Plaque Placement Research Articles

MO‐FG‐210‐01: Commissioning An US System for Brachytherapy: An Overview of Physics, Instrumentation, and Techniques

Ultrasound (US) is one of the most widely used imaging modalities in medical practice. Since US imaging offers real‐time imaging capability, it has becomes an excellent option to provide image guidance for brachytherapy (IGBT). (1) The physics and the fundamental principles of US imaging are presented, and the typical steps required to commission an US system for IGBT is provided for illustration. (2) Application of US for prostate HDR brachytherapy, including partial prostate treatments using MR‐ultrasound co‐registration to enable a focused treatment on the disease within the prostate is also presented. Prostate HDR with US image guidance planning can benefit from real time visualization of the needles, and fusion of the ultrasound images with T2 weighted MR allows the focusing of the treatment to the specific areas of disease within the prostate, so that the entire gland need not be treated. Finally, (3) ultrasound guidance for an eye plaque program is presented. US can be a key component of placement and QA for episcleral plaque brachytherapy for ocular cancer, and the UCLA eye plaque program with US for image guidance is presented to demonstrate the utility of US verification of plaque placement in improving the methods and QA in episcleral plaque brachytherapy.Learning Objectives: To understand the physics of an US system and the necessary aspects of commissioning US for image guided brachytherapy (IGBT). To understand real time planning of prostate HDR using ultrasound, and its application in partial prostate treatments using MR‐ultrasound fusion to focus treatment on disease within the prostate. To understand the methods and QA in applying US for localizing the target and the implant during a episcleral plaque brachytherapy procedures.

Does Post–Neoadjuvant Therapy PET Response Predict Pathologic Outcomes in the Treatment of Sarcomas?

sarcomas (10), and other malignancies (2). 4 of these patients had radiation associated sarcomas within prior radiation field for different malignancies. Materials/Methods: The median age of the patients at diagnosis was 51 (range 7-75). The patients were treated from Feb, 2000 to Oct, 2013. 6 patients were treated with dural plaques during both stages of planned 2-stage operations. 46 patients were planned for treatment during one of the staged resection. The types of plaques used included Y-90, P-32 and Ir-192. Median dose was 10 Gy (range 7.5 e 17 Gy) prescribed to the dural surface in a single fraction. The median length of the dural plaque is 36mm, and the median arc of the dural plaque is 153 . All patients had also received preand/or postoperative photon/proton external beam radiation therapy. We limit spinal cord dose to 63/54 Gy RBE to surface/center. Results: In 7 of 51 patients, dural plaque brachytherapy was not given (4 because of intraoperative anatomic constraints, and 3 because of dural tears). Results are based on intention to treat analysis. The median follow up time from date of planned dural plaque brachytherapy is 17.7 months. Of the 3 patients treated for primary disease and had local recurrence, 2 presented with radiation associated sarcoma, which significantly limited their external beam radiation dose. No acute or late myelopathy could be attributed to dural plaque brachytherapy. 6 patients had intraoperative dural tear (none directly caused by plaque placement). In 3 of these 6 patients, dural plaque treatments were given. In 1 of the 3 patients, a persistent CSF leak developed postoperatively, and it eventually resolved without intervention. Conclusions: Dural plaque brachytherapy allows high dose of radiation to be safely delivered to the dural surface. Dural plaque shall be considered in situation when tumors are in close proximity to spinal cord, and sufficient dose of radiation cannot be delivered with external beam radiation therapy alone. Author Disclosure: D.D. Yip: None. T.F. DeLaney: None. A. Jacobson: None. F.J. Hornicek: None. J.H. Schwab: None. T.C. Mauceri: None. Y. Chen: None.

