Collaborative Ocular Melanoma Study Eye Research Articles

Equivalent uniform RBE-weighted dose in eye plaque brachytherapy.

Brachytherapy for ocular melanoma is based on the application of eye plaques with different spatial dose nonuniformity, time-dependent dose rates and relative biological effectiveness (RBE). We propose a parameter called the equivalent uniform RBE-weighted dose (EUDRBE) that can be used for quantitative characterization of integrated cell survival in radiotherapy modalities with the variable RBE, dose nonuniformity and dose rate. The EUDRBE is applied to brachytherapy with 125I eye plaques designed by the Collaborative Ocular Melanoma Study (COMS). The EUDRBE is defined as the uniform dose distribution with RBE=1 that causes equal cell survival for a given nonuniform dose distribution with the variable RBE>1. The EUDRBE can be used for comparison of cell survival for nonuniform dose distributions with different RBE, because they are compared to the reference dose with RBE=1. The EUDRBE is applied to brachytherapy with 125I COMS eye plaques that are characterized by a steep dose gradient in tumor base-apex direction, protracted irradiation during time intervals of 3-8 days, and variable dose-rate dependent RBE with a maximum of about 1.4. The simulations are based on dose of 85Gy prescribed to the farthest intraocular extent of the tumor (tumor apex). To compute the EUDRBE in eye plaque brachytherapy and correct for protracted irradiation, the distributions of physical dose have been converted to non-uniform distributions of biologically effective dose (BED) to include the biological effects of sublethal cellular repair, Our radiobiological analysis considers the combined effects of different time-dependent dose rates, spatial dose non-uniformity, dose fractionation and different RBE and can be used to derive optimized dose regimens brachytherapy. Our simulations show that the EUDRBE increases with the prescription depths and the maximum increase may achieve 6% for the tumor height of 12mm. This effect stems from a steep dose gradient within the tumor that increases with the prescription depth. The simulations also show that the EUDRBE increase may achieve 12% with increasing the dose rate when implant duration decreases. The combined effect of dose nonuniformity and dose rate may change the EUDRBE up to 18% for the same dose prescription of 85Gy to tumor apex. The absolute dose range of 48-61Gy (RBE) for the EUDRBE computed using 4 or 5 fractions is comparable to the dose prescriptions used in stereotactic body radiation therapy (SBRT) with megavoltage X-rays (RBE=1) for different cancers. The tumor control probabilities in SBRT and eye plaque brachytherapy are very similar at the level of 80% or higher that support the hypothesis that the selected approximations for the EUDRBE are valid. The computed range of the EUDRBE in 125I COMS eye plaque brachytherapy suggests that the selected models and hypotheses are acceptable. The EUDRBE can be useful for analysis of treatment outcomes and comparison of different dose regimens in eye plaque brachytherapy.

Generation and comparison of 3D dosimetric reference datasets for COMS eye plaque brachytherapy using model-based dose calculations.

A joint Working Group of the American Association of Physicists in Medicine (AAPM), the European Society for Radiotherapy and Oncology (ESTRO), and the Australasian Brachytherapy Group (ABG) was created to aid in the transition from the AAPM TG-43 dose calculation formalism, the current standard, to model-based dose calculations. This work establishes the first test cases for low-energy photon-emitting brachytherapy using model-based dose calculation algorithms (MBDCAs). Five test cases are developed: (1) a single model 6711 125 I brachytherapy seed in water, 13 seeds (2) individually and (3) in combination in water, (4) the full Collaborative Ocular Melanoma Study (COMS) 16 mm eye plaque in water, and (5) the full plaque in a realistic eye phantom. Calculations are done with four Monte Carlo (MC) codes and a research version of a commercial treatment planning system (TPS). For all test cases, local agreement of MC codes was within ∼2.5% and global agreement was ∼2% (4% for test case 5). MC agreement was within expected uncertainties. Local agreement of TPS with MC was within 5% for test case 1 and ∼20% for test cases 4 and 5, and global agreement was within 0.4% for test case 1 and 10% for test cases 4 and 5. Dose distributions for each set of MC and TPS calculations are available online (https://doi.org/10.52519/00005) along with input files and all other information necessary to repeat the calculations. These data can be used to support commissioning of MBDCAs for low-energy brachytherapy as recommended by TGs 186 and 221 and AAPM Report 372. This work additionally lays out a sample framework for the development of test cases that can be extended to other applications beyond eye plaque brachytherapy.

