 26. Other than the COMS guidelines, there are no standardized procedures for episcleral eye plaque use. The American Brachytherapy Society (ABS) therefore formed a panel to issue guidelines for the use of brachytherapy for choroidal melanomas.

Section snippets

Methods and materials

Selected members of the ABS with expertise in choroidal melanoma brachytherapy performed a literature review that, supplemented by their clinical experience, allowed formulation of specific recommendations and directions for future investigation in choroidal melanomas. These recommendations were made by consensus opinion and supported by published data whenever possible. In addition, an external multispecialty panel of recognized experts in the field reviewed the consensus recommendations and

Results

Episcleral plaque brachytherapy is a complex procedure, and the ABS recommends that these procedures should only be undertaken in specialized medical centers with expertise in this sophisticated treatment program. The results of the deliberation of the panel and the ABS recommendations are given in the following sections.

Conclusion

Brachytherapy represents an effective means of treating patients with choroidal melanomas. Guidelines are established for the use of brachytherapy in the treatment of choroidal melanomas. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose reporting policies. These guidelines will be modified as further clinical results become available.

Acknowledgements

The authors wish to express their gratitude to Mr. David Carpenter for editorial assistance. The authors acknowledge the support of the Board of Directors of the American Brachytherapy Society and thank Drs. Beth Erickson and Marvin Rotman for their valuable suggestions.

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