Extraocular Muscle Repositioning and Diplopia: Associated with Ophthalmic Plaque Radiation Therapy for Choroidal Melanoma

To evaluate extraocular muscle surgery associated with plaque brachytherapy for choroidal melanoma. Single-center retrospective cohort study. Three hundred twenty-nine eyes of 329 consecutive patients with clinically diagnosed choroidal melanoma. Palladium 103 plaque brachytherapy with or without extraocular muscle surgery. Type of muscle surgery required for each tumor location, timing, incidence, and duration of diplopia, as well as treatment. Two hundred fifty-four patients (n = 254/329; 77.2%) required muscle surgery. One hundred seven patients (n = 107/329; 32.5%) required surgery on 2 or more muscles. Of 373 muscles repositioned, the lateral rectus muscle (n = 115/373; 30.8%) and inferior oblique muscle (n = 70/373; 18.7%) were the most common, correlating to intraocular tumor location (P<0.001). Only 6 tumors (n = 6/61; 9.5%) originating from the iris and ciliary body required muscle surgery for plaque placement. Of the 312 patients with a preoperative visual acuity better than 20/400, diplopia was reported at the first postoperative visit by 41 patients (n = 41/312; 13.1%), 2 of whom had not undergone muscle surgery. Diplopia resolved spontaneously within 1 month in 18 patients (n = 18/41; 43.9%), between 1 and 6 months in 12 patients (n = 12/41; 29.3%), and at more than 6 months in 5 patients (n = 5/41; 12.2%). Among the 312 patients, persistent diplopia occurred in 6 patients (1.9%), including 1 who had not undergone muscle surgery. Treatment was declined in 1 patient, 3 patients (n = 3/41; 7.3%) were treated with prisms, and 2 patients (n = 2/41; 4.9%) required surgery. Extraocular muscle surgery frequently is required for plaque brachytherapy. Although transient diplopia occurred in 11.2% of patients, persistent diplopia occurred in only 1.9% of patients and was treatable.

Monte Carlo Simulation of the Treatment of Eye Tumors with 106Ru Plaques: A Study on Maximum Tumor Height and Eccentric Placement

Background/Aims: Ruthenium plaques are used for the treatment of ocular tumors. There is, however, a controversy regarding the maximum treatable tumor height. Some advocate eccentric plaque placement, without a posterior safety margin, to avoid collateral damage to the fovea and optic disc, but this has raised concerns about marginal tumor recurrence. There is a need for quantitative information on the spatial absorbed dose distribution in the tumor and adjacent tissues. We have overcome this obstacle using an approach based on Monte Carlo simulation of radiation transport. Methods: CCA and CCB ¹⁰⁶Ru plaques were modeled and their geometry embedded in a computerized tomography scan of the eye of a patient. Different tumor sizes and locations were simulated with the general-purpose Monte Carlo code PENELOPE. Results: Cumulative dose-volume histograms were obtained for the tumors and the tissues at risk considered. Plots of isodose lines for both plaques were obtained in a computerized tomography study. Conclusions: Ruthenium eye plaques are an adequate treatment option for tumors up to around 5 mm in height. According to our results, assuming a correct placement of the plaque, a tumor of 6.5 mm apical height is about the maximum size that can be treated safely with the large CCB plaque.

Quantifying the dosimetric influences of radiation coverage and brachytherapy implant placement uncertainty on eye plaque size selection

Quantify the dosimetric adequacy of the 2003 American Brachytherapy Society report tumor margin recommendations for Collaborative Ocular Melanoma Study (COMS) eye plaque size selection for radiation coverage and clinical plaque placement uncertainties. Plaque heterogeneity-corrected dose distributions were generated for the range of available COMS plaque diameters (φplaque) and radionuclides. These dose distributions were used to determine the radiation dose distribution diameter (φ℞) at the eye surface for each plaque as a function of central axis prescription depth (d℞) to assess adequacy of a 2-3-mm margin for various gross tumor volume (GTV) basal diameters (φGTV). Four sets of ellipsoidal tumors (φGTV=5, 8, 11, and 14mm) with a range of apical heights (dGTV=2-8mm) were contoured in a reference CT environment. Plaque placement uncertainties were quantified as circumferential displacements (Δ) at the outer scleral surface. Tumor dose-volume histograms were generated and compared for all Δ with D90 and D95 used to evaluate tumor margin adequacy. For equivalent φplaque and prescription depths, φ℞ values were typically 0.4-0.8mm less for (103)Pd than for (125)I or (131)Cs. Δ≤3mm resulted in D90 and D95 values as low as 68% and 64% of the prescription dose, respectively. (103)Pd plaque dose distributions were more sensitive than (125)I or (131)Cs to placement uncertainties. The American Brachytherapy Society-recommended tumor margin may be inadequate for prescription dose coverage given COMS plaque radiation characteristics and placement uncertainties. Better coverage is achieved assuming a GTV-to-planning target volume total basal expansion of 3mm or greater and/or prescribing beyond the tumor apex.