Analysis of dose to the macula, optic disc, and lens in relation to vision toxicities – A retrospective study using COMS eye plaques

PurposeThe aim of this study was to relate common toxicity endpoints with dose to the macula, optic disc, and lens for uveal melanoma patients treated with Iodine-125 Collaborative Ocular Melanoma Study (COMS) eye plaque brachytherapy. MethodsA cohort of 52 patients treated at a single institution between 2005 and 2019 were retrospectively reviewed. Demographics, dosimetry, and clinical outcomes were recorded. Univariate, relative risk, and Kaplan-Meier analyses were performed to relate dose to toxicity endpoints including retinopathy, vision decline, and cataracts. ResultsBy the end of follow up (Median = 3.6 years, Range = 0.4 – 13.5 years), 65 % of eyes sustained radiation retinopathy, 40 % demonstrated moderate vision decline (>5 Snellen lines lost), and 56 % developed cataracts. Significant (p < 0.05) risk estimates exist for retinopathy and VA decline for doses >52 Gy to the macula and >42 Gy to the optic disc. Moreover, dose to the lens > 16 Gy showed a significant risk for cataract formation. Kaplan-Meier analysis demonstrated significantly different incidence of radiation retinopathy for > 52 Gy to the macula and > 42 Gy to the optic disc. In addition, the Kaplan-Meier analysis showed significantly different incidence of cataract formation for patients with lens dose > 16 Gy. ConclusionsDose-effect relationships exist for the macula and optic disc with respect to the loss of visual acuity and the development of retinopathy. To better preserve vision after treatment, further research is needed to reduce macula, optic disc, and lens doses while maintaining tumor control.

Ocular malignancies treated with iodine-125 low dose rate (LDR) brachytherapy at a single high-volume institution: A retrospective review.

The aim of our study is to document our cases of choroidal melanoma treated with low dose rate (LDR) brachytherapy and to correlate the dosimetry and radiobiology with clinical effects and oncologic outcomes. Data from 157 patients treated from 2014 to 2018 with LDR brachytherapy were used for this investigation. Treatments used a collaborative ocular melanoma study eye plaque and Iodine-125 radioactive seeds. The seeds activities were chosen to deliver 85 Gy to the tumor apex or to a prescription point (if the apex < 5 mm). The plaque sizes used were 10, 12, 14, 16, 18, 20, and 22 mm including notched or deep notched. The plaques were modeled in Varian BrachyVision version 11.6 (Varian Medical Systems) with seed coordinates from the AAPM Task Group 129. The Task Group 43 from AAPM was used for brachytherapy dose planning. Dose data were extracted for the apex, prescription point, sclera, retina opposite to the implant, lens, macula, and optic disc. The radiobiological dosimetry were calculated using appropriate α/β ratios found in the literature and then correlated to clinical side effects. Average biologically effective dose for associated organs at risk were calculated in cases where toxicity occurred. These included: radiation cataract (70.66 Gy), disc atrophy (475.49 Gy), foveal atrophy (263.07 Gy), radiation papillopathy (373.45 Gy), radiation maculopathy (213.62 Gy), vitreous hemorrhage (1437.68 Gy), vascular occlusion (1080.93 Gy), nonproliferative retinopathy (1066.89 Gy), proliferative retinopathy (1590.71 Gy), exudative retinal detachment (1364.32 Gy), and rhegmatogenous retinal detachment (2265.54 Gy). Average biologically effective dose was higher in patients who developed radiation induced long term side effects than in the whole patient population except for radiation maculopathy. In spite of the small patient population and short-term follow-up, it is of interest to correlate the radiation induced effects and create a guideline for the improvement of the treatment of patients treated with LDR brachytherapy.

