RESUMEN
PURPOSE: The purpose of this investigation is to delineate the risk factors in the development of neovascular glaucoma (NVG) after helium-ion irradiation of uveal melanoma patients and to propose treatment technique that may reduce this risk. METHODS AND MATERIALS: 347 uveal melanoma patients were treated with helium-ions using a single-port treatment technique. Using univariate and multivariate statistics, the NVG complication rate was analyzed according to the percent of anterior chamber in the radiation field, tumor size, tumor location, sex, age, dose, and other risk factors. Several University of California San Francisco-Lawrence Berkeley National Laboratory (LBNL) patients in each size category (medium, large, and extralarge) were retrospectively replanned using two ports instead of a single port. By using appropriate polar and azimuthal gaze angles or by treating patients with two ports, the maximum dose to the anterior segment of the eye can often be reduced. Although a larger volume of anterior chamber may receive a lower dose by using two ports than a single port treatment. We hypothesize that this could reduce the level of complications that result from the irradiation of the anterior chamber of the eye. Dose-volume histograms were calculated for the lens, and compared for the single and two-port techniques. RESULTS: NVG developed in 121 (35%) patients. The risk of NVG peaked between 1 and 2.5 years posttreatment. By univariate and multivariate analysis, the percent of lens in the field was strongly correlated with the development of NVG. Other contributing factors were tumor height, history of diabetes, and vitreous hemorrhage. Dose-volume histogram analysis of single-port vs. two-port techniques demonstrate that for some patients in the medium and large category tumor groups, a significant decrease in dose to the structures in the anterior segment of the eye could have been achieved with the use of two ports. CONCLUSION: The development of NVG after helium-ion irradiation is correlated to the amount of lens, anterior chamber in the treatment field, tumor height, proximity to the fovea, history of diabetes, and the development of vitreous hemorrhage. Although the influence of the higher LET deposition of helium-ions is unclear, this study suggests that by reducing the dose to the anterior segment of the eye may reduce the NVG complications. Based on this retrospective analysis of LBNL patients, we have implemented techniques to reduce the amount of the anterior segment receiving a high dose in our new series of patients treated with protons using the cyclotron at the UC Davis Crocker Nuclear Laboratory (CNL).
Asunto(s)
Segmento Anterior del Ojo , Glaucoma Neovascular/etiología , Helio/efectos adversos , Melanoma/radioterapia , Neoplasias de la Úvea/radioterapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Enucleación del Ojo , Femenino , Helio/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , ProbabilidadRESUMEN
PURPOSE: To determine the efficacy of silicone rod frontalis sling ptosis repair in selected patients. METHODS: The authors retrospectively studied 35 consecutive patients who underwent silicone sling ptosis repairs in 6 lids at the University of California, San Francisco. RESULTS: Preoperative diagnoses included congenital ptosis causing developmental delay or possible amblyopia in children younger than 3 years of age, chronic progressive external ophthalmoplegia, third-nerve palsy, myasthenia gravis, and ocular restriction secondary to glaucoma filtering valves. With a mean follow-up of 22 months, good-to excellent final lid height was achieved in all 61 lids. Recurrence of the ptosis occurred in four lids (7%), requiring replacement of the silicone rod in two lids and revision of the original sling in two lids to reach the final lid height. Chronic exposure keratopathy without corneal infection occurred postoperatively in 9 (15%) of 61 eyes, all in patients with an inadequate or absent Bell phenomenon. Chronic corneal problems did not develop in any of the children. Extrusion of the sling with or without infection occurred in three foreheads (5%) in two patients younger than 15 years of age. CONCLUSION: Silicone rod is an effective material for use in frontalis suspension in treating severe ptosis with poor levator function. Children younger than 3 years of age with congenital ptosis and developmental delay or possible amblyopia can undergo silicone frontalis suspension to achieve good visual results. The elasticity and ease of adjustment of the silicone rod are ideal characteristics for a suspensory material used to correct severe ptosis associated with a minimal or absent Bell phenomenon, such as in chronic progressive external ophthalmoplegia, myasthenia gravis, or third-nerve palsy.
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Blefaroptosis/cirugía , Párpados/cirugía , Elastómeros de Silicona , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Blefaroptosis/congénito , Blefaroptosis/etiología , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Músculos Oculomotores/cirugía , Complicaciones Posoperatorias , Recurrencia , Estudios RetrospectivosRESUMEN
Retrospective and ongoing analyses of clinical records from 347 primary intraocular melanoma patients treated with helium ions at LBL will allow examination of the exposure-response data for human cataract; which is a complication of the therapy from incidental exposure of the lens. Direct particle beam traversal of at least a portion of the lens usually is unavoidable in treatment of posterior intraocular tumors. The precise treatment planned for each patient permits quantitative assessment of the lenticular dose and its radiation quality. We are reporting our preliminary results on the development of helium-ion-induced lens opacifications and cataracts in 54 of these patients who had 10% or less of their lens in the treatment field. We believe these studies will be relevant to estimating the human risk for cataract in space flight.