Expression of 12 cytokines in aqueous humour of uveal melanoma before and after combined Ruthenium‐106 brachytherapy and transpupillary thermotherapy

To determine the aqueous humour levels of 12 cytokines in eyes with uveal melanoma and whether their expression changes after combined Ru-106 brachytherapy and transpupillary thermotherapy (TTT). Aqueous humour samples were collected from 20 patients with previously untreated uveal melanoma undergoing combined Ru-106 brachytherapy and TTT, both at the time of plaque placement and removal. Using multiplex biochip array technology, 12 different cytokines were measured, including interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), tumour necrosis factor (TNF)-α, interferon (IFN)-γ, epidermal growth factor (EGF) and monocyte chemoattractant protein (MCP)-1. Aqueous humour from 20 patients undergoing cataract surgery was used as control. IL-6, IL-8, IFN-γ and MCP-1 were highly expressed in uveal melanoma, whereas IL-2, IL-10 and TNF- α were low in expression. There was a positive correlation between tumour height and IL-8 level (p = 0.020). Vascular endothelial growth factor tends to be highly expressed in melanoma-containing eyes (p = 0.056). Levels of IL-6, IL-8 and IL-1β increased after the mean 117 ± 38 hrs of brachytherapy and adjunctive TTT with a tumour apex dose of 61 ± 28 Gy and a scleral contact dose of 786 ± 226 Gy. Increase in levels of IL-6 (p = 0.003) and IL-8 (p = 0.046) positively correlated with scleral contact dose. Cytokines such as IL-6, IL-8, IFN-γ and MCP-1 may be implicated in the progression of uveal melanoma. Ocular irradiation from a Ru-106 plaque promoted an increase in the levels of IL-6, IL-8 and IL-1β, modulation of which could be useful in managing radiation-related side effects.

Evaluation of the surgical learning curve for I-125 episcleral plaque placement for the treatment of posterior uveal melanoma: a two decade review

PurposeTo evaluate the surgical learning curve in episceral plaque brachytherapy placement in the management of posterior uveal melanoma.MethodsA retrospective chart review of two cohorts of 250 consecutive patients undergoing plaque placement for posterior uveal melanoma from 2002 to 2004 and from 2008 to 2009 was conducted. The plaque–tumor apposition rates verified by intraoperative echography were evaluated and correlated with surgical volume over a 19-year period.ResultsIn an initial study of 29 consecutive patients undergoing plaque placement from January 1992 to January 1995, a suboptimal plaque placement rate of 21% (n = 29) was identified. This percentage declined to 12% (n = 100) from January 2002 to January 2004, and further declined to 4% (n = 150) from June 2008 to August 2009. The tumor–plaque apposition rates for these three groups were 79% (1992–1995), 88% (2002–2004), and 96% (2008–2009). An estimated surgical volume of 1275 cases was performed to achieve a >90% precision rate for first application of primary plaque centration.ConclusionThere are challenges to mastering the precise placement of radioactive plaques for posterior uveal melanoma. We have demonstrated a significant learning curve for plaque placement techniques, and have emphasized the importance of intraoperative ultrasound in the verification of plaque placement, thus allowing for intraoperative repositioning.