EyeDose: An open-source tool for using published Monte Carlo results to estimate the radiation dose delivered to the tumor and critical ocular structures for 125I Collaborative Ocular Melanoma Study eye plaques

PurposeRadiation side effects and visual outcome for uveal melanoma patients managed with plaque radiotherapy are dependent on the radiation dose administered to the tumor and nearby healthy tissues. We have developed an open-source software tool, EyeDose, to simplify and standardize tumor and critical structure dose reporting for Collaborative Ocular Melanoma Study eye plaques. Methods and MaterialsEyeDose is a MATLAB-based program that calculates point dose and volume dose metrics for standard models of the tumor and critical ocular structures. It uses published three-dimensional dose distributions for eye plaques, calculated with Monte Carlo methods, which are oriented with respect to the eye using the tumor's position on a fundus diagram. A standard model for the ocular structures was created using published measurements and patient CT scans. EyeDose reports radiation statistics for the fovea, optic disc, lens, lacrimal gland, retina, and tumor. The dosimetric margin for implant placement uncertainty is also calculated. ResultsEyeDose calculations were validated against previously published Monte Carlo results for eight different tumor positions, including the dose to the fovea, optic disc, lacrimal gland, lens, and along the central axis. EyeDose accepts a spreadsheet input for rapidly processing large retrospective patient data sets, with an average run time of <40 s per patient. EyeDose is published as an open-source tool for easy adaptation at different institutions. ConclusionsEyeDose calculates radiation statistics for Collaborative Ocular Melanoma Study eye plaque patients with Monte Carlo accuracy and without a treatment planning system. EyeDose streamlines data collection for large retrospective studies and can also be used prospectively to assess plaque applicability.

EyeDose: An Open Source Tool For Calculating The Radiation Dose Delivered To The Tumor And Critical Ocular Structures For 125I COMS Eye Plaques

Radiation side effects and visual outcome for uveal melanoma patients managed with plaque radiotherapy are dependent on the radiation dose administered to the tumor and nearby healthy tissues. The AAPM Task Group Report 129 recommends that the dose to critical normal structures be recorded, preferably using heterogeneity corrected dose distributions. We have developed an open source software tool, EyeDose, to simplify and standardize tumor and critical structure dose reporting for COMS eye plaques. This work builds upon the accomplishments of previous researchers and aims to combine the best features of prior tools, including the accuracy of Monte Carlo, the elimination of manual contouring and the treatment planning system, the standardization of eye geometry, and precise plaque localization using high resolution fundus diagrams. The software may be used for prospective clinical decision making, for example to help with plaque size selection or a comparison of plaque radiotherapy versus proton therapy, or to rapidly process large retrospective data sets, without repetitive manual entry, for reporting on the relationships between dosimetry and outcomes. EyeDose is a Matlab program that calculates point and volume (DVH) dose metrics for the tumor and critical ocular structures. The three-dimensional dose distributions for 125I Collaborative Ocular Melanoma Study (COMS) eye plaques, calculated with Monte Carlo methods, are oriented with respect to the eye using the tumor’s position on a fundus diagram. A standard model for the ocular structures was created using published measurements and patient CT scans. EyeDose reports radiation statistics for the fovea, optic disc, lens, lacrimal gland, retina, and tumor. The dosimetric margin for implant placement uncertainty is also calculated. EyeDose calculations were validated against published Monte Carlo results for nasal, temporal, inferior, and superior tumor positions, including the dose to the fovea, optic disc, lacrimal gland, lens, and along the central axis. The EyeDose program demonstrated close agreement with published Monte Carlo results. The mean, median, and maximum point dose differences between EyeDose and previous Monte Carlo studies were 0.0, 0.0, and 0.5 Gy. The mean difference, reported as %volume, among the DVH calculations was -0.2% ± 0.2% (Std. Dev.) with a range from -1.08% to 0.05%. The execution time averaged <40 sec. per patient on an Intel i-5-6500 CPU @ 3.20 GHz with 32 GB RAM. EyeDose is published as an open source tool for easy adaptation at different institutions. EyeDose calculates radiation statistics for COMS eye plaque patients with Monte Carlo accuracy and without a treatment planning system. EyeDose streamlines data collection for large retrospective studies and can also be used prospectively to assess plaque applicability.

An improved treatment planning and quality assurance process for Collaborative Ocular Melanoma Study eye plaque brachytherapy