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Catarata/etiología , Helio/efectos adversos , Cristalino/efectos de la radiación , Melanoma/radioterapia , Neoplasias de la Úvea/radioterapia , Adulto , Medicina Aeroespacial , Anciano , Estudios de Seguimiento , Humanos , Iones , Persona de Mediana Edad , Aceleradores de Partículas , Traumatismos por Radiación/etiología , Radioterapia/efectos adversos , Medición de RiesgoRESUMEN
OBJECTIVE: To delineate the factors in the development of visually significant cataract after helium ion irradiation of eyes with uveal melanomas. DESIGN: Retrospective analysis with multivariate analysis using life tables and Cox proportional hazard models in addition to other nonparametric techniques. PATIENTS: All patients with a noncataractous other eye and adequate dosimetry data who were treated with helium ion irradiation. RESULTS: Significant cataracts (grade 3+ or 4+ on a 0 to 4+ scale) developed in 129 patients (44%). The risk of cataract development peaked at 3 years (25% per person-year) and then declined to a sustained level of 7% to 9% per year after 7 years. In multivariate analysis, the percentage of lens included in the treatment port was the predominant predictive correlate with time to significant cataract (relative risk of 2.97 for a 25% increase in the percentage of lens in the treatment port). Patient age, preexisting cortical opacity, and ultrasound tumor height were also significant; ciliary body involvement and tumor dose had smaller effects. Kaplan-Meier analysis demonstrated an increased rate of cataractogenesis with each increment of the percentage of lens in the treatment port; when more than half of the lens was in the beam, the risk of cataract exceeded 90% within 7 years. CONCLUSIONS: Cataract development after helium ion irradiation is a function of the amount of the lens in the beam. Unlike neovascular glaucoma that develops mainly in the first few years after treatment, cataract continues to develop during the entire length of follow-up.
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Catarata/etiología , Cristalino/efectos de la radiación , Melanoma/radioterapia , Neoplasias de la Úvea/radioterapia , Adulto , Anciano , Catarata/patología , Femenino , Helio , Humanos , Cristalino/patología , Tablas de Vida , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Dosis de Radiación , Radioterapia/efectos adversos , Estudios RetrospectivosRESUMEN
Monoclonal antibodies and flow cytometry were used to study lymphocyte, monocyte and tumor cell antigen expression in uveal melanoma. Forty-one melanomas were studied after various forms of treatment. An antimelanoma antibody, 13A3E, stained 81.7% of the cells. Tumors treated with helium ions or 125I plaques had 13A3E staining reduced to 62.5%, p = 0.011. HLA-A,B,C stained 85.4%, and HLA-DR stained 7.0% of the cells. T cells (CD3 positive) comprised 4.5% (range 0.1-29.2%) of total cell population. Natural killer (NK) cells, B cells and macrophages were present in small numbers (mean less than 2.5% in each case). Tumors with numerous T cells (greater than 5%), were used for T cell subtype studies. The mean helper/inducer (CD4) to cytotoxic/suppressor (CD8) ratio was 1.00 (range 0.11-3.15). CD8 decreased, and CD4 increased with age in unirradiated tumors (p less than 0.02).
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Antígenos de Neoplasias/análisis , Melanoma/inmunología , Monocitos/inmunología , Subgrupos de Linfocitos T/inmunología , Neoplasias de la Úvea/inmunología , Adulto , Anciano , Anticuerpos Monoclonales , Citometría de Flujo , Antígenos de Histocompatibilidad Clase I/inmunología , Antígenos de Histocompatibilidad Clase II/inmunología , Humanos , Inmunofenotipificación , Melanoma/patología , Persona de Mediana Edad , Neoplasias de la Úvea/patologíaRESUMEN
We retrospectively analyzed archival retinoblastomas from 44 eyes. The percentage of cycling cells were increased in younger patients, those with advanced disease, and cases with poor prognosis. These data suggest that all cell cycle studies may yield important insights in retinoblastoma.
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ADN/metabolismo , Neoplasias del Ojo/genética , Retinoblastoma/genética , Envejecimiento/fisiología , Aneuploidia , Ciclo Celular , Neoplasias del Ojo/patología , Humanos , Retinoblastoma/patología , Estudios RetrospectivosRESUMEN
Recent advances in flow cytometry allow for study of DNA content in paraffin-embedded pathology material. Using refinements of published techniques, we retrospectively correlated tumor cell DNA content (ploidy) with histologic findings and clinical outcome in 79 patients with uveal melanoma. Patients were included using these selection criteria: enucleation without adjunctive therapy performed at the University of California at San Francisco between 1956 and 1979, tumor located in ciliary body or choroid, and pathology material and complete follow-up data available. The DNA histograms were classifiable as diploid or hyperploid in 64 cases. The mean coefficient of variation for diploid histograms was 6.6%. Twenty-three patients (36%) had hyperploid tumors. Hyperploidy was correlated with worse outcome. The effect was most marked for DNA indexes of over 1.4. A Cox proportional hazards model showed that the effects of tumor diameter and cell type were insignificant in comparison with the effect of the DNA index.
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ADN de Neoplasias/análisis , Melanoma/genética , Neoplasias de la Úvea/genética , Humanos , Melanoma/mortalidad , Melanoma/secundario , Pronóstico , Neoplasias de la Úvea/mortalidad , Neoplasias de la Úvea/secundarioRESUMEN
We correlated predicted radiation distributions in 29 patients with uveal melanoma (treated with 5,000 to 8,000 rads of helium ion therapy) with fundus photography and visual field deficits. The tumor was entirely within the treatment region in all patients. The fraction of the predicted high-dose and low-dose regions corresponding with an absolute scotoma was fitted by a linear regression model (r2 = .721) with three independent variables: dose region, initial condition, and time since therapy. The defect in the maximum-dose region increased at an average rate of 0.270/year. This differed (P = .002) from the rate in the penumbra region: (0.104/year). The rate in the penumbra differed (P = .01) from that in the predicted low-dose region, where scotoma did not increase with time. The pattern and time course of visual field loss in the different radiation dose regions tended to support the conclusion that isodose calculations are accurate. The data were consistent with the hypothesis that visual loss secondary to irradiation results primarily from radiation vasculopathy and not from direct damage to photoreceptors or ganglion cells. Development of an absolute scotoma may require a dose in excess of 5,000 rads.