SU-E-T-589: IGRT-Assisted Episcleral Eye Plaque Brachytherapy

Purpose: The goal of episcleral eye plaque brachytherapy has been to deliver a prescribed dose to the apex of an intra‐ocular malignancy. Advances in dose calculation and image guidance allow for optimal plaque treatment planning. The BEBIG Plaque Simulator™ utilizes calibrated fundus collages to more precisely localize intra‐ocular tumors volumes, thus enabling physicists to plan plaque therapies that deliver the prescribed dose to the tumor while quantifying and limiting dose to critical optical structures, including the macula, optic disc, and lens. Methods and Materials: A retrospective study of 30 patients at our institution who previously received episcleral eye plaque brachytherapy based on conventional treatment planning techniques. For each patient, the originally defined Ultrasoundtumor dimensions, plaque specifications (COMS universal or notched), and treatment times were entered into Plaque Simulator. Fundus collages were calibrated and overlaid on a retinal diagram. The tumor was placed over the delineated tumor on the fundus collage. Doses to the tumor apex, macula, optic disc, and lens were calculated using TG‐43U1 formalism after assuming correct plaque placement. Results: Localization of intra‐ocular tumors allowed for accurate plaque placement and realistic dose calculation for critical structures. Recreated plans validated the original prescriptions while elucidating doses to critical structures. Doses to the macula and optic disc have been correlated to clinical outcomes, including radiation maculopathy and optic neuropathy, in an effort to evaluate dose thresholds that can be enforced in future plaque therapies. Conclusions: The use of image guidance gives radiationoncology‐ophthalmology teams the ability to deliver plaque therapy with the intent to control the tumor and spare critical structures. Dose determination may highlight the necessity of proper plaque placement, plaque size, source strength, and carrier angle optimization to deliver the prescribed dose while reducing dose to critical structures below suggested thresholds in order to preserve vision.

Severe keratitis following corneal cross-linking for keratoconus

performed and the patient underwent proton beam radiotherapy. Two years after proton beam radiotherapy, the tumour thickness was 3.5 mm but the patient developed a recurrent vitreous haemorrhage and neovascular glaucoma requiring enucleation. Pathological examination showed a partially necrotic choroidal melanoma of epithelioid cell type, with vascular hyalinization from the radiotherapy. The mitotic count was 1 ⁄ 40 high power fields. Numerous macrophages were seen. The sclera adjacent to the tumour showed collagen degeneration and calcification (Fig. 2). Apical tumour recurrence after ruthenium plaque radiotherapy is rare, even with eccentric plaque placement (Damato et al. 2005; Lommatzsch et al. 2000; Summanen et al. 1993). This case therefore raises the possibility that treatment failure occurred because of intrascleral calcification beneath the tumour. We suggest that this finding should prompt a higher dose of brachytherapy or an alternative form of radiotherapy, such as proton beam radiotherapy.

A Universal, Notched, Episcleral Plaque Set for Brachytherapy of Intraocular Tumors Adjacent to the Optic Nerve

When applying radioactive plaque brachytherapy to intraocular tumors adjacent to the optic nerve, a notched plaque is usually used to produce a dose distribution encircling the optic disc. Due to the posterior tumor location and the limitation in eye rotation, plaque placement, alignment, and anchoring with sutures often presents technical difficulties. This article describes a universal notched episcleral plaque set consisting of a 20 mm base notched plaque, a set of open gold rings, and conventional silicon seed carriers ranging in size from 10 mm to 20 mm. This set is designed to minimize the present difficulties when treating tumors of various sizes located adjacent to the optic nerve. The design also allows for accurate echographic imaging for tumor-plaque alignment. The assembled plaques were tested on a human cadaver eye, showing the effectiveness of echographic localization as well as the ease of plaque fixation.

SU‐FF‐T‐74: Preplanning of Suture Coordinates for Episcleral Plaque Therapy

Purpose: Episcleral plaques are attached to the eye by sutures which affix eyelets to the sclera. Historically, plaque position was determined by transilluminating the eye to cast a shadow of the tumor onto the sclera, outlining this shadow, and subsequently deciding where to suture the eyelets. 3D modeling enables scleral coordinates for each eyelet to be determined prior to surgery. Methods: The retinal diagram is a polar map of the retinal surface in which the posterior pole is located at the center of the map surrounded by radial spokes representing meridians and concentric rings of lattitude which terminate at the limbus which is the border of the cornea and sclera. Eyelet coordinates on an equivalent scleral diagram can be expressed using a meridian, a chord distance from the limbus along that meridian, and the chord distance between the eyelets. It is common to express diagram meridians as clock hours so coordinates for a plaque with two eyelets might be something like: eyelet ♯1 along the 12:40 o'clock meridian, 9.1 mm from the limbus, eyelet ♯2 along the 2:10 meridian 9.4 mm from the limbus, and 9.2 mm between the eyelets. Results: Over 300 patients have been treated at USC using calculated suture coordinates. Only in a handful of cases involving anterior tumors for which fundus photography was impossible was it necessary to empirically adjust coordinates. Admittedly subjective observation suggests that plaque placement to within about 8 degrees circumferentially and 0.5 mm radially of the planned position is routinely achievable. Examples will be presented. Conclusion: When the tumor location can be accurately determined from fundus photography, the placement of a plaque and its suture eyelets can be accurately preplanned. Conflict of Interest: Software which implements this technology is licensed by BEBIG GmbH for distribution under the name Plaque Simulator.