PurposeTo develop a treatment planning platform for episcleral Collaborative Ocular Melanoma Study plaque therapy in an established treatment planning software and to improve an existing quality assurance (QA) process for nonuniformly loaded plaques that measures air kerma strengths (AKSs) and loading profile. Materials and MethodsTreatment planning is performed in Pinnacle using scripts that let the planner choose plaque size and notching. Scripts load seed positions for each plaque and five source groups corresponding to available stock seeds that can be placed into each seed position. Contours are loaded that display the model eye and the plaque itself. Plaque QA is performed using a modification of our previous pinhole apparatus by replacing x-ray film exposure with an optical camera and scintillating film system. The captured image is processed to remove background and to correct the intensity of seeds on the plaque periphery. Measured total optical counts provide an estimate of total plaque AKS. ResultsTreatment planning of eye plaques using Pinnacle, in conjunction with our stock inventory of seeds, is established as standard practice at our center. Planned plaques can vary from uniformly loaded to asymmetrically loaded notched plaques. Using the optical camera system for assessment of the seed loadings has decreased QA time from 40 min/plaque to 10 min/plaque. Total AKS of each plaque can be measured using the optical camera with an accuracy of 10%. ConclusionsTreatment planning is performed on a Health Canada–approved software that accommodates nonuniform plaque loading. Optical imaging of the plaque provides absolute total AKS and the relative seed arrangement in the plaque.

Evaluation of dose enhancement in presence of gold nanoparticles in eye brachytherapy by 103Pd source.

In recent years, the use of gold nanoparticles in radiation therapy has been introduced as a new approach in radiotherapy. The aim of this study is to investigate the effect of gold nanoparticles (GNPs) in plaque brachytherapy for choroidal melanoma using Monte Carlo (MC) simulation. MCNPX code was used for simulation of human eye, 103Pd (model 200) brachytherapy source and the 20mm COMS eye plaque that was loaded with 24 103Pd seeds and standardized by Collaborative Ocular Melanoma Study (COMS). The tumour was defined from the inner surface of choroid with 0.55cm height and latticed with gold nanospheres and it was filled with different concentrations of 5, 10 and 15mg/g GNPs, separately. Dose rate and dose enhancement factor in tumour and normal tissues of the eye (without gold) was examined for this case and compared with gold-water mixture of the same concentrations distributed in the tumour. The results show that with increasing the concentration of GNPs, the dose in the tumour increases and the dose to the normal tissues decreases. Furthermore, the time that is required to deliver the prescribed dose to the tumour decreases. In the gold nanosphere case for 5, 10 and 15mg/g concentrations, the DEF in the apex of the tumour are 1.28, 1.46, 1.44 and at the distance of 6.5mm in the normal tissue (outside the tumour) this factor would be 0.82, 0.73 and 0.68. The comparison between two cases of gold nanospheres and gold-water mixture shows that when the gold concentrations are defined as mixed with water, the dose enhancement in the first depths are higher than when the gold-nanoparticles are distributed inside the tumour. Furthermore due to more reduced particle flux for water-mixture case, by an increase in the depth the dose enhancement in gold-nanosphere increases compared with gold-water mixture case.

Dosimetry of 125I and 103Pd COMS eye plaques for intraocular tumors: Report of Task Group 129 by the AAPM and ABS

Dosimetry of eye plaques for ocular tumors presents unique challenges in brachytherapy. The challenges in accurate dosimetry are in part related to the steep dose gradient in the tumor and critical structures that are within millimeters of radioactive sources. In most clinical applications, calculations of dose distributions around eye plaques assume a homogenous water medium and full scatter conditions. Recent Monte Carlo (MC)-based eye-plaque dosimetry simulations have demonstrated that the perturbation effects of heterogeneous materials in eye plaques, including the gold-alloy backing and Silastic insert, can be calculated with reasonable accuracy. Even additional levels of complexity introduced through the use of gold foil "seed-guides" and custom-designed plaques can be calculated accurately using modern MC techniques. Simulations accounting for the aforementioned complexities indicate dose discrepancies exceeding a factor of ten to selected critical structures compared to conventional dose calculations. Task Group 129 was formed to review the literature; re-examine the current dosimetry calculation formalism; and make recommendations for eye-plaque dosimetry, including evaluation of brachytherapy source dosimetry parameters and heterogeneity correction factors. A literature review identified modern assessments of dose calculations for Collaborative Ocular Melanoma Study (COMS) design plaques, including MC analyses and an intercomparison of treatment planning systems (TPS) detailing differences between homogeneous and heterogeneous plaque calculations using the American Association of Physicists in Medicine (AAPM) TG-43U1 brachytherapy dosimetry formalism and MC techniques. This review identified that a commonly used prescription dose of 85 Gy at 5 mm depth in homogeneous medium delivers about 75 Gy and 69 Gy at the same 5 mm depth for specific (125)I and (103)Pd sources, respectively, when accounting for COMS plaque heterogeneities. Thus, the adoption of heterogeneous dose calculation methods in clinical practice would result in dose differences >10% and warrant a careful evaluation of the corresponding changes in prescription doses. Doses to normal ocular structures vary with choice of radionuclide, plaque location, and prescription depth, such that further dosimetric evaluations of the adoption of MC-based dosimetry methods are needed. The AAPM and American Brachytherapy Society (ABS) recommend that clinical medical physicists should make concurrent estimates of heterogeneity-corrected delivered dose using the information in this report's tables to prepare for brachytherapy TPS that can account for material heterogeneities and for a transition to heterogeneity-corrected prescriptive goals. It is recommended that brachytherapy TPS vendors include material heterogeneity corrections in their systems and take steps to integrate planned plaque localization and image guidance. In the interim, before the availability of commercial MC-based brachytherapy TPS, it is recommended that clinical medical physicists use the line-source approximation in homogeneous water medium and the 2D AAPM TG-43U1 dosimetry formalism and brachytherapy source dosimetry parameter datasets for treatment planning calculations. Furthermore, this report includes quality management program recommendations for eye-plaque brachytherapy.