Intra‐operative Echographic Localization for Radioactive Ophthalmic Plaques in Choroidal Melanoma

The objectives were to evaluate the beneficial effect of intra-operative echographic plaque site localization and to assess the rate of complications of postplaque insertion. This paper is a descriptive study of 48 patients with choroidal melanoma who underwent iodine-125 (I(125)) or ruthenium-106 (Ru(106)) plaque radiotherapy with intra-operative echographic confirmation of plaque placement with the aid of a nonradioactive plaque (dummy) at McGill University Health Centre from 1997 to 2003. Patients' mean age was 63.7 years; 52% (25/48) male, 48% (23/48) female. Twenty-seven percent (13/48) of the tumors were confined to the right eye and 73% (35/48) to the left eye. Forty-eight percent (23/48) of the tumors were located posterior to the equator, 14.6% (7/48) were anterior to the equator, 18.7% (9/48) in posterior pole, and 18.7% (9/48) at equator. Sixty-nine percent (33/48) received I(125) and 31% (15/48) had Ru(106) treatment. Ninety percent of the dummy plaques were initially positioned suboptimally and required repositioning under echographic guidance. At mean follow-up of 18.8 months, there was no tumor-related death or metastasis, but one patient required enucleation. The dummy plaque technique under echographic visualization resulted in reduction of radioactive exposure time during surgery of up to 50%. Intra-operative echographic utilization has the ability to localize precisely the tumor-plaque relationship, thereby optimizing the radiation delivered to the choroidal melanoma, while minimizing the surgeon's exposure time.

Transscleral Fine-Needle Aspiration Biopsy of Macular Choroidal Melanoma

To report transscleral 30-gauge fine-needle aspiration biopsy (FNAB) for cytology and cytogenetics in eyes with macular choroidal melanoma. Prospective, interventional case series. Twenty-five patients (25 eyes) who underwent transscleral 30-gauge FNAB of macular choroidal melanoma immediately prior to iodine-125 plaque placement were included in this study, conducted at a tertiary care university hospital. The main outcome measures were FNAB feasibility, cytology, cytogenetic analysis for monosomy 3, and surgical complications. Transscleral 30-gauge FNAB of choroidal melanoma in the macula was performed in 24 of 25 (96%) eyes and was not feasible owing to insufficient exposure in one eye (4%). Biopsy was diagnostic of choroidal melanoma in 17 of 24 (71%) eyes. Fluorescent in situ hybridization (FISH) and/or GeneChip 500k NspI Mapping array (Affymetrix, Santa Clara, California, USA) analysis for monosomy 3 was completed in 16 of 24 (67%) revealing monosomy 3 in five eyes and disomy 3 in 11 eyes. Retinal perforation (four eyes) did not require treatment or result in retinal detachment; submacular hemorrhage (nine eyes) and vitreous hemorrhage (five eyes) cleared spontaneously within one month. Transscleral FNAB of macular choroidal melanoma is feasible in most eyes and frequently yields cytogenetic information relevant to prognosis.

Quality assurance in episcleral brachytherapy

Abstract Purpose: The treatment of choroidal melanoma and other ocular tumors can be approached by means of epiescleral brachytherapy. The process involves several specialiced professionals, different methods to obtain measurements (radioactive sources, tumor) and a complex process to apply every treatment. A program of quality assurance would minimize the possibility of inaccuracy and would optimize the information flow. The purpose of this work is to establish a flow chart that guarantees the information efficiency and a protocol for episcleral brachytherapy. Methods: The flow chart of the process is elaborated, explaining each of the points of information, delimiting responsibilities and fixing period of performance identifying the most important steps for coordination Results: The scheme of the process flow chart is:Diagnosis; treatment Indication; epiescleral brachytherapy Protocol; ultrasound, funduscopy; CT, MR; Record and analysis of information; treatment volume definition; treatment planning and optimization; Quality assurance of sources and applicators; Preparation of the set applicator – sources; Plaque placement; Patient and radiation surveillance; Plaque recovery; Follow‐up. Conclusions: The example gathered in the present work shows the importance of the establishment of programs of quality assurance in treatments as episcleral brachytherapy or any other radiation treatment.Acknowledgments:This work has been financed partly by a grant of the Junta de Castilla y León (Order SAN/1322/2006 of August 22, BOCYL of August 29, 2006)