Improved Eye Plaque Brachytherapy Dosimetry Using Monte Carlo Methods

Eye plaque brachytherapy is a sight-preserving medical procedure in which radioactive sources are reproducibly arranged within a collimating source backing and temporarily sutured to the eye. The procedure was established as an alternative to enucleation or eye removal for the treatment ocular melanoma. The 1987 Collaborative Ocular Melanoma Study (COMS) standardized this treatment technique in a prospective, randomized clinical trial; however, dose calculations were performed using simple assumptions. These assumptions used the point-source dosimetry formalism, omitted dose anisotropy, and ignored the presence of dose perturbing material heterogeneities. Monte Carlo (MC) simulations from the mid-1980s to the present have critically evaluated these assumptions and indicated where improvements in practice could be made. Various investigators have used MC to evaluate plaque design, choice of source radionuclide, X-ray fluorescence from plaque components, plaque material heterogeneity attenuation, and patient tissue heterogeneity attenuation, among others. These publications are reviewed with emphasis on clinically relevant observations. In addition, MC simulations of standard COMS eye plaques using MCNP5 are made and compared to published data using other MC codes. Good agreement is observed between radiation transport codes with differences <2%, for points within the eye globe. These results indicate that historically delivered radiation doses were systematically lower than prescribed doses. Practical considerations for implementing MC calculations in the clinic are introduced, and the need for a heterogeneity-corrected treatment planning system to ensure treatment uniformity across medical centers and for different treatment techniques is discussed.

WE‐A‐BRB‐01: Accurate Dosimetric Characterization of a Fully Loaded 20 Mm COMS I‐125 Eye Plaque Using Specially Designed GAFCHROMICTM Film

Purpose: The majority of eye plaques used in the U.S. are of Collaborative Ocular Melanoma Study (COMS) design with I‐125 brachytherapy seeds. Treatment planning is usually done using the TG‐43 formalism, not accounting for the gold alloy backing and Silastic insert, which significantly reduce the dose, as calculated by BrachyDose Monte Carlo (MC) (www.physics.carleton.ca/clrp/eye_plaque/). Dosimetric characterization of a fully loaded 20 mm COMS plaque using radiochromic film is reported. Methods: A 20 mm COMS eye plaque was uniformly loaded with 24 6711 I‐125 seeds at 6.75 U/seed. Measurements were performed using specially designed single layer GAFCHROMIC EBT1 film sandwiched perpendicular to the plaqueˈs central axis at depths 0 – 19 mm between inserts of a Solid Water “eye” phantom located at the center of a 30×30×30 cm3 full scatter Solid Water phantom. The films were calibrated using a 6711 I‐125 seed in Solid Water, applying the TG‐43 formalism. Results: Dose distributions in planes perpendicular to the central axis of the plaque are radially isotropic and uniform. Measured depth dose on central axis as well as off‐axis profiles, agree well with the results of MC. At 3 mm from the inner sclera, the measured dose rate is 12.5% lower than TG‐43 dose rate in homogenous water, similar to 11.9% for MC. The thin flexible film enabled measurements of the dose at the surface of the plaque. Results on duplicate films agree within 5.5%. Conclusions: GAFCHROMIC film in a Solid Water phantom is a convenient, accurate, and reproducible dosimeter for I‐125 eye plaque dosimetry. Dose measurements on the inner surface of the plaque enable precise assessment of the scleral dose and its homogeneity, and of the active area of the plaque for coverage determination. This work validates the MC simulations about the dose reduction effect by the plaqueˈs backing and insert.In‐Kind support of materials provided by Oncura, Inc., Arlington Heights, IL and by International Specialty Products, Inc., Wayne, NJ

Alternative Dose for Choroidal Melanoma Treated With an Iodine-125 Radioactive Plaque: A Single-Institution Retrospective Study

The Collaborative Ocular Melanoma Study (COMS) established iodine-125 plaque brachytherapy as an accepted standard treatment for medium-size choroidal melanoma. In the COMS, the prescription dose was 85 Gy. This is a retrospective review of our outcomes in patients treated with lower doses than those used in the COMS. From 1990 to 2004, 62 patients were treated with iodine-125 plaque brachytherapy for choroidal melanoma. COMS eye plaques were used with dose prescribed to the apex of the tumor. The median and average dose rates at the tumor apex were 63.5 cGy/h and 62.7 cGy/h, respectively. The median and average total doses were 63.0 Gy and 62.5 Gy (range, 56-69 Gy), respectively. The median and mean durations of implant were 100.0 hours and 101.1 hours (range, 71-165 hours). Median follow-up time was 58.2 months. The 5-year outcomes including overall survival, disease-free survival, cause-specific survival, local failure, secondary enucleation rate, and visual acuity (VA) <20/200 were estimated using the Kaplan-Meier method. Overall, there were 7 local failures, 4 distant failures, and 10 secondary enucleations (6 due to local failure and 4 due to treatment complications). Univariate analysis was performed to identify significant prognostic factors associated with disease-free survival (baseline VA in tumor eye, tumor shape), cause-specific survival (diabetic retinopathy), local failure (none found), secondary enucleation rate (diabetic retinopathy, basal tumor dimension) and VA <20/200 (diabetic retinopathy, tumor shape, age, retinal detachment, treatment depth, and history of vision-limiting condition). Our survival and local control outcomes are comparable to those of the COMS. However, VA at 5 years seems to be better. Lower doses of radiation could potentially lead to better visual outcomes.

A comprehensive dosimetric comparison between 131Cs and 125I brachytherapy sources for COMS eye plaque implant

Purpose To verify the dosimetric characteristics of 131Cs source in the Collaborative Ocular Melanoma Study (COMS) eye plaque brachytherapy, to compare 131Cs with 125I in a sample implant, and to examine the accuracy of treatment planning system in dose calculation. Methods and Materials Monte Carlo (MC) technique was used to generate three-dimensional dose distributions of a 16-mm COMS eye plaque loaded with 131Cs and 125I brachytherapy sources separately. A spherical eyeball, 24.6 mm in diameter, and an ellipsoidal tumor, 6 mm in height and 12 mm in diameter, were used to evaluate the doses delivered. The simulations were carried out both with and without the gold and gold alloy plaque. A water-equivalent seed carrier was used instead of the silastic insert designed for the traditional COMS eye plaque. The 13 sources involved were also individually simulated to evaluate the intersource effect. In addition, a treatment planning system was used to calculate the doses at the central axis for comparison with MC data. Results The gold plaque had significantly reduced the dose in the tumor volume; at the prescription point of this study, that is, 6 mm from the edge of inner sclera, the gold plaque reduced the dose by about 7% for both types of 131Cs and 125I sources, but the gold alloy plaque reduced the dose only by 4% for both types of sources. The intersource effect reduced the dose by 2% for both types of sources. At the same prescription dose, the treatment with the gold plaque applicator tended to create more hot regions for either type of sources than were seen with the homogeneous water phantom. The doses of TPS agree with the MC. Conclusion The 131Cs source is comparable to the 125I source in the eye plaque brachytherapy. The TPS can provide accurate dose calculations for eye plaque implants with either type of sources.