SU‐FF‐T‐104: Clinical Field Matching Using Intraoperative 90‐Y Brachytherapy Plaques

Purpose: A foil in a semi‐cylindrical polycarbonate plaque has been developed and used to intraoperatively irradiate the dura for sarcomas of the spine in 16 patients. As smaller plaques are easier to place in restricted surgical fields, an investigation of field matching requirements was undertaken to evaluate the possibility of multiple site irradiations using small plaques. Method and Materials: Using a brachytherapy treatment plaque and a cylindrical dosimetry phantom with the same radius, irradiations were performed using radiochromic film (GafChromic HS). 2 Gy was delivered, and the plaque was then moved to a position that would abut (0 mm) or overlap (1.5 mm, 3.0 mm, 4.5 mm, or 6.0 mm) with the previous plaque placement and an additional 2 Gy was delivered. Simulated field matching irradiations based on the plaque dose profile were also generated for 0 to 5 mm overlaps in 1 mm increments. Results: Measured peak % prescribed dose (%PD) and gap width below the 90% prescribed dose level (G90%) were determined to be −87% and 11.6 mm when abutting; −60% and 6.2 mm with 1.5 mm overlap; and −47% and 5.0 mm with 3.0 mm overlap. The dose profile was effectively flat with 4.5mm overlap and a peak overdosage of +34% was observed with 6.0 mm overlap. The simulated %PD and G90% were determined to be −84% and 9.5 mm when abutting; −77% and 8.2 mm with 1.0 mm overlap; −65% and 7.0 mm with 2.0 mm overlap; −45% and 5.0 mm with 3.0 mm overlap; and −17% and 2.5 mm with 4.0 mm overlap. A peak overdosage of +18% was observed with 5.0 mm overlap. Conclusion: A 5 mm plaque placement overlap provides for adequate field matching with the plaque, improving its clinical utility and allowing for greater flexibility in the surgical environment.

Choroidal Melanoma With Hematogenous Spread to the Liver: F-18 FDG PET/CT Findings

Melanomas usually metastasize through the lymphatic route. However, choroidal melanoma invariably disseminates hematogenously to the liver. Liver metastasis develops in approximately two thirds of patients with recurrent uveal melanoma. The PET scan is a sensitive tool for the detection and localization of hepatic and extrahepatic metastatic choroidal melanoma. We report a patient with a history of choroidal melanoma in the left eye. The patient had undergone a scleral plaque placement followed by an enucleation and an implant. He was referred to us for a PET scan for restaging. No prior PET scan was available for comparison. An implant in the eye with intense FDG-avid liver metastasis should raise suspicion of choroidal melanoma.

Long-Term Results of Plaque Thinning with Carbide Burs, Small Incisions and Venous Grafting for Correcting Complex Penile Curvature in Peyronie’s Disease: Poor Results of an “Ideal” Approach

We evaluated the long-term results of plaque thinning by carbide burs, small transverse incisions and venous grafting for correcting complex penile curvature in patients with Peyronie's disease. A total of 13 patients with Peyronie's disease and complex penile curvature received plaque thinning by carbide burs equipped with a fraise, small plaque incision and venous grafting. All patients were available for long-term followup at a mean of 29 months. Preoperatively the mean dorsal curvature angle was 73 degrees with an additional malrotation in 4 patients. Followup consisted of a standardized interview and 3-dimensional photo documentation during erection. Although penile straightening was achieved intraoperatively, dorsal curvature (mean 35 degrees) recurred in 8 men, of whom 3 noticed this deterioration after a longer period. Penile shortening (mean 3.3 cm.) occurred in 7 patients, and decreased rigidity during intercourse occurred in 4. Hypothetically, a combined technique of thinning, incision and grafting seems to be an ideal surgical approach for correction of complex penile curvatures in Peyronie's disease without plaque excision. Although the penis had been completely straightened intraoperatively, severe dorsal curvatures recurred and significant penile shortening became obvious in more than half of the patients. Manipulation of the plaque may be associated with activation of the disease, with all of the risks of recurrence and deterioration. Due to the poor results of the thinning procedures, we stopped using this surgical approach and now prefer a combination of small incisions and grafting only.

Plaque incision and venous patch grafting for Peyronie's disease.

To evaluate the results of plaque incision and venous patch grafting to correct the dorsal curvature associated with Peyronie's disease. 18 patients with Peyronie's disease were treated surgically. All of the patients have dorsal penile curvature for more than one year causing intromission impossible or with some difficulty because of curvature. Median penile angulatio was 60 degrees (range 45 degrees-75 degrees). A transverse incision about 2 cm long was made on the plaque where maximal site of curvature was identified. The saphenous vein harvested from the ankle region is opened longitudinally and its endothelial surface is placed and sutured in contact with the tunical defect. Complete penile straightening was achieved in 16 (88.8%) cases and only two patients have residual curvature less than 30 degrees permitting sexual intercourse. None of the patients returned to baseline preoperative angulation state in the follow up period. 3 patients (16.6%) reported penile shortening, but only one was concerned and showed dissatisfaction about it. 6 patients (33.3%) have transient changes in penile sensation that resolved within 4 months. Plaque incision and placement of saphenous vein patch graft offers a 94.4% satisfactory result in Peyronie's disease causing penile dorsal curvature.

Transillumination for accurate placement of radioactive plaques in brachytherapy of choroidal melanoma

PURPOSE: To present a technique for accurate plaque placement in episcleral brachytherapy of choroidal melanoma. METHODS: The tumor margins are marked on the scleral surface, and a dummy plaque is temporarily sutured to the globe. A fiber optic light pipe is then wedged into the space between the sclera and the plaque. Because of the reflecting inner surface of the plaque, the perimeter of the plaque can easily be observed during indirect ophthalmoscopy as a circle of light surrounding the tumor. By this method, it is possible to determine the exact position of the entire plaque in relation to the tumor and make the necessary adjustments. When the correct position is found, the dummy plaque is replaced by a radioactive plaque. RESULTS: Since 1993, we have routinely used this procedure in episcleral brachytherapy. CONCLUSION: This modified transillumination technique facilitates a correct positioning of episcleral plaques.

Plaque radiation therapy for malignant melanoma of the iris and ciliary body

PURPOSE: To report on plaque radiation therapy for malignant melanomas involving the iris and ciliary body. METHODS: Twenty-two eyes (22 patients) with anterior uveal melanomas were treated with 103Pd ophthalmic plaque radiation therapy. Transillumination and ultrasonography were used to evaluate ciliary body involvement and posterior iris extension. Plaques were placed onto the cornea to treat the anterior tumor margins. The targeted-zone included the tumor and a 2 to 3 mm tumor-free margin. After plaque removal, patients were examined at 1 day, 7 days, 4 weeks, and then every 3 to 6 months thereafter. Systemic evaluations for possible metastatic disease were performed every 6 months. RESULTS: After plaque radiation therapy, the melanomas decreased in thickness (mean 47%) in all 22 eyes, and no secondary enucleation was performed. One patient died of metastatic melanoma 5 years after radiation therapy. Despite anterior plaque placement that covered portions of the cornea, no epiphora, eyelash loss, or visually significant corneal opacities were noted. Whereas 15 of 21 phakic eyes (71%) developed secondary cataract, no eyes developed ischemic or neovascular radiation maculopathy. Four eyes were noted to have glaucoma before treatment, and two developed it after irradiation. Twenty of 22 eyes (91%) were within 2 lines of their pretreatment visual acuity. After radiation, the mean ± SD follow-up was 56 ± 34.4 months (range, 9 to 117 months). CONCLUSIONS: Plaque radiotherapy of melanomas involving the iris and ciliary body resulted in excellent local control with preservation of vision. Although there was high incidence of secondary cataracts, 103Pd plaque radiation therapy resulted in no visually significant corneal opacity or radiation retinopathy.