Improving quality assurance for assembled COMS eye plaques using a pinhole gamma camera

A quality assurance system has been designed to verify the location and strength of seeds loaded in a brachytherapy eye plaque. This system consists of (1) a pinhole camera in conjunction with a Lumisys ACR-2000i computed radiography (CR) unit to image the location and measure the relative strength of the seeds with autoradiography, and (2) a source strength jig with a survey meter to estimate the total activity of the seeds in the plaque. Five holders of different sizes were made for fixation of the COMS (Collaborative Ocular Melanoma Study) plaques (12, 14, 16, 18, and 20 mm) in the camera. The plaque-to-pinhole distance (dpp) has been optimized to be 30 mm to give approximately uniform intensity on the CR image for uniformly loaded COMS plaques. The pinhole-to-detector distance (dpd) can be kept at either 30 mm for 1:1 scale, or at larger distances for higher magnification. For a 1:1 scaling and pinhole diameter of 0.345 mm, useful images are obtained with time-activity product (mCi sec) ranging from 5 to 250 mCi sec. Within this range, the pinhole system is able to differentiate seed activities of >10%. The resulting pinhole autoradiograph is able to (1) confirm the correct number of seeds loaded in the plaque, (2) verify the proper sitting of the seeds in the silastic carrier and the plaque, (3) verify the relative activity distribution of the seeds loaded in the plaque, and (4) potentially evaluate the integrity of the seed. The source strength measurement system is able to measure the total strength of seeds in the plaque ranging from 10 to 80 mCi with an uncertainty of 5%.

COMS eye plaque brachytherapy dosimetry simulations for P103d, I125, and C131s.

Monte Carlo (MC) simulations were performed to estimate brachytherapy dose distributions for Collaborative Ocular Melanoma Study (COMS) eye plaques. Brachytherapy seed models 200, 6711, and CS-1 Rev2 carrying P103d, I125, and C131s radionuclides, respectively, were modeled and benchmarked against previously published values. Calculated dose rate constants ΛMC were 0.684, 0.924, and 1.052 cGy h-1 U-1 (±2.6%, k=1 uncertainty) for models 200, 6711, and CS-1 Rev2, respectively. The seeds were distributed into 10, 12, 14, 16, 18, 20, and 22 mm-diameter COMS eye plaques. Simulations were performed in both heterogeneous and homogeneous environments, where the latter were in-water and the former included the silastic seed carrier insert and gold-alloy plaque. MC-based homogenous central axis dose distributions agreed within 2%±1% (±1 s.d.) to hand-calculated values. For heterogeneous simulations, notable photon attenuation was observed, with dose reduction at 5 mm of 19%, 11%, and 9% for P103d, I125, and C131s, respectively. A depth-dependent correction factor was derived to correct homogenous central-axis dose distributions for plaque component heterogeneities, which were found to be significant at short radial distances.

Improved treatment planning for COMS eye plaques

A recent reanalysis of the Collaborative Ocular Melanoma Study (COMS) medium tumor trial concluded that incorporating factors to account for anisotropy, line source approximation, the gold plaque, and attenuation in the Silastic seed carrier into the dose calculations resulted in a significant and consistent reduction of calculated doses to structures of interest within the eye. The authors concluded that future eye plaque dosimetry should be "performed using the most up-to-date parameters available." The reason these factors are important is attributable to the low energy (125)I radiation (approximately 28 keV) that is primarily absorbed by the photoelectric process. Photoelectric absorption is quite dependent on the atomic composition of the absorbing material. Being 40% silicon by weight, the effective atomic number of Silastic is significantly greater than that of water. Although the AAPM TG43 brachytherapy formalism inherently addresses the issues of source anisotropy and geometry, its parameter that accounts for scatter and attenuation, the radial dose function g(r), assumes that the source is immersed in infinite homogeneous water. In this work, factors are proposed for (125)I that correct for attenuation in the Silastic carrier and scatter deficits resulting from the gold plaque and nearby air. The implications of using (103)Pd seeds in COMS plaques are also discussed. An existing TG43-based ophthalmic plaque planning system was modified to incorporate additional scatter and attenuation correction factors that better account for the path length of primary radiation in the Silastic seed carrier and the distance between the dose calculation point and the eye-air interface. Compared with homogeneous water, the dose-modifying effects of the Silastic and gold are greatest near the plaque surface and immediately adjacent to the plaque, while being least near the center of the eye. The calculated dose distribution surrounding a single (125)I seed centered in a COMS 20 mm plaque was found to be consistent with previously published examples that used thermoluminescent dosimetry measurements and Monte Carlo methods. For fully loaded 12 and 20 mm plaques, calculated dose to critical ocular structures ranged from 16%-50% less than would have been reported using the standard COMS dose calculation protocol. Treatment planning for COMS eye plaques that accurately accounts for the presence of the gold, Silastic and extraocular air is both possible and